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LECTITEES ON" FEYEE 
 
 DELIVERED IN THE THEATRE OP THE MEATH HOSPITAL 
 AND COUNTY OF DUBLIN INFIRMARY. 
 
 £- 
 
 BY 
 
 WILLIAM STOKES, M.D., D.C.L. Oxox., F.E.S., 
 
 REGIUS PROFESSOR OF PHYSIC IN THE UNIVERSITY OF DUBLIN, 
 PHYSICIAN TO THE QUEEN IN IRELAND. 
 
 EDITED BY 
 
 JOHjST WILLIAM MOOSE, M.D..F.KQ.C.P. 
 i 
 
 ASSISTANT PHYSICIAN TO THE CORK STREET FEVER HOSPITAL, 
 
 EX-SCHOLAR AND DIPLOMATS IN STATE MEDICINE 
 
 OF TRINITY COLLEGE, DUBLIN. 
 
 
 3f- S3 / 
 
 PHILADELPHIA: 
 
 H E N E Y 0. LEA 
 
 1876. 
 
C^5 
 
 
 *»t. Qflace Lib. 
 
THE FOLLOWING PAGES 
 
 §w Jttateti to 
 HENRY WENTWORTH ACLAND, M.D., LL.D., F.R.S., 
 
 REGIUS PROFESSOR OF MEDICINE IN THE UNIVERSITY OF OXFORD ; 
 HONORARY PHYSICIAN TO H.R.H. THE PRINCE OF WALES. 
 
 WHOSE ENLIGHTENED EFFORTS TO SHOW THE RELATIONS OF CURATIVE AND 
 
 PREVENTIVE MEDICINE TO THE HIGHEST INTERESTS OF 
 
 MAN HAVE EARNED FOR HIM THE GRATITUDE 
 
 OF ALL HIS FELLOW-WORKERS. 
 
PEEFACB 
 
 It seems fitting I should mention that the following Lectures, the 
 delivery of which has been spread over a considerable period of time, 
 were not given in any regular sequence, so as to form a continued or 
 systematic course. On the contrary, most of them were delivered at 
 irregular intervals, and all as extemporary discourses. In one remark- 
 able instance, this has led to the repetition of a very peculiar case of 
 internal abscess in convalescence from Fever with icterus. As stated 
 in the text, I was at first inclined to regard the liver as the primary seat 
 of the abscess ; but at page 149 I have given reasons for concluding 
 that the lesion was originally in the spleen. Several years intervened 
 between the delivery of the first, and that of the second, lecture in 
 which the case is mentioned. 
 
 The place in which I spoke should be remembered — namely, the 
 theatre of a General Hospital, containing, indeed, separate fever wards, 
 but also wards for the treatment of cases other than those of essential 
 disease. And so, with the view of publication, it became necessary 
 to employ a good deal of selection as to the subject-matter of each 
 lecture. Some of them, so far back as the year 1854, were edited by 
 my friend and former pupil Dr. Lyons, and appeared in the Medical 
 Times and Gazette under the head of " Clinical Lectures on Fever." 
 
 Since that time, I need not say, the study and the teaching of Fever 
 have been continued in the Meath Hospital, with at least one impor- 
 tant result — namely, the valuable and original work of my trusted 
 friend and late colleague Dr. Hudson, a work worthy to follow that 
 of Dr. Graves for its learning, judgment, and practical worth. 
 
 It appeared to me that lectures addressed to successive classes of 
 clinical students, and grounded on constantly renewed observations 
 in the sick ward throughout many years, would have a value different 
 in kind from, if not superior to, any exhaustive history of fever, 
 especially as regards the various theories of the disease or the obser- 
 vations made by others. 
 
 I have ever believed that the great object of a clinical instructor 
 
VI PREFACE. 
 
 is twofold — first, that he should teach rather by example than by 
 precept; and, secondly, that he should act more as a fellow-student 
 than as a master. In this way the members of his class, associated 
 with him in investigation, will learn as much or more by his example 
 as they would by his precepts. They will taste the pleasure of 
 original work and the value of self-instruction, and perceive that their 
 great object is less to be taught by another than, in following his 
 steps, to learn to teach themselves. This shows the superiority of 
 clinical over systematic teaching in medicine. The former admits of 
 immediate demonstration; and, from the ever-varying combinations 
 and characters of essential disease, no one lecture can, as it were, 
 repeat another. 
 
 But while his discourses must vary from time to time, according 
 as they may deal with the infinitely varied complications of local 
 secondary disease, or in relation to the " epidemic character" of the 
 essential or general malady, the duty of the teacher should ever be to 
 imbue the minds of his hearers with the state of his own convictions 
 on the subject in general. Thus he will furnish them with a knowl- 
 edge less of particulars or of theories than of those broad principles 
 which in after-life will guide them in dealing with disease. 
 
 In the following Lectures I have considered in some measure the 
 question of the separate identity of typhus and typhoid fevers, but I 
 have not entered into it as fully as the labours of other observers in 
 various countries might have encouraged me to do. I have preferred 
 to dwell on the great subject of the relation of the secondary affec- 
 tions of fever to the essential malady, and in the light of that relation 
 to discuss the question of treatment. 
 
 No one can deny that a normal case of typhus will show striking 
 differences from a normal example of typhoid ; yet that these differ- 
 ences belong rather to species than to genera, and that the principles 
 of treatment of the two affections are the same, must,, as it appears to 
 me, be admitted. In fact, the study of the points of agreement between 
 the two forms of Continued Fever under discussion will be more 
 valuable than that of their differences. 
 
 They are both essential affections, in which the local anatomical 
 changes are secondary to, or resulting from, the fever. 
 
 They are both subject, although in varying degrees and at different 
 times, to the Law of Periodicity. 
 
PEEFACE. Vll 
 
 The characters of the constitutional and local symptoms in both 
 vary as to intensity, amount, seat, combination, period of appearance 
 and of cessation, and effect upon the primary disease. 
 
 In both, the local symptoms may be only functional, or more or 
 less connected with anatomical change. 
 
 In both, local change may interfere with the law of periodicity, or 
 even be attended by cessation of the constitutional symptoms. This 
 has been observed more frequently in typhus than in typhoid. 
 
 In both, the action of the law of periodicity applies not only to the 
 general condition, but also to the secondary affections. 
 
 In both, the local or secondary malady may take on a consequent 
 condition of reactive irritation, thus adding a symptomatic to the pri- 
 mary fever. 
 
 The essential and local characters of both vary with the "epidemic 
 constitution" of the time being. 
 
 The symptoms of local disturbance, which are reliable as a guide 
 to diagnosis where essential disease does not exist, in a great measure 
 lose their significance in the presence of both forms of Continued 
 Fever. 
 
 In both, any or all of the functions may be disturbed singly, col- 
 lectively, or successively, with or without corresponding anatomical 
 change. 
 
 In both, deposits of tubercular matter may occur as a secondary 
 local affection. 
 
 Similar exciting causes seem occasionally capable of giving rise to 
 either form of fever. 
 
 In "relapse cases" — I do not mean cases of Relapsing Fever — the 
 character of the second attack may differ widely from that of the 
 first. Thus typhus may give place to typhoid, or vice versa. 
 
 The petechial or the measly eruption of typhus may coexist with 
 the rose-spots of typhoid. 
 
 Both forms are contagious, although in different degrees. 
 
 As I have said, the principles of treatment in both are the same. 
 
 These Lectures do not pretend to give even a sketch of all that is 
 known or believed to be known respecting Fever. Nothing will be 
 found in them relating to histological .research, the ohemico-vital 
 states of the fluids or organs, or the analysis of the laws of crisis. The 
 wide questions of the correlation or convertibility of essential disease 
 are barely touched upon. Some of the facts connected with the 
 
Vlll PREFACE. 
 
 change of type of disease, especially as regards the local affections of 
 essential maladies, are mentioned. I have also spoken of the short- 
 comings of the numerical system in medicine, of which Professor 
 Trousseau, in the introduction to his immortal work, 1 writes as 
 follows : — 
 
 "Si la statistique appliquee a la medecine n'elevait pas trop haut 
 ses pretentions, si elle se considerait non comme la clef de voute de 
 toute science, mais comme un procede' un peu moins imparfait que la 
 plupart de ceux que Ton suivait jusqu'ici, je ne songerais qu'& la 
 louer, qu'a la presenter a votre choix, parce que re'ellement je la crois 
 utile ; mais elle fait tant de bruit pour de si pauvres re'sultats, qu'on 
 ne peut, en conscience, l'aider & tromper la jeunesse par une sorte de 
 charlatanisme d'exactitude et de verite." 
 
 The difficulties attending the application of the numerical system 
 are nowhere greater than in the study of essential fever, because of 
 the ever-changing nature of the epidemic type of the disease and of 
 its secondary local affections. 
 
 I cannot close this Preface without expressing my deep sense of 
 obligation to my distinguished colleague Dr. Arthur Wynne Foot for 
 a valuable record of temperatures in Fever, collected for the most part 
 under his personal supervision in the wards of the Meath Hospital 
 during the last three years. 
 
 ' Clinique medicale de l'Hotel-Dieu de Paris, deuxieine edition, tome l er , Introduction, 
 p. xliv. 
 
CONTENTS 
 
 PAET I. 
 
 ESSENTIAL FEVER AND ITS SECONDARY AFFECTIONS. 
 
 LECTURE I. 
 
 PAGE 
 
 Introductory — Injurious influence on the student and practitioner of having 
 studied surgical cases exclusively — Influence of timidity from want of intimacy 
 ■with bed-side treatment of fever — Erroneous views in relation to the frequency 
 of inflammatory disease — Inflammation not the primary cause of many local 
 though acute affections — Errors of Broussais — Abuse of the antiphlogistic 
 treatment 1 
 
 LECTURE II. 
 
 Change of Practice as regards the treatment of fever — Change of type in disease 
 from sthenic to asthenic — Views of Alison — Sir Robert Christison — The author's 
 views — Evidence (1) from symptoms, (2) from appearances of blood drawn by 
 venesection, (3) from pathological appearances of internal viscera, and of serous 
 membranes, (4) from isolated sthenic cases, and (5) from influence of treat- 
 ment — Signs of a return to sthenic forms of disease — Vital character of disease 10 
 
 LECTURE III. 
 
 Fever described, but not defined, as "a condition of existence without any known 
 or necessary local anatomical change and subject to new laws, different from 
 those of health" — Error committed by the school of Broussais — The " Law of 
 Periodicity" — Danger to the fever patient due to the primary disease or to its 
 secondary complications — Secondary affections of continued fevers more incon- 
 stant than those of the exanthemata — Classification of diseases: (1) Diseases 
 having an anatomical character; (2) neuroses, having no known anatomical 
 character; (3) fevers, subject to the law of periodicity, causing secondary affec- 
 tions, transmissible by contagion ......... 20 
 
 LECTURE IV. 
 
 Contaoion — Exclusive doctrines are to be deprecated — Endemic disease arises 
 independently of contact — The numerical system of Louis fails in practical 
 medicine — Evidence in favour of contagion from the Doctrine of Chances — In- 
 vestigations of Dr. Whitley Stokes and the Bishop of Cloyne; with Dr. Paget's 
 remarks thereon — Variation in the degree of contagiousness of acute essential 
 diseases . . .27 
 
 LECTURE V. 
 
 Causes of Fever — Preventive and Curative Medicine contrasted — Risk of error In 
 limiting the number of the causes of disease — The correlation and the convcrti- 
 bility of disease two important questions, the answers to which are not as yet 
 fully or satisfactorily determined 34 
 
 Appendix A 40 
 
X CONTENTS. 
 
 LECTURE VI. 
 
 PAGE 
 
 Varieties of Fever as observed (1) in different epidemics, (2) in the same epi- 
 demic, and (3) in members of the same family, living under the same conditions 
 — This last-named fact is corroborative of the doctrine of the essentialism of 
 fever — Definition of the term epidemic character of fever — Outbreaks of 1818-19, 
 1826-27, and 1847 contrasted — Typhus and typhoid or enteric fever appear to 
 be but species of the same genus — Contagiousness of typhoid fever — Dr. Flint's 
 memoir — Principles of treatment of fever of any type must be based on an ac- 
 quaintance with the laiv of periodicity, to which the disease is subject . . 42 
 
 LECTURE VII. 
 
 Points of Resemblance in the various forms of fever a more practical subject for 
 investigation than their distinctions — As regards the principles of prognosis, 
 diagnosis, and management, the various forms of fever lose their separate and 
 individual significance — Points of resemblance between typhus and typhoid — 
 The famine fever in 1847 — Recapitulation 49 
 
 LECTURE VIII. 
 
 Division of Fevers into Essential and Symptomatic— No anatomical expression 
 for the disease — Secondary affections of fever — These may, and do, frequently 
 produce organic changes — The presence of essential disease invalidates the 
 ordinary rules of diagnosis — Illustrations of the truth of this statement — Local, 
 symptoms of fever are (1 ) functional or nervous; (2) anatomical, i. e., depending 
 on special anatomical changes : (3) secondarily inflammatory, i. e., arising from 
 reactive inflammation, itself due to the typhous infiltration of some part or 
 organ of the body — Similar symptoms may arise from essentially opposite con- 
 ditions in disease — Illustrations of the proposition that fever is capable of pro- 
 ducing local symptoms ivithout organic change ....... 55 
 
 LECTURE IX. 
 
 Local Changes in Fever are symptomatic, subject to laiv of periodicity, and prob- 
 ably depend on the presence of a specific typhous deposit — This deposit pos- 
 sesses a vital, specific character — Illustrations of this statement — The principal 
 pathological conditions in fever are (1) functional, (2) intercurrent and secondary 
 irritations of (a) mucous membranes, (h) parenchymatous structures, (c) serous 
 membranes, (3) secondary irritations associated with typhous deposits, (4) inde- 
 pendent typhous deposits, (5) neactive inflammations due to these deposits, (6) 
 softening of organs — Effect of locality in determining the seat of secondary 
 affections of fever — Effect of social rank in the same direction — Prognosis un- 
 favorable and treatment by stimulation so far contra-indicated in cases where 
 nervous symptoms preponderate 64 
 
 LECTURE X. 
 
 Secondary Bronchial Affection of Fever — Pneumo-typhus of Rokitansky — 
 Views of this author as to the anatomical expression of typhus and typhoid 
 respectively — Description of the bronchial affection of fever; frequent absence 
 of symptoms therein — Rales sonorous, mucous, or crepitating ; no increased 
 Bonoriety — This affection is not ordinary "bronchitis" ; it comes on silently and 
 subsides spontaneously— 'Argument from the effects of treatment by stimula- 
 tion — Modes of termination of the affection ....... 72 
 
 LECTURE XL 
 
 Bronchial Affection of Fever, continued — Alternating secondary affections — Im- 
 perfect convalescence due to reactive bronchitis — Cases resembling phthisis — 
 Three forms of tubercular disease, as a sequela of fever, (1) coexisting tubercle, 
 (2) acute consequent tubercle. (3) consequent softened tubercle — Diagnosis based on 
 the want of accordance between physical signs and symptoms in suspected phthisis 
 after fever — Expectoration of small calculi some mouths after bronchial typhus 
 — Tubercular fever in the typhus epidemic of 1826-1827 — This fever may be 
 contagious ............. 78 
 
CONTENTS. XI 
 
 LECTURE XII. 
 
 PA8E 
 
 Secondary Pneumonic Complications of Fever — Secondary congestion or consolida- 
 tion of lung — The term "typhoid pneumonia" is incorrect — "Acute asthenic 
 pulmonary disease," or "typhoid pneumonia," appears under seven forms — 
 " Aborted typhus" in connection with the occurrence of lung consolidation — 
 Local disease may assume a sthenic type even in the presence of a general 
 asthenic condition — Description of the secondary pulmonary affection of fever 
 under its three principal forms — Differential diagnosis between this disease 
 and acute primary pneumonia, based on both pathological and anatomical 
 grounds .............. 89 
 
 LECTURE XIII. 
 
 Pneumonic Complications of Fever, continued — "Typhoid pneumonia," so called, 
 is not dependent on a coexistent gastritis — Correct view is that both pulmo- 
 nary and intestinal lesions spring from the one parent condition, that of fever 
 — Physical signs of ordinary pneumonia are often found, but in an irregular 
 succession, in the secondary pneumonic affection — Sign of tympanitic resonance 
 in latter, first described by Dr. Hudson — Probable causes of the production of 
 this percussion sound — The author's views — Dr. Lyons' views — Three explana- 
 tions of the production of the sign — Frequent absence of crepitus redux in 
 resolution of secondary typhous disease — When inflammatory affections do 
 occur in fever, they are reactive or tertiary in their nature — Typhous affec- 
 tion of the larynx — Rokitansky's "laryngo-typhus" . . . . .98 
 
 LECTURE XIY. 
 
 The Heart in Fever — The state of the pulse, especially in typhus, not always a 
 reliable guide — Weakening of the heart may coexist with a full, bounding 
 pulse — Slow pulse in convalescence is consequent on a typhous weakening of 
 the heart — Rapid pulse in convalescence is of unfavourable import, pointing to 
 (1) tuberculosis, or (2) secondary reactive inflammation of the mucous glands of 
 the intestine, or (3) phlegmasia dolens — In such cases the local malady assumes 
 the prominence hitherto presented by the essential disease — Illustrative case 
 of hepatic (?) abscess in convalescence from the yellow fever in 1826-1827 — 
 Intermittent fever at close of epidemic in 1827 — Frequency of phlegmasia 
 dolens — Bleeding in cold stage, after Dr. Mackintosh — Failure of quinine in 
 cases of simulative ague, arising from (1) phlegmasia dolens, (2) urinary dis- 
 ease, and (3) the puerperal state ... 106 
 
 LECTURE XY. 
 
 The Heart in Fever, continued — Louis' conclusions, based on post-mortem observa- 
 tions — Typhous softening of the heart during life first studied at the Meath 
 Hospital in epidemic of 1837-39 — As regards state of the heart, fever cases 
 fall into three categories: those accompanied by (1) no alteration in heart's 
 action, except of rate; (2) weakness after a few days, consequent on depressed 
 • vital power; (3) cardiac excitement — Neither a depressed nor an excited state 
 of the heart in fever necessarily implies organic change — Dynamic condition of 
 the heart a more important indication for treatment than presence or absence 
 of any structural change — True carditis very rare in fever — Typhous weaken- 
 ing predominates in left side of the heart — State of involuntary muscular fibre 
 in acute essential disease is of great importance — Laenuec's theory as to typhous 
 softening of heart erroneous, for there is no correspondence between the soft- 
 ening of voluntary and involuntary muscular structures — Illustrations from 
 yellow fever of 1820-27 — Exemption of heart from typhous affection is a 
 ground for a favourable prognosis — Continued excitement of heart equally a 
 ground for a bail prognosis — Excited heart with compressible pulse most 
 unfavourable — Transfusion of blood under these circumstauces — Absence of 
 red blood after death, the only noteworthy pathological appearance in this case 
 — Blood-waste in fever to be met by administration of nourishment . . 114 
 
XU CONTENTS. 
 
 LECTURE XVI. 
 
 PAGE 
 
 The Heart in Fever, continued — Depression of the heart, more marked in typhus 
 than in typhoid — Signs of the change connected with (A) the impulse, (/>') 
 the sounds — The phenomena attending depression are variable — Description of 
 their development, generally from the fourth day. 
 
 A. Impulse: — Possible sources of error in diagnosis: (1) constitutionally feeble 
 
 impulse, (2) emphysema of lungs — Necessity for comparison of condition of 
 heart from day to day — Peculiar modification of impulse in certain cases — 
 Vermicular action — Effect of position on impulse of heart — Loss of impulse 
 generally progressive, sometimes rapid — " Where differential diagnosis is diffi- 
 cult or impossible it is often unnecessary as a guide to immediate practice" — 
 Retrocession of the local malady is gradual. 
 
 B. Sounds: — First phase of lesion: second sound becomes relatively, but not 
 
 positively, augmented. Second phase; disappearance of first sound. Third 
 phase: disappearance of both sounds (a condition of most unhopeful augury) 
 — Foetal character of the sounds in some cases — Speculations as to failure of 
 second sound — Loss of impulse and failure of sounds generally advance pari 
 passu, but not invariably so — As failure of sounds begins at the left side, so in 
 recovery the phenomena follow the inverse course ...... 121 
 
 LECTURE XVII. 
 
 The Heart in Fever, continued — Post-mortem appearances in extreme typhous soft- 
 ening — This affection not followed by chronic disease of the heart — Periods of 
 invasion and of retrocession — Diagnosis of actual softening depends on (1) the 
 character of the fever, and (2) the presistence of physical signs of failure of 
 the heart — Simultaneous lessening of both sounds (foetal heart) — Its bearing 
 on the treatment by stimulants — Slowness of pulse in convalescence from 
 typhous softening — Analogy to fatty degeneration of heart with slow pulse — 
 In latter case the phenomenon, however, is constant — Occasional reversal of 
 the order in which the signs of typhous softening show themselves — Prognosis 
 more favourable with depressed than with excited heart — Former condition is 
 more amenable to treatment — Report on an epidemic of typhus at Stockholm 
 in 1841, by Professor Huss — Cardiac murmurs in fever, especially in advanced 
 stages of typhoid and relapsing fever are generally basic and systolic functional 
 in character, and occasionally accompanied by veuous murmurs in the neck — 
 Difficulty of distinguishing the first and second sounds of the heart in certain 
 cases of disease: (1) chronic bronchitis, with weak and irregular heart and 
 congested liver: (2) late stages of some forms of fever — Example of the 
 latter — Diagnosis drawn from a want of accordance in the symptoms . . .117 
 
 LECTURE XVIII. 
 
 Secondary Intestinal Complications of Fever — General and introductory remarks 
 — A generic resemblance between the various forms of fever — Secondary abdo- 
 minal complications are more frequently observed in typhoid fever, but do not 
 exist as its necessary anatomical character — Dothinenteritis was largely pre- 
 valent in the typhus epidemic of 1826-28 — Fever must be observed independ- 
 ently in each epidemic and in every country — Typhoid fever almost without 
 characteristics symptoms — Illustrative case ; extensive intestinal ulcerations 
 found after death — Vital symptoms of intestinal complication: (1) thirst, (2) 
 swelling of belly, (3) diarrhoea, (4) ileo-csecal tenderness, (5) increased action 
 of abdominal aorta, (ti) rigidity of adbominal muscles — Three forms of abdo- 
 minal swelling: (1) early and moderate tympany, (2) doughy condition, (3) 
 slight ascites — Increased action of abdominal aorta — Case of, in perforation of 
 the stomach— Analogous local arterial excitement in (1) whitlow, (2) rheuma- 
 tism — Diagnosis from aneurism — Intestinal complications seem to interfere 
 largely with action of the law of periodicity — Early elevation of local irrita- 
 tion checks deposit, and so prevents future mischief — Hence relief of symptoms 
 by early depletion as practised by Broussais, who misinterpreted the matter, 
 and was led to look upon the general fever as but symptomatic of a local 
 lesion 135 
 
CONTENTS. Xlll 
 
 LECTURE XIX. 
 
 PAGE 
 
 Intestinal Complications of Fever, continued — They resemble all the other secon- 
 dary affections of fever in their general characteristics and relations to the 
 primary essential malady — More frequent in typhoid, but occurring in typhus 
 also, as, for example, in the epidemic of 1826-27 — Pathological appearances 
 observed in the intestinal tract in fever — Yet these appearances were not neces- 
 sarily found after death even where severe abdominal symptoms existed in life 
 — Eruption of rose spots in fever ....... . . 142 
 
 LECTURE XX. 
 
 Intestinal Complications of Fever, continued — Division into three categories, with 
 reference to the vital symptoms: I. These symptoms are absent, although the 
 silent disease may be great in amount ; II. Local symptoms are evident; III. 
 Symptoms and pathological changes are both well marked — Further description 
 of the epidemic of 1826-27 — Sudden access of intense abdominal pain, followed 
 by icterus and gangrene — Fatality of this complication — Splenic(?) abscess oc- 
 curring in the first case of recovery, and discharging through the lung — Resem- 
 blance of this form of fever to the yellow fever of the tropics — Dr Lawrence's 
 observations — Dr. Graves' observations 146 
 
 LECTURE XXI. 
 
 Intestinal Complications of Fever, continued — Organic changes — Perforation of 
 intestine — Of common occurrence in 1826-29: (1) Generally rapidly followed 
 by symptoms of peritonitis; (2) but may be unattended by local symptoms in 
 progressive cases, or again may induce only limited peritonitis (adhesions) ; (3) 
 Symptoms of perforation may be veiled by the coexistence of intense irritation 
 in another cavity of the body — Illustrative case — Time of occurrence of perfora- 
 tion as observed in six cases — Diagnosis of internal solutions of continuity is 
 based on sudden development, without apparent exciting cause, of new, local, 
 violent, and often rapidly fatal symptoms — Cases to which this rule of diag- 
 nosis is applicable — In effusion into a serous sac the degree of resulting inflam- 
 mation is determined chiefly by the quality of the effused fluid — Examples — 
 Influence of an irruption of pus in producing serous inflammation contrasted 
 with that of an irruption of blood — Physiological difference between pus cor- 
 puscle and white-blood cell — The formation of conservative adhesions seems to be 
 rarer in peritonitis than in pleuritis— Case of hepatic abscess in which adhe- 
 sions occurred and recovery followed (diagnosis from abdominal aneurism) . 151 
 
 LECTURE XXII. 
 
 Secondary Nervous or Cerebro-Spinal Complications of Fever — When they 
 predominate, prognosis is unfavourable — Of all secondary typhous affections 
 they are least connected with organic change — Probable reason ; mucous mem- 
 branes and skin undergo anatomical change more readily than serous mem- 
 branes — Cerebral inflammation rarely observed in fever — Purpuric fever of 
 1867 an exception — Absence of organic change in typhous cerebral derange- 
 ment does not lessen its importance as regards prognosis and treatment — 
 Inadmissibility of routine treatment, either antiphlogistic or by stimulation, in 
 fever — Results obtained by Louis as to relation between head symptoms and 
 pathological change in fever — Actual cercbritis, when it does occur in fever, is 
 a tertiary phenomenon — Dr. Hudson's cases — Study of analogies is of impor- 
 tance in essential diseases ; thus relief of headache in early stage of smallpox 
 by leeching is analogous to good results of moderate depletion in early stages 
 of some cases of fever — Further examples of the effect of lessening vascular 
 supply in controlling development of smallpox eruption — Analogy in case of 
 secondary affections of fever — Nervous symptoms arise from three conditions: 
 (1 ) influence of fever-poison, (2) urtcmia, (3) specific secondary inflammation, 
 probably erysipelatous in character . . . . . . . .159 
 
XIV CONTENTS. 
 
 LECTURE XXIII. 
 
 PAGE 
 
 Nervous Complications of Fever, continued — Cerebrospinal fever — Phenomena of 
 fever inconstant and variable, except, perhaps, the phenomenon of increased 
 temperature — Type of fever also varies in different epidemics — Two examples: 
 (1) yellow fever of 1826-27, (2) malignant purpuric, or cerebrospinal fever of 
 1867 — Dr. E. W. Collins' report on latter — There exists a "constitutional ele- 
 ment" in the disease, so that the cerebro-spinal arachnitis can hardly be held 
 to be a primary, idiopathic affection — Evidences of essentiality from presence 
 of other phenomena in connection with the skin, etc. — Reports to the Medical 
 Society of the King and Queen's College of Physicians in Ireland on the epidemic 
 of 1867 — Inconstancy and variability of the symptoms in the outbreak — Dr. 
 H. Kennedy's views — Symptoms of the disease — Petechise — Early setting in of 
 putrefaction — Retraction of head; sometimes persistent after disappearance 
 of other local and general symptoms, and sometimes persistent after death — 
 Recapitulation: Points to be considered in connection with epidemic of 1867: 
 (1) yellow fever of 1826-27, (2) cerebro-spinal arachnitis of 1846 (Dr. Mayne), 
 (3) coincidence of cases of malignant measles in 1867, and (4) hemorrhagic 
 and purpuric smallpox in epidemic of 1871-72 ...... 165 
 
 LECTURE XXIV. 
 
 Nervous Complications of Fever, continued — Hysteria — Occurrence of hysteria, 
 especially at an early stage, of unfavourable import — View that hysteria is 
 always symptomatic of uterine excitement is quite erroneous — Nymphomania 
 only a loeal and accidental manifestation — Hysteria is observed in males as 
 well as in females in fever — Case of erotic symptoms in typhoid fever occur- 
 ring in a young girl, reported by Dr. A. W. Foot — In early stage of fever hys- 
 teria generally is the precursor of severe nervous symptoms — Its appearance 
 may lead to serious complications later in the disease — Illustrative cases — 
 Hysterical symptoms are sometimes connected with actual or organic disease, 
 especially in acute affections — Dr. Cheyne's observation : Hysteria a ground for a 
 good prognosis in every disease, fever alone excepted — Outbreak of hysteria, affect- 
 ing the abdomen, in female fever ward of Meath Hospital — Anomalous symp- 
 toms in advanced stages of fever often due to hysterical state — Case of typhous 
 hysteria in the male followed by cerebritis 173 
 
 PART II. 
 
 TREATMENT OF FEVER. 
 
 LECTURE XXV. 
 
 Introductory Remarks— Principles on which the treatment of fever is to be based 
 — True meaning of the word empiric. Historical retrospect — The Symptomolo- 
 gical, the Anatomical, the Rational or Eclectic Schools — Essence of fever cannot 
 be determined by pathological anatomy — Etiology of fever is indefinite . . 177 
 
 LECTURE XXVI. 
 
 No specific line of treatment — Respect to be had (1) to the essential disease, (2) to 
 its local and secondary effects — Failure of specifics in early stage of fevers — 
 Want of success in the endeavour to found a science of therapeutics on experi- 
 mental physiology or pathology — Effects of the action of the law of periodicity 
 wrongly attributed to the adoption of therapeutical measures — Sustenance by 
 food and stimulants — Two sources of danger to the fever patient: (1) primary 
 effects of the fever poison in causing depression, (2) supervention of secondary 
 local disease — Views of Dr. Graves on the subject of giving food in fever . 185 
 
CONTENTS. XV 
 
 LECTURE XXVII. 
 
 PA8E 
 
 Stimulants in Fever — Views as to the nutrient properties of stimulants are to be 
 received with caution — Anticipatvie use of stimulants — Meaning of the term — 
 Considerations to be taken into account in resolving upon this method of treat- 
 ment : (1) prevailing epidemic character of the disease, (2) previous condition 
 of the patient — " Sinking of vital power" — Illustrative case — Stimulation often 
 unsuccessful in the intemperate, and in those whose brains are over-worked, 
 (3) development of symptoms of severe typhus, (4) development of fever odour 
 — Contrast between typhus and typhoid as regards period at which stimulation 
 is called for — Condition of the heart, a guide — Physical signs of cardiac weaken- 
 ing 193 
 
 LECTURE XXVIII. 
 
 Stimulants in Fever, continued — Signs in connection with the heart of the agree- 
 ment of stimulants: (1) return of impulse, (2) return of first sound, (3) 
 gradual fall in the rate of the pulse — In cases of "foetal heart" great boldness 
 in stimulation is needed — No certain rules as to quantity of wine and whiskey 
 or brandy required — Examples of free use of stimulants in malignant typhus — 
 Case of Hardcastle (typhoid fever) — Eruption of vesicles as a secondary com- 
 plication — Bed-sores ..... ...... 201 
 
 LECTURE XXIX. 
 
 Stimulants in Fever, continued — Case of Hardcastle, continued — Treatment by 
 food and stimulants in extreme cases — Presence of cerebral symptoms to a 
 great extent unfavourable to the exhibition of stimulants — Necessity for daily 
 observation to the effects of the treatment in each case — Signs of disagreement 
 of stimulants — Routine practice is in every instance to be deprecated — Falla- 
 cies of the numerical system in therapeutics — History of routinism — Its results 
 — Description of routinism in the treatment of fever ..... 212 
 
 LECTURE XXX. 
 
 Treatment of the Local Secondary Affections in Fever — Relative importance 
 of these affections as regards prognosis — Bronchial Affection — Necessity for 
 administration of stimulants and nourishment — Danger of exhibition of tartar 
 emetic — Failure of emetics — Turpentine-punch — Dry-cupping, poulticing, blis- 
 tering — Internal remedies: bark, ammonia, spirit of chloroform, turpentine — 
 Acute Consolidation of the Lung — Its three forms — Treatment of the first 
 form by dry-cupping, blisters, quinine, turpentine, and wine — Of the second 
 form by local depletion simultaneously with the administration of wine — Of the 
 third form, externally by iodine and blisters, internally by tonics and iodide of 
 potassium 222 
 
 LECTURE XXXI. 
 
 Treatment of Intestinal Secondary Affections — Two chief indications: (1) alle- 
 viation of symptoms, (2) modification of typhous deposition — Poulticing — Local 
 depletion in early stage — Analogy in variolous eruption — Danger of alterative 
 or purgative treatment at the outset of Continued Fever — Necessity for caution 
 — Constipation — Diurrhmn — Poultices, demulcents, sedative astringents, injec- 
 tions of flax-seed tea — Tympany — Turpentine injection — Diet in diarrhoea — 
 Perforative peritonitis — Opium our sheet-anchor — Danger of the antiphlogistic 
 method — Dr. Murchison on the treatment of this accident — Bran poultices and 
 warm fomentations — Hemorrhage from the intestine iu fever — Not to be inter- 
 fered with unless continued and excessive — Treatment by astringents, opium 
 — Illustrative case .......... . 227 
 
XVI CONTENTS. 
 
 LECTURE XXXII. 
 
 PAGE 
 
 Treatment of the Nervous Secondary Symptoms of Fever — Headache — Cold 
 lotions, warm fomentations, moderate leeching, shaving the head, cold affusion, 
 ice — Delirium — Treatment depends on (1) period of case, (2) presence of hyper- 
 emia of the brain, or otherwise — Ice, leeches, shaving the head, cold affusion 
 in active delirium — Nourishment and wine in passive or anaemic delirium — 
 Sleeplessness — Moderate leeching, cold affusion, ice — Turpentine in constipa- 
 tion and tympany — Catheterism in distended bladder — Sedatives — Opium, 
 tartar emetic and opium, hyoscyamus, bromide of potassium, chloral, wine — 
 Convulsions — Most formidable in fever — Uremic, due to (1) retention of urine : 
 catheterism ; (2) suppression of urine : dry cupping and poulticing over kidueys, 
 diluents, diuretics, aperient enemata, promotion of action of the skin . . 237 
 
 LECTURE XXXIII. 
 
 Phlegmasia Alba Dolens — The swelling is not always painful, or white in appear- 
 ance — Symmetry of the affected limb not lost — Professor Trousseau's views as 
 to the etiology of the affection — Phlegmasia (1) of puerperal women, (2) in 
 scrofulous and (3) cancerous cachexise — Pulmonary embolism caused by phleg- 
 masia — Case of phlegmasia after typhus fever — Treatment of the affection — 
 General Conclusion 245 
 
 Appendix B 253 
 
 INDEX 257 
 
LECTURES ON FEVER. 
 
 PART I. 
 
 ESSENTIAL FEYER AND ITS SECONDARY AFFECTIONS. 
 
 LECTURE I. 
 
 Introductory — Injurious influence on the student and practitioner of having studied 
 surgical cases exclusively— Influence of timidity from want of intimacy with bed- 
 side treatment of fever — Erroneous views in relation to the frequency of inflamma- 
 tory disease — Inflammation not the primary cause of many local though acute 
 affections — Errors of Broussais — Abuse of the antiphlogistic treatment. 
 
 Several of the hospitals io Dublin, considered as schools for 
 clinical study, have the advantage of being essentially medico-chi- 
 rurgical hospitals — that is to say, that in them the student, in con- 
 nection with his surgical pursuits, may see and study most forms of 
 the so-called medical diseases, which include not only the acute and 
 chronic local diseases, but the various forms of essential affections, 
 including continued fevers. 
 
 I am anxious to draw the attention of the surgical student to the 
 all-important subject of fever; for when we consider the enormous 
 extent to which this fell disease, or group of diseases, prevails over 
 the world, and also that it is in itself a special study, we cannot help 
 believing that the student who has not dealt with fever, no matter 
 how ably he may have been educated in surgery and in the history 
 of visceral diseases, has but half learned his business. 
 
 The importance of a practical knowledge of fever, as distinguished 
 from that obtained from books or lectures, is not yet sufficiently 
 impressed on the surgical student. If such a one possesses a reflect- 
 ing mind, he will have abundant and bitter causes of regret at having 
 neglected his hospital opportunities, whereby alone he can obtain that 
 intimacy with the subject which will be his guide and safeguard in 
 after-life. It is in the fever-wards alone that he can learn the price- 
 less lesson that there is a large class of diseases, whose nature and 
 property it is to get well of themselves, which require little or no 
 1 
 
2 LECTURES ON FEVER. 
 
 medication or daily interference. This lesson is not to be learned 
 from purely surgical studies, one effect of which leads in medicine to 
 the nimia diligentia, so common a fault in practice, so clear a sign that 
 the medical mind has not been formed. He will see that what the 
 patient requires is in many cases only time, and to be kept from 
 sinking by proper support. He will come to learn how this great 
 fact of the spontaneous cessation of disease bears on all therapeutical 
 research in fever by showing him that he is not to confound the post 
 hoc with the propter hoc. He will learn that there are few questions 
 more difficult of determination than the effect of any special remedy, 
 or even general mode of treatment in diseases which are under the 
 law of periodicity; and thus he will be taught caution in drawing 
 conclusions as to his own practice, while he will be charitable in re- 
 flecting upon that of others. Take for example the case of rheumatic 
 fevers. How long have physicians been seeking for a specific treat- 
 ment? Venesection, blistering, mercury, opium, bark, alkalies, acids, 
 have all had their advocates, whose statements are supported by 
 genuine cases, and yet the question remains unsolved; would not the 
 disease have subsided of itself as well, and as quickly, as under any 
 specific treatment? And in case of recovery, may not this even have 
 occurred notwithstanding the treatment ? 
 
 I heard with great pleasure the report by my distinguished friend 
 Dr. Sibson, read at the meeting of the British Association at New- 
 castle-upon-Tyne, in which a long series of cases of rheumatic fever 
 was detailed as having been successfully treated without any medicine 
 beyond small doses of peppermint water — given, I presume, to satisfy 
 the minds of the patients that something was being done for them 
 beyond keeping them warm in bed till the disease subsided. 
 
 It is not to be understood that Dr. Sibson does not recognize the 
 frequency of local inflammation in rheumatic fever, and the necessity 
 of meeting it in many cases. But his researches are directed to show 
 the comparative uselessness of a specific treatment. 
 
 I well remember the time when surgeons, who had been otherwise 
 well educated, but had never in their student days seen or attended a 
 case of typhus fever, objected to deal with such a case, and were of 
 course, from apprehension of contagion, more or less ineffective when 
 brought to perform any operation such as catheterism, and so on. 
 
 All students who are looking to the public service, whether in the 
 civil, military, or naval department, should be taught by those who 
 assume their direction or instruction that they cannot tell when they 
 may have to deal with fever even on a great scale, and that, as the 
 principle of treatment of all fevers is the same, the study of the dis- 
 
GENERAL CONsI DERATIONS. 3 
 
 ense at home will fit them to meet the yellow fever, the bilious 
 remittent, the camp fever, the plague of the Levant, and the cholera 
 of India. 1 
 
 How few of our surgical students are aware of the fact shown by 
 Sir Gilbert Blane that in the Peninsular War more men died of fever 
 than from all other causes, including the sword. 
 
 But, further, the student who confines himself to merely a surgical 
 ward often enters on his profession unfitted by timidity to meet his 
 foe. I have known several instances where surgeons in civil practice, 
 though willing to do their duty, were always nervous on entering a 
 fever ward. I do not say that such men were cowards in the ordinary 
 sense of the word, or that the feeling of danger would make them 
 shrink from discharging their duty; but there is a condition which 
 may be described as physical fear, distinct from moral fear ; a condi- 
 tion of susceptibility to contagion, which is doubtless lessened by 
 intimacy with disease. I know of a gentleman who was called to 
 inspect the body of the first victim of cholera in the earliest and great 
 epidemic of 1832. The case occurred some miles from Dublin. 
 During his return he had many of the symptoms which threaten an 
 attack of cholera. He had the abdominal pains, the feeling of immi- 
 nent death — "the cold meditation of death" of the old authors — cramps, 
 and other symptoms. For two days these recurred. The epidemic 
 shortly afterwards burst out with violence in the city, when, feeling 
 that if this condition persisted he would be unable to do his duty, he 
 entered a crowded temporary cholera hospital, where he remained 
 for thirty-six hours in close attendance on the sick. During the first 
 eighteen hours seven patients died, it may be said, in his arms. I 
 need not say that all the yielding of the system he had shown rapidly 
 disappeared. I know of another case, where a gentleman, now an 
 eminent member of the profession, was cured of repeated attacks of 
 cholerine by undertaking the office of house surgeon to a large cholera 
 hospital, where, under the direction of the late Dr. Mackintosh, he 
 had to conduct the treatment by venous injection in many cases. To 
 mention a third instance, the case of Mr. West and his party is quoted 
 by my father, Dr. Whitley Stokes, in his pamphlet on Contagion. 2 
 During the expedition to Egypt under Sir Ralph Abercrombie Mr. 
 West was ordered to take charge of a pest hospital at Rosetta in the 
 beginning of May, 1801. In this house he was shut up for four 
 months. His staff consisted of an assistant surgeon, an Italian ; an 
 English soldier; and of Arab servants. " No one of the party took 
 
 1 See Swan's Edition of Sydenham, page 75. 
 
 - Observations on Contagion, 2d edit., Dnbliii. 1818. 
 
4 LECTURES ON FEVER. 
 
 the disease, although Mr. West operated and dressed the buboes 
 himself, and treated sores from anthraces so extensive that half a 
 pound of flesh sometimes came off by sloughing; and although the 
 servants washed the sheets, bedding, and bandages, rubbed the patients 
 with mercurial ointment extensively, supported the faint, tied the 
 delirious, and buried the dead. In short, they were exposed as fully 
 as possible to contagion. At this time the plague was so severe at a 
 village twenty-five miles from Eosetta that one-fourth part of a popu- 
 lation of 400 died within a month. I have said that none of the 
 party took the disease. Great attention was paid to cleanliness, and 
 the house was a roomy building, situated on an elevated bank over 
 the Nile and exposed to the northwest sea breeze. 
 
 On this singular result Dr. Stokes remarks, "Mr. West's deep in- 
 terest in the discharge of his duty and in the improvement of his 
 profession must have contributed to turn his mind from the selfish 
 melancholy contemplation of his personal risk, a risk which one of 
 our best officers fairly compared to that of a hundred battles. Such 
 has been the triumph of good sense, temperance, firmness, and in- 
 dustry ; and Mr. West has earned a civic crown which some men will 
 venture to compare with the laurels of the greatest conquerors." 
 
 The surgical student who has not studied fever in the living sub- 
 ject, and himself felt the responsibility of its management, is in this 
 position : the doctrine of the universality — or of the extraordinary 
 frequency, whichever you will — of inflammation has been impressed 
 on his mind in every possible way, for the ordinary practice at the 
 commencement of a course of surgery used to be to occupy the student 
 for many weeks with the history of inflammation. Inflammation is 
 thus placed in the foremost rank. It is the great thing to which his 
 earliest attention is directed, and naturally it appears to him to be the 
 key to all medical and surgical knowledge. It is still more impressed 
 upon him by the kind of experience he gets during a considerable 
 part of his studies. That experience is obtained in a surgical ward, 
 and it is hence very natural that he should have exaggerated notions 
 of the importance and frequency of one morbid process. Too often 
 at the end of his course he finds that he has been taught only inflam- 
 mation, he has seen little else than inflammation, and he believes in 
 little else than inflammation. A great many students are educated 
 in this way, and they go forth to the world ignorant of two facts in 
 practical medicine and surgery, the importance of which cannot be 
 overrated. The first is the existence of an enormous number of acute 
 and dangerous diseases which are not inflammatory — of diseases, as I 
 said before, which are acute, which are dangerous, and still further, 
 
GENERAL CONSIDERATIONS. 5 
 
 which are febrile. The idea has never been impressed on their minds 
 that there may be a local, acute, febrile, and most dangerous disease 
 which is not only, to use the words of a recent author, not inflamma- 
 tion, but something the very opposite of inflammation. When we 
 consider that it is in the various forms of fever that these conditions 
 are met with, and when we recollect the extent to which fever pre- 
 vails over the world, we are justified in declaring that when we 
 compare diseases in which inflammation is the primary condition with 
 those in which it is not, the former fall immeasurably short of the 
 latter in number and importance. 
 
 The other great fact is that the student has not learned the error of 
 exclusive antiphlogistic treatment in the management of ordinary 
 primary inflammation. From not having had to deal with local dis- 
 eases, which require not the lancet, not starvation, but rather tonics 
 and wine, he has never become accustomed to, or familiar with, the 
 latter remedies. He is timid in the use of these measures, and even 
 in the ordinary primary diseases he follows too long the common rule 
 of antiphlogistic treatment instead of changing in time to one of a 
 tonic and stimulating nature. The erroneous application of the anti- 
 phlogistic method arose subsequent to a change of doctrine from 
 humoralism to solidism. 
 
 In order to get a clearer notion of this matter, let us go a little 
 back. Before pathological anatomy became a science it was held 
 that a large number of diseases depended on the alterations of the 
 fluids. But when anatomy was directed to the investigation of dis- 
 ease medical opinion underwent a change, and solidism succeeded to 
 humoralism. Disease was then an alteration of the solids, the living 
 tissues of the body. Now, I wish to impress upon you that solidism, 
 as was then understood, soon came to mean more than its original 
 name would imply; and solidism plus the doctrine. of inflammation 
 became the ruling dogma of the day. 
 
 For the same mode of investigation, which established the frequency 
 and variety of alterations of the solids, showed that in many cases 
 there was a common character recognized as the result of inflamma- 
 tion. This paved the way for the introduction of the so-called 
 physiological doctrine, which referred all diseases to alterations of 
 vitality in the solids — not generally as affecting the whole system, 
 but local — not differing from one another by any special characters, 
 but in degree only. A disease was, then, either a plus or a minus 
 vitality in the affected organ, and its symptoms were explained by the 
 sympathies of that organ. But as so many diseases were attended 
 with vascularity, deposition, and increased sensibility, it was inferred 
 
6 LECTURES ON FEVER. 
 
 that most local affections, and the more important diseases, were ex- 
 amples of augmented vitality in the part, producing not only the 
 local symptoms but those also which arose from the sympathetic 
 irritation. This doctrine spread rapidly, and there were many rea- 
 sons why it should do so. Tt was specious, simple, and had for its 
 founder a man of extraordinary energy and eloquence. In this world 
 any doctrine which is novel and has an energetic and eloquent apostle 
 will not want for converts, and Broussais was a man of great talent, 
 experience, and practical knowledge. He was, however, deficient in 
 reasoning power, and, in my opinion, an imperfect pathological anato- 
 mist. The doctrine became popular on the Continent from the facility 
 which it promised in the treatment of disease, for as the great majority 
 of diseases was symptomatic of the plus vitality of some organ, we 
 had only to discover the part in which this excess of life was seated, 
 and to modify it, of course, by antiphlogistic treatment. 
 
 When the investigations of Broussais and his followers were di- 
 rected to the Examination of fever cases, it was found, on the Continent 
 more especially, that local disease frequently existed in the gastro- 
 intestinal tube. At once, then, the doctrine followed, that fever 
 formed no exception to the rule — that it was symptomatic of a plus 
 vitality of the gastro-intestinal tube; and we were led to believe that 
 fever could be at once cured by leeching, by starvation, by poultices 
 to the bell v, and by such means. 
 
 It is curious that there are some circumstances connected with fever 
 which greatly tended to prop up this doctrine. We shall see by-and- 
 by, that an essential condition of fever is periodicity ; that it is a 
 disease which has a tendency to spontaneous termination at a given 
 time. It is like a paroxysm of ague, only prolonged as it were. This 
 will give the best idea of fever. This mysterious law of periodicity 
 implies that the system has the power of curing itself — that is to say, 
 that the diseased action will spontaneously subside either suddenly or 
 gradually. Now, it is found that there are a variety of circumstances 
 which interfere with the operation of this extraordinary law of spon- 
 taneous cure. One of these is the existence of a local irritation in 
 anv part of the system. 
 
 We see this remarkably exemplified in cases of ague. We shall 
 very often find that in cases of intermitting fever the treatment by 
 bark will not succeed; and when we come to inquire the cause of this, 
 we find that there is some local inflammation present. If we can 
 remove that local inflammation, then the treatment by bark succeeds. 
 Broussais appealed strongly to the following fact: that in cases of 
 fever, after free depletion of the abdomen, the patients speedily re- 
 
GENERAL CONSIDERATIONS. 7 
 
 covered. So they did : but the nature of the fact was misinterpreted. 
 Those patients had a local secondary disease in the intestine, which 
 interfered with, or prevented, the operation of the law of periodicity. 
 When that local disease was modified or removed, the law of perio- 
 dicity came again into action, and the patient recovered.. The fever 
 did not subside because it was symptomatic of a disease of the intes- 
 tine; but it subsided because, the disease of the intestine being re- 
 moved or modified, it was reduced to its normal state, as it were to its 
 state of simplicity, and then the law of periodicity was enabled to act. 
 
 The doctrine of the purely symptomatic nature of fever was re- 
 ceived extensively on the Continent, in America, and in England and 
 Ireland, but not so extensively in the schools of the two latter coun- 
 tries. There was a much greater reluctance to the reception of the 
 physiological doctrine in this country and in England than on the 
 Continent, or in America, and this is highly creditable to the British 
 and Irish medical mind. Many reasons might be adduced to explain 
 why this was so, but we shall not enter at length. into them. I may, 
 however, observe that English medicine had. received a great degree 
 of excellence from the writings of the old masters in England — from 
 the writings of Sydenham, Haygarth, Fothergill, and other men of 
 that order. These great medical observers had, unknowingly, taught 
 the true medical philosophy. They had taught a rational eclecticism, 
 and hence they implanted in the minds of the British medical inves- 
 tigators great reserve and extreme caution in the reception of new 
 doctrines. 
 
 Still, however, upon the younger members of the profession the 
 doctrine had a wonderful influence. A large number of the junior 
 members of the medical and surgical profession in this country, during 
 the last quarter of a century, or perhaps the last half century, were 
 strongly imbued with this doctrine, and went forth to practise over 
 the world, influenced by the theory of inflammation being the sole 
 cause of diseases, and believing that the whole practice of medicine 
 was reduced to the removal of local inflammation. 
 
 Another cause, however, I cannot help noticing here. About this 
 time, owing to the unhappy and calamitous division of the profession 
 into medicine and surgery, arose those corporate distinctions that have 
 done so much to retard the progress of science in these countries; 
 exclusive schools of surgery sprang up, and consequently, as I ob- 
 served at the commencement, a large and increasing number of young 
 men were educated without having ever seen a case of fever. They 
 were educated in surgery ; they were educated in a surgical ward, and 
 were sent forth naturally advocates of inflammation, because they had 
 
8 LECTURES ON FEVER. 
 
 seen nothing else ; and thus, ill prepared, they went forth to combat 
 fever — that disease which numbers more victims than any other — 
 over the wide dominions of the British crown, in America, in the 
 West Indies, in Asia, in Africa. These men in hundreds— I may 
 say thousands — went out ignorant of the fearful enemy they had to 
 encounter, and trusting in the teachings which compared the ordinary 
 phenomena of ophthalmia, or those of the healing of an incised wound, 
 or those of the cicatrization of an ulcer, with the symptoms of that 
 terrible group of diseases which embraces the plague, the yellow fever, 
 the bilious remittent, the malignant ague, and the typhus fever. 
 
 There is nothing more difficult, gentlemen, than for a man who 
 has been educated in a particular doctrine to free himself from it, 
 even though he has found it to be wrong. There is something in 
 a human mind which renders the reception of a doctrine, if it be a 
 bad one, a most dangerous circumstance. It is like the imbibition 
 of a particular poison or miasma. We find that some men who have 
 been once exposed to the miasmata which induce intermitting fever 
 will, for nearly the whole course of their lives, be incapable of getting 
 rid of that influence which has been once received. And thus it is 
 not only with physical but with moral or intellectual impressions. 
 
 I have said that it is difficult to unlearn. This fastening of false 
 doctrine in the mind is one cause ; but there are other causes too. 
 The indolence of many men prevents them taking the trouble to 
 unlearn. The pride of many men has the same effect; and, above all 
 things, there is this, that a very large number of students, not only 
 of surgery, but of medicine, although they were taught the technicali- 
 ties of the profession — the alphabet of their profession, as it were — 
 were not taught what is infinitely more important, namely, how to 
 teach themselves. Now, this ought to be the grand object of every 
 teacher of medicine, and, indeed, of any science of observation. I 
 believe that no man can be fully and entirely taught anything. He 
 must teach himself. And what the teacher has to do, and what I have 
 ever set before myself as my highest duty, is to endeavour to teach 
 you how to teach yourselves. 
 
 We can easily anticipate what the result of all this must have been ; 
 and I believe I am not saying too much when I declare that a large 
 proportion of the fearful mortality to which our gallant army has been 
 subjected in the colonial service has been owing to the circumstances 
 to which I now draw your attention — the fact of the medical officers 
 going out with erroneous doctrine fastened in their minds. 
 
 This name of inflammation is an unfortunate one, and it is to be 
 regretted that it was given to the process in question. It gives the 
 
GENERAL CONSIDERATIONS. 9 
 
 idea of a fire which must be quenched by its opposite, water; of a heat 
 which must be quenched by its opposite, cold ; of vascularity — ful- 
 ness of the bloodvessels — which must be met by measures which will 
 empty those vessels. It gives the idea of a fever, an excitement which 
 is only to be met by abstinence, by starvation, or, as the French term 
 it, dilte absolue, which means no diet at all. The fact is, gentlemen, 
 that the formula of contraria contrariis has as little title to respect in 
 legitimate medicine as that of similia similibus in quackery. Both are 
 false ; and I really believe that any exclusive application of either for- 
 mula is both ignorant and mischievous in the highest degree. 
 
 The next great error was, that although the surgical student had 
 plenty of opportunities of seeing symptomatic fever, he had no oppor- 
 tunity of seeing the essential fever, and he naturally confounded the 
 two together. And hence, in this country and abroad, for many years 
 the abuse of the antiphlogistic treatment was carried to an extent which 
 it is frightful to contemplate. Conditions of the system which required 
 wine, bark, stimulants, careful nutrition, were met by the lancet, by 
 leeches, and by starvation. I remember when I was a student of the 
 old Meath Hospital, there was hardly a morning that some twenty or 
 thirty sufferers from acute local disease were not phlebotomized. The 
 floor was running with blood ; it was dangerous to cross the prescrib- 
 ing hall for fear of slipping; and these scenes continued to be wit- 
 nessed for many years. The cerebral symptoms of typhus fever were 
 met by opening the temporal artery, or by a large application of leeches 
 to the head ; and it sometimes happened that the patient died while the 
 leeches were upon his temple — died surely, and almost suddenly. An 
 eminent apothecary in this city assured me that when he was serving 
 his apprenticeship there was hardly a week that he was not summoned 
 to take off a large number of leeches from the dead body. I mention 
 these circumstances to show to what extent, even in our own country, 
 the abuse of this doctrine had been carried. It is not so now. Those 
 who have been in the habit of attending fever hospitals in this country 
 will bear me out when I say that the lancet is an instrument now very 
 seldom indeed employed in our wards. But while all this is true, it 
 must be understood that I am far from going the length of some 
 modern physicians in their wholesale condemnation of the antiphlo- 
 gistic treatment in various forms in the management even of essential 
 fever. To this subject I purpose to return in my next lecture. 
 
10 LECTURES ON FEVER. 
 
 LECTURE II. 
 
 Change of Practice as regards the treatment of fever — Change of type in disease from 
 sthenic to asthenic — Views of Alison — Sir Robert Christison — The author's views 
 — Evidence (1) from symptoms, (2) from appearances of blood drawn by venesec- 
 tion, (3) from pathological appearances of internal viscera, and of serous mem- 
 branes. (4) from isolated sthenic leases, and (5) from influence of treatment — Signs 
 of a return to sthenic forms of disease — Vital character of disease. 
 
 Based on the doctrine that local inflammation or irritation was the 
 exciting cause of febrile disease, we observe the wide-spread adoption 
 of an antiphlogistic treatment in fever. The doctrine of essentiality 
 of disease was ridiculed. Venesection in fever was common, and its 
 traditional employment was supported by modern theory; the use of 
 wine and other stimulants was forbidden, and many a life was sacri- 
 ficed to this unphilosophical method of looking at disease. 
 
 But for nearly half a century we observe a change in practice in 
 the opposite direction. General blood-letting is rarely practised; local 
 bleeding in a very modified way ; while stimulants have been, by one 
 school, clearly employed in an unjustifiable manner. 
 
 So complete was the change in practice, that venesection, from being 
 a routine treatment, the performance of which was entrusted to junior 
 students, became the rarest of surgical operations. Within the last 
 twenty years I have known several surgeons who had never performed 
 or even witnessed the operation. I remember having to instruct a 
 hospital surgeon of remarkable ability in the operation. For a period 
 of nearly twenty years the use of the lancet was unknown in our 
 wards, and in latter times, when venesection was occasionally prac- 
 tised here, it was instructive as well as amusing to see how the class 
 crowded round to witness for the first time a proceeding so unusual. 
 
 We can hardly conceive a revolution in practice more complete. 
 In place of the loss of blood we have the exhibition of stimulants. 
 In place of a system of almost starvation we have the careful use of 
 nutriment. 
 
 This change in practice, depending on change in the vital character 
 of disease, was followed by the charge against many of our predecessors 
 and teachers that they were mistaken practitioners, ignorant of true 
 pathology, and little better than blind followers of traditional error. 
 Not only have their powers of observation been questioned, but even 
 
GENERAL CONSIDERATIONS. 11 
 
 their morality and honour have been assailed ; and it has been suggested 
 that the whole doctrine of change of type in disease was an invention 
 to cloak former errors. 
 
 It is interesting to note that this is not the first time that charges 
 of a similar kind have been brought against the profession. Thus 
 Broussais arraigned the existing and former practitioners for not treat- 
 ing fevers and acute diseases by local bleeding and starvation. Can 
 there be stronger evidence than this that our modern practice is not a 
 novelty ? All his predecessors were in error; because they practised 
 as we do now. I say that this charge was remakable, inasmuch as the 
 author's views largely influenced European practice for many years. 
 
 But the thinking man finds it hard to believe that the fathers of 
 British medicine were always in error, or that they were bad observers 
 and mistaken practitioners. They, indeed, have rested from their 
 labours, but their works remain ; and he who reads the writings of 
 Sydenham, of Haygarth and of Fothergill, of Heberden and Fordyce, 
 of Gregory, Cullen, Alison, Cheyne, or Graves, must have a very 
 inapprehensive mind, if he fail to discover that there were giants in 
 those days, and that the advocacy of such ideas only indicates a state 
 of mind not consonant with the modesty of science. 
 
 The declaration that it has been or can be proved by a more 
 advanced pathology that bleeding never was the proper remedy for 
 fevers and inflammations has as yet no scientific ground. It is not 
 yet given to us, notwithstanding all our advance in normal and in 
 morbid anatomy, in the physiology of health or of disease, to be able to 
 say, from the most minute examination of the dead organ or structure, 
 what were all the conditions which attended it during life, under the 
 influence of disease; what were its local vital phenomena; what was 
 the accompanying constitutional state, whether sthenic or asthenic. 
 
 But, let us ask, which is the more probable of these two supposi- 
 tions? First, that our predecessors were bad observers, incapable of 
 divining the truth, and blind adopters of an antiquated and mis- 
 chievous method — or, secondly, that the type of disease has changed, 
 and that almost in our own time. It fortunately happens that we 
 can examine a living witness of great authority in this matter, and 
 can refer to the works of two more who have left us their written 
 testimony. Sir Kobert Christison is still among us, in health and 
 intellectual vigour — long may he be so — Dr. Alison and Dr. Graves 
 have been but lately removed. 
 
 Now, all these testify that the character of disease has changed from 
 a sthenic to an asthenic type ; that is to say, from a condition in which 
 inflammatory action was the prominent feature to another where that 
 
12 LECTURES ON FEVER. 
 
 state was absent, or, if present, only ephemeral — a condition observ- 
 able in essential and local diseases, in which the antiphlogistic treat- 
 ment agreed well, and was productive of great relief, to one in which 
 a tonic, stimulant, and supporting regime was found the best method 
 of guiding the system to a happy termination of the disease. 
 
 It is very important to note that these views were not formed from 
 any historical study of the recorded labours of others, but come before 
 us as the actual observations of the great men whose names I have 
 stated. They tell us that which they know — that which they them- 
 selves have seen. If we refuse this collective though separate and 
 independent evidence— if we hold, with Professor Bennett and with 
 Dr. Markham, that the doctrine of change of type is untenable — we 
 must believe one of two things : either that these distinguished men 
 were deceived or were themselves deceivers. From this alternative 
 there is no escape. 
 
 Let us hear Dr. Alison: " 'When we reflect on these facts, we can- 
 not think it unlikely that the result of the inquiry which I have stated 
 as so important may be to show either that all causes capable of excit- 
 ing diseased action in the animal economy, or, more probably, that 
 the liability to diseased actions in the different departments of the 
 animal economy itself, are subject to variations, which are made 
 known to us only by the variation of such phenomena themselves; 
 occurring merely in the natural course of time — an element affecting 
 all vital phenomena quite differently from its agency on inanimate 
 nature; and the effects of which, on living beings, we must take as 
 ultimate facts, to be carefully observed, arranged, and classified, but 
 which we are not to expect to be resolved into any others, which the 
 study of this department of the works of Providence presents." 
 
 When I read these words of Alison, the best man I ever knew, it 
 is with a feeling of wonder how it has happened that men should 
 forget what reverence is due to his memory, whether we look on 
 him personally as a man of science and a teacher; or at his life as 
 an exemplar of that of a soldier of Christ. 
 
 Sir Robert Christison 1 shows that the change of treatment in acute 
 diseases is to be considered with reference to fever as well as to local 
 affections. He bears witness that the abandonment of bleeding in 
 idiopathic fevers preceded by a good many years its abandonment in 
 acute inflammation ; and that this change in practice took place gradu- 
 ally in all acute inflammations, not alone in pneumonia, because of the 
 improved diagnosis of the disease, but in all others, in many of which 
 
 1 Memoir on the Changes which have taken place in the Constitution of Fevers and 
 Acute Inflammation in Edinburgh during the last Forty-six Years. 1856. 
 
GENERAL CONSIDERATIONS. 13 
 
 no sensible progress in diagnosis had been made. Looking at the 
 fever epidemics of Edinburgh from the beginning of the present cen- 
 tury, he shows conclusively that in 1817-20, and in 1826-29, their 
 characters were those of Cullen's synocha and synochus — inflamma- 
 tory, relapsing, critical. 
 
 Speaking of the epidemics of 1817-20, he dwells on the hard, in- 
 compressible pulse, the ardent heat of the skin, the florid hue of the 
 venous blood and the impetus with which it escaped almost per saltum 
 from the vein, the vivid glow of the surface, and the distracting pain 
 and pulsation of the heart and chest. 
 
 Similar phenomena occurred in the epidemic of 1826-29, and in 
 both bleeding was largely practised with the happiest effects; so that 
 in the former epidemic the mortality, which was at first one in twenty- 
 two, fell to one in thirty — a result which disposes of the charge of 
 malpraxis against the profession. 
 
 But in 1834 Sir Eobert found that probably for two years pre- 
 viously a change had been going on ; synocha had disappeared ; 
 synochus had lost the vehement reaction of its early stages; typical 
 typhus was much more common ; and what did not come up to 
 Cullen's mark of fully formed typhus was what physicians would 
 now commonly call mild typhus, with more of introductory reaction 
 than we observe at present, but with less than in the two epidemics 
 of 1817-20 and 1826-29. 
 
 "In epidemic fevers," says this distinguished physician, "a change 
 may take place in the constitutional part of the fever; and this change 
 has been exemplified in Edinburgh during the last forty years, by a 
 transition from the sthenic or phlogistic character in the first twelve 
 years to the asthenic or adynamic character in the twelve years which 
 have just elapsed." 
 
 And he adds these most remarkable words : — 
 
 " If this change be admitted to have been proved, there is an end 
 to all difficulty in accounting for the abandonment of blood-letting in 
 the treatment of our fevers. In point of fact, I am able to state very 
 positively that the abandonment of bleeding in fever was suggested 
 by the observation of a change in the constitution of fever, and in the 
 effects of the remedy on it, and not by any other circumstance, 
 whether extraneous or intrinsic. It is impossible to ascribe such 
 change of practice, as Dr. Bennett has done in the instance of pneu- 
 monia, to an improved knowledge of disease. We have improved 
 our knowledge of fever so far as to have been for some time well 
 acquainted with the form of enteric typhus (dothinenteritis), which 
 was unknown, or not recognized, at the commencement of our epi- 
 
14 LECTURES ON FKVER. 
 
 demies. Bat this is a rare form of fever in Edinburgh, scarcely 
 belonging to its epidemics at all. And as to our only undoubted 
 epidemic fevers, typhus and synocha with their intermediates, we 
 cannot be truthfully said to be the better acquainted with them in 
 1857 than we were in 1830. 
 
 "I have given, I hope, a sounder explanation, less flattering per- 
 haps to the rising generation of physicians, but surely more honour- 
 able to physic itself, more creditable to medical observation and 
 experience, more consonant with the advanced state of medical 
 philosophy. My own convictions on the subject are so strong that I 
 regard nothing as more likely than that in the course of time some 
 now present will see the day when a reflux in the constitution of 
 fever will present it again in its sthenic dress, and again make the 
 lancet its remedy. And in that event it is not impossible that, while 
 we are now charged with giving up blood-letting, because it was dis- 
 covered to have never been the proper method of cure, we shall 
 hereafter be assailed by some new enthusiast in blood-letting, who, 
 in imitation of Dr. Welsh, and regardless of the fate of his doctrines, 
 will accuse us, with equal justice, of having our late fevers asthenic 
 and typhous by blindly withholding their fittest remedy." 
 
 Since the delivery of my address on " Change of Type in Disease" 
 before the British Medical Association at Leamington, in the year 
 1865, I have received numerous letters on the subject from many 
 leading physicians in England and Ireland. The testimony of these 
 gentlemen has been of the strongest character in favour of the occur- 
 rence of an asthenic type of local inflammatory disease within the last 
 forty years. 
 
 That the type of both local and essential disease varies within 
 certain limits of time we must believe. That a more asthenic form of 
 disease has for nearly half a century prevailed in these countries is, I 
 hold, an incontrovertible truth, and a time may come when those 
 whose experience is of a later date will speak of the practice of their 
 predecessors with greater modesty and more reverence. 
 
 T may now add the results of my own experience in this matter. 
 I remember the period when the change of type took place in Ire- 
 land, and am under the impression that it was observed earlier in this 
 country than in Scotland, or at least in England. The great epidemic 
 of fever in 1827 was a remarkable one from its compound nature, 
 and seemed to be made up of synocha, synochus, and enteric typhus. 
 But nothing was more remarkable than the vehemence of the inflam- 
 matory reaction in many cases; and it is a curious fact that this was 
 sometimes seen at its highest pitch in the relapses, when it was often 
 
GENERAL CONSIDERATIONS. 15 
 
 t 
 
 far more violent and dangerous than in the first attack. Local bleed- 
 ing was largely employed. In many cases venesection or arteriotomy 
 had excellent results; so that, although there were abundance of cases 
 with prostration, and others marked by the typhoid condition, the old 
 sthenic character had not disappeared. The amount of wine used at 
 that time in hospitals was quite insignificant as compared with its 
 consumption in more recent times. 
 
 Between 1822 and 1828 the sthenic character of essential and local 
 disease existed, and the lancet was freely used — often, as I believe and 
 have elsewhere stated, with too great freedom. But I well remember 
 observing the frequent occurrence of the phenomena mentioned by 
 Sir Robert Christison — the vehement action of the heart, the incom- 
 pressibility of the pulse, the vivid redness of the venous blood, and 
 the force with which it spouted, almost per sallum, from the orifice in 
 the vein. I have myself taken as much as sixty ounces in a case of 
 active cerebral congestion, with hemiplegia, before any impression 
 was made on the arterial excitement; in this case complete success 
 followed. In rheumatic fever, too, we found the use of the lancet in 
 the early stage of the disease to be productive of great relief. Vene- 
 section was seldom employed more than once, but its effect was to 
 shorten the duration of the disease, to lower the fever, to lessen the 
 liability to the so-called metastases, and to render the whole case much 
 more amenable to treatment. 
 
 But I have not bled in rheumatic fever for the last thirty years, for 
 the whole character of the disease has changed. We have not had for 
 many years the bounding pulse, the exaggerated heat and sweating, 
 or the same liability to acute inflammations of the internal parts. The 
 action of the heart is often feeble, and the tonic and supporting plan 
 seems called for from an early period. Another point worthy of 
 remark is, that cardiac and aortic murmurs of the anasmic kind have 
 for many years been much more frequently observed, both during 
 the attack and in the convalescence, and these demand the use of iron 
 for their removal. 
 
 In judging of this question the evidence of those who have been 
 intimate with acute diseases in this country during the period of 1820 
 to 1830 or 1835 must be attended to on this point. As already stated, 
 I have received a vast number of communications from experienced 
 and practical men, who had no theory to support, all telling the same 
 tale, all testifying to the fact that a change in the vital character of 
 acute disease was observed. This was particularly seen in rheumatic 
 fever, which gradually lost its quality of high reaction, as shown by 
 the great heat of the skin, the bounding and resisting pulse, the vigour 
 
16 LECTURES ON FEVER,, 
 
 of the heart's action ; the frequency and severity of metastasis, not 
 only as regards external but internal structures whose functions were 
 violently disturbed. Cases, too, of visceral inflammation, independent 
 of rheumatic complication, and marked by high reaction, pain, and 
 great functional disturbance, were common. This was well seen in 
 the cases of pleuropneumonia, in pericarditis, and in peritonitis, in 
 all of which violence of symptoms, high reaction, and great pain and 
 rapidity of morbid processes were the rule. Now, since the asthenic 
 character of acute disease has set in, all this has changed. The violent 
 acute and commonly suppurative pneumonia is rarely met with. We 
 frequently meet cases of pericarditis in which, but for the physical 
 signs, the disease could not be recognized, or its being overlooked 
 would be excusable — you have seen many cases with little or no 
 oppressive distress or throbing of the heart. And as to acute peri- 
 tonitis, formerly so well known, there has rarely been seen in any of 
 our wards a case of it that did not result from the perforation of the 
 intestine in enteric fevers. 
 
 It is needless to add examples; let us rather turn to another kind 
 of evidence. Hitherto the change of type has been recognized and 
 determined less by anatomical observation than by the observation of 
 symptoms, and still more by the application of therapeutical tests. 
 Kemedial measures of a certain kind were found to fail and to be 
 hurtful, where they were formerly safe and successful ; and, conversely, 
 the use of a supporting system of tonics, and the free employment of 
 stimulants, were found necessary and safe where formerly they did 
 mischief. 
 
 That morbid anatomy adds its testimony to the truth of the doc- 
 trine of the change of type in disease will, I believe, appear from 
 considerations based on observed facts. Thus, after or about the time 
 when an asthenic tendency was first noticed in Ireland, a change was 
 detected in the condition of the blood drawn by venesection. The 
 buffed and cupped character became very rare, and I well remember 
 expressing my surprise at the absence of the fibrinous coat in cases 
 in which we had fully expected its presence. In place of the small, 
 dense, almost spherical crassamentum, we had a soft clot, with little 
 if any separation of serum ; while, instead of the buffy coat with 
 inverted edges, we had a thin sizy pellicle. This circumstance was 
 one of those which led us to be more aud more cautious in the use of 
 the lancet. 
 
 Again, the specimens of acute disease have had for many years a 
 character very different from that commonly met with in Dublin 
 between 1820 and 1830. As a general rule, these specimens all 
 
GENERAL CONSIDERATIONS. 17 
 
 showed appearances indicative of a less degree of pathological energy. 
 In pneumonia, for example, the redness, firmness, compactness, and 
 defined boundary of the solidified lung was seldom seen ; and that 
 state of dryness and vivid scarlet injection, to which I ventured to 
 give the name of the first stage of pneumonia, became very rare. In 
 place of these sthenic characters, we have had a condition more 
 approaching to splenization — the affected parts purple, not bright red; 
 friable, not firm ; moist, not dry ; and the whole looking more like 
 the result of diffuse than of energetic and concentrated inflammation. 
 
 Let us now turn to the serous membranes, and the same story is 
 repeated. The high arterial injection, the dryness of the surface, the 
 free production, close adhesion, and firm structure of the false mem- 
 branes in acute affections of the arachnoid, pericardium, pleura, and 
 peritoneum, which had been so familiar, ceased in a great measure to 
 make their appearance. The exudations began to assume a more or 
 less hemorrhagic phase, serous or sero-fibrinous effusions tinged with 
 colouring matter replacing the old results of sthenic inflammations. 
 The effused lymph lay like a pasty covering, rather than a close and 
 firm investment as before; it was thin, ill-defined, and transparent in 
 varying degree. All this tallied exactly with the change in the vital 
 character of the disease. 
 
 It has happened to me — and I mention this in evidence that we were 
 not mistaken with reference to cases of the sthenic character — that a 
 few instances of disease in its old phase of high inflammatory reaction 
 have appeared in isolated examples and at irregular intervals of time, 
 so that we at once recognized their nature, and employed with success 
 the old treatment in all its vigour— employed the lancet, though for 
 many years it had been laid aside. This is important as showing 
 that there are influences, their nature as yet unknown, which affect 
 the vital character of local disease in an inconstant manner. 
 
 During the last few years we have not been without signs of a 
 return to the old sthenic forms of disease. Even fifteen years ago a 
 typical case of the old form of acute pleuropneumonia occurred in 
 this city in the practice of the late Dr. Oroker. The symptoms were 
 those of the highest inflammatory reaction, attended by violent excite- 
 ment of the heart. There was great pain and dyspnoea, a bounding 
 pulse, a burning skin, and the rusty and tenacious sputa which for 
 many years had not been seen in our hospital wards. This patient 
 was treated by free venesection, copious leeching, and the exhibition 
 of tartarated antimony; and though the lung had passed largely into 
 consolidation, the patient made a complete and rapid recovery. Cases 
 of a similar kind have reappeared in our wards during the last three 
 2 
 
18 LECTURES ON FEVER. 
 
 years, and the use of the lancet, which for a quarter of a century was 
 unknown with us, has been on several occasions resumed, and in all 
 such cases with the very best results. The relief has been always 
 immediate, the resolution of the disease, as shown by physical exami- 
 nation, generally rapid, and the convalescence, with one exception, 
 most satisfactory. In three out of four cases the treatment consisted 
 in one bleeding, which sometimes was followed by the application of 
 six or eight leeches to the seat of pain. No further treatment beyond 
 the use of the simplest palliatives was employed. 
 
 Must we not, then, agree with Sir Kobert Christison that the disuse 
 of venesection, so remarkable in these countries during a period of 
 about forty years, is wrongly appealed to as evidence of our advance 
 in the healing art? We are not to hold that the former practice of 
 venesection was improper or unscientific; and while we admit that, 
 under the influence of old custom and the anatomical theory of disease, 
 blood-letting was abused in many cases, we must be careful not to drift 
 into the opposite error of neglecting this remedy where it is called for, 
 nor be guilty of the folly of holding that the physicians of the past 
 two or three generations were bad observers and harmful practitioners. 
 That they were men of truth is obvious to every one who understands 
 disease, and who takes at its proper value the opinion of those who show 
 such overweening confidence in the present so-called pathological 
 medicine — so much based upon mere structural and chemical changes 
 — and such neglect of some important medico-ethical considerations, 
 as, for example, the modesty of science and the practice of a reve- 
 rential spirit towards those whose works prove that they were great 
 and truthful men. 
 
 The change of type is to be seen in the character of the symptoms 
 and, as I have endeavoured to show, in the condition of the patho- 
 logical changes. But it is to be recognized chiefly by the therapeu- 
 tical test, by the behaviour of disease, whether general or local, under 
 treatment. It may be well to repeat that the change seems to date in 
 the present century from about the time of the first invasion of cholera, 
 and has continued more or less ever since. 
 
 The change from sthenic to asthenic (so far as we at present know) 
 is one more of the vital than of the structural or chemical characters 
 of disease. The symptoms indicate, as it were, a lower tension of all 
 the vital phenomena. The convalescence is less perfect and slower, 
 as are also the physical signs of the resolution of local disease. The 
 capability of bearing a reducing treatment is singularly diminished. 
 Local lesions exhibit a greater latency. The nervous system shows 
 
GENERAL CONSIDERATIONS. 19 
 
 earlier signs of depression, while tonics or stimulants have been 
 better borne. 
 
 So far as medical experience goes, we are forced to admit that the 
 foundation for the healing art must rest on another, if not a broader, 
 basis than that of anatomical and of chemical changes in disease. 
 There are differences — and for want of a better name we may call them 
 vital — which more intimately relate to life and health than to the 
 anatomical or chemical changes produced by disease; and these are 
 to be reached by the study of the living phenomena of the body, and 
 of the influence of agents upon them. In truth, the fruitless attempt 
 to base medicine upon anatomical or even chemical changes should 
 be a lesson to those who neglect the infinitely varied mutations of 
 vital or of nervous action. 
 
 The healing art, whether medicine or surgery, requires a wider 
 field of study than is afforded by the dissecting-room or the laboratorj^. 
 The anatomists, the histologists, and the chemists of some of the 
 modern schools of medicine would derive a deep practical lesson from 
 the words of Goethe, 1 who says, alluding to the insufficiency of mere 
 anatomy to explain the mysteries of life — 
 
 For he who seeks to learu, or gives 
 Descriptions of, a thing that lives, 
 Begins with " murdering, to dissect," 
 The lifeless parts he may inspect — 
 The limbs are there beneath his knife, 
 And all — but that which gave them life ! 
 Alas ! the spirit hath withdrawn — 
 That which informed the mass is gone. 
 They scrutinize it, when it ceases 
 To be itself, and count its pieces, 
 Finger and feel them, and call this 
 Experiment — analysis. 
 
 The study of normal anatomy being then fruitless in solving the 
 problem of healthy life, it might be anticipated that researches as to 
 morbid structure have thrown but a fitful and limited light on disease. 
 In truth, the knowledge of Curative or of Preventive Medicine is not 
 to be learned in the dissecting-room of a medical school, or in the 
 dead-house of a hospital. Until this truth be acted on, many precious 
 years of the best time of the student's life will be wasted. It has been 
 attempted to base medicine on pathological anatomy, as if by its study 
 we could solve the infinitely varied problems of disease and of thera- 
 peutics. The explanation of even death through anatomical research 
 
 1 Faustus. Translated by John Anster, LL.D., of Trinity College, Dublin. 1835. P. 
 120. 
 
20 LECTURES ON FEVER. 
 
 is admissible only in exceptional cases. But it is of value — less as a 
 key to the origin and cause of disease, than to diagnosis and the 
 science or the many changes which attend morbid action. 
 
 LECTURE III. 
 
 Fever described, but not defined, as " a condition of existence without any known or 
 necessary local anatomical change and subject to new laws, different from those of 
 health" — Error committed by the school of Broussais — The " Law of Periodicity" — 
 Danger to the fever patient due to the primary disease or to its secondary compli- 
 cations — Secondary affections of continued fevers more inconstant than those of 
 the exanthemata — Classification of diseases: (1) Diseases having an anatomical 
 character ; (2) neuroses, having no known anatomical character; (3) fevers, subject 
 to the law of periodicity, causing secondary affections, transmissible by contagion 
 
 Fever is a condition more easily described than defined, and it is 
 far easier to declare what it is not than what it actually is. During the 
 continuance of a fever the system seems, as it were, to enter upon a 
 new and special phase of existence. Most, if not all, functions are 
 liable to be either interrupted or modified in a varying degree, and 
 this possibty without the occurrence of any local anatomical change. 
 We cannot say, I believe, what fever is in its essence, yet one thing 
 appears certain — that it is not symptomatic of the organic changes 
 which may be found combined with it, but is rather the generator and 
 governor of those affections. It is, then, a condition without any 
 known or necessary local anatomical change. 
 
 It is true that in certain forms of fever there are secondary mani- 
 festations of local disease. The pustulation of the skin in variola, 
 the ulceration of the intestine in the so-called typhoid, and the bron- 
 chial congestion in typhus, are examples of these conditions. But 
 looking at fever in a wide sense, we may safely hold that these sec- 
 ondary anatomical changes are inconstant in their amount, in their 
 nature, and even in their seat; inconstant as to their time of appear- 
 ance, their symptoms, their intensity, and their decadence, and utterly 
 incompetent to explain the phenomena of the disease. 
 
 The great fact remains, that in epidemics of fever cases arise in 
 which, after the general symptoms have run their course, so as to 
 present a perfect specimen of the general disease, we may dissect the 
 brain, spinal marrow, nerves, the pulmonary and gastro intestinal 
 mucous membrane, the liver, every organ you please, and find no 
 anatomical change. I believe we may say that when the fatal diseases 
 
THE LAW OF PERIODICITY. 21 
 
 of the world are considered, the most destructive are those which have 
 no recognized anatomical character. You may believe that when we 
 speak of fever generally, secondary lesions are either wanting or are 
 inconstant in their amount or in their nature. Upon their incom- 
 petence to explain the matter I have already remarked. 
 
 It will naturally be asked, If this be so, how did the French school 
 commit the extraordinary error of declaring that a special anatomical 
 change characterized every case of fever ? The reason is simply this : 
 they committed two grave errors in medical philosophy: first, in 
 confounding the effect with the cause; and secondly, in assuming the 
 nature of a disease over the world from its observation in one locality. 
 Had Broussais and his followers studied fever in Ireland, Scotland, 
 or England ; had they gone abroad and examined it in the East or 
 West Indies, or on the coast of Africa, we should have heard little of 
 the doctrine that fever was not essential, but only symptomatic of this 
 or that local inflammation. 
 
 Observation has long shown that fever is a state of existence under 
 a law of periodicity, and this is more or less true as to the general 
 affection and as to its local results, though this law is more often 
 manifest in the case of the former than in that of the latter. In the 
 disease, I believe under any of its forms, two sources of danger affect 
 the patient. One of these is death from simple depression of all the 
 vital powers; for the poison of fever, like that of the rattle-snake, has 
 a directly depressing influence on the system. Another source of 
 danger is the production of secondary diseases. A general notion of 
 this will be best obtained by considering an ordinary case of small- 
 pox. The patient is taken ill ; he has shivering, fever, pain, vomiting, 
 and so on ; and then we observe vesicles on the surface, these vesicles 
 filling with pus, afterwards drying, and then disappearing. No man 
 will say that the fever was symptomatic of the eruption. It is exactly 
 the reverse ; the eruption was the result of the fever. So it is in fever ; 
 the local disease is the product of the general. There is, however, 
 this difference between what we term continued fever, typhus, or 
 typhoid, and the exanthemata, that while in the latter the local affection 
 is almost always accompanied by certain characters, it is not so with 
 respect to the secondary diseases of the fevers specified. However, 
 between the exanthemata and typhus fever there is this point of 
 resemblance, that the secondary affections are utterly incompetent to 
 explain the general phenomena of the disease, while in typhus, and, 
 I believe, in typhoid, they are doubly inconstant in their seat, their 
 nature, and their amount — and this is true even in cases occurring 
 during the same epidemic. But they are of very great importance. 
 
22 LECTURES OX FEVER. 
 
 It may be asked, Are they inflammations? I believe they are not 
 inflammations, or, if they be such, they have a specific character. 
 Certainly in their first stages they are not inflammatory ; but in many 
 instances, after they have existed in their non-inflammatory state, 
 there comes on a reactive irritation, so that we may then have a mixed 
 condition of essential and symptomatic fever. In my opinion this is 
 the history of the ulcerations of the intestine so common in typhoid 
 fever, for in the beginning — as in variola — we often find tumefaction 
 and infiltration without increased vascularity. It has been proved 
 that in many cases the morbid process goes no further, and we have 
 retrocession of the infiltration, as we see retrocession in the eruption 
 of smallpox. 
 
 It may be laid down that while the great majority of separate 
 diseases catalogued in books have an anatomical character, fever is 
 wanting in this particular with regard to the practice of medicine. 
 We may, then, divide diseases into three great classes. 
 
 In the first class we have diseases which have an anatomical cha- 
 racter — diseases to which we can give an anatomical expression. I 
 need not occupy your time in giving examples of this class. 
 
 In the next place, we have a most important class of diseases which, 
 in the present state of our knowledge, cannot be connected with any 
 recognized anatomical character, and yet they are not fevers. I allude 
 to the neuroses, or, as they are commonly termed, nervous affections; 
 of these mania, epilepsy, lock-jaw, hydrophobia, hysteria, chorea, con- 
 vulsions, are familiar instances. Here we have some most remarkable 
 affections, which have not any known anatomical character; that is to 
 say, we cannot yet show that they depend upon any known or ascer- 
 tained anatomical change of any portion of the system, including the 
 brain, spinal marrow, and nerves. The general character of this 
 singular group of affections, which we call neuroses, shows that, what- 
 ever be the nature of the disease, the seat of it is in the nervous system ; 
 but, in the present state of anatomical knowledge, we are not justified 
 in saying what the condition of the nervous system is to which they 
 owe their origin ; whether it is an organic change at all, or whether, 
 supposing such a change to exist, its amount is proportionate to the 
 violence of the symptoms. Even the results hitherto obtained by the 
 microscope have been chiefly negative ; the microscope has added but 
 little to what was before known on those subjects. I may state here, 
 lest you should fall into a misapprehension, that I do not wish you to 
 believe that organic change is not found in any of these diseases. 
 The fact is, that in many of them such does exist; but when we come 
 to inquire what those organic changes are, we find that they are so 
 
FEVERS AND NEUROSES. 23 
 
 inconstant, so variable, frequently so similar in opposite diseases, that 
 they have hitherto altogether failed to throw any positive light upon 
 the subject. 
 
 This, then, is the second class of diseases; the first class having an 
 anatomical character, the second having no anatomical character. 
 Now we come to the third class, which comprises fevers. Fevers, as 
 we have already said, have no anatomical character. Then, it will be 
 asked, how do they differ from the neuroses? As far as we know, and 
 strictly speaking, they differ very little ; but there is this feature con- 
 nected with them, that fever seems to be a special condition of life 
 which is to exist for a certain time, and then to cease— that is to say, 
 it is under the law of periodicity; and in this respect the phenomena 
 of fevers differ very much from those of the pure neuroses. There 
 are other differences, too, between fevers and neuroses. It is quite 
 true that in a large number of fevers death may take place without 
 any organic change that we can demonstrate anatomically; but it is 
 true, on the other hand, that in a large number of cases there is a 
 tendency to the development of what are to be designated the secon- 
 dary lesions of the disease. Thus, if we compare these two classes, 
 the neuroses, which are not fevers, and the fevers properly so called, 
 we find this great difference, that among the former (as for example 
 in hydrophobia) we do not see any tendency to the development of 
 ulcers of the intestine; in epilepsy we do not find any tendency to 
 the development of bronchial diseases; in mania we do not see a 
 cutaneous eruption ; in convulsions we do not find any of these various 
 organic changes produced. This tendency, then, to generate or pro- 
 duce local anatomical changes secondary to the fever is another re- 
 markable distinction between this class of affections and the pure 
 neuroses. 
 
 There is a third very remarkable distinction between them. Fevers 
 — using the term in a general sense, embracing, as I have already 
 pointed out, a great number of essential diseases, as the exanthemata, 
 typhus, plague, and yellow fever — are capable of being transmitted 
 by contact or by vicinity; many of them — J believe almost all— are 
 more or less contagious. So that in their subjection to the law of 
 periodicity, in their liability to generate or produce various organic 
 changes in different parts of the system, and in their transmissibility 
 by contagion, we have three very important distinctive characters, 
 although we cannot reduce them to an anatomical expression. 
 
 A great deal has been written on the subject of the proximate 
 cause of fever, and theory upon theory has been promulgated. We 
 are, however, at this moment as ignorant of the proximate cause of 
 
24 LECTURES ON FEVER. 
 
 fever as we were in the time of Cuilen, or even long before him. It may 
 be expected, however, looking at the advance of medical knowledge, 
 that the proximate cause or causes of fever will yet be discovered ; 
 but it is a general and justifiable opinion that essential fevers result, 
 in most cases, from the introduction of a poison into the system. The 
 whole of the phenomena of poisoning by organic matter seem to point 
 out a close analogy between fevers and those diseases in which a 
 poison is introduced into the system. If a man who is in perfect 
 health is exposed to the contagion of syphilis, in a short time his 
 system becomes a laboratory for the formation of syphilitic poison, 
 and he is capable of communicating the disease. As far as we can 
 form a judgment on this question we may say that there is a very 
 close analogy indeed between fevers and toxic diseases, whether they 
 be fevers which are the result of contagion or not; and in this way we 
 see a connecting link between fevers, which we call acute diseases, 
 and diseases which are neither acute nor febrile. Thus, for example, 
 we do not say that a patient who is labouring under syphilis, which 
 he has caught by contagion, is in fever; but he is, nevertheless, under 
 a condition which, so far as the chemico-vital state of his body is con- 
 cerned, is somewhat analogous to fever ; that is to say, his system has 
 received a poison, and having received that poison, it seems to work 
 upon it, or the poison to work on the system, and the result is that 
 the system becomes a generator of the same poison that it has re- 
 ceived. 
 
 Now let us go a little further into this subject. I might give 
 various other illustrations; and, indeed, I think you will find that 
 some unexpected analogies will arise in this matter, and that you will 
 even perceive an analogy between two such opposite diseases — such 
 dissimilar diseases as typhus fever and pulmonary consumption. For 
 there can hardly be a doubt that, under certain circumstances, tuber- 
 cular matter introduced into the system acts like contagious matter, 
 and that it produces a development of tubercular disease in the system 
 thus infected. Such cases, then, may be considered as examples, if 
 you will, of very chronic fevers, long-continued fevers, and fevers 
 which are not, apparently at least, under the influence of the law of 
 periodicity. I am perfectly persuaded that the more we study that 
 class of diseases, which seems to be general rather than local, we shall 
 find that the possibility of contagion will be more and more exhibited. 
 I am strongly of opinion that the majority of the acute essential dis- 
 eases are contagious, and I think it certain that there are other diseases 
 also which we do not call fevers that are contagious. It is hardly 
 possible to doubt the contagiousness of cholera ; and we may go still 
 
FEVERS AND TOXIC DISEASES. 25 
 
 further, and extend the possibility of contagiousness even to such dis- 
 eases as tubercular affections, and perhaps even further. 
 
 We know that scarlatina, measles, and smallpox are generally con- 
 stant in their phenomena, and especially in the phenomena of their 
 secondary changes — so much so that in them the secondary change 
 is taken as a distinctive mark of the disease. These affections are 
 probably, as I said before, more directly contagious; and it becomes 
 a question whether this may arise from the circumstance that the 
 matter of contagion in these cases is more elaborated — is perhaps 
 more perfect according to its kind — or whether greater facilities are 
 afforded for the conveyance of contagious matter during the desqua- 
 mative processes so common in these diseases. The patient who con- 
 tracts the disease is very much in the same position as a person who 
 contracts syphilis; that is to say, that an organic poison of a special 
 kind, whose essential characters, however, are so subtle as to escape 
 chemical investigation, has been presented to his system and has 
 affected him. The phenomena of typhus and typhoid are more 
 variable ; and this may arise from the want of constancy in the exciting 
 cause. We can hardly suppose a man to get smallpox unless he has 
 been infected by another who has had smallpox. But continued 
 fever, or typhus fever, seems capable of being produced by a great 
 number of causes, or, if I may so speak, by a number of imperfectly 
 developed or imperfectly acting causes, and these, of course, may be 
 infinitely various. We also see this very curious difference between 
 typhus fever and the exanthemata, that while among exanthemata, so 
 far as we know, the one exciting cause produces its own disease — the 
 exciting cause of smallpox producing smallpox, that of scarlatina pro- 
 ducing scarlatina, that of measles producing measles — this does not 
 seem to be the case with respect to fever. For here is one of the most 
 important and interesting facts connected with the entire subject, that 
 the same exciting cause — at least as far as we can see of it — is capable 
 of producing different kinds of fever in different persons. This great 
 fact has not been sufficiently dwelt on by the various writers on fever 
 on the Continent and in England, especially by that class of men 
 whose object seems to have been to make themselves classifiers of 
 diseases — makers of classifications — at which nature laughs. 
 
 Here is another of the great facts which show the inexpediency of 
 drawing hard and fast lines of distinction between what are termed 
 typhus fever and typhoid lever — that the one exciting cause will in one 
 person produce one form of fever and in anotheradifferent form of fever. 
 Now, we see nothing of this sort in the exanthemata. What may be the 
 reason of this it is diificult to say; and we explain it very often by 
 
26 LECTURES ON FEVER. 
 
 expressing the fact in different words. It is supposed that it may be 
 due to some variation in the state of receptivity of the body at the time. 
 For in the production of the effect of the poison there are two elements: 
 first, the nature and composition of the poison which is to act; and, 
 next, the chemico-vital state of the body which is to be acted on. The 
 two causes combined produce the result — -fever. But if, the cause 
 being the same, the bodies be in different states, we may expect dif- 
 ferent kinds of fevers; and this is all that we can say on the subject. 
 
 Now let me address especially the junior members of the class, or 
 those who have hitherto worked exclusively in the surgical wards. I 
 want them to look on the local acute diseases of fever as they would 
 look on the pustules of smallpox, the efflorescence of erysipelas, or the 
 eruption in measles or scarlatina. In these maladies the manifest local 
 disease most commonly affects the skin, but is clearly secondary to 
 a specific morbid state of the system. It runs its course and subsides 
 spontaneously, and unless in exceptional cases the constitutional dis- 
 turbance subsides with it. 
 
 Now, this seems to be the case in the secondary affections of fever, 
 whether they be attended with anatomical change or be simply neu- 
 rotic, whether the head, chest, or abdomen shows signs of disease. 
 This latter is the product of the essential condition — that is, of the 
 fever — and not its cause. You may meet cases where but one cavity 
 is affected, even throughout the fever, where the three cavities are 
 simultaneously engaged, where they are severally attacked, or where, 
 in the whole course of the fever, there is no anatomical change. 
 
 Now, what I want you to believe, and what, when your actual ex- 
 perience of successive epidemics has been obtained, you cannot help 
 believing, is, that as regards these secondary diseases, there is no con- 
 stancy in their production — none as to amount, none as to intensity 
 — and you may add, as to their combination and even their seat. Im- 
 portant though they may be, frequent as certain forms of them are in 
 certain epidemics or in certain localities, they may be looked on more 
 in the light of accidents than of constant occurrences. 
 
 They may be occasionally so extensive and so intense as that death 
 may be probably attributed to them; while, on the other hand, their 
 amount may be very trifling, and have no proportion to the severity 
 of the general malady. In fact, it is impossible to predicate what 
 course the secondary disease may take from spontaneous and some- 
 times sudden retrocession to extreme disorganization. Thus the 
 affection of the lung may vary from a slight to a dangerous degree of 
 bronchial irritation, with congestion, causing extensive and rapid 
 consolidation, and even a fatal sphacelus. Or there may be a great 
 
CONTAGION. 27 
 
 development of tubercle, either confined to the lung or engaging many 
 other organs. Again, a rapid consolidation may take place — generally, 
 as it were, silently — and attended by a cessation of the fever. We 
 shall return to this when discussing the pulmonary complications. 
 So also you will find great variations in the nature and intensity of 
 the abdominal affections, from slight partial congestion, with or with- 
 out deposit in the mucous glands of the intestine, to extreme relaxa- 
 tion, softening, and perforation of the tube — it may be in many places 
 with or without general acute peritonitis — or, as certain cases in the 
 epidemic in 1827, there may be numerous intussusceptions, great con- 
 gestion and enlargement, with softening of the spleen ; and, though 
 the intestinal suffering be extreme, even without ulceration or per- 
 foration of the tube. 
 
 Now, gentlemen, what I wish you to bear in mind is, that the re- 
 lation between the anatomical states of organs in fevers is a variable 
 one, whether as regards the seat, the combination, the intensity of the 
 affection, or the time of its appearance, or its effect on the general 
 malady. Every great epidemic of fever, of whatever kind, must be 
 studied first separately, and then comparatively, and you will find 
 that the history of fever is a much wider subject than you might infer 
 from books. 
 
 LEGTURE IV. 
 
 Contagion — Exclusive doctrines are to be deprecated — Endemic disease arises inde- 
 pendently of contact — The numerical system of Louis fails in practical medicine — 
 Evidence in favour of contagion from the Doctrine of Chances — Investigations of Dr. 
 Whitley Stokes and the Bishop of Cloyne ; with Dr. Paget's remarks thereon 
 — Variation in the degree of contagiousness of acute essential diseases. 
 
 As I have said, a striking difference of fevers, compared with the 
 pure neuroses and the structural diseases, is their contagious nature. 
 
 With regard to this characteristic, medical opinion has been long 
 divided ; and I would advise you, as a general rule, not to range your- 
 selves among the advocates of any exclusive doctrine. You are not, 
 therefore, to stand in the false position of men who are fighting for a 
 particular doctrine, whether they be contagionists or non-contagionists. 
 Should you do so, your mind will be occupied with the excitement of 
 controversy rather than with the search for truth. You will become 
 
28 LECTURES ON FEVER. 
 
 advocates, while you cease to be inquirers, and once this change occurs 
 in the mind of the observer, he loses caste in the ranks of science. 
 
 The advocates of an exclusive doctrine on each side of this great 
 question are able to produce many facts in evidence of their particular 
 views. The facts thus brought forward may be, and probably are, 
 in each case true; but the conclusions drawn from them may not be 
 warranted. It would thus be wrong to infer that a disease was not 
 contagious from the failure of evidence of its communication even in 
 many instances. Equally illogical would be the deduction that a dis- 
 ease arose only by contagion, even where multiplied examples of such 
 an origin could be appealed to. 
 
 There can be no doubt that disease has originated, and may 
 originate, without contagion. This must be obvious to every man. 
 
 Again, we see a vast number of cases in which disease is endemic. 
 I need scarcely allude to the common case of ague. There are certain 
 districts where ague is constantly produced, and where, if a man who 
 has not had ague goes, and is not in contact with any human being 
 whatever, he will, almost certainly, get the disease. Here, then, 
 clearly, there has been disease independently produced, or at least 
 without human contagion. There are certain districts in South 
 America and in the West Indies, vast districts on the coast of Africa, 
 forest districts in Hindostan, where, if a man sleeps for a single night 
 — although we will suppose him to be alone, without any companions 
 but the wild beasts of the forest — he will get some form of fever. 
 We see also, if we look at the records of medicine, unquestionably 
 even within the later periods of the world's history, the appearance of 
 new diseases, totally new diseases. So that we cannot at all deny that' 
 disease may be generated, and that it may spread without the interven- 
 tion of human contagion. We must believe, I say, in the origin of dis- 
 eases under some exciting cause; but that exciting cause need not be 
 human contagion. On the other hand, innumerable facts show that fever 
 existing in the system is capable of being propagated from one man 
 to another; that it is, in fact, a contagious disease in the strictest sense; 
 and this transmission of the disease may not be merely by contact, 
 but by vicinity — within, it is true, a limited space. Now, the facts 
 which we must rely on to impress this doctrine of contagion on your 
 mind, when you come to examine them, will appear less direct than 
 you might suppose. A great number of men who have written on 
 this subject were really but ill-instructed in the rules of logic; they 
 have not been trained to think properly and argue correctly on the 
 subjects they were considering. For instance, it was a great object 
 with a number of the French school, especially with the disciples of 
 
CONTAGION. 29 
 
 Broussais and advocates of the physiological doctrine, to establish the 
 non-contagiousness of disease. For the doctrine of contagion implies 
 essentiality; and the physiological doctrine was opposed to all essen- 
 tiality. According to this doctrine, there was no such thing as essen- 
 tial disease. Every disease was local and inflammatory; every fever 
 was symptomatic. Therefore, in their anxiety to overturn essen- 
 tialism, they found this outwork, as it were, of contagion, which should 
 be carried. And nothing can be more singular, or, I may say, heroical, 
 than the efforts which a number of the French physicians made to 
 establish the non-contagiousness even of the most contagious diseases. 
 Many of them went out to the Levant and exposed themselves pur- 
 posely to the contagion of plague — put on the clothes of persons who 
 were labouring under it; slept in the beds with plague patients; inocu- 
 lated themselves with the matter from the buboes of persons labour- 
 ing under the disease, in some instances actually inoculated themselves 
 with the blood of plague patients. "Well, in many cases these experi- 
 menters did not take the plague, and this fact is still relied upon as a 
 proof of the non-contagiousness of plague and of fever generally. But 
 you will at once see how very inconsequential these experiments are. 
 Here are four or five cases of failure of contagion, and as well might 
 you argue that corn does not grow from seed because one grain sown 
 in the earth will sometimes fail to produce the plant. I may state 
 here, however, that some of these investigators paid the terrible penalty 
 of death in their zeal for science, for they did take the plague and 
 were lost. 
 
 Among the direct facts which satisfy our minds as to the contagious 
 nature of fever are the circumstances attending its spread through large 
 masses of people. I need hardly here allude to the singularly forcible 
 argument in favour of contagion which may be drawn from the frightful 
 mortality of our Irish medical brethren in the years of 1847 and 1848. 
 This subject I have already alluded to in the theatre of the Meath 
 Hospital, and it is one which we can hardly look back upon without 
 shuddering. The simple fact alone of the mortality of that class of 
 individuals who are most exposed to the disease, furnishes an argu- 
 ment in favour of contagion which we would but weaken by any 
 observations upon it. 
 
 There is a mode of dealing with the indirect evidence for contagion, 
 to which I shall now draw your attention. You all know that Pro- 
 fessor Louis, of Paris, founded what he terms the numerical s}'stem 
 of medical investigation; that is to say, he attempted to reduce the 
 facts of medicine to numerical expression ; so that we should be able, 
 as he supposed, to make medicine an almost exact science. My opinion, 
 
30 LECTURES ON FEVER. 
 
 I may state, generally speaking, on the subject is, that for the establish- 
 ment of all that part of medicine which consists in fixing the data of 
 physical diagnosis, the frequency or infrequency of certain pathological 
 changes and matters of that kind, the numerical system is infinitely 
 valuable; but that we cannot, or have not yet been able to apply it 
 so as to furnish rules of treatment. For the object of the numerical 
 physician and that of the practical physician — if I may make use of 
 such a distinction — are different. The object of the numerical phy- 
 sician is to ascertain a rule of treatment which will cure the greatest 
 number of cases out of a given number; but that should not be your 
 object, or that of practical physicians. It is very well to know that 
 such results have been obtained; but it does not follow that you are 
 to act on them. Your course is not blindly to adopt the formula 
 founded on numerical data when it is shown that by its use you can 
 cure the greatest number out of a given number; your object is to cure 
 the diseases of A, B, or C, as they may come before you. And you 
 are not to neglect what you believe to be right in the case of A, B, or C, 
 because you have this array of figures declaring to you that such and 
 such a course, different from that you may be about to pursue, is the 
 rule for saving the greatest number of lives out of a given number. 
 But we may safely use numbers in a different way — as, for example, 
 in investigating the data of a particular doctrine. 
 
 My father, when Professor of the Practice of Medicine in the Royal 
 College of Surgeons, directed his attention very much to the subject 
 of contagion. He was a strong advocate of the doctrine of contagion. 
 Perhaps he went too far in his belief in the exclusiveness of this 
 doctrine. Perhaps, also, he went too far in denying the views of the 
 epidemists, or of the non-contagionists. However, that hasxHothing 
 to say to the present question. He thought that, in looking at the 
 general circumstances which attend the spread of an epidemic in this 
 country, the probabilities for or against the doctrine of contagion 
 might be submitted to calculation. One of his most intimate friends 
 was the late Dr. Brinkley, Bishop of Cloyne, who was at one time the 
 Astronomer-Royal of Ireland. He was admittedly one of the very 
 first mathematicians of his day, and especially skilled in that difficult 
 part of mathematical investigation — the Doctrine of Chances. 
 
 In the progress of an epidemic in Ireland (and doubtless also in 
 other countries) in a family of twelve persons the disease has been 
 known to attack eleven out of the twelve. In some cases, the passing 
 of the fever through so large a proportion as eleven individuals out 
 of twelve has taken a very considerable period of time, as you may 
 readily understand. It has taken about three months to go through 
 
CONTAGION. 31 
 
 them all. Now, my father proposed these two problems to the Bishop 
 of Cloyne for solution: — 
 
 1st. An epidemic prevails so severely that one person out of seven sickens. 
 A family of twelve is selected in a particular district before the epidemic has 
 visited it. What is the chance that eleven out of that family will take the 
 disease, supposing the sickness of one of the family does not promote the 
 sickening of another — that is, supposing the disease not to be contagious, 
 and supposing the family to be not unusually liable to the disease ? 
 
 The answer furnished by Dr. Brinkley was, that the probability against 
 such an event is 189,600,000 to 1. That is a very singular and extra- 
 ordinary result. 
 
 2d. The same general conditions being assumed, and also that the number 
 of inhabitants of a district is 7000, what is the chance that in a family of 
 twelve within the district eleven will sicken ? 
 
 Answer : The chance then is 300,000 to 1 that no family of twelve persons 
 in a population of 7000 will have eleven persons sick. 
 
 These numbers furnish proofs so convincing of the truth of the 
 doctrine of contagion, though by no means in an exclusive sense, that 
 it is hardly necessary to go further. The facts on which they were 
 based are ascertained facts; they have been not uncommon facts in epi- 
 demic fever; but, recollecting this, the chances against their happen- 
 ing, if the disease were not contagious, would be 189,600,000 to 1 in 
 the one case, and 300,000 to 1 in the other. 
 
 On this subject I have had the honour of receiving a letter from Dr. 
 Paget, of Cambridge; and I would not be doing justice to you, or to 
 the question generally, if I did not state the objection made by this 
 eminent physician, as to the soundness of the conclusions in favour of 
 contagion, which appear deducible from these calculations. Dr. Paget 
 observes that the form in which the problems are stated excludes the 
 consideration of all local influences except contagion; in this he is 
 perfectly correct. He considers that had this element of local influence, 
 besides contagion, been included, it must necessarily have diminished, 
 by whatever was its real value, the overwhelming result which the 
 calculations, as they now stand, give in favour of contagion. But even 
 Dr. Paget himself admits that — taking the case of the second calcu- 
 lation — if the consequence of these deductions on the score of local 
 causes were to reduce the probability of 300,000 to 1 to that of 1000 
 to 1, yet this latter probability would be sufficient to carry con- 
 viction to the mind of any candid person. He, however, observes 
 that we have unhappily no means of estimating numerically the 
 requisite deductions, no means of calculating the effect of noxious 
 exhalations from decomposing organic substances, of bad food and 
 other assignable causes, which have been supposed capable of pro- 
 
32 LECTURES ON FEVER. 
 
 moting the spread of fevers ; and be properly remarks that Bishop 
 Brinkley's results include, with contagion, the possible effects not only 
 of known but also of all unknown causes which may make an indi- 
 vidual household more liable to fever than their neighbours. 
 
 While I feel indebted to Dr. Paget for having drawn my attention 
 to this point, and to the importance of noticing it, when the numerical 
 value of these results is considered, I think it well to mention that in 
 my father's " Observations on Contagion" there is nothing which 
 would lead one to believe that he advocated that doctrine in an ex- 
 clusive sense. His object in proposing the problems was to show the 
 great probability in favour of the doctrine of contagion as one and a 
 principal cause of epidemical disease, and this irrespective of the 
 question whether or not other causes might be held to coexist. The 
 result seems to establish the certainty of the existence of contagion 
 as an important cause of the phenomena in question. The singular 
 array of figures is valuable as establishing the fact that contagion has 
 a real existence. The terms of the questions may be held to embrace 
 all other possible causes of sickness. My opinion, however, is that 
 in Ireland local influences have not that great importance either as 
 generators or promoters of fever which some believe them to have. 
 
 We must believe that the causes of fever, independent of mere con- 
 tagion, are various in the extreme, that they are probably nume- 
 rous and complicated, acting in combination rather than singly, and 
 varying in their effects not only in consequence of their own properties 
 and combinations, but also as regards the condition of the individual in 
 whom fever is developed. Dr. Paget, in observing that our pathology of 
 fever is not so perfect as to assure us that there are no exciting causes 
 besides those which are commonly allowed, notices the comparative 
 immunity of infants and persons above forty years of age from the 
 typhoid fever with rose spots, and affections of Peyer's glands, etc., 
 indicating that the constitution of the individual is an element in the 
 question. 
 
 You are then to understand that, while we believe in the contagious 
 nature of fever as an established fact, we do not go the length of saying 
 that all cases of fever originate by contagion. In the present state 
 of knowledge we must, I think, admit that certain combinations of 
 physical circumstances may produce fever, either in a single case or in 
 masses of men. It is hardly possible to gainsay this; but it is at least 
 as well if not better proved that this fever is capable of being com- 
 municated by actual contact, or by vicinity, from one individual to 
 another. 
 
 If we look to other diseases which affect the whole economy, we 
 
CONTAGION. 33 
 
 find analogies between them and fever; so far, at least, that in them a 
 morbid condition exists which reveals itself in two ways: one, a state 
 of general ill-health; and the other, the production of local and specific 
 alterations. Take, for example, tubercle and syphilis. 
 
 The last of these is, at all events, contagious; and though we can 
 hardly show any mode of its production except by communication 
 from one person to another, yet we must believe that at one time 
 causes independent of such a mode of communication did exist, and 
 were capable of originating the disease; and it may be that, as the 
 world advances, and the general exciting causes of fever are diminished, 
 or perhaps removed, this disease too, like syphilis, may only be pro- 
 duced and exist by means of its communication from one person to 
 another; and we may hope that such a state of things would be a step 
 to the extinction of fever, at least as a disease affecting communities 
 of men. 
 
 If it be true that we may admit two phases in the history of acute 
 essential diseases, one in which they are not only communicable, but 
 capable of original production by causes independent of contact with 
 the sick, and the other when these latter causes ceased to operate, and 
 the disease is reduced simply to a special condition, which can be 
 communicated only by contact, it is easy to perceive that, so far as 
 prevention and ultimate extinction are concerned, the difficulties 
 attendant on the matter will be greatly diminished. Let us assume 
 that, so far as the cessation of the operation of general external causes 
 is concerned, variola and syphilis are similarly circumstanced, and 
 we may hope, from what has occurred with respect to the former dis- 
 ease, that a similar diminution of fever may yet be attained, when it has 
 at last passed into the condition of a merely contagious disease. 
 
 That almost all cases of acute essential disease are contagious I 
 have long believed. The amount or degree of contagiousness varies 
 according to many circumstances, such as the nature of the malady, 
 the amount of exposure, the physical condition of those so exposed, 
 and the character of the epidemic. There can be no doubt that in 
 different epidemics — apparently of similar diseases — the character of 
 contagiousness varies remarkably, and I am glad to perceive that 
 modern British authorities now admit that even typhoid or enteric 
 fever may be propagated by contagion. 
 
 "Some physicians," writes my father, 1 " in arguing against the con- 
 tagious nature of certain fevers, have ventured on the adoption of a 
 principle which appears to me very untenable — namely, that a dis- 
 
 1 Observations on Contagion, p. 25. 
 
34 LECTURES ON FEVER. 
 
 ease can have but one cause — and hence they infer that the advocates 
 of contagion, instead of supposing, as they do at present, that contagion 
 is the general cause of fevers, with which famine, filth, damp, or cold 
 co operate singly or collectively, should suppose that one only of these 
 causes can be the true cause of every particular disease, and that the 
 admission that other causes contribute to disease is in fact a confession 
 that contagion does not." 
 
 For contagious disease, such as typhus or typhoid, though it may 
 occasionally attack individuals of the oppulent classes, runs like wild- 
 fire through an indigent and unhealthy population. The power of 
 resistance is lessened, and all the evils of the asthenic conditions are 
 increased. 
 
 LECTURE V. 
 
 Causes of Fevee — Preventive and Curative Medicine contrasted — Risk of error in 
 limiting the number of the cures of disease — The correlation and the convertibility of 
 disease two important questions, the answers to which are not as yet fully or satis- 
 factorily determined. 
 
 With respect to those causes which may be held to be capable of 
 exciting fever, irrespective of contagion, I have only to say that as yet 
 we know but little about them; and we have the highest authority 
 for believing that the origin of epidemics is one of the most obscure 
 and difficult subjects in the whole range of physical inquiry. But I 
 cannot help expressing my belief that too much stress has been laid 
 upon the effects of miasmata resulting from imperfect drainage, or the 
 want of ventilation and of public cleanliness in general. No one will 
 for a moment suppose that I wish to teach that these influences do 
 not act in deteriorating the physical health and moral condition of a 
 people, and in thus increasing the mortality of any existing epidemic, 
 and that their removal is not an imperative duty of every government 
 and community. 
 
 For some years past great attention has been paid in England and 
 on the Continent, especially in Germany, to sanitary science — that is 
 to say, to Preventive as distinguished from Curative Medicine. If we 
 compare the relative importance of these two great branches of medi- 
 cal science, it seems true that a greater value should be attached to 
 the first than to the second branch, and for this reason, that the well- 
 being of infinitely greater numbers of mankind depends more on 
 Preventive than on Curative Medicine. 
 
PREVENTIVE MEDICINE. 35 
 
 The great end of the former is to preserve the health of the masses 
 of mankind so as to prevent or to diminish the necessity of the latter. 
 The one is a matter to be dealt with by a large and wise legislative 
 code ; the other is dependent on the slow advance of medical science, 
 and on the individual character and attainments of those who are to 
 carry it out. The one embraces everything, as Dr. Acland has well 
 shown, which relates to the physical and the moral well-being of 
 nations, 1 the grinding of the poor, the consumption of human life, 
 as it were fuel for the production of wealth. 
 
 Selfishness, indulgence, unrestrained vice, and every cause which 
 tends to deteriorate the body come within its extended scope. Its 
 object is the health and the happiness of our fellow-creatures. Its 
 rules are plain and patent to all, and depend not on vexed questions 
 of difficult science; so that it promises to be the noblest pursuit open 
 to human beings, and he would be a bold man who dared attempt to 
 predicate its triumphs or to limit its results. 
 
 The occurrence and the spreading of epidemical disease have long 
 engaged the attention of advocates of sanitary reform ; but it does not 
 appear that as yet the difficulties connected with these questions can 
 be said to have been at all satisfactorily solved, even though the im- 
 portance of sanitary measures be frankly admitted. 
 
 The paramount doctrine which has prevailed in England ascribes 
 epidemics to want of cleanliness, overcrowding, deficient or impure 
 air and water supply, imperfect drainage, and so on; while the cessa- 
 tion of local outbreaks of disease after the adoption of a sanitary reform 
 is appealed to in proof that the evils in question arose solely from 
 removable influences. But the argument is defective — it is like that 
 of the therapeutists as regards essential diseases, which run their ap- 
 pointed course and then spontaneously disappear. Epidemics of fever 
 in this way resemble isolated cases. They also have their periods of 
 invasion, of maturity, and of decadence, and the subsidence of an epi- 
 demic is in many instances by no means traceable to the adoption 
 of certain sanitary measures. The experience of all great epidemics 
 establishes this fact. 
 
 There is, however, one theory or doctrine which underlies the whole 
 history of British sanitary reform, and this is — that many, if not all, 
 forms of endernical or of epidemical disease can be traced to some 
 preventable or removable cause, and that by putting a stop to over- 
 crowding, and by improving the quality of the water and the air in a 
 locality, we may prevent the occurrence of such afflictions. 
 
 1 National Health. By Henry W. Acland, F.R.S., Regius Professor of Medicine in 
 the University of Oxford, etc. etc. 1871. 
 
36 LECTURES ON FEVER. 
 
 I need not here point out to you the tendency which exists in many 
 minds to attribute great phenomena to too limited a cause or causes. 
 Thus, for example, some form of essential disease arises and spreads 
 in a particular locality. This is inspected, imperfect sewerage is dis- 
 covered, and the evil abated by the adoption of proper measures. 
 Then the sanitarians triumphantly appeal to the circumstances as 
 proving that the outbreak was the direct result of the alleged nui- 
 sances, and perhaps of them alone. 
 
 By this line of argument many sanitarians of that class who have 
 not received a scientific education, and who know but little of the 
 history of disease, hold that such unwholesome and removable in- 
 fluences may originate diseases which are themselves dissimilar. 
 
 But the question before us is, Are those influences in this country 
 the sole or the chief causes of fever? It is difficult to believe that they 
 are, because in Ireland, not only in the isolated dwellings of the poor 
 which are scattered over the face of the country, but in the towns also, 
 all those causes which result from the imperfect drainage of dwellings, 
 from the accumulations of decomposing organic matters in their vi- 
 cinity, and from imperfect ventilation, are, I regret to say, but too 
 constant and too general; and yet the production of fever, whether spo- 
 radically or epidemically, is inconstant and irregular in the highest 
 degree. Why should these causes produce fever at one time and not 
 at another? Why should districts remain for years free, or compara- 
 tively free, from fever, while the supposed exciting causes remain in 
 full force? or, again, why if the cause be constant, should the epi- 
 demic character of the fever vary? We may say, excluding the con- 
 sideration of isolated cases, that each epidemic has a special or pre- 
 dominant character; thus, the great epidemic of 1826 and 1827 was 
 very different from the epidemic which preceded it in 1818, and from 
 those which followed it in 1836 and in 1847. It was in the epidemic 
 of 1826-27 that we observed the almost universal prevalence of the 
 secondary disease of the intestine; perforations of the intestinal tube 
 were common; and yet, since that period, such an accident is rarely 
 met with, either in the fever itself or during the period of con- 
 valescence. It was at that time, too, that those singular and fatal 
 cases of yellow fever, to which we shall have to allude, occurred 
 intercurrently. In this fever, also, termination by well-marked crisis 
 was commonly observed, a circumstance which is comparatively rare 
 in the epidemics of maculated typhus in this country. 
 
 I do not put forward these views as in any way original, for Dr. 
 Graves long held the opinion, and taught it in this theatre, that 
 something more than the effect of local causes, as the term is com- 
 
graves' views as to causes of typhus. 87 
 
 monly understood, was necessary to explain the occurrence of epi- 
 demics in Ireland. Let me read to you a quotation from his seventh 
 lecture, one of those devoted to the consideration of fever: 1 "That 
 fever, in Ireland at least, depends on some general atmospheric change 
 which affects the whole island simultaneously, independent of situa- 
 tion, aspect, height above the level of the sea, dryness or moisture of 
 the soil, or any other circumstance connected with mere locality, is 
 proved by the fact, that when typhus begins to increase notably in the 
 Dublin hospitals, we may always rest assured that a nearly simulta- 
 neous increase of fever will be observed at Cork, Gal way, Limerick, 
 and Belfast. For a considerable period there was a great tendency 
 among physicians to refer the origin of typhus, and of almost every 
 variety of fever, to malaria or unwholesome emanations from the soil, 
 produced by the decomposition of vegetable matter. In Ireland facts 
 do not bear out this hypothesis, for, as already stated, when an epidemic 
 of fever has become established it breaks out simultaneously in situa- 
 tions the most different, and in some where no such emanations can 
 be supposed to exist ; thus I have seen a whole family affected in the 
 telegraph situated at the summit of Killiney, a mountain formed of 
 hard granite; and, indeed, the granite districts beyond Rathfarnham, 
 Tallaght, and Killikee supply the Meath Hospital with its worst cases 
 of typhus." Further on he observes, " Although ready to allow the 
 general improvement of the health of the public from improved drain- 
 age, improved habits of cleanliness, and increased comforts, yet I 
 cannot admit that in Ireland we 'are to expect any notable diminu- 
 tion of fever from the operation of these causes. In making this state- 
 ment you are aware that I am opposing the usually prevalent opinion. 
 The grounds for my dissent have been partly explained to you already, 
 for, according to my observation, the increase or diminution of fever in 
 Ireland arises from some unknown general atmospheric or, if you will, 
 climatic influence, quite independent of locality, and consequently the 
 most improved and thoroughly drained towns and country districts are 
 quite as liable to epidemics of typhus as are the most neglected and 
 marshy parts of our island. The causes which occasion these epidemics 
 are, on the other hand, in no way connected with the notable variations 
 of the seasons; for with us the ravages of typhus are observed some- 
 times in dry, sometimes in rainy seasons, and its epidemics appear 
 quite uninfluenced by the cold of winter or the heat of summer." . 
 In Ireland the habits of the poor as to uncleanliness and over- 
 
 1 Clinical Lectures on the Practice of Medicine. Reprinted from the Second Edi- 
 tion, 18b'4, p. 62. 
 
38 LECTURES ON FEVER. 
 
 crowding call for great reform, especially in our towns, where poverty, 
 neglect, and overcrowding so often make them foci of endemical 
 disease. The condition of our country towns and villages is simply 
 deplorable, disgraceful to the local authorities, and in too many in- 
 stances to the proprietary, frequently heedless as to the social and 
 physical condition of those who live under them. Even the state of 
 the metropolis, possessing a Public Health Committee, is shocking, and 
 has been ably shown by Dr. Grimshaw in a recent communication to 
 the Medical Society of the College of Physicians, Ireland. 1 
 
 What I wish you to believe, gentlemen, is, as I have already stated, 
 that our fever is epidemic, proceeding from general but unknown 
 causes — and also contagious ; and no one can deny that causes which 
 would act in depressing the health and moral energy of a people, by 
 rendering them less able to resist the effects of disease, would increase 
 the general- mortality. The influence of bad ventilation and over- 
 crowding I need not here dwell on; nor, on the other hand, need I 
 occupy your time with more arguments to establish the truth of the 
 doctrine of contagion. You will find in the writings of Sir Robert 
 Christison, of Dr. Murchison, and of Dr. Graves convincing evidences 
 on these points; and let me again refer to the great argument drawn 
 from the liability to contract fever observed among the medical prac- 
 titioners of Ireland, especially in the epidemic of 1847. 
 
 The occurrence of offensive odours proceeding from the putrescence 
 of organic matter naturally led to the widespread idea that the ob- 
 jectionable smell was the exciting cause of sickness, and that all sani- 
 tarians had to do was to remove the sources of air and water pollu- 
 tion. But though the researches of Murchison and of Sir William 
 Jenner go far to connect what has been called typhoid or enteric fever 
 with the existence of noxious emanations from human excreta, other 
 weighty questions remain. 
 
 For example, Are these emanations the sole cause of the so-called 
 pythogenic or enteric fever? Is this fever essentially different from 
 typhus ? Can it be propagated by contagion, irrespective of exposure 
 to putresence? Can it originate from the contagion of typhus? Is 
 the relation of the local to the general malady the same as in typhus? 
 And do the principles of treatment materially differ? Again, we 
 must put to ourselves this most important query: Does sanitary 
 reform, in providing a supply of pure air, pure water, sufficient drain- 
 age, and so on, act by extinguishing the sources of epidemical disease ? 
 
 1 That, notwithstanding, the presence of filth does not itself presuppose the presence 
 of fever will appear from the facts relative to certain places in the country districts 
 of Ireland, which will he found iu Appendix A. 
 
CORRELATION AND CONVERTIBILITY. 39 
 
 Or is it that by the consequent improvement of the health of the 
 population the community is better able to resist illness, be it con- 
 tagious or non-contagious, and to lessen its severity when it does 
 supervene? 
 
 This, I apprehend, is, in the present state of our knowledge, the safe 
 and practical way in which to regard these all-important questions. 
 Civilization demands that all deleterious influences, all that offends 
 the senses, should be removed or checked, and the population of a 
 country placed under the most favourable sanitary conditions, es- 
 pecially as to its supply of air, water, food, and clothing; but the sub- 
 ject is a wide one, and embraces far more than the actual origin of 
 endemical or even epidemical disease. 
 
 With reference to the presumed origin of that form of fever called 
 by Dr. Murchison the Pytho genie Fever, I would warn you, without in 
 the slightest degree throwing doubt on the value of his researches, 
 not to follow the system of attributing complex phenomena, or states 
 of things, to a single cause, or to a too limited number of causes. 
 
 " This supposition of a single cause of the effects we witness is 
 quite unsupported by nature. Every animal, every plant, every rock, 
 requires for its production the co operation of many causes that we 
 know of, and most probably of many more that we have not yet dis- 
 covered. All nature depends ultimately upon a single cause, but it 
 has pleased that Almighty Cause that the effects which concern us 
 immediately should arise from the co-operation of several of His 
 creatures." 1 
 
 There is another habit against which I would put you on your guard : 
 the one, namely, of holding that every disease of which a description 
 appears in our nosologies is a peculiar and isolated entity, separated 
 by hard and fast lines from any other either in its nature or in its 
 exciting cause. The attention of physicians has been awakened to 
 the doctrine of the correlation of zymotic diseases, 2 a doctrine which 
 has been long suspected, to be true by practical men. 
 
 Yet, it may be asked, can we not go a step further, and consider 
 whether essential diseases are not convertible as well as correlative ? I 
 think that before the session is over you will meet with instances 
 which will incline you to arrive at both conclusions. Cases will occur 
 to you, especially during the prevalence of an epidemic, where the 
 disease seems to hesitate as to what particular character it will 
 assume, so that it is often a matter of the most extreme difficulty, even 
 
 1 observations on Contagion. By Whitley Stokes, M.I). , p a 25. 
 
 2 Zymotic Diseases, their Correlation and Causation. By A. Wolff, F.R.C.S. Eug. 
 1872. 
 
40 LECTURES ON FEVER. 
 
 when an eruption is well out, to say to which of the exanthemata the 
 individual case belongs. Under such circumstances the public used 
 to regard it as a mark of ignorance if the attendant were unable to 
 give an exact name to the malady, but they are more enlightened now. 
 
 APPENDIX A. 
 
 The following are some extracts of a letter from a gentleman of 
 great ability and truthfulness, who holds an important public appoint- 
 ment in the South of Ireland. He had been requested by the com- 
 missioners of a town in that part of the country to inspect the state 
 of the town and report on the works necessary for sewage improve- 
 ment. 
 
 It was about the year 1865, when there was some apprehension of 
 an epidemic of cholera : — 
 
 "I went," says this gentleman, "through every lane and street, and ex- 
 amined all the tenements of every class in the latter end of January or 
 beginning of February. There were no main sewers in any but the princi- 
 pal streets, and none of these had them for their whole length. The lanes 
 and alleys leading off from these streets were mostly very narrow, and- had 
 no outfalls for sewerage discharge except surface channels, and very few of 
 the houses had any back entrance; a good many had neither yards nor back 
 entrances. But all had dung-pits. If not behind, they were contrived in 
 the widest parts of the lanes by being sunk and inclosed with walls, so as to 
 hold from 8 to 12 cubic yards of manure each. Where the tenement had 
 not the 'easement' of a dung-pit or yard, or right to part of the common 
 way, the manure was stored in the dwelling house. Most of the houses 
 were thatched cabins, but several rows of two-storied houses were built, and 
 a good many one-storied slated houses of small size were to be found con- 
 taining four apartments. I discovered in one of these rows, which had very 
 small backyards (not half the size of the house in any case), that the whole 
 of the ground-floor, and part of the house, except the staircase and passage 
 leading to it, were filled with manure (the scrapings of the roads and streets) 
 tightly packed to the height of eight feet ; and in the rooms above there were 
 two families living — one in each room. The manure had of course heated, and 
 was steaming up through the chinks of a badly-laid floor, the under side of 
 which was dripping wet from the the fermentation below. 
 
 "In several of the rows having backyards the surface water was allowed 
 to run through the whole length of the lane from yard to yard, and the 
 occupier of the lowest tenement was looked upon as having the most valu- 
 able holding of the whole lot, and something like the Chinese care of liquid 
 manure was shown by extra mould or refuse being provided to absorb or 
 soak it up. The parts of the town to which this description may apply 
 covered about 25 acres, and almost every part of that surface was teeming 
 with etfluvia from such decayed substances of every sort as are admitted to 
 be of the most noxious kind, without any provision whatever for carrying 
 off the putrid water which is always to be seen in so wet a climate as this. 
 
 "The population is about 6000, of which two-thirds live in cabins fur- 
 
APPENDIX A. 41 
 
 nished with the inevitable dung-pit. These cabins contain 700 families at 
 the least. The dung-pit averages 10 cubic yards in content, so that on 25 
 acres we have at least 7000 cubic yards of fetid matter, with 4000 people 
 breathing the exhalation of such an accumulation as could not, I think, be 
 found elsewhere in Ireland. 
 
 " But nevertheless this town has always been a remarkably healthy place. 
 There is a fever hospital which has not been full since the famine dysen- 
 tery in 1847-8, and which is very frequently empty. There is no dislike 
 on the part of the poor to go into this hospital, because it is not the work- 
 house, so that the few fever cases that do occur arc quickly removed out of 
 the crowded houses. 
 
 "It was asked — 'How can such a state of things be? or how can it be 
 accounted for that such good public health can exist amidst all this rotten- 
 ness giving rise to the miasmata so well known as certain producers of 
 fever and cholera?' I suggested that there were two great advantages in 
 favour of health, namely: an ample supply of the very best water and 
 smoky houses. The subsoil of the town is gravel and sand to a great depth, 
 and in this there are many strong springs, the purest water being met with 
 at 6 or 8 feet under the surface. The fuel used is all turf, and the blackened 
 walls of the inside of the houses showed that the inhabitants lived in an 
 atmosphere of peat smoke. I cannot help thinking that such smoke, pos- 
 sessing as we know preserving or antiseptic properties, must act as a 
 deodorizer and preventive against infection or malaria. 
 
 " I asked one of the occupiers who lived over his dung-heap in an upper 
 floor how he could expect to escape death by fever or cholera to himself or 
 some of his family (a wife and five children), and his reply was, ' Sure we 
 might as well be dead as never to have a bit of dung for the garden.' 
 
 " Some legislator has said that 'Ireland is an anomaly ' — may be the san- 
 itary statistics of this town are another proof of this." 
 
 The inhabitants of this town escaped the endemical disease so 
 common in other towns of the south of Ireland, perhaps because, in 
 addition to the pure water and turf smoke, an intimacy with malaria 
 for many generations had at last made them insusceptible to it. 
 
 Dr. Pratt, in a paper read before the Surgical Society of Ireland, 
 recently touched upon this same question. After alluding to the 
 widely accepted theory of the actual origin of fever, as proceeding 
 from the decomposition of animal and vegetable matter, he observes 
 that "after an experience of nearly a quarter of a century as an Irish 
 dispensary medical officer, it is his firm conviction that these agencies 
 alone considered cannot be productive of fever of any type. Were 
 it otherwise, Ireland would before this have been depopulated from 
 sea to sea. " 
 
 " Among the Irish agricultural classes," he adds, " the farm yards 
 are simply the open spaces either in the front of their dwellings or 
 close behind, the offices, cow-houses, stables, etc., forming a component 
 part of them ; the farm-yard manure carefully heaped, in many in- 
 stances up to the very door, and in such a way that it often becomes 
 a problem to the perplexed doctor, whose aid is desired within, how 
 
42 LECTURES ON FEVER. 
 
 to effect an approach (especially when called on in the dead of night) 
 without sticking ankle deep in mire or filth, or, perhaps, coming to a 
 worse grief in the shape of a souse in a slough of despond. 
 
 "Such is the state of affairs during the winter months. In the hot 
 weather of summer the pits from which the accumulated manure has 
 been removed to the farm, serve as receptacles for slops and refuse of 
 all sorts thrown from the houses. These slops, fermenting in warm 
 weather, produce a green stagnant pool. The gases generated show 
 themselves as bubbles on the surface, which in due time burst, and, 
 of course, discharge their supposed noxious contents in the immediate 
 vicinity of the dwelling, with all its inmates, old and young." 
 
 Dr. Pratt observes that, in such places, a case of fever, of any type, 
 rarely occurs; the average length of life is high, and illness, except 
 common colds and infantile diseases, is almost unknown. 
 
 Even in instances where the peasantry live in a worse condition, 
 the cattle, pigs, and poultry occupying the same room, and the refuse 
 being swept into a pit close by the fireside, he has found the families 
 hale and sound, and strangers to fever. 
 
 LECTURE VI. 
 
 Varieties of Feverrs observed (1) in different epidemics, (2) in the same epidemic, 
 and (3) in members of the same family, living under the same conditions— This 
 last-named fact is corroborative of the doctrine of the essentialism of fever — De- 
 finition of the term epidemic character of fever — Outbreaks of 1818-19, 182G-27, 
 and 1847 contrasted — Typhus and typhoid or enteric fever appear to be but species of 
 the same genus — Contagiousness of typhoid fever — Dr. Flint's memoir — Principles 
 of treatment of fever of any type must be based on an acquaintance with the law 
 of periodicity, to which the disease is subject. 
 
 The varieties of fever depend upon diverse circumstances. We 
 may take, for instance, the disease in its epidemic character. It may 
 be laid down as an axiom that no two epidemics of fever have been 
 precisely similar as regards the character and aspect of the disease 
 presented to our observation on the two occasions. No doubt in the 
 history of a series of epidemics, extending over a space of many 
 years, some — nay, many — cases analogous in symptoms, and even sim- 
 ilar in their mode of termination and in their result, may come under 
 our notice. Thus, if the outbreak of 1880 is compared with that of 
 1820, cases will be found recorded in the history of the morbility of 
 the former year the counterparts of which, so far as relates to symp- 
 
EPIDEMICAL DIVERSITY OF FEVER-TYPE. 43 
 
 toms, sequelae, and result, may have been observed ten years before. 
 Apart, however, from individual exceptions, when any two or more 
 epidemics are taken into consideration, they will generally appear to 
 differ widely one from another. 
 
 But not only has this diversity of type and character been noticed 
 in distinct epidemics, separated by intervals of time, but even in one 
 and the same epidemic numerous cases have occurred, characterized 
 by symptoms essentially distinct, and marked by as widely varied 
 conditions of the bodily system. In one group of cases there will be 
 present utter prostration of strength, and intense depression of vital 
 energy; in another group we may observe abundant vitality and 
 almost unimpaired muscular and nervous force. In the same epi- 
 demic, again, fevers may vary in duration ; one lasting but five days, 
 another not terminating till the fortieth or forty-fifth day, or even 
 later. Once more, we find infinite variations as to the period of the 
 essential disease at which secondary complications will show them- 
 selves. In some cases the secondary affections in one or more organs 
 may not become developed or apparent until after the twenty-first or 
 even the forty-second day of the disease. The seat, too, of compli- 
 cations may be in one set of cases the brain, in another the thorax, 
 and in a third the abdomen. 
 
 We may trace this Protean character of fever even further. That 
 in two epidemics, separated it may be by a wide interval of time from 
 each other, the type of the disease, its attendant phenomena, its com- 
 plications, its duration, and so on, should vary much was perhaps not 
 to be marvelled at. That even in the same epidemic the disease should 
 present varying forms and characters is more remarkable, though still 
 easy of comprehension. But we can carry our investigations a step 
 further, and we shall meet with still more striking results. When 
 fever appears in a family, living in some confined situation in a large 
 city or town, in a badly ventilated dwelling, perhaps in the midst of 
 an unwholesome and densely populated neighbourhood, several mem- 
 bers of that family may be struck down by the disease. They may 
 sicken simultaneously or one after the other, so that we are afforded 
 an opportunity of witnessing the effect of the malady on them indi 
 vidually. Under such circumstances it has been observed that a 
 marked variety is presented in the condition of the several patients. 
 One will have the disease in its severest form, another will experience 
 but a mild attack ; some will suffer from protracted fever; others will 
 go through an illness of the briefest duration ; one will have petechise, 
 another will present no eruption: one will display critical phenomena, 
 
44 LECTUEES ON FEVER. 
 
 whilst another will recover without crisis of any kind ; one will have 
 typhus, another typhoid, or even rheumatic, fever. 
 
 Now this is a most remarkable fact, and one strongly corroborative 
 of the doctrine of essentialism in fever. We might a priori suppose 
 that where there existed a certain similarity in the physical and moral 
 characteristics of persons so closely related by consanguinity, so alike 
 in habits from living together, and so uniformly subjected to the 
 same mode of life, those persons when exposed to the influence of one 
 and the same poison or virus of contagious fever would present one 
 and the same type of the disease. 
 
 It is of the greatest importance, gentlemen, that you should devote 
 your most attentive consideration to reflections such as these in your 
 study of fever, in order that you may be prepared for any exigency 
 arising from the varied and complex aspects in which the disease will 
 present itself before you — in order that you may be duly armed and 
 fitted to encounter the deadly, the subtle enemy you will have to meet. 
 
 The constancy in variability of which I have just spoken in rela- 
 tion to fever applies also to all forms of local epidemics. As in the 
 case of individuals, so of epidemics, one outbreak of fever will be 
 marked by profound prostration of the system, by a loss of strength 
 requiring the exhibition of stimulants, while another will present evi- 
 dences of a sthenic condition of the patients, calling for an exactly 
 opposite mode of treatment. This is what is termed the epidemic 
 character of the disease. I remember the fever of 1818 and 1819, the 
 equally formidable outbreak of 1826 and 1827, and lastly the great 
 epidemic of 1847. If we compare the first with the last of these vis- 
 itations, we shall find that they possess many points of resemblance. 
 Both were examples of severe typhus fever, both had maculae in 
 patches, both were petechial. The epidemic of 1826-27 was of a 
 milder but more diffusive type; in it vast numbers were indeed attack- 
 ed by the fever, but the great and profound sinking of the system 
 which prevailed in the other epidemics I have mentioned was not 
 present in this. 
 
 So widely spread was the last-named epidemic (that of 1826-27) 
 that at the Meath Hospital we were obliged to have additional accom- 
 modation for patients provided. Sheds were built, canvas tents were 
 erected, their floors covered with hay, on which the crowds of patients 
 conveyed to the hospital in carts were literally spilled out. I have 
 seen as many as ten patients lying on the hay awaiting their turn to 
 be attended to. In fact, so immense was the number of sufferers that 
 it became impossible to bestow medical care upon them all ; indeed, 
 a large number of them got no medicine whatever, but all received 
 
TYPHUS AND TYPHOID. 45 
 
 reasonable care and comfort. Abundance of whey was provided, and 
 on this, without any farther treatment, numbers got well through the 
 fever — as Dr. Rutty, speaking of the year 1739, quaintly observed, 
 " abandoned to the use of whey and Grod's good providence." I 
 doubt not that the mortality among those treated after this primitive 
 fashion was not greater than that among the patients subjected to 
 medical treatment secundum artem. It should be observed that there 
 was more of an inflammatory character evinced in this epidemic, the 
 skin being hot and dry, the pulse hard and full, etc. 
 
 Fever, you are aware, has been somewhat arbitrarily divided into 
 two classes, or placed under two great heads — typhus and typhoid. 
 Typhus fever is held to take its origin from the vitiated air and the 
 unhealthy condition of body resulting from the crowding together of 
 masses of human beings, coupled, perhaps, with neglect of cleanliness, 
 absence of proper ventilation, clothing, and food, and the prevalence 
 of indolent and disorderly habits. The emanations arising from over- 
 crowding, or ochlesis, as it is termed, doubtless predispose in an extra- 
 ordinary degree to the outbreak and spread of this form of fever, 
 a form of the disease which has received various titles — some from 
 its connection with ochlesis, as camp fever, jail fever ; others from the 
 peculiar morbid phenomena attending it, as putrid fever (when it dis- 
 plays a tendency of the solids to run into decomposition) ; spotted fever 
 (from the maculse or spots so frequently observed on the surface of 
 the body in this form of disease) ; and others again from its well- 
 known formidable character and too often fatal result, as typihus gravior, 
 malignant fever, etc. 
 
 Typhus also is regarded as being the more dangerous form of the 
 disease, but I am by no means convinced that this opinion is correct. 
 There is, however, one reason why this idea should be entertained by 
 British physicians ; the epidemics of fever which have been most 
 fatal in these countries have been of the typhus kind, whilst it may 
 be said that we have had repeated visitations of the typhoid form of 
 fever attended with a comparatively slight mortality. Typhus fever, 
 when it comes, at once assumes the true epidemic character, whereas 
 typhoid more frequently prevails endemically, and with less direct 
 fatal results. 
 
 Typhoid, enteric, or pythogenic fever is generally attributed to 
 emanations from putrid matter, or, according to Dr. Budd, to the ex- 
 posure to contagious matter contained in the evacuations of patients 
 suffering under the disease. This contagious matter may be intro- 
 duced into the .system either through the medium of the air in ;t gaseous 
 form or by means of contaminated drinking water. Typhoid lever is 
 
46 LECTURES ON FEVER. 
 
 considered to be essentially an epidemic disease ; in other words, it 
 may occur in particular situations. The opinion was almost univer- 
 sally held that this form of fever was non-contagious, but the adherents 
 to this doctrine are becoming less numerous of recent years. If it 
 were a fact that typhoid fever was not a contagious disease, we should 
 have a marked and important distinction at once established between 
 it and typhus, but it is not so. I do not say that typhoid fever is so 
 contagious as typhus, yet I will not admit that the former possesses 
 the attribute of being non-communicable. I would strongly urge you, 
 gentlemen, to be very cautious in admitting the line of distinction 
 which authors have drawn between these forms of disease as regards 
 the question of contagion, and you may depend upon it that the num- 
 ber of diseases propagated by contagion is much greater than what is 
 generally admitted. We can found no distinction between typhus 
 and typhoid upon the circumstance that one of these fevers, as, for 
 instance, typhus, is contagious and the other not. I have long be- 
 lieved in the contagion of the non-petechial, or, if you will, the typhoid 
 fever of this country. In the epidemic of 1826-27, to which I have 
 before referred, and which was essentially an epidemic with the so- 
 called anatomical characters of the typhoid disease, we had abundant 
 proofs of contagion; and in this very hospital many of our most 
 zealous students were at that time attacked with fever. 
 
 It may be here observed, that although this epidemic was one 
 essentially of the so-called typhoid form, characterized by absence of 
 the symptoms of putrescence, by frequent relapses, by recovery, by 
 crisis, and in very many cases by evidences of disease of the intestinal 
 glands; yet the attendants on the sick, when they were themselves 
 attacked, presented in many cases the symptoms of genuine typhus. 
 It was during this epidemic that I contracted typhus fever; and shortly 
 afterwards one of my clinical clerks, who had been distinguished 
 for his zeal in his attendance on the sick, fell ill. We both had bad 
 maculated typhus without any symptoms of dothinenteritis ; in my 
 case the disease ran a course of fourteen days; and in neither instance 
 was there any relapse. 
 
 A very remarkable instance of the contagiousness of typhoid fever 
 has been placed on record by Dr. Austin Flint, of Buffalo, United 
 States, in a memoir "On the Transportation and Diffusion by Con- 
 tagion of Typhoid Fever," published in 1852. In a small isolated 
 community, consisting of nine families, at North Boston, county of 
 Brie, New York, typhoid fever had been quite unknown up to the 
 autumn of 1843. Indeed, in no part of the county of Erie was the 
 disease known to have occurred up to the time mentioned. On the 
 
TYPHUS AND TYPHOID. 47 
 
 21st of September in that year, however, a young man from Warwick, 
 Massachusetts, being on a journey westward, took lodgings at the 
 tavern of North Boston, kept by a man named Fuller. He had been 
 ill for several days, undoubtedly labouring under typhoid fever. He 
 died on the 19th of October at the tavern, which was a place of daily 
 resort for the members of seven families, with one exception living 
 within a few rods of each other. One family, consisting of several 
 persons, was on terms of hostility with the innkeeper, and so all inter- 
 course was precluded. Twenty-three days after the arrival of the 
 stranger, two members of the innkeeper's family were attacked with 
 the disease from which he suffered. Subsequently five other cases 
 occurred in this family. In all the other families, with one exception 
 already noted, cases more or less numerous were observed within the 
 space of about a month from the date of the case first developed after 
 the stranger's arrival; and during this period more than one-half the 
 population became affected. The family in which no case occurred 
 was the only one of the seven which was not brought into direct con- 
 tact with the disease. The other two families resided at a distance, 
 and seemed to be out of the reach of infection. 
 
 So extraordinary was this outbreak that the popular opinion in the 
 neighbourhood was that the head of the family in feud with Fuller the 
 innkeeper had poisoned a well used daily by the latter, and by six 
 other families, of which five were attacked. That this opinion was 
 not correct was proved by a careful examination of the water by two 
 leading chemists of Buffalo, when it was found to be remarkably pure, 
 " the only foreign ingredient detected being a small proportion of 
 saccharine substance, which was explained by the fact that the vessel 
 in which the water was transported had previously been used as a 
 molasses jug. " 
 
 Typhus, again, is said to be an essential disease, affecting the entire 
 economy; whilst typhoid has been looked on as & non-essential, or 
 merely a symptomatic affection. The inadmissibility of this view has 
 already been, I trust, sufficiently indicated in a former lecture. Tt is 
 a doctrine at variance with practical experience; it is a theory quite 
 incompatible with observed facts. Owing to the ever-varying nature 
 of fever, many of its secondary phenomena may or may not be 
 present— we may have typhus without measly eruption or macular; 
 we may have typhoid without diarrhoea, rose-spots, or any other symp- 
 tom said to be pathognomonic. We are compelled to admit that pa- 
 thological anatomy has failed as a means of pointing out any essential 
 distinction between these two forms of fever. Anatomy, it is true, 
 may reveal to us certain morbid changes and abnormal conditions in 
 
48 LECTURES ON FEVER. 
 
 different organs in many cases of either typhus or typhoid. But 
 these alterations are only the results, not even the necessary or con- 
 stant results, of the primary disease; and so they throw no light upon 
 the object of our search — a vital distinction between the two fevers. 
 
 Even as regards the presumed causes of the diseases — ochlesis, civic 
 miasm, poverty, hunger, or cold — are not the conditions supposed to 
 be requisite for the development of typhoid present in cases where 
 typhus is generated by overcrowding? Are not filth, putrescence, 
 impure water, and foul air probably existent in such a state of things ? 
 Do these influences produce at one time pythogenic, and at another 
 typhus, fever? Do they excite both diseases at once in the same indi- 
 vidual? Does A get typhus, while B, exposed to the very same influ- 
 ences, and under perfectly similar circumstances, contracts typhoid? 
 
 The treatment of fever, whether it be typhus or typhoid, is reducible 
 to a simple formula, and is essentially the same in both types ofdisease. 
 We know of no cure for fever; no man has ever cured it. It is, how- 
 ever, curable spontaneously. If you leave it to its own course, it is 
 capable of curing itself. It will spontaneously subside. Remember- 
 ing the law of periodicity, the great object of the physician should be 
 to gain time, preserving the patient from the dangers which threaten 
 him, which belong to this special state of life. If he can be kept 
 alive to the 14th day, the 21st, the 36th, or even the 60th day, recovery 
 will probably ensue. Every day, every hour of existence preserved 
 and sustained is a clear gain. The risks that he runs are due to debil- 
 ity or to the influence of the secondary affections. We, so to speak, 
 cure the patient by preventing him from dying. We endeavour to 
 gain our end by combating the exhaustion which threatens to prove 
 fatal to him with food, with stimulants, and with tonics. We seek to 
 obviate or to modify the dangers of the local diseases by meeting them 
 as early as we can discover their presence, bearing in mind the depress- 
 ing influence of the general malady. Herein lies the secret of the 
 treatment of fever. We watch the progress of the disease throughout 
 its varying phases; we meet by judicious treatment, as they arise, 
 the symptoms of secondary and local malady; we sustain the system 
 as far as practicable; we preserve the sufferer at the least expense to 
 the constitution ; and we wait patiently until the hour shall strike 
 when, in accordance with the mysterious law of periodicity, the fever 
 shall have departed and convalescence shall have begun. 
 
RESEMBLANCES OF TYPHUS AND TYPHOID. 49 
 
 LECTURE VII. 
 
 Points of Resemblance in the various forms of fever a more practical subject for 
 investigation than their distinctions — As regards the principles of prognosis, diagno- 
 sis, and the management, various forms of fever lose their separate and individual 
 significance — Points of resemblance between typhus and typhoid — The famine fever 
 in 1847 — Recapitulation. 
 
 Referring to the last lecture, it may be observed that in these 
 days the attention of investigators on fever has been directed rather 
 to the distinctions between its various forms than to their points of 
 resemblance, and yet it may be asked whether, looking at the end 
 and object of the study of disease, the latter consideration is not the 
 more important. 
 
 Indeed, the more experience of essential disease a man acquires 
 the less value he will attach to the classification of it, at least in these 
 latitudes ; for though he will find that the mere nosological distinc- 
 tions (as given in books) are abundant, yet the grounds of action in 
 practice depend more on the general nature of disease than on its 
 specific characters, which, though sufficiently well marked under 
 certain circumstances, are not so fixed as to warrant the belief that 
 they indicate an absolute speciality in disease. 
 
 This seems more certain in those forms of essential disease which 
 are classed under the general head of Continued Fevers, such as 
 typhus, relapsing or famine fever, and the typhoid or enteric — the 
 pythogenic fever of Dr. Murchison. 
 
 There can be no doubt that in a fever hospital you will see various 
 cases not presenting the same characters. One patient is prostrated 
 at an early period of his illness, his nervous system much affected, 
 the heart weak, and the skin covered with petechial spots, while in 
 the next bed may be one with comparatively little of the nervous 
 symptoms, without eruption, except a few rose spots on the front of 
 the body, and with less prostration ; his condition does not seem so 
 alarming as that of his neighbour, but it may be that his disease will 
 prove fatal, while in the other case there will be a perfect recovery. 
 
 Between these two cases you may find many other points of differ- 
 ence in the history, the exciting cause, the amount of prostration, and 
 the seat and apparent extent of local change. You may, if you will, 
 call one of them typhus and the other typhoid, pythogenic, or enteric 
 4 
 
50 LECTURES ON FEVER. 
 
 fever. That will do no harm. The name of the disease would be an 
 important question if it implied such a difference in nature as would 
 call for a complete difference in treatment. But as regards the great 
 principles of prognosis, diagnosis, and the management which will 
 assist nature in the effort to throw off the disease, they are the same ; 
 and. so far these cases, though they may individually differ, yet seem 
 to belong to the same family. 
 
 I have said that I hold the study of the resemblances or points of 
 agreement among these diseases, to be of more value than that of 
 their differences, and for this reason, that the former bears on the 
 question of treatment much more than does that of their distinctions. 
 
 Now, remembering that fever is a condition of which it cannot be 
 said that there is any certain anatomical character, it may be held, 
 even if we confine ourselves to but two forms — typhus and typhoid : — 
 
 First: — that they are both essential fevers, in which the local dis- 
 ease is secondary to, and produced by, the general ailment. 
 
 Secondly: — that the general malady is influenced by the laws of 
 periodicity. 
 
 Thirdly : — that its symptoms may be modified by the local second- 
 ary affections, as to their seat, complications, period of appearance, 
 intensity, retrocession, and behaviour under treatment. 
 
 Fourthly : — that in both diseases the local affections are inconstant 
 as to seat, period of appearance, intensity, complication, and subsi- 
 dence ; varying according to the locality, the duration of the malady, 
 the epidemic character, the exciting causes, the habit of body, and the 
 influence of treatment. 
 
 Fifthly : — that both may exist, and even run their course, without 
 the production of recognizable local disease. This appears to be more 
 often true in the case of typhus than of the other forms of fever, yet 
 even in the typhoid or enteric fever there is no constancy of relation 
 between the symptoms and the local change, and in both the local 
 diseases are inconstant in seat, amount, and time of appearance, and 
 incompetent to explain the phenomena of the malady. 
 
 Sixthly : — that these local diseases are, like the general affections, 
 subject to the law of periodicity — that is, they spontaneously subside, 
 sometimes before the disappearance of the fever, at other times after- 
 wards. 
 
 But when reactive irritation sets in, various structural changes may 
 occur, and the fever originally essential may become more or less 
 symptomatic. This we may see in very prolonged cases of typhoid. 
 
 There are yet other points of resemblance, of which the most im- 
 portant is that both forms of disease are contagious, though probably 
 
SPECIES, NOT GENEEA, OF FEVER. 51 
 
 in different degrees. This is now admitted by the best observers. 
 Furthermore, there is a species of evidence more often attainable 
 in an Irish than a British hospital. You know that we have not 
 unfrequently in the wards the whole, or nearly the whole, of a family 
 sick of fever. The patients have occupied the same dwelling, too often 
 the same room, and they have sickened successively and within short 
 intervals of time. It is difficult to believe but that there has been 
 a similarity in the exciting cause of disease in all, and there is a 
 strong probability that the sickness of one has promoted that of 
 another. Now, in this group what do we find ? Is it that the same 
 character of fever affects them all ? Nothing of the kind — one patient 
 may be in maculated typhus; in another there is no eruption; in 
 another the case is typhoid, or the so-called pythogenic or enteric 
 fever; and so on among them. Even cases of rheumatic fever may 
 occur. But this is not all ; second attacks arise, but these are not 
 necessarily — not, I might say, even commonly — repetitions of the first 
 ailment or group of symptoms. In the typhus fever patient they may 
 be those of typhoid; in the non-maculated there may be abundant 
 macula?. In the other cases similar circumstances occur, the second 
 attack presenting types differing from the first ; one has a short fever, 
 another a long one ; one a complicated, the other a comparatively 
 simple attack ; one with predominance of cerebral, another with that 
 of pulmonary symptoms, and another with all those of enteric or 
 pythogenic fever ; one requiring stimulants in the second attack, 
 though there was no failure of circulation in the first; and similar 
 differences may be seen as to the remaining complications. 
 
 Do not these facts point to the conclusion that there is but a slight 
 tension, so to speak, in the individuality or separate characters of the 
 various forms of fever, and that in their essence and from a practical 
 point of view they may be looked on as species rather than genera — 
 the genus being fever, that condition on which anatomical investiga- 
 tions, in the words of Graves, throw but a negative light? I tell you 
 — not that you are to look at every case of fever as similar in character, 
 in complications — that would be bad teaching, as your experience 
 would soon convince you — but that it is a condition much more various 
 than you would suppose, were you to form your notions of it from 
 books. Its many forms are closely related. The exciting causes of 
 one may produce another; the secondary effects have not the con- 
 stancy which authors describe in seat, in number, in complications, 
 or in effect on the general malady. These forms of disease have all 
 two great characters in common — essentiality and periodicity. Why 
 they differ in general and local phenomena it is hard to say, but we 
 
52 LECTURES ON FEVER. 
 
 know little of the receptivity of the living body, the laws of the 
 variations of that receptivity, and those which govern its results. 
 This department of vital chemistry is still to be worked out, nor does 
 the study of the apparent exciting causes of the various forms of 
 fever give us much stronger grounds for belief in their essential 
 differences. Dr. Murchison, in his treatise on the Continued Fevers 
 of Great Britain, a work which is one of the greatest ornaments of En- 
 glish medical literature, enters at length into the distinctions between 
 typhus and the relapsing or famine fever, and labours to show that 
 while the one can be traced to overcrowding, the cause of the other 
 is destitution. Yet he admits the observations of Alison, David Smith , 
 and Henry Kennedy, which show that in one epidemic, in the same 
 family, even from the same bed, both forms of fever have been ob- 
 served. In wide-spread epidemics, he observes, we may have at first 
 relapsing fever only, then relapsing fever and typhus together, and, 
 last of all, typhus alone. "Whatever be the explanation," he says, 
 " the circumstance is remarkable; but it does not justify the conclusion 
 that the two fevers are identical." 1 And he says further on : " As far 
 as I know, the statement remains uncontroverted, that in all cases 
 where fever can be proved to have been imported into a locality by a 
 single case, typhus has produced typhus; and relapsing fever, relaps- 
 ing fever." 
 
 To a great extent the observations which I have offered as to the 
 relationship between typhus and typhoid seem to apply to that between 
 typhus and the relapsing or famine fever. I think the name of 
 " Famine Fever" one of doubtful fitness. In the epidemic of 18A7-48, 
 which followed the disastrous famine of Ireland, the contagious nature 
 of the disease was too well established, as shown by the terrible mor- 
 tality of the members of the medical profession, and of many of the 
 country gentlemen. Now, if ever the characters of typhus were 
 shown, it was then. Every form of continued fever occurred — in 
 thousands of cases — relapsing fever, typhoid or enteric fever, and the 
 worst form of typhus that could be seen. All the forms were con- 
 tagious, and this, whether the subjects of the disease had or had not 
 been exposed to destitution or overcrowding. The truth seems to be 
 that, while every separate epidemic has more or less of a common 
 character, all great epidemics (at least in this country) may be called 
 mixed, so far as the occurrence of individual cases is concerned. All 
 the circumstances which we have noted as to the relation of typhus 
 to typhoid may be said to occur as to relapsing fever. 
 
 1 A Treatise on the Continued Fevers of Great Britain. Second ed. 1873, p. 342. 
 
TYPHUS AND RELAPSING FEVER. 53 
 
 Without discussing how much is owing to destitution and how 
 much to the attendant overcrowding, whether two epidemic diseases 
 run their courses pari passu, or whether the fever, of whatever form 
 it may be, has been modified by the previous starvation — let us deal 
 with some important facts observed in this hospital in the epidemic of 
 1847. 
 
 Although, as might be expected, the number of deaths from famine 
 within the precincts of Dublin, as compared with the country districts, 
 was trifling, still we had not a few opportunities of observing the 
 effects of famine in these wards. Many sufferers from want of food 
 made their way into the city, and falling down exhausted in the streets, 
 were conveyed by the police to the hospital. They had all a strange 
 resemblance. The face — and indeed the whole of the bod}' — showed 
 a dusky hue, the eyes were sunken and with little expression, the 
 features pinched and marked by a profound melancholy; the surface 
 was cool, either dry and shrivelled, or clammy, and in all cases the 
 body exhaled a heavy earthy smell. These people were as a rule 
 apathetic; they made no complaint, but seemed only anxious to be 
 placed in bed and allowed to rest. They asked for neither food nor 
 drink. There were no symptoms of fever, and the natural desire of 
 all who saw them was to give a generous support. But it was speedily 
 found that such a course was a dangerous — it might be said, a fatal 
 one. In several cases animal food and wine seemed to act like a deadly 
 poison, and even where a more cautious use of nutriment was adopted, 
 the patients being fed as infants for days together until the collapse 
 seemed to be overcome, the system would, as it were, explode into the 
 very worst form of maculated typhus, in which death commonly 
 occurred on the fifth day of the fever, and in some cases even earlier. 
 And this is to be noted in relation to the reports of the relapsing 
 fever as observed at the London Hospital in 1843, where the desire 
 for food was general. Similar observations were made in Glasgow 
 and elsewhere, and this craving appetite, not alone in the remission 
 but in the paroxysm of the fever, is appealed to as evidence that the 
 relapsing form of fever is really a famine fever. 
 
 But whether the character of frequent recurrence of short attacks 
 of fever be owing to the previous contamination of the system by 
 starvation or not, we shall not discuss. Certain it is that relapses had 
 been common in our wards after 1830. But to say that the epidemic 
 character observed was that of a relapsing fever — 'namely, a short 
 fever with intervals of apyrexia — is to give a very imperfect idea of 
 the disease. Since then the typical relapsing fever — the five day fever 
 — has been often met with, sometimes showing an epidemic tendency. 
 
54 LECTURES ON FEVER. 
 
 but in very many instances being apparently unconnected with desti- 
 tution. I may observe that in such cases enlargement of the spleen 
 was common, and that in no case did the exhibition of quinine in the 
 intervals of the fever prevent the relapse. 1 
 
 But in Ireland an interesting circumstance in relation to the terri- 
 ble famine fever was that, in a few years after the cessation of the 
 epidemic of 1847, fever, which For so many years seemed rooted 
 throughout the land, gradually disappeared to a singular degree. 
 The numerous fever hospitals in the country towns were closed, dis- 
 posed of, or otherwise utilized, and I remember a period of several 
 years in which our wards were all but empty. We may leave to 
 others to speculate on the cause of this. 
 
 About this time the level of Lough Neagh, in the County Antrim, 
 was much reduced by arterial drainage, and a large space of marshy 
 ground on its shores rendered dry. Fever, which had been long pre- 
 valent in this locality, was observed to have become very rare, and 
 this was attributed to the drainage; yet it is more likely that the sub- 
 sidence of the endemic typhus was but an example of the change 
 which had occurred over the whole country. 
 
 Let me recapitulate some of the leading points as to fever which 
 cannot be too deeply engraved on your minds: — 
 
 Its essentiality. 
 
 Its contagiousness in various degrees. 
 
 Its existence often independently of local or anatomical change. 
 
 The relation of the local to the essential malady. 
 
 The influence of the local malady upon the general fever. 
 
 The inconstancy as to seat, time of appearance, number, impor- 
 tance, and complication of the local or secondary affections, 
 and their incompetence to explain or account for the pheno- 
 mena of fever. 
 
 The periodicity of these phenomena, seen not alone in the general 
 malady, but more or less in the secondary affections. 
 
 The occurrence of more than one form of fever in the same epi- 
 demic. 
 
 The speciality in character according to the epidemic. 
 
 The similarity in the principles of treatment of the general malady 
 and of the local changes. 
 
 These characteristics will serve as landmarks to you whether you 
 have to deal only with an isolated case of fever of any form, or with 
 a wide-spread epidemic of thousands of cases, and I believe they will 
 
 1 See Murchison, loc. cit. p. 408. 
 
NO ANATOMICAL EXPRESSION FOR FEVER. 55 
 
 more or less be found to apply to every form of the disease, and in 
 every latitude of the world. Let them be engraved upon your minds. 
 It may be necessary to say to the j unior members of the class that I clai m 
 no originality in putting them forward. I believe that they existed 
 in the minds of most practical and experienced men from the time of 
 Fordyce to our own, and are based on their recorded observations. 
 
 Gentlemen, I speak to you, and I have always endeavored to do so, 
 less as a teacher than as a fellow student — a senior one of course, but 
 still, not as a master, but as a comrade. 
 
 We shall find as we advance in the true method of studying medi- 
 cine — which is mainly, the practice of it — that we shall attach less 
 weight to the distinctions and classifications of essential diseases given 
 in books, instilled into our minds in our student days, and clinging 
 to us in the early years of professional life, than to the facts connected 
 with their history, resemblances, and treatment. 
 
 Believe me, we shall find this a better use. of our time. 
 
 Medical literature and medical teaching give many lessons not 
 written in the book of nature, and, when you stand face to face with 
 disease, all such will have to be ignored or forgotten. 
 
 LECTURE VIII. 
 
 Division of Fevers into Essential and Symptomatic — No anatomical expression for 
 the disease — Secondary affections of fever — These may, and do, frequently produce 
 organic changes — The presence of essential disease invalidates the ordinary rules 
 of diagnosis — Illustrations of the truth of this statement — Local symptoms of fever 
 are (1) functional or nervous; (2) anatomical, i.e. depending on special anatomical 
 changes; (3) secondary inflammatory, i.e. arising from reactive inflammation, itself 
 due to the typhous infiltration of some part or organ of the body — Similar symp- 
 toms may arise from essentially opposite conditions in disease— Illustrations of the 
 proposition that fever is capable of producing local symptoms without organic change. 
 
 Tiie division of fevers into essential and symptomatic is admitted by 
 most observers. I showed you that amongst essential fevers we may 
 reckon a great variety of diseases. All the exanthemata are essential 
 fevers; so also are influenza, rheumatic fever, typhus, typhoid, intermit- 
 tent and remittent fevers, the plague, the yellow fever, and I believe 
 w<e might also add cholera. 
 
 As I have already said, we may describe fever, without defining it,, 
 as being a special morbid state or condition of existence subject to 
 the law of periodicity, in which the animal economy is found acting 
 under apparently -new laws. In this altered state of life general 
 
56 LECTURES ON FEVER. 
 
 features common to all or to most cases are observed, but the accom- 
 panying secondary phenomena are many and extremely varied. 
 
 Tn my opinion, you may take this with you as the basis of your 
 views on fever — that, in the present state of our knowledge, we 
 possess no anatomical expression for the disease. We do not know 
 why secondary affections are sometimes absent, or at what period they 
 appear in various portions of the system. Even with the assistance 
 of the microscope no anatomical character of fever is as yet discovered. 
 
 However, although it is capable of destroying life without the pro- 
 duction of any anatomical change, we find that fever does frequently 
 produce such organic changes, and that these in turn influence the 
 symptoms of the malady. 
 
 The secondary affections of fever, from which such changes directly 
 arise, are not to be regarded as separate diseases, distinct from the 
 essential malady. It would be just as rational to assert that the 
 various affections of syphilis — the cutaneous disorders, the periostitis, 
 the ulceration of the throat, and so ou — were distinct and separate 
 diseases, as to say the same of the secondary and local complications 
 of fever. The secondary affections in fever are not its anatomical 
 character, for it precedes them and exists without them. 
 
 If such affections are confined to or predominate in the belly, we 
 may have tympany, thirst, diarrhoea, and a variety of other symptoms. 
 If the chest is engaged, we may have difficult breathing, livid coun- 
 tenance and the other conditions resulting from imperfect arterializa- 
 tion of the blood. A diseased intestine may cause death by exhaus- 
 tion or by perforation, or a secondary bronchial affection or congestion 
 of the lung may destroy life by asphyxia — not an uncommon case in 
 individuals whose bronchial affection has been taken no note of in the 
 early course of the fever. This secondary disease may have been 
 long progressive ; it is often overlooked and neglected from its latency, 
 and a large number of those cases in which death takes place from 
 what is called effusion into the chest, attributed to debility or exhaus- 
 tion, are in reality examples of a neglected bronchial affection, recog- 
 nized only when it is too late. 
 
 Yet in essential fever we must be cautious in arriving at a just 
 estimate of the value of symptoms, referable to either the brain, chest, 
 or abdomen. 
 
 The existence of the state or condition of fever invalidates those 
 rules of diagnosis which are so important where the essential disease 
 is not present. Many sad mistakes in the treatment of fever are 
 attributable to ignorance of this fact. 
 
 Suppose you find a man who is not the subject of essential fever 
 
LOCAL SYMPTOMS OF FEVER. 57 
 
 suffering acute pain in the head, with delirium, injected eyes, rapid, 
 hard pulse, and so on; the chances are that the man has arachnitis. 
 But let him have such a fever, and this group of symptoms cannot be 
 taken as indicative of the existence of local inflammation. You 
 would commit a grave error were you to treat this man for a disease 
 the presence of which it is impossible to assume from the symptoms, 
 just because the man has essential fever. 
 
 Again, symptoms may arise indicating an affection of some part of 
 the intestinal canal, and yet the stomach or intestines may be per- 
 fectly free from disease. Thus in nosological books we read that a 
 hot, dry tongue, preternaturally red and parched, is a symptom of 
 gastritis. So it might be if the patient had not fever. But we know 
 that in many cases the treatment which would be proper were there 
 no fever will not answer now. On the contrary, stimulants will prob- 
 ably be required. We give the man brandy, wine, and food, and the 
 tongue becomes pale and moist. 
 
 The foregoing remarks lead me to speak more fully of the local 
 symptoms in fever. These we find to be of several kinds. One class 
 of them may be termed functional or nervous : that is to say, singular 
 phenomena of functional alteration occurring without necessary or 
 corresponding organic changes. I believe that there are none of the 
 great organs of the body which in fever may not exhibit this curious 
 class of symptoms. In connection with the brain we have delirium 
 constantly as a functional condition in fever; pain also, convulsions, 
 coma, and so on. If we go to the thorax we often find cough and 
 accelerated breathing without any anatomical change of the lung. If 
 we turn to the abdomen, we find many of the symptoms which are 
 attributed to anatomical change, yet they may exist altogether inde- 
 pendent of it. We find tenderness of the epigastrium, and yet no 
 gastritis, no peritonitis, no inflammation of the liver; we find swelling 
 of the abdomen, or diarrhoea, without any anatomical change; and so 
 we observe that there are none of the great organs that may not 
 occasionally exhibit symptoms depending, so far as we can ascertain, 
 solely upon functional disturbance. This is the first class of symp- 
 toms. 
 
 The next class includes those which are connected with special 
 anatomical change. Wc may have this change in the brain, lungs, 
 heart, spleen, or in the glands of the intestine. In the lungs we 
 recognize it by rale, cough, expectoration, the filling up of the tubes 
 with muco-puriforrn matter, and on dissection, by tumefaction of the 
 mucous membrane, attended by lividity, vascularity, softening, or 
 even ulceration. In the heart we find it accompanied by signs of 
 
58 LECTURES ON FEVER. 
 
 softening of this organ, generally speaking at first confined to the 
 arterial or systemic heart. Many of you are, no doubt, familiar with 
 the local changes which occur in the spleen and in the intestine. 
 
 Then we come to the third class of local affections in fever, and 
 this is a very curious and important one. The condition of the parts 
 here is, as it were, a compound one. The organ is supposed to have 
 suffered infiltration of what is termed the typhous matter; it has 
 become swollen and enlarged. This is a condition which is capable 
 of retrocession, without any consequent injury to the part; but in 
 certain cases this retrocession does not take place, or is interrupted 
 by actual inflammation of the tissues which are thus infiltrated. 
 
 Thus we have three important classes of local affections, two of 
 which, though organic at first, are not inflammatory, but may become 
 complicated with secondary or reactive inflammation. * 
 
 There is, I believe, a fourth set of local symptoms, or of local affec- 
 tions if you will, in fever, which has not, perhaps, received sufficient 
 attention. I think it is extremely likely that, in certain cases, we 
 have organs suffering from want of a natural supply of blood, and that 
 this is extremely likely to take place as far as the nervous system, at all 
 events, is concerned. Any of you that have turned your attention to 
 the subject of the fatty degeneration of the heart — so often brought 
 before the Pathological Society of Dublin — will recollect that one of 
 the most remarkable symptoms of this affection is, that the patient 
 is liable to repeated and extraordinary attacks of nervous disease, 
 shown by a frequent threatening of syncope, or by apoplectic seizures 
 continually repeated, sometimes without consequent paralysis, but in 
 other cases with a temporary paralysis. This is an illustration of the 
 development of important nervous symptoms, not from fulness or 
 congestion of the brain, but from ansamia; and it is one of many illus- 
 trations of the great pathological proposition — that similar, or nearly 
 similar symptoms, may arise from essentially opposite conditions. We 
 know that apoplexy and paralysis frequently arise from hemorrhage 
 into the brain ; we find that they also arise from anasmia of the brain. 
 In the disease to which I so long directed the attention of the classes 
 in this hospital — the typhous softening of the heart — there is a proba- 
 bility that the brain, under those circumstances, suffers from anaemia; 
 and it may be — though this is a point which has not been sufficiently 
 worked out — that some of the extraordinary nervous symptoms in 
 fever, to which we can assign no anatomical cause, really proceed 
 from an anasmic condition of the brain, the result of a temporary 
 softening or weakening of the left ventricle — in fact, that in typhoid 
 or in typhus fever there is produced, for a certain number of days, 
 
FUNCTIONAL LOCAL SYMPTOMS. 59 
 
 the condition which is seen as a chronic state in the fatty degeneration 
 of the heart. It requires very little acumen to perceive that if the 
 brain is liable to this fourth and curious set of local disturbances, 
 other organs may suffer in the same way. I merely throw out this 
 for your consideration. But we might inquire whether the tolerance 
 of wine in fevers is in any way to be explained by an anaemic state 
 of the brain. There are few things more curious than the power 
 which is shown by patients in fever of bearing a quantity of wine or 
 brandy without intoxication. They will often swallow many times 
 more wine than would make them drunk if they had not fever, and 
 wine becomes a sedative rather than a stimulant so far as symptoms 
 are concerned. Does not this indicate a state of the brain the oppo- 
 site in some respects to that of health ? I do not want you to believe 
 that all the good effect of wine is derived from its action on the 
 weakened heart, for it may be that the direct influence of the stimu- 
 lant itself on the nervous matter is the cause; but, whether we take 
 one or both modes of action, its effect indicates a condition of the 
 circulating and nervous systems the opposite to that of inflammation, 
 as we understand the term. 
 
 We come now to think on this important proposition, that the 
 condition of fever, or, if you will, the poison of fever, is capable of 
 producing local symptoms without organic change. We can easily 
 understand the poison of fever producing a general fever without any 
 local symptoms, but it requires a good deal of teaching and observa- 
 tion to persuade men that the poison of fever is capable of producing 
 local symptoms without any organic change. It is quite impossible 
 to exaggerate the importance of this proposition as a guide in the 
 practice of medicine, for it is because it has not been sufficiently 
 accepted — because it has not been engraved upon the minds of medical 
 and surgical students — that so much mischief is done in the treatment 
 of fever. 
 
 Remember the grand rule — and if you did nothing else for the 
 whole of the session but learn it, your time would be well spent — 
 that those rules of diagnosis of local diseases which are to be accepted 
 as true in cases which are not essential fever lose their value to a great 
 degree when the primary disease is such. This applies to the local 
 symptoms in connection with the three great cavities. You are not 
 to apply the rules of diagnosis drawn from the observation of diseases 
 which are not fever to the symptoms in fever, because fever is a special, 
 essential state, and has its own conditions and its own rules. And this 
 confirms the observation which I made in the introductory lecture, 
 that the student, no matter how extensive his education may have been 
 
60 LECTURES 0"N FEVER. 
 
 in surgery and in medicine outside a fever hospital, has really learned 
 only half of his business if he has not studied fever at the bedside. 
 In consequence of ignorance of this rule, men having a case of fever, 
 with symptoms which, they had been led to believe, in cases not es- 
 sential fever, were indicative of local inflammation, at once proceeded 
 to treat the case as one of local inflammation. 
 
 The patient on the tenth or twelfth day of typhus fever is watchful, 
 delirious, violent, complains of great distress in his head, and so on. 
 Well, what does the practitioner do who has not learned this rule ? He 
 shaves the head ; he applies ice to it ; puts on a dozen or two of leeches ; 
 and what is the result? The result too frequently is, that the patient 
 sinks rapidly. The symptoms in this case were not the result of inflam- 
 mation of the brain; they were not from hyperemia of the brain. 
 There was, perhaps, an exactly opposite state: at all events it was 
 not such as to require depletion; the patient was suffering under 
 general debility, and he sank under the treatment. This is still a 
 common case. I have seen applications of leeches to the head in an 
 advanced stage of fever with delirium, almost as certainly fatal as a 
 pistol shot through the brain would be. Here let me give you the 
 observations of Louis illustrative of the actual value of the symptom 
 of delirium as an indication of inflammation of the brain in fever; 
 and I may mention here that as Louis' observations were drawn from 
 the Continental typhoid fever, they must be considered as still more 
 applicable to typhus, because in typhoid fever there seems to be a 
 greater probability that the local symptom is more closely connected 
 with the local irritation than it is here. He took, in the first place, 
 twelve fatal cases of typhoid fever which did not present the symptom 
 of delirium. In four of these cases he found redness of the brain, in 
 six the brain was perfectly healthy, and in two there was slight cere- 
 bral softening. Now let us take his twelve other cases, in which 
 delirium was an extreme^ prominent symptom. In many of them 
 the patients were violently delirious. In five of these cases there was 
 redness of the brain, in rive it was perfectly healthy, in one there was 
 slight softening, and in one slight injection. 
 
 Now compare these two sets of results. Where there was no 
 delirium four patients presented redness of the brain; where there 
 was delirium five presented redness of the brain. Where there was 
 no delirium in six the brain was perfectly healthy; where there was 
 violent delirium in five it was free from disease. The other cases may 
 go for nothing. This result is extremely valuable, as showing how 
 very little we can depend upon the symptoms of excitement of the 
 
INFREQUENCY OF ORGANIC CHANGE. 61 
 
 brain as an indication of inflammation when the patient is in essential 
 fever. 
 
 Now let us go to some other organ — take the heart. " Well," you 
 will say, "the heart need not be taken, because in most of our cases 
 the heart shows a depressed and not an irritated state." But there 
 are many cases of fever in which the heart is violently excited, as you 
 will have frequent occasion to see. What is the result of dissection 
 in these cases of excited heart in fever? There are two conditions 
 which, according to ordinarily received notions, should lead you to 
 expect irritation or inflammation of an organ: first, that the patient 
 has fever, and next that you have an organ in a state of great excite- 
 ment. If the patient had not typhus or typhoid fever, but had rheu- 
 matic fever and an excited heart, the chance would be that that organ 
 would be found in a condition of inflammation. If a man has typhus 
 or typhoid fever, and his lungs are excited, we find bronchitis or 
 pneumonia; if his pleura is excited, we find pleuritis, and so on. But 
 here is a case of typhus fever with extraordinary excitement of the 
 organ, and when you come to dissect the parts you find the heart per- 
 fectly healthy — not the slightest sign of disease is found — and the 
 same observation will frequently apply to the digestive system. You 
 will have tenderness on pressure of the abdomen, extreme thirst, 
 nausea, and vomiting. Yet on dissection the mucous membrane will 
 be found pale, and there will be no sign of disease. 
 
 Again, take the eye. Delirium ferox with an injected eye is the 
 expression of inflammation of the brain where the patient has not 
 essential fever. But take a case of typhus or of typoid fever, and is 
 the injected eye a sign of cerebritis? Certainly not. It is merely to 
 be looked on as a local affection under the dominion of the general 
 disease. The truth is that disease of a really inflammatory character 
 is the rarest thing possible in typhus or typhoid fever ; it is so rare that 
 many do not believe that it ever occurs. Apply this axiom, then, to 
 treatment, and see what becomes of that doctrine which advocates 
 bleeding in fever, which advocates starvation and purging, and forbids 
 the use of wine and other stimulants. There is another very impor- 
 tant view or argument to be referred to here, which all practical men 
 will understand. If fever was a group of inflammations, or if it was 
 symptomatic of any one inflammation — in other words, if it was an 
 inflammatory disease — we ought to expect that in the larger number 
 of patients who had gone through the process of fever chronic dis- 
 eases of organs would be developed. If a patient has acute rheu- 
 matism, we find that his heart may become engaged. He recovers 
 from the rheumatism, and then he often has a progressive organic 
 
62 LECTURES ON FEVER. 
 
 disease of his heart. When you reflect upon the extent of fever, the 
 great number of persons that have been at some time in their lives 
 attacked with fever, you should at once come to the conclusion that 
 if those fevers were examples of groups of local inflammations, we 
 should have a much greater quantity of organic local diseases conse- 
 quent upon them : but what is the fact ? The fact is that such acci- 
 dents are extremely rare. How few cases can be adduced of confirmed 
 mania as a consequence of fever. How few cases can be adduced of 
 paralysis, of apoplexy, or of hydrocephalus as a consequence of fever. 
 Surely if in this enormous number of Gases of fever with violent head 
 symptoms there had been inflammation of the brain, in some of them, at 
 all events, we should have as a consequence progressive disorganiza- 
 tion of the part. 
 
 Again, take the thorax. How few instances are there on record 
 of chronic progressive pneumonia after fever; how few of chronic 
 pleuritis; how few cases of atrophy of the lung; how few of ana- 
 tomical changes which end in progressive organic disease, which has 
 started from an inflammatory disease that took its origin pending a 
 fever. Go to the heart. We have two classes of heart affections in 
 fever — one a softening and weakening of the heart, and the other an 
 excitement of the heart. I do not care which of them you take. Do 
 we find that, after a recovery from fever, in persons who have had 
 either of these affections of the heart during fever, there is a liability 
 to valvular disease, that there is a liability to hypertrophy of the 
 heart, that there is an adhesion of the pericardium? Nothing of the 
 kind. The fact is that those organs have never been in a state of in- 
 flammation. They have suffered pending the fever, and the fever 
 having terminated, the organs are restored to their normal condition. 
 This is a very important consideration, and you may extend it still 
 further. If fever was an inflammation of the bloodvessels, it is not 
 to be supposed but that we should have many cases of disease of the 
 aorta in the thousands of persons who have gone through fever. 
 Yet we find no such results. If we go to the digestive system (and 
 this is, perhaps, the system of all others which is most liable to 
 organic change — at least in the Continental fevers), how few cases do 
 we find — or have we any case to show — of chronic peritonitis as the 
 result of fever? Not one that I know or ever read of; and yet the 
 patient may have had symptoms of severe irritation of the abdomen 
 pending his fever. In fact, all that we know of disease of the peri- 
 toneum in connection with fever is simply that, in certain cases of 
 ulceration of the intestine, a solution of continuity of the peritoneum 
 takes place, the fecal matter is effused into the cavity, and the patient 
 
ILLUSTRATIONS OF THE ARGUMENT. 63 
 
 dies of acute peritonitis. But that does not touch the argument. 
 "Where are the cases of chronic diseases of the liver springing out of 
 typhus fever ? It has been long a portion of medical doctrine — it 
 has become traditional — and everything that is traditional in medicine 
 is to be respected — that fever has a depuratory effect on the system. 
 Now, whether it has such an effect or not we shall not here inquire ; 
 but the very fact of the existence of that doctrine, which is much 
 older than pathological anatomy, implies, at all events, a general 
 belief that fever does not necessarily lay the foundation of permanent 
 damage to organs ; for if it did damage the various organs that exhibit 
 local symptoms in the course of the affection, we should not have the 
 doctrine of its depuratory effects established. The cases of a chronic 
 ulcerative condition of the intestinal tube might be adduced in oppo- 
 sition to these views, but I do not place very much weight upon 
 them. We may divide them into two classes ; in the one diarrhoea 
 or some other symptom is established during the fever, which latter 
 runs on indefinitely — here the typhous disease of the mucous glands 
 has been attended with reactive irritation, and this has interfered with 
 the action of the law of periodicity — so that the fever runs on in- 
 definitely. In the next case the fever may be supposed to have 
 ceased, but so much disorganization has occurred that the ulcerative 
 process seems to go on as it might be supposed to do in another case 
 where no typhus had preceded it. 1 
 
 1 The cases related by Dr. Cheyne in the first and second volumes of the Dublin 
 Hospital Reports appear to be examples of this form of disease. He describes them 
 as follows (vol. i. page 29) : " In these cases the distress of the patient often bore 
 no proportion to the dauger he was in ; the former was very little, while the latter 
 was extreme. The disease would proceed 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 would take his food regularly. The only circum- 
 stance in his situation which demanded attention was that he regained neither flesh 
 nor strength ; he expressed no desire to leave his bed. Then his pulse became quick 
 and his tongue dry, and he would complain of dull pain or uneasiness in his belly, 
 attended with soreness on pressure, and a degree of fulness in the upper part of the 
 abdomen ; the fulness was not elastic nor hard, nor indeed was it considerable. 
 Then came on a loose state of the bowels and great weakness : probably at the next 
 visit the patient was lying upon his back, with a pale, suuk countenance and a very 
 quick, feeble pulse, his mind without energy. Then the stools (mucous) passed from 
 him in bed, and the urine also; perhaps a hiccup came on; next his breathing 
 became very frequent, in which case death was at no very great distance." 
 
6i LECTURES ON FEVER. 
 
 LECTURE IX. 
 
 Local Changes in Fever are symptomatic, subject to law of periodicity, and probably 
 depend on the presence of a specific typhous deposit — This deposit possesses a 
 vital, specific character — Illustrations of this statement — The principal pathologi- 
 cal conditions in fever are (1) functional, (2) intercurrent, and secondary irritations 
 of (a) mucous membranes, (&) parenchymatous structures, (c) serous membranes, 
 (3) secondary irritations associated with typhous deposits, (4) independent typhous de- 
 posits, (5) reactive inflammations, due to these deposits, (6) softening of organs — 
 Effect of locality in determining the seat of secondary affections of fever — Effects of 
 social rani: in the same direction — Prognosis unfavourable and treatment by stimu- 
 lation so far contra-indicated iu cases where nervous symptoms preponderate. 
 
 In the immediately preceding lecture we have seen that the presence 
 of local symptoms during the course of an attack of fever does not 
 necessarily imply or foreshadow the occurrence of any known ana- 
 tomical change. To learn this point is to advance a great way in our 
 knowledge of fever and of its treatment. On the other hand, obser- 
 vation during life sand post-mortem inspection prove that local diseases 
 involving alterations of structures — such as thickening, softening, 
 vascularity, effusions, ulcerations, and gangrene — may be produced 
 in various organs during the course of a fever. 
 
 Now, the great point in practice relating to these changes is, that 
 they are symptomatic of the fever, secondary to the fever, and, in all 
 probability, under the same law of periodic action as the general 
 malady itself, at least so long as they remain uncomplicated with in- 
 flammatory reaction. They do not appear to begin with the fever, 
 but they arise after it has existed for a certain time. There is the 
 greatest variety in the period of their occurrence, and in their combi- 
 nations; they may, as I have just now said, spontaneously subside 
 with the fever; they may interfere with its critical termination ; and, 
 in certain cases where this does not occur, and when the general 
 character of typhus disappears, progressive disorganization may go 
 on in the structures which have been already affected. 
 
 In what way are we to consider the nature of these secondary 
 affections in fever? It appears now pretty well established that in 
 the follicular intestinal disease of the Continental fevers there is a 
 special typhous deposit which, at least in the cases of recovery, is 
 under the law, first of a progressive, and then of a retrogressive influ 
 ence ; just as in variola we observe the progressive maturation and 
 
SPECIFIC TYPHOUS DEPOSIT. 65 
 
 absorption of the pustule. Eecent pathologists have applied this 
 principle to many other of the local diseases in fever ; and although 
 the existence of a special deposit is not yet so well or so fully estab- 
 lished in the case of thoracic and cerebral complications, or at least in 
 the case of parenchymatous as compared with membranous struc- 
 tures, still we may believe that an action analogous to that which 
 occurs in the glands of Peyer and Briinner, though perhaps not so 
 apparent, is developed in all the secondary diseases of fever which are 
 not purely functional. 
 
 In speaking of a specific deposit in the secondary diseases of fever, 
 I do not wish to convey to you the impression that this deposit 
 presents any definite characters whereby it can be distinguished from 
 other morbid products; for, even with the aid of the microscope, we 
 cannot discover any special distinctive characters in the deposit found 
 in the follicles of the intestine, or in other forms of the secondary 
 affections of fever. It was at one time believed that the so-called 
 " massa typhosa" did present special histological elements; .but more 
 recent research has shown that these views are erroneous. Still it is 
 possible that, although we cannot determine the existence in it of any 
 specific physical character, it yet possesses a vital specificism. Let us 
 illustrate this by referring to two specimens of pus — one taken from 
 the pustule of variola, the other from an ordinary abscess ; histo- 
 logically they will appear similar, yet that they have different vital 
 characters no one can doubt. But other conditions are found associ- 
 ated with this typhous deposit, or occurring when we cannot demon- 
 strate its existence. Under this head we class many of those 
 appearances described as inflammatory — such as redness, softening, 
 tumefaction, and so on. 
 
 Some have supposed that these states indicate a reactive inflamma- 
 tion, and that such does often occur, especially in the intestine, is 
 abundantly proved by the researches of Eokitansky and various 
 authors. I think it, however, extremely probable that in certain 
 structures or organs — as, for example, the lung — these appearances 
 of inflammation may precede or accompany the typhous deposit, or 
 that they may occur even without such a deposit at all; and I think 
 it likely that the liability to actual deposit is much less in the lung 
 than in the intestinal glands, and greatly less in the brain and nerves 
 than in either the thoracic or the digestive systems. Were it other- 
 wise, typhous and typhoid fever would be more fatal diseases than 
 they are, death being produced in the one case by coma, and in the 
 other by asphyxia. 
 
 But, even though upon a close dissection we may not find anything 
 5 
 
66 LECTURES ON FEVER. 
 
 beyond the recognized appearances of inflammatory action of the 
 mucous membrane, we are to believe that this condition, just like 
 the typhous deposit, is secondary to the fever, and partakes of its 
 specific character. It is not a simple idiopathic inflammation, nor is 
 its existence to lead us into the errors of the antiphlogistic school- 
 This condition, however, although specific and secondary, has still 
 some characters of irritation, or inflammation if you will; and this 
 fact points to the adoption, in certain cases, of a practice which, to the 
 mere theorist, appears inconsistent — namely, the use of local depletion 
 to relieve the suffering organ, while at the same time we employ a 
 general tonic aud stimulating medication. 
 
 Let me now indicate to you the principal pathological conditions 
 with which, in the treatment of a case of fever, the physician has to 
 deal. 
 
 First. We have those remarkable functional derangements which 
 are unaccompanied by any known anatomical changes. They may 
 occur in relation to any of the organs : but they are, perhaps, more 
 important and certainly more frequent in the nervous than in the 
 respiratory or digestive systems, at all events in typhus. 
 
 Secondly. We meet with intercurrent and secondary irritations or 
 inflammations affecting principally the mucous membranes, less fre- 
 quently the parenchymatous structures, and still less frequently the 
 serous surfaces. These irritations, although not associated, so far at 
 least as we can discover, with any special deposit, are nevertheless of 
 a specific character, and under the influence of the laws which govern 
 the general disease. 
 
 Thirdly. We have the conditions now specified associated with, 
 though probably for a short time preceding, the typhous deposit, just 
 as we see in variola the vascularity of the skin often preceding and 
 accompanying the vesicular eruption. 
 
 Fourthly. We may observe the typhous deposit occurring indepen- 
 dently of any other alteration, and apparently not associated with any 
 irritative process. 
 
 Fifthly. We observe the reactive inflammation supervening on the 
 typhous deposit — a condition which has been so well described by 
 Rokitansky, and which may produce progressive ulcerations, abscess, 
 or even sphacelus of the affected parts. 
 
 Lastly. There is a condition of softening of organs, upon the nature 
 of which we have as yet no very definite ideas. In some instances 
 it seems to be produced by an interstitial deposit of typhous matter, 
 while in others it is difficult or impossible to prove the existence of 
 such a deposit. This state of softening, as we shall presently see, is 
 
VARIATION OF SECONDARY AFFECTIONS. 67 
 
 one of great practical importance. Its influence upon the heart, as 
 you all know, is most remarkable. Its existence in that organ de- 
 mands special attention, and there is good reason to believe that the 
 same state, when affecting others of the involuntary muscles — such as 
 those of the air tubes, and perhaps of the intestinal canal — has an 
 important influence on the symptoms and progress of the disease. 
 
 I trust that, having followed me in the foregoing considerations 
 as to a few of the pathological conditions of fever, you are now in a 
 position to examine more closely some of the most remarkable local 
 or secondary affections that may occur in the course of an attack of 
 essential fever. 
 
 In their seat, if not in their nature, these affections are observed to 
 vary in different countries. On the Continent — at least in France, 
 and throughout a large portion of Germany — the frequency, and prob- 
 ably the preponderance, of the secondary disease of the intestines is a 
 fact that must be admitted. So remarkable, indeed, is the predomi- 
 nance of the tumefaction and ulceration of the mucous glands of the 
 intestine in France, that Andral, in the first edition of the Clinique 
 Medicale, described fevers under the general head of diseases of the 
 digestive system ; and yet Andral was no blind follower of Broussais. 
 In Ireland, however, we do not find this remarkable preponderance 
 of the secondary diseases of the digestive system ; but when I make 
 this statement I wish you to understand and to adopt this principle 
 that all descriptions of the anatomical characters of fever, as it prevails 
 here or elsewhere, are to be accepted only so far as they apply to the 
 prevailing epidemic. And although it is true that, on comparing the 
 French typhoid fever with our typhus, the existence of follicular dis- 
 ease of the intestine appears to be almost the rule, and its absence 
 the exception in the former affection, while in the Irish typhus this 
 condition of the intestine is rare, you must bear in mind that in 
 Ireland, in our own time, we have had a great epidemic of what was 
 certainly typhus fever, in which the condition of the intestine accu- 
 rately represented that which is found to prevail on the Continent. 
 This is an important fact, and one which some of the Continental 
 writers on pathology do not seem to be aware of, or they would not be 
 so apt to adopt arbitrary distinctions and positive opinions on the 
 matter. In the epidemic of the years 1826, 1827, and part of 1828, 
 disease of the mucous glands of the intestine was sj frequent that its 
 existence might be held to be the rule, and its absence the exception; 
 and it is also true that intestinal ulcerations have been repeatedly ob- 
 served in maculated typhus of Ireland, their amount and frequency 
 varying with the epidemic influence. Let me refer you again to 
 
68 LECTURES ON FEVER. 
 
 Dr. Cheyne's papers in the first and second volumes of the Dublin 
 Hospital Reports. 
 
 Similar observations have been made in Scotland also. What, then, 
 shall we say of that doctrine which declares that there is an essential 
 distinction or difference, marked by pathologico-anatomical characters, 
 between the Continental fever and our typhus, or between the con- 
 tinued fever of Great Britain and fever as we have it in Ireland? — a 
 difference to be expressed in this way, that in the Continental or in the 
 British continued fever there is extensive ulceration of the intestine, 
 while in the Irish fever this condition is wanting. Dr. Lombard, of 
 Geneva, whose experience of fever in this country was manifestly 
 insufficient to justify his coming to any decided opinion on the subject, 
 holds that we have in Great Britain and Ireland two different fevers, 
 one highly contagious, which he calls the Irish typhus, and in which 
 cephalic symptoms predominate to the exclusion of abdominal ulcer- 
 ations ; the other sporadic, and most likely not so infectious, in which 
 the abdominal symptoms are more pronounced, so much so that the 
 follicular disease and consequent ulceration are always present. These 
 two fevers are, in the opinion of this writer, to be found in most parts 
 of Great Britain ; but the first is most prevalent in Ireland, and in 
 places whither the Irish come in great numbers; the other, similar to 
 the European sporadic fever, is met with in all places, varies with the 
 seasons, and is not necessarily produced by, or under the influence 
 of, contagion. Had Dr. Lombard been aware that ulcerations of the 
 intestine are frequently met with in our petechial typhus, and, again, 
 that the typhoid fever, or at least a fever with extensive dothinenteritis, 
 has raged epidemically for two years in this country, he would have 
 been slow in venturing to settle the question in so decided a manner; 
 and I have before mentioned to you that during the prevalence of 
 any particular epidemic in this country we meet with cases agreeing in 
 all their general characteristics, and having the distinctive marks of 
 typhus; in one set of which follicular ulceration is met with, while 
 in another it is absent. 
 
 If, however, we inquire what are the diseases secondary to typhus, 
 for the removal or modification of which we are most often called on 
 in the wards of a fever hospital, especially in the worst cases of pete- 
 chial typhus, I would say that it is the pulmonary rather than the 
 gastro-intestinal complications. Certainly the secondary disease of the 
 bronchial surface is often the most formidable of the local affections 
 in our Irish typhus. So great, indeed, is the frequency of this com- 
 plication, that long before I was aware of the opinions of Rokitansky 
 on this point I frequently suggested in my lectures whether the sec- 
 
BRONCHIAL AFFECTION OF TYPHUS. 69 
 
 ondary bronchial disease might not be held to stand in the same 
 relation to the Irish typhus that the follicular disease of the intestines 
 in France bears to the fever in that country. Let me read to you a 
 passage from Rokitansky's work, translated by Dr. Day for the ori- 
 ginal Sydenham Society, bearing on the points before us. He speaks 
 as follows of the effect of the typhous process on the mucous mem- 
 brane of the air passages: "In primary bronco-typhus the general 
 disease originally localizes itself here, avoiding all other mucous mem- 
 branes, even that of the intestine, for which in general the typhous 
 process shows the most decided preference. The latter mucous mem- 
 brane exhibits, however, in many cases a recognizable though always 
 subordinate and secondary development of the follicles, in which the 
 adjacent mesenteric glands participate, and in such cases it is very 
 often a difficult matter to distinguish the typhous element in the 
 above-named affection of the bronchial mucous membrane. The 
 peculiar stasis of the spleen and of the great cul de sac of the stomach, 
 the remarkable intumescence of the former, and the singular charac- 
 ter of the blood, the typhous nature of the general disease, and es- 
 pecially the altered condition of the bronchial glands invariably serve, 
 together with other symptoms, to indicate the typhous nature of the 
 bronchial affection. The alteration occurring in the bronchial glands 
 is of the same character as that affecting the mesenteric glands in 
 abdominal typhus. They become swollen to the size of a pigeon's or 
 even of a hen's egg, are of a dark violet colour, which afterwards becomes 
 lighter, present a relaxed and friable appearence, and are infiltrated 
 with a medullary typhous matter. Like typhous mesenteric glands, 
 they may become the seat of a tumultuous metamorphosis, and thus, 
 either with or without perforation of the adjacent mediastinum, may 
 give rise to pleurisy. This form is often combined with pneurno- 
 typhus and typhous pleurisy, and is beyond all doubt the basis of 
 the spotted contagious typhus, and very probably also of the Irish 
 and North American typhus, forms of the disease which in the 
 majority of cases run their course without any intestinal affection. 
 With us this affection is rare, and in point of frequency is not to be 
 compared with abdominal typhus." 
 
 I may here observe that by the term " tumultuous metamorphosis" 
 is implied the occurrence of violent symptoms with suddenness and 
 rapidity of progress. Dr. Day remarks that Rokitansky has used the 
 term in a new sense, but it means generally — as I understand it — that 
 a violent and reactive inflammation occurs in the parts altered by the 
 typhous process, which may cause great congestion, turgescence, per- 
 foration, or even gangrene. As Rokitansky does not indicate any 
 
70 LECTURES ON FEVER. 
 
 distinctive features between the spotted contagious typhus and the 
 Irish and American typhus, we may safely hold them to be the same 
 disease. 
 
 With respect to the question of the comparative frequency and 
 importance of the pulmonary as contrasted with the nervous symp- 
 toms in fever, as it affects the lower and upper classes in this country, 
 my impression is — taking the experience of a long series of years — 
 that the secondary bronchial or, to speak more generally, the pulmo- 
 nary complications are much more frequent and dangerous in hospi- 
 tal than in private practice. It is not easy to explain why this should 
 be so, but certainly we find a greater preponderance of nervous 
 symptoms in the typhus fever as it affects the upper classes of society 
 than in cases of the disease as we meet with it in hospital; while in 
 hospital practice the nervous symptoms, though we cannot say that 
 they are absent, less frequently require special interference. No 
 doubt we meet with coma, delirium, and subsultus tendinum occa- 
 sionally, but the predominance of nervous symptoms in the early 
 periods of typhus which is so common in the upper classes of society 
 is less often seen in our wards; and if you will reflect on the simple 
 fact that we so rarely have to shave the head among our hospital 
 patients, you will see the truth of what I say. Remember, too, how 
 many cases we have had in which, while all the symptoms of typhus 
 — such as prostration, weakness of the heart, eruptions of maculae 
 and petechias, and well-marked secondary diseases of the mucous 
 membrane of the intestines — were present, the patients' minds re- 
 mained nearly unclouded, and no symptom occurred calling for any 
 special measures directed to the head. The typhus of Ireland, then, 
 is not characterized, as Dr. Lombard has described it, by a preponde- 
 rance of cephalic symptoms, at least when it occurs in that class from 
 which he supposes the best specimens of the disease to be drawn. He 
 is as incorrect in his statements about the predominance of cephalic 
 symptoms as when he says that the absence of follicular ulcerations 
 of the intestines is a distinctive murk of Irish typhus. 
 
 In the typhus fever of the upper classes in this country the ner- 
 vous symptoms are generally much more aggravated and developed 
 at an earlier period ; and it may be that this preponderance of the 
 nervous symptoms, this tendency to affections of the brain in one 
 class, even though these affections be principally toxic and func- 
 tional, is a cause of the comparative exemption of such cases from the 
 secondary bronchial disease. As you advance in the study of general 
 pathology, you will find plenty of examples in which diseases of 
 structure or of deposition are suspended or replaced by purely ner- 
 
INFLUENCE OF SOCIAL RANK. 71 
 
 vous affections. Explain it as we will, the general proposition appears 
 true that the nervous symptoms, comparatively speaking, are less 
 developed in the fever of the lower classes, while those indicative of 
 disease of the mucous membranes are much more prominent ; and 
 conversely that in the upper ranks symptoms indicative of irritation 
 of the mucous surfaces are less prominent, while the nervous symp- 
 toms are severe; and this, perhaps, may throw some light upon the 
 doctrine, which has been long held by many, that the mortality of 
 fever is greater in proportion as we. ascend in the scale of society. 
 
 I have already told you that, as regards prognosis, the preponder- 
 ance of any of the nervous symptoms of fever should cause us more 
 apprehension than that of any other class of symptoms, and especially 
 when this preponderance is observed in an early period of the disease. 
 This greater susceptibility of the nervous system in the higher classes 
 may itself be a cause why we cannot use wine with as great liberality 
 in this -class as with ordinary hospital patients. And this, again, may 
 explain the greater fatality in private practice, inasmuch as, in conse- 
 quence of the excitement of the nervous system and the frequent in- 
 capability to bear stimulants largely, we are debarred from the use 
 of that which is the great medicine in fever. 
 
 I think we may lay it down as a principle that the more the sec- 
 ondary affections of fever are anatomical, the greater will be the utility 
 of stimulants; and conversely the more they are functional, and espe- 
 cially in cases where these symptoms are more closely related to the 
 cerebro-spinal centres, the less will be the efficacy of wine. It might 
 be supposed, from a priori considerations, that the man in the higher 
 classes of life who has been accustomed to the use of wine would 
 require it more and derive greater benefit from it in the course of a 
 fever, which — it must be remembered — is a disease of debility and 
 prostration, than the peasant who has not been habituated to the reg- 
 ular use of stimulants; but I believe that the very reverse is the fact, 
 and that the greatest triumphs of the stimulant treatment in fever are 
 to be found when it affects the agricultural peasant, whose nervous 
 system has not been excited either by the use of stimulants or by 
 intellectual exertion. I know that some will object to this on the 
 ground that our Irish peasantry are habitually intemperate, but this 
 charge of intemperance is only one of the many erroneous statements 
 put forth with reference to our countrymen. 
 
 The Irish peasant is not habitually intemperate — neither do his 
 means permit nor his inclinations lead him to be so. When he does 
 indulge it is on special occasions, but in hospital we seldom meet a 
 case of injury to the geueral health produced by a course of intern- 
 
72 LECTURES ON FEVER. 
 
 perance in the peasant. The case is no doubt different in the class of 
 artisans who are the inhabitants of our large cities and towns. In 
 this class we find that when fever attacks an individual we can neither 
 use stimulants with the same boldness nor reckon on their success 
 with the same confidence as among the more sober classes of the popu- 
 lation. In this respect the Irish are not peculiar. 
 
 LECTURE X. 
 
 Secondary Bronchial Affection of Fever — Pneumotyphus of Rokitansky — Views of 
 this author as to the anatomical expression of typhus and typhoid respectively — 
 Description of the bronchial affection of fever ; frequent absence of symptoms 
 therein — Rales sonorous, mucous, or crepitating ; no increased sonority — This 
 affection is not ordinary "bronchitis;" it comes on silently and subsides sponta- 
 neously — Argument from the effects of treatment by stimulation — Modes of termin- 
 ation of the affection. 
 
 In our inquiry into the secondary affections of fever we shall have 
 to consider manifestations of disease in the lungs, which have so strong 
 a claim on our attention from the frequency of their occurrence and 
 the important results by which they are followed. We will take up 
 the subject of the bronchial affection of fever in the present lecture. 
 
 This affection is so frequent and common in maculated typhus that 
 Rokitansky proposed to found a momenclature for the various forms 
 of fever in accordance with the most striking secondary diseases 
 characteristic of them. Thus he designated typhoid as typhus abdorn- 
 inalis, and maculated typhus us pneumotyphus. He considered that, 
 whilst typhoid affected the intestinal mucous membrane as its second- 
 ary anatomical result, typhus, on the other hand, engaged the pulmon- 
 ary tissues ; that " as the anatomical expression of typhoid fever was 
 intestinal ulceration, so the anatomical expression of typhus was dis- 
 ease of the mucous membrane of the chest." 
 
 Now, in making statements such as these the great German patholo- 
 gist seems to me to have gone too far. I believe him to be in error 
 in his assumption respecting typhoid, as he equally is at fault in his 
 conclusion touching the bronchial affection of typhus. If he had 
 said, "In the cases of typhoid which have come under my cognizance 
 and treatment I invariably found disease of the intestinal canal to be 
 present, and in all my cases of typhus gravior the bronchial tubes and 
 mucous membrane of the chest were diseased," he would have been 
 
GASTRO-CATARRHAL TYPHUS. 73 
 
 correct. But cases both of typhoid and typhus of the severest char- 
 acter and most prolonged continuance may occur unattended by the 
 symptoms of local disease which have been regarded as so constant 
 in their appearance, and which have even been asserted to constitute 
 the disease of which the fever is merely symptomatic. 
 
 At the same time we must not repudiate Rokitansky's views simply 
 because they differ from those based on the study of fever in this 
 country. The German observations have been made in good faith, 
 and are of value so far as they are pathological records of the 
 phenomena of fever as observed in a different country and as affecting 
 a distinct race of people. In the typhus fever of our own land we 
 often meet with serious engagement of the bronchial tubes. We not 
 infrequently see a similar morbid affection in cases of typhoid; but 
 in typhus this local disease always makes its appearance at a compa- 
 ratively early stage of the fever, whilst in typhoid it usually comes on 
 at a later period. Again, we have had in this country a form of dis- 
 ease strangely opposed to all such artificial distinctions as those of fever 
 under the headings of typhus abdominalis and pneumotyphus ; it was 
 called gasiro- catarrhal typhus, a term which sufficiently indicates the 
 character of the disease. 
 
 To a person who is not in the habit of examining patients in fever 
 very closely, the frequency and importance of the bronchial disease 
 would not appear very evident or striking as he walks round the wards 
 of an Irish fever hospital. We find the patient, perhaps, in a state of 
 stupor, but from this he is easily roused. He is covered with petechial 
 spots, red or livid, as the case may be. There is nothing remarkable 
 about his breathing; he is not reported to have any cough; his pulse 
 is probably 120 or 130, and his heart is weak. That patient, with 
 but little hurry of breathing, not complaining of any distress, and 
 without cough, may be, and frequently is, at that very time in an ad- 
 vanced stage of the secondary bronchial disease. When you apply 
 the stethoscope, and make the patient draw a deep breath, you are 
 surprised at the great amount of disease that is revealed, although the 
 symptoms of the important affection are absent. One would expect 
 that in such a case there would be lividity of the countenance from 
 the non-arterialization of the blood ; but here is one of the curious 
 things connected with fever which it is extremely difficult to explain 
 — that you will often see but little lividity in such cases. At all 
 events it is not sufficient to draw attention to the condition of the 
 patient's lung. In most patients labouring under bad typhus there 
 is a peculiar dusky hue of the face, and this whether the bronchial 
 disease were present or not. But I have over and over again seen 
 
<4 LECTURES ON FEVER. 
 
 the most extensive bronchial disease, where every tube seemed to be 
 half-filled, and yet where little of that kind of lividity which we see in 
 a case of asthma or of bad suffocative catarrh existed. Let us con- 
 sider this fact for a moment, for it is full of matter for reflection. What 
 does it tell us? It announces this highly important principle, that in 
 their formation, and in their progress, the secondary diseases of fever 
 are, as it were, silent. They occur without the usual symptoms which 
 are observed in idiopathic inflammations. They are not idiopathic 
 inflammations, and therefore they have not the symptoms of them. 
 Let us omit no opportunity of impressing on our minds the fact that 
 these diseases are not inflammations. They form silently ; they ad- 
 vance silently ; they subside silently, generally along with the fever, 
 but sometimes before it has ceased. Consider for a moment the form- 
 ation of a pustule in an ordinary case of smallpox. The pustule gives 
 no notice of its formation. You turn down the clothes, and you find 
 the arm covered with vesicles; the patient has not complained, but 
 you find there is the eruption. So it is with respect to the bronchial 
 disease in typhus ; so it is with respect to the intestinal disease in 
 typhoid. We see the bronchial disease forming in this singular and 
 latent manner, without excitement or suffering of the patient. We 
 see the same in the intestine and in the heart. The softening of the 
 heart, so commonly noticed in fever, is in its commencement and all 
 through a silent process. The process of change up to its maximal 
 intensity, and that of retrocession to the period of recovery, considered 
 simply, when they are not interfered with by accidental irritation, go on 
 silently. Thus the disease may proceed to its maximum without 
 symptoms, and retrocede without symptoms. Now, under these circum- 
 stances, I have said that, when you apply the stethoscope, you very 
 often find extensive rales. These rales may be sonorous, mucous, or 
 crepitating; the degree of each of those characteristics varying in 
 every case, and in different portions of the lung, in the same indi- 
 vidual. When you use percussion, you find that there is no dulness 
 anywhere. I have not observed, in the bronchial affection of typhus 
 (ever, the curious result of percussion which we see in cases of primary 
 bronchial disease. I allude to increase of sonority of the chest. This 
 is a very remarkable fact. In a large number of cases of acute inflam- 
 matory bronchitis, it is remarked that, so far from the chest being dull, 
 it is actually clearer than natural ; and this is explained by the circum- 
 stance that there is a great accummulation of air in the air-cells of the 
 lung — that, in fact, every little air-cell of the lung is in a condition of 
 distension; it is full of air, which cannot find a ready egress during 
 expiration, in consequence of the tumefied state of the bronchial tubes . 
 
BRONCHIAL AFFECTION NOT BRONCHITIS. 75 
 
 and hence we have the increase of sonority. I have not observed this 
 in cases of typhus fever where there was no consolidation of the lung; 
 but, at the same time, it is to be noted that we have not specially 
 studied this point in fever cases. When the patient draws a deep 
 breath we frequently find that the rales go on increasing up to the 
 very end of the inspiratory act; and in certain cases, the following 
 curious circumstance is noticed, and it is one of those which illustrate 
 what T have termed the silent action of the disease. On applying the 
 stethoscope, you may hear but little, or a loose, rale in the larger bron- 
 chial tubes, or in some of their secondary ramifications — that is, during 
 ordinary breathing. If you contented yourself with such an exami- 
 nation, you might come to the conclusion that there was very little 
 the matter with the patient's lung — slight mucous disease in the lower 
 part of the trachea, or in the very large tubes. But you might be al- 
 together wrong; for, under these circumstances, it frequently happens 
 that when the patient is made to draw a deep breath, you are startled 
 with the extent and intensity of the rales running to the very end of 
 the inspiratory act. It is in this condition that the patient's life is 
 seriously endangered ; for if this bronchial disease does not retrocede, 
 but continues to advance, it may happen that the sufferer falls sud- 
 denly into a condition of asphyxia, tracheal rattle comes on, and he dies 
 a mechanical death — in fact, he dies suffocated. You may leave your 
 patient apparently going on very well, and be summoned to him in 
 the course of a few hours, to find him in articulo mortis. This is a 
 common occurrence, as I mentioned to you before, in persons in whom 
 the bronchial disease has been overlooked or neglected. 
 
 You will commonly hear it said that this or that patient in typhus 
 has got bronchitis; and, if we were to be guided by physical signs 
 alone, such a statement would seem to be correct. But I wish you to 
 believe that the essence of this affection is not bronchitis, but rather 
 a special condition of the air-passages, secondary to the fever, the 
 result either of the typhous deposit or of the vascularity with tumes- 
 cence to which I have already alluded. If bronchitis — that is to say, 
 if inflammatory action supervenes — it must yet be considered as reac- 
 tive and specific. I am anxious to lay stress upon this, because there 
 are still many practitioners who hold that the physical signs of bron- 
 chitis are sufficient to establish the existence of primary inflammation. 
 Now, I do not know any characteristic difference between the physi- 
 cal signs which may occur in ordinary idiopathic bronchitis and those 
 which present themselves in typhus when the air-tubes are engaged. 
 In both there may be sonorous, sibilant, mucous, and crepitating 
 rales; and yet the two diseases are pathologically distinct. Observe 
 
76 LECTURES ON FEVER. 
 
 that whatever diminishes the calibre of the tubes, whether it be 
 deposit, typhous congestion, or true inflammation, will give rale; 
 whatever causes secretion, whether it be true inflammation or some- 
 thing the very opposite of inflammation, will give rale. We have, as 
 I said before, in typhus the physical signs which are observed in true 
 bronchitis ; but beware how, in any given case of fever, you conclude 
 from their presence that the patient has true bronchitis. In certain 
 cases there may be reactive irritation ; but never forget that the ty- 
 phous disease alone, without any inflammation whatever, is competent 
 to produce all the signs of bronchitis. Why do I urge this so much 
 on you? Because I wish to avail myself of every opportunity of 
 removing from your minds the erroneous doctrines of inflammation 
 which have beenso long in vogue. We are greatly influenced by 
 names; and though I do not suppose that there are many who would 
 treat a case of the bronchial affection in fever with the same reducing 
 measures which they would employ in the idiopathic disease, yet I 
 am sure that the idea of these signs proceeding from inflammation 
 makes many of us, who have not yet unlearned our early teachings, 
 timid in the use of stimulants. 
 
 We find that this bronchial disease runs a course exactly analogous 
 to that of the other secondary affections of fever. It comes on in- 
 sidiously, or, as I said before, silently ; it gradually advances to its 
 maximum, and sometimes increases to that degree that the patient 
 dies by asphyxia. This is often the case when the disease has not 
 been recognized at an early period. It is in almost all cases preceded 
 by the symptoms of fever for several days. I think in the best marked 
 cases it first shows itself about the fourth or fifth day of the disease, 
 but it may supervene at any period of the case. It subsides spon- 
 taneously. You will have abundant opportunities of observing the 
 following curious circumstance in the subsidence of this disease, either 
 when the affection runs its natural course or when it has been neces- 
 sary to treat it specially. In the true idiopathic bronchitis, when a 
 patient is placed under treatment, we observe the disappearance of 
 the rales to be gradual ; they are less intense and less complicated day 
 by day ; and this goes on probably for a week or ten days, or it may 
 be a fortnight or more, before the last shade of rale disappears. In 
 the t\ phous affection, on the contrary, you will often observe that the 
 most extensive, intense, and complicated rales disappear as if by en- 
 chantment, leaving the respiratory murmur perfectly pure. This 
 sudden di a ppearance of the physical signs is only an argument among 
 many to show their non-inflammatory origin. Nothing can be more 
 remarkable than this ; it seems analogous to the sudden disappear- 
 
SUBJECT TO LAW OF PERIODICITY. 77 
 
 ance of the eruption of scarlatina from the skin. You may often see 
 this eruption lasting for three or four days, and then suddenly disap- 
 pearing, leaving the skin white and pure. Consider the case of the 
 lung in the same way, and in place of the scarlatina eruption take 
 the secondary bronchial disease — or eruption, if you will — and you 
 can understand the occurrence of a similar change. Mind, I do not 
 say this happens in all cases; and I suppose that for its occurrence 
 it is necessary that there shall have been little, if any, reactive irrita- 
 tion. And, as I said before, we see it in cases not only where the 
 disease has been little, if at all, interfered with by treatment, but in 
 others in which we have used such remedies as dry cupping, counter- 
 irritation, and various stimulant medicines. Here the practitioner is 
 often surprised at the rapid and complete success of his treatment, 
 and may take credit to himself for bringing about a change which 
 was to a great degree, at all events, induced by the operation of the 
 law of periodicity, to which the secondary local effects, as well as the 
 essential disease, are subject. 
 
 In the next place we find that the best treatment in such cases is 
 the stimulant. The mere circumstance of a patient having or pre- 
 senting the most intense signs of bronchitis in typhus fever does not 
 by any means warrant us in bleeding him, in reducing him, in exhibit- 
 ing tartar emetic, or in withholding wine. Nothing of the kind; the 
 best treatment for such cases is the free use of wine, ammonia, turpen- 
 tine, bark, dry-cupping, and so on. 
 
 Another argument is drawn from the interesting fact, that in a 
 large number of cases of softened heart in typhus we find a combina- 
 tion with the bronchial disease, and it is quite fair to conclude that 
 the conditions of the lung and heart, as regards the influence of typhous 
 poison on the muscular structure of both these organs, are similar. 
 We have long held the opinion that what is called "effusion into the 
 chest" in catarrhal typhus is a consequence of the weakening of the 
 muscular structures of the bronchial tubes. The practical conclusion, 
 then, to be drawn is, that the physical signs of bronchitis in a case of 
 maculated typhus fever should not make you conclude that the patient 
 had bronchial inflammation ; and therefore you should not treat the 
 case as such. 
 
 I have just stated that the bronchial affection of fever does not 
 always disappear with extreme rapidity. Cases frequently occur 
 where that affection subsides as an attack of ordinary bronchitis does 
 — the rales become more scattered and less intense, and they finally 
 cease. In a third class of cases, even after the essential disease has 
 departed, the patient may be placed in imminent danger from effusion 
 
78 LECTURES ON FEVER. 
 
 on the chest; or, again, while he may not be exactly threatened with 
 asphyxia, yet his aspect and general condition may become eminently 
 suggestive of the presence of pulmonary consumption. He loses 
 strength, and grows pallid and emaciated. A loose cough sets in 
 sometimes, with profuse expectoration. In short, the bronchial affec- 
 tion simulates phthisis. Under these circumstances a quack sees the 
 patient and pronounces him to be far gone in consumption. After a 
 time the bronchial affection subsides, the sufferer rapidly improves — 
 in fact, gets well — and the quack wins all the credit of having cured 
 a case of confirmed phthisis. 
 
 So important do 1 regard this subject of imperfect or protracted 
 recovery from the bronchial disease of typhus to be, that I purpose 
 to devote our next lecture to its further investigation, and to a con- 
 sideration of the kindred topic of tubercle as a sequela of fever. 
 
 LECTURE XI. 
 
 Bronchial Affection of Fever continued — Alternating secondary affections — Imper- 
 fect convalescence due to reactive bronchitis — Cases resembling phthisis— Three 
 forms of tubercular disease, as a sequela of fever, (1) coexisting tubercle, (2) acute 
 consequent tubercle, (3) consequent softened tubercle —Diagnosis based on the want of 
 accordance between physical signs and symptoms in suspected phthisis after fever — 
 Expectoration of small calculi some months after bronchial typhus — Tubercular 
 fever in the typhus epidemic of 1826-27 — This fever may be contagious. 
 
 There is a remarkable type of fever, incidentally referred to in a 
 former lecture and not at all uncommon in this country, in which we 
 have an alternating disease, as it were, between the abdominal and the 
 pulmonary organs in continued fever. This is a very bad form of 
 fever — one of the worst. We find that to-day — we shall say — the 
 chest is greatly loaded, that we get no good respiratory murmur ; 
 there are most intense rales, and all the symptoms of extensive disease 
 of the lung are present. At this time the belly is soft; it is not ten- 
 der on pressure; and there is no diarrhoea. Things go on for two or 
 three days, when we find the belly to be swollen, tympanitic, tender 
 on pressure; there is diarrhoea; and on applying the stethoscope to 
 the chest we find it comparatively free, and the rales either gone or 
 almost altogether gone. 
 
 We turn our attention to the abdomen, and, on relieving the symp- 
 toms there to a certain degree, the chest again shows signs of disease; 
 and in this way the affection alternates as it were between the two 
 
ALTERNATING- SECONDARY AFFECTIONS. 79 
 
 great cavities, and forms a combination which is extremely difficult 
 of management. And I think that these cases of gastro-catarrhal 
 typhus — that is to say, of typhus with secondary disease in the two 
 cavities, that disease meanwhile alternately varying in its severity — 
 are more likely to be followed by the development of tubercle after 
 the disease has subsided than the catarrhal typhus without abdominal 
 complication. But on this point I do not wish you to believe that my 
 mind is completely made up. My opinion is one of those that men 
 form gradually and unknowingly, without being able to refer the 
 sources of that opinion to any particular observation. But it does 
 not happen in every case that the bronchial disease of typhus either 
 subsides in that sudden manner we have been speaking of or advances 
 to such a height as to destroy the patient's life. 
 
 There is another case, and a very important one, where we observe 
 an imperfect convalescence, the chest remaining very much engaged. 
 That is to say, after all the general symptoms of fever have subsided, 
 the petechiae have disappeared, the typhous expression has vanished, 
 and the patient is anxious for food, we find that the phenomena of 
 the chest remain but little altered; that there is extensive bronchial 
 rale. In this case it appears to me that what has happened is, that a 
 reactive inflammation has occurred, and that a form of bronchitis has 
 been added to the typhous disease. Something very similar to this 
 occurs in the case of disease of the intestine in fever. This has been 
 indicated by Dr. Cheyne as one of the cases of imperfect convalescence 
 in fever. It would appear as if a secondary inflammation supervened 
 upon the typhous alteration of the intestine, and this caused the con- 
 valescence to be imperfect. It is extremely probable that the same 
 thing occurs in the lung. There is nothing more important, gentle- 
 men, in the study of diseases than to keep analogy continually before 
 us ; and you may expect that the processes of disease observed in one 
 cavity of the body will be repeated in the others. The case in the 
 wards to which we gave the turpentine was a good example of this. 
 
 These cases are frequently mistaken for phthisis — and this is not 
 to be wondered at, for the patients have a very phthisical aspect: they 
 are emaciated by fever; they have often a species of semi-hectic upon 
 them; they have cough; their respiration is difficult; and they have 
 frequently profuse expectoration. You will say, then, Is there any 
 difference between the symptoms in these cases at this stage and those 
 in cases of phthisis? I do not know of any difference but this, that in 
 the patients labouring under phthisis there is often a very copious 
 muco-puriform expectoration — a thing rarely seen during the presence 
 of the disease in i'o\cr. It is very natural, then, that, under these 
 
80 LECTURES ON FEVER. 
 
 circumstances, a practitioner seeing a patient for the first time might 
 come to the conclusion that he was phthisical ; and it is quite proper 
 that all physicians in this state of things should be apprehensive of 
 such a condition, because it is certain that in some instances of typhus 
 fever a disposition to permanent organic change in the lung seems to 
 have been created by the disturbance of the system in consequence of 
 the fever. 
 
 We have three forms of tubercular disease induced in this way. 
 The first is what I may term acute coexisting tubercle. This is a most 
 curious form, in which, while the petechias are still on the surface, 
 the lung becomes full of soft cheesy matter. 
 
 Let me call your attention particularly to this disease. We have 
 not seen many instances of it, and but on one occasion had we a post- 
 mortem examination ; but this was a very well-marked case. It 
 occured several years back in our wards, and was one of those cases 
 which we do not easily forget. The patient, a man between 30 and 
 40 years of age, had enjoyed perfect health up to the time when he 
 was attacked with fever ; he was not subject to any form of chronic 
 bronchitis, or of pulmonary irritation ; so that there is not the slightest 
 reason to believe that tubercular matter existed in his lungs before 
 he was attacked with the fever. He came here at the end of the first 
 week of his illness with the usual symptoms of maculated typhus, 
 complicated by the secondary bronchial disease. So far there was 
 nothing unusual about the case. It was observed, however, that the 
 rales were more intense in the right than in the left lung; that there 
 was a greater amount of large crepitus than we commonly see in the 
 typhous disease, indicating that the minute tubes were much engaged. 
 The chest was perfectly clear on percussion, but I took alarm at the 
 great amount of bronchial rale which had become developed at so 
 early a period. The patient was treated by dry-cupping, blistering, 
 and the use of senega with carbonate of ammonia; but yet we did not 
 observe that these measures produced any sensible effect on the 
 physical signs — a circumstance which should have still further 
 increased our apprehensions, but at that time we had no suspicion of 
 what the result was to be. There was no remarkable suffering; the 
 patient did not complain of dyspnoea, his breathing was not much 
 accelerated, and, in short, he had no symptom which would distin- 
 guish his case from ordinary typhus with severe bronchial disease. 
 We now, however, observed that day by day, with nothing but a 
 bronchial rale, the anterior portion of the chest, especially on the 
 right side, became equably yet progressively dull, although there was 
 little if any change in the character of the large but crepitating rale, 
 
ACUTE COEXISTING TUBERCLE. 81 
 
 nor was there any indication of hepatization — the lung always 
 continued permeable to air. The petechias remained remarkably 
 stationary. About the eighth or ninth day the patient began to sweat 
 profusely. And this sweating appeared to occur in two paroxysms 
 within the twenty-four hours, so that he seemed to have a combina- 
 tion of severe hectic and of typhus fever. He died on or about the 
 twelfth or thirteenth day of his disease, the front of the right side 
 having become very dull, but not absolutely so, and the large crepitus 
 remaining with singular constancy all through. On the day of his 
 death the petechial eruption had scarcely faded. 
 
 Although we had never had any instance of the acute development 
 of cheesy degeneration pending the typhous state, yet I ventured 
 to make the diagnosis of the disease here, for the physical phenomena 
 were precisely those which occur in ordinary acute inflammatory 
 cheesy infiltration of the lung. The right lung was found to contain 
 a great quantity of soft, gray, cheesy matter, deposited in isolated 
 patches, varying from the size of half a pea to that of a hazel-nut. 
 The masses were not encysted; they were soft, but yet showed no 
 appearance of suppuration. A few deposits of the same kind were 
 found on the left side. 
 
 The great amount of this deposit is in itself sufficient to prove that 
 it was one of the secondary affections of the typhus fever; for although 
 a man may live with a certain amount of chronic tubercle developed 
 in his lung, it is quite impossible to conceive that he could have had 
 such a quantity of soft cheesy matter, nearly filling up one lung, 
 while his health and respiratory function remained unaffected, as was 
 the case in this man until the occurrence of the typhus fever. 
 
 I believe that this was but the extreme degree of what often occurs 
 in fever; and we shall just now see that there are strong grounds for 
 holding that cheesy matter is formed, though in smaller quantities, 
 during the secondary bronchial disease of fever, and yet the patient 
 recovers without having the symptoms of phthisis. 
 
 The next form we term acute consequent tubercle; that is to say, when 
 the patient has passed through his fever, and has had an interval of 
 repose, everything apparently promising a perfect recovery, there is 
 a sudden explosion of tubercular disease, with symptoms of high irri- 
 tation, and with a rapid development of miliary and granular tubercle. 
 
 The last form, which is not by any means so frequent as the others, 
 
 is the consequent softened tubercle, in which, when a patient who has 
 
 had catarrhal disease in the eurly periods of his fever has recovered, 
 
 although with an imperfect convalescence, the- disease passes, some- 
 
 6 
 
82 LECTURES ON FEVER. 
 
 times rapidly, into the ordinary pulmonary phthisis, and is followed 
 by the same result. 
 
 I spoke to-day in the wards of a practical question, as to your diag- 
 nosis, when called to a patient who has gone through typhus fever, 
 and in whom the chest is very much engaged; this is a case to which 
 you will be often called in consultation. The patient has been under 
 the care of another person ; he has gone through severe fever; he is 
 on the 25th, or the 30th, or the 36th day of his illness, and appear- 
 ances of his being consumptive occur. It is possible that the patient 
 may be of a consumptive family, and an alarm is excited. He has 
 wasted in flesh; he has quick pulse; he may have had some sweats; 
 he has cough and muco-puriform expectoration. Well, such is his po- 
 sition. You are called on then to say, in the common phrase, whether 
 his lungs are affected or not. You examine the chest carefully; and, 
 if you find the following circumstances present, you may in most 
 instances be able to assure the patient's friends that as yet the patient 
 is not phthisical. If you find that the physical signs of bronchitis are 
 universal, that in no part of the chest you fail in discovering sonorous, 
 mucous, or muco-crepitating rales, in various degrees of combination 
 — in other words, stethoscopic indications that every 'portion of the 
 bronchial tree is equably affected — if, then, with this universality 
 and intensity of bronchial signs, you find that the patient's respiration 
 is not much excited, that he is not complaining of dyspnoea, or that his 
 respiration is not rapid, you may be almost certain that the patient is 
 labouring only under the remains of typhous bronchial disease, and 
 that he has not yet passed into a phthisical condition. You make the 
 diagnosis here, gentlemen, from a source which you will find of great 
 importance: it is a diagnosis from the want of accordance of phenomena. 
 What do you find here? Signs of universal bronchial affection. Now, 
 we know that in ninety-nine cases out of a hundred of the development 
 of tubercle after fever, where there is universality of deposit there is 
 extreme constitutional suffering — there is great dyspnoea — there is 
 extraordinary acceleration of breathing, so that in the case above speci- 
 fied the want of accordance between the extent of disease and the 
 amount of suffering leads you to a negative diagnosis, and enables 
 you to declare that as yet the patient is not the subject of consumption. 
 If, on the other hand, this patient had, with the physical signs which 
 I have described, any hurried or difficult breathing, and the signs and 
 symptoms of great irritation of the lung, it would be quite impossible 
 to say that he had not consumption. In a very large number of cases 
 you will find that this rule will apply. In bronchial disease following 
 not only typhus fever, but a variety of other affections, you can apply 
 
SECONDARY INFILTRATION OF LUNGS. 83 
 
 this rule of diagnosis very commonly indeed; in the remittent fever 
 of children you can apply it; in cases of the bronchial disease which 
 follows measles or scarlatina, and in a variety of other affections, the 
 diagnosis from the want of accordance of the phenomena is appli- 
 cable. It is very important, indeed, to study carefully those means 
 of diagnosis which are available where you have not an opportunity 
 of repeated observation. In most cases of consultation the consulting 
 physician sees the patient but once. If you should be able to see him 
 three or four times, at intervals of two or three days, you would not 
 be under this difficulty ; but by this weapon of diagnosis, if I may 
 make use of such a phrase, you will be able — even by seeing the 
 patient but once — to give a satisfactory diagnosis. 
 
 I have drawn your attention to the great probability that exists 
 that in many cases of fever, with the secondary bronchial disease, 
 there is developed not merely the affection of the mucous membrane, 
 but more or less of actual organic change, consisting in a local deposi- 
 tion of tubercle; and yet it does not follow that the patient will ever 
 have the symptoms of phthisis. He may recover, and often does 
 recover completely, with a perfectly pure respiratory murmur, with- 
 out any cough, or without any symptoms whatever of disease, but 
 after a period varying from three months to nine months he expecto- 
 rates a few calculi. There cannot be any doubt, when all the circum- 
 stances of the case are considered, that those calculi were petrifactions 
 of deposits which were formed pending the fever, and which, from 
 their being small and isolated, without any consolidation of the sur- 
 rounding tissue, and from their having been unaccompanied by 
 cavities, altogether escaped observation. The number of individuals 
 who have gone through this bronchial typhus, and at some subse- 
 quent period are observed to expectorate small calculi, is quite suffi- 
 cient to warrant this conclusion. 
 
 Now, looking at the entire subject, I think it more than probable 
 that, in many cases, even where this proof of the previous, occurrence 
 of tubercular deposit has not existed, such deposit has gone through 
 a process of calcification, and the patient has not afterwards passed 
 into phthisis. The cure may be effected either by calcareous trans- 
 formation, absorption, or suppuration at a number of points so minute 
 as to elude detection by physical means, the signs being lost or con- 
 founded with those of ordinary bronchial disease. I think that this 
 occurs in many cases in which we have a doubtful convalescence, 
 with a quick pulse and a hectic state, in those who have had fever 
 with severe bronchial disease. 
 
 How are we to look on this tubercular deposit as a result of the 
 
84 LECTURES ON FEVER. 
 
 typhous state? Were these patients already subjects of the phthisical 
 diathesis, although no actual deposit had taken place at the time of 
 their being attacked with fever? Or are we to look upon tubercular 
 matter as occasionally one of the secondary secretions of fever? I 
 strongly incline to the latter view. This much, at all events, is certain, 
 that in a large number of cases there were, previously to the attack 
 of contagious typhus, no existing symptoms or physical signs of 
 phthisis, nor did the patients present those characteristics which indi- 
 cate a tendency to this affection. Tubercular deposit, as one of the 
 secondary products of fever, is probably to be looked upon as among 
 the rarer consequences of the disease; for although we have seen 
 many instances of it, yet in the great majority of cases of fever with 
 bronchial disease there is no evidence of its having occurred. Why 
 it should occur in one case, and not in another, we do not know; bat 
 it is very probable that there are great varieties in the nature of the 
 typhous deposit in different patients and in different epidemics. It is 
 not unreasonable to suppose that the inconstancy which we observe 
 witli respect to the seat, amount, periods, and complications of the 
 secondary diseases of fever should be also repeated as to their 
 chemico pathological characters. And thus one patient may have a 
 secretion or deposit which is not tubercular, while another exhibits 
 this alteration to a greater or less degree. All this, you will see, 
 bears strongly on the question of the specific or non-specific nature 
 of tubercle after fever; and the facts which we have just now been 
 examining seem to point to the conclusion that the doctrine of tubercle 
 being a purely heterologous product, resulting from a specific con- 
 tamination of the system, is one which we must be cautious in accept- 
 ing. But there are other circumstances in relation to this matter 
 with which you should be acquainted. 
 
 Hitherto we have been dealing with cases in which the tubercular 
 formation seemed to be, as it were, an accident in the chain of typhous 
 phenomena; cases in the majority of which, at all events, the actual 
 amount of the deposit was geuerally inconsiderable. I have already 
 spoken of one case in which a great quantity of cheesy matter was 
 formed during the existence of a genuine and well-marked typhus fever, 
 but in the instances hitherto under consideration we may hold that the 
 deposit was but a superaddition to the ordinary secondary bronchial 
 disease. Let us now inquire whether there is any evidence of a 
 fever closely allied to, if not identical with, typhus or typhoid fever, and 
 in which the secondary lesion is purely the deposit of tubercle — the 
 tubercular matter and the fever standing in. the same relation one to 
 the other as the matter of the smallpox pustule does to the essential 
 

 TUBERCULAR FEVER. 85 
 
 disease of variola. I cannot pretend to give you any extended infor- 
 mation on this point, but the following circumstances are important. 
 
 In the epidemic of typhus fever of 1826 and 1827 the two most 
 remarkable circumstances were the great prevalence of the follicular 
 disease of the intestines and the liability to relapse. In a good many 
 instances it was found that the fever in the relapse was of a more severe 
 character than in the first seizure. You may have observed something 
 of the same sort during the present season; for we have had several 
 instances in which, while the first attack ran a period of only from five 
 to eight days, with the comparatively mild symptoms of what is called 
 typhoid fever, the patients, on relapsing, had severe, long-continued, 
 and maculated fever. In some of them, too, the bronchial system, which 
 had escaped in the first illness, was profoundly engaged during the sec- 
 ond attack. It was found that in several instances in which the patients 
 had gone through the first attack of fever, and relapsed, they presented 
 a group of symptoms very different from those in the primary illness. 
 The fever was much more violent, the sufferings greater, and the 
 local symptoms more numerous and decided. One case I shall never 
 forget. A young woman had gone through the usual primary attack of 
 fever, and recovered satisfactorily. There was nothing either in her 
 previous history or in the symptoms of her fever to distinguish this 
 case from that of hundreds that had passed through our wards. After 
 remaining a few days in a state of convalescence, this girl was reported 
 to me as having relapsed. As there was nothing unusual in this, we 
 merely directed the ordinary expectorant and cooling treatment; but 
 on the second or third day it was plain that the disease was taking 
 on a new character. The patient had symptoms of local suffering, or 
 irritation, if you will, in all the cavities. The head was hot and pain- 
 ful, she was delirious; the heart was excited, and the pulse was rapid 
 and wiry, the skin was burning hot, and the general symptoms were 
 those of the most severe ataxic fever, with the greatest agitation and 
 distress. 
 
 But I have not yet enumerated all the symptoms of this singular 
 case. In addition to the high fever and cerebral excitement, the 
 patient suffered from unceasing and extreme dyspnoea, running into or- 
 thopncea. The countenace was swollen and livid. There was a constant 
 cough, with a scanty bronchitic expectoration, and pain of both sides. 
 Then the symptoms of irritation in the belly were as well marked. 
 It was greatly swollen, tympanitic, hot, and painful on pressure. The 
 tongue was red, dry, and cracked; the thirst immoderate, and she 
 had frequent diarrhoea.. Now, observe that no effort of ours pro- 
 duced the slightest alleviation of any of her symptoms; and under this 
 
86 LECTURES ON FEVER. 
 
 storm of disease she sank on the seventh day from the commencement 
 of the relapse. We found, on dissection, an almost universal deposit of 
 miliary and granular tubercle. • I never saw anything similar before, 
 nor have I seen anything like it since. The lungs, liver, spleen, uterus, 
 kidneys, as well as all the serous membranes, were implicated; and 
 the amount of the disease, particularly in the lungs, liver, spleen, and 
 arachnoid, was beyond anything that you can imagine. The deposit 
 was of the same character everywhere. It was the disseminated tuber- 
 cle, not the infiltrated, consisting of gray semi-transparent granules, 
 the size of mustard seeds or smaller. In the lungs no one portion was 
 less engaged then another. The little tubercles, some semi-transparent, 
 others white, or yellow, and opaque, were so closely packed that they 
 all but touched one another; yet each was distinct. There was no in- 
 osculation, or running of one into the other ; nor was there one among 
 these myriads of deposits that showed any trace of suppuration. The 
 bronchial membrane was of a deep red colour, and the pulmonary 
 structure, which was nowhere hepatized, presented a bright scarlet hue. 
 In the spleen, which was enlarged, the deposits were nearly as abun- 
 dant as in the lung ; a few of them had attained a larger size and a 
 more granular structure. The pericardium, peritoneum, and arach- 
 noid membrane were all studded as closely as possibly with the miliary 
 tubercles. 
 
 Now, reflect on this case. Who can doubt this extraordinary 
 deposit was the result of the second attack? The very quantity of it 
 is sufficient to prove this; for, if we take even the lung, no one could 
 believe that this amount of disease existed, either before the first 
 attack or during the period of convalescence, when there were apy- 
 rexia and quiet breathing; again, remember that all these deposits 
 were in the same or very nearly the same degree of development, 
 and that this disease occurred in a patient who had gone through her 
 first fever without any remarkable symptoms — during an epidemic 
 when relapse was so frequent as to be considered almost the rule. 
 
 Gentlemen, this might be called a tubercular fever. Call it, how- 
 ever, what you will, it was a fever, with secondary lesion of a pecu- 
 liar kind. This change, or local disease, was in one sense anatomical, 
 no doubt, in that there was tangible visible alteration; but it set the 
 local anatomical divisions of fever at nought, from the fact of its being 
 universal. The disease was, indeed, as essential as the malady or 
 fever which produced it. Why tubercular matter was produced here 
 in such incredible quantities, and in so short a time, we do not know. 
 Why, in the same epidemic, this patient, in common with many 
 others, suffered in this way, while the great majority of the sick reco- 
 
CASE OF TUBERCULAR FEVER. S< 
 
 vered, we cannot tell — any more than why one patient in fever, and 
 in the same epidemic, shall have disease in the mucous glands of his 
 intestine; a second, congestion and typhous deposit in his lungs; a 
 third, an enlargement of his spleen; a fourth, a softened heart; a fifth, 
 presenting all these changes combined; and so on, with an. endless 
 variety. 
 
 In this singular case it is probable that the immediate cause of 
 death was asphyxia, for the lungs were almost completely filled with 
 the deposits ; but there was so much local disease of the same kind 
 elsewhere that it is difficult to say how much or how little the deposit 
 in the lungs acted in causing death, especially when we recollect that 
 the fever alone, from its very virulence and malignity, might have 
 destroyed the patient. Had there been a smaller amount of tubercle 
 in the lungs, she might have thrown off the fever, and afterwards died 
 with the symptoms of rapid phthisis. This occurrence was observed 
 by us in several instances during that very epidemic; and in some the 
 period which elapsed between the efessatiftn of the fever and death, 
 with all the symptoms and physical signs of suppurative tubercle, 
 was not more than from ten days to a fortnight. On dissection the 
 lungs were found everywhere filled with softened tubercle, which in 
 many places had formed small anfractuosities. 
 
 The observations which I have now made to you refer to the con- 
 nection between fever and the occasional production of cheesy or of 
 tubercular matter, as one of its secondary effects, and I think I have 
 said enough to show you that tubercular deposit and the typhous state 
 frequently stand to one another in the relation of effect and causet 
 We might now inquire whether there are other forms of essential 
 fevers in which the tubercular deposit is a necessary consequence 
 — in which, to use the language at present in vogue, it becomes the 
 anatomical character of the fever. You know that I am not fond of 
 discussing the distinctions of fever. The cases which I have laid 
 before you were examples of tubercular deposit developed in the 
 relapse period of fever; and although in this relapse certain anatomical 
 characters were developed, we are not on that account to say that the 
 essence of the fever in its relapse was different from that in its first 
 period. You all know that typhus fever may relapse into typhoid 
 fever, and typhoid into typhus. I am compelled to use the expression 
 of one fever relapsing into another, which is an inaccurate one, for 
 want of a better, and you all must know my meaning. But is there 
 any form of fever in which the tendency to produce tubercle, or the 
 actual production of it, is from the very commencement a distinctive 
 character? The following circumstances occurred in the practice of 
 
S3 LECTURES ON FEVER. 
 
 the late Mr. Cusack, and, as far as they go, they seem to prove that 
 there may be a true, essential, and tubercular fever, which also may 
 be contagious, affecting many members of one family. 
 
 An infant at the breast, eight weeks old, was attacked with fever. 
 The principal local symptoms were oppression of breathing and ful- 
 ness of the abdomen. The child refused its food, and death took 
 place at the end of the third week. On dissection the lungs were 
 found filled with miliary tubercle, and the same deposit was exten- 
 sively exhibited upon both pleuras and peritoneum. 
 
 The next case, which occurred in this family, was that of a girl 
 seven years of age. She took ill just at the period of the death of 
 her sister, and her symptoms were closely similar to those of the infant 
 just spoken of. She had fever, oppression of breathing, and swelling 
 of the abdomen. It was thought that the origin of this disease might 
 be from malaria, and on this account she was removed to the country ; 
 but she died within six weeks from the invasion of the fever. On 
 dissection a precisely similar state of parts was discovered, the viscera 
 being extensively filled with disseminated tubercle, and yet without 
 any suppuration of the deposit. 
 
 Now comes the most important fact connected with this history. 
 The two brothers of this girl, who had been at school, arrived to 
 spend their vacation just at the time of her death. They came to the 
 country house in which she had died. Their ages were respectively 
 eight and nine years. Within the first week the elder sickened; he 
 had fever; oppression of breathing, soon followed by cerebral symp- 
 toms; he also died with signs of effusion on the brain ; and on dissec- 
 tion the pia mater, arachnoid, lungs, and peritoneum all presented 
 the tubercular deposit, with the same character as in the preceding 
 cases. Upon his death his younger brother sickened ; in this case, 
 in addition to the symptoms of fever, the local suffering was princi- 
 pally referred to the head. The child, after going through a tedious 
 illness, recovered without showing any symptoms of phthisis. Dur- 
 ing his illness his eldest sister, aged twelve, became affected with 
 fever having the same general character as that which was presented 
 in the other cases, but without any decided local symptoms; she also 
 recovered. 
 
 It might, perhaps, be better were I to leave these facts before you 
 without comment, but I cannot avoid expressing my opinion that 
 they go far to establish not only the existence of a form of fever of 
 which the anatomical result is often tubercle, but also that this fever 
 may be, under certain circumstances, contagious. 
 
 The essentiality, also, of this species of fever is indicated in the 
 
SECONDARY PNEUMONIC COMPLICATIONS OF FEVER. 89 
 
 history of the foregoing cases ; for we observe the same want of con- 
 stancy as to the appearance, amount, and seat of the secondary deposit 
 which is so striking a characteristic of the secondary local affections 
 of other essential diseases. The fourth and fifth cases probably illus- 
 trate the want of constancy observed in fevers in relation to the 
 secondary affections and their results. 
 
 LECTURE XII. 
 
 Secondary Pneumonic Complications of Fever — Secondary congestion or consolidation 
 of lung — The term "typhoid pneumonia" is incorrect — "Acute asthenic pulmonary 
 disease," or "typhoid pneumonia," appears under seven forms — "Aborted typhus" 
 in connection with the occurrence of lung consolidation — Local disease may assume 
 a sthenic type even in the presence of a general asthenic, condition — Description of 
 the secondary pulmonary affection of fever under its three principal forms — Differ- 
 ential diagnosis between this disease and acute primary pneumonia, based on both 
 pathological and anatomical grounds. 
 
 The study of the affections of the lungs in fever leads us next to 
 examine a class of cases in which a congestion more or less severe, or 
 it may be a consolidation of the lung, takes place in connection with 
 the typhous state. You have already witnessed several cases of this 
 kind. In some there have been signs only of a congestive state, 
 affecting a portion of one or both lungs; a state stopping short of 
 consolidation, and indicated by a crepitus with large bubbles — a 
 muco-crepitating rale, without much dulness, or the other signs of 
 impermeability of the pulmonary tissue. In other instances, however, 
 we have observed the occurrence of decided dulness. Between these 
 extremes we meet with a number of cases varying in the degree or 
 amount of the diseased action. 
 
 To these cases the general term of "typhoid pneumonia" has been 
 given. But you will be convinced, when your experience has been 
 enlarged, that under this term many different forms of disease have 
 been classed; and it is very doubtful whether a true pneumonia is 
 ever developed in the course of a fever. You will meet with the 
 physical signs which attend pneumonia; but these, as you all must 
 know, are insufficient to establish the existence of the disease; and 
 even these very physical signs are seldom so well marked, so com- 
 plete as it were, as in simple inflammation of the lung. Nor, again, 
 do they follow in the regular succession which we find in true pneu- 
 monia. 
 
90 LECTURES ON FEVER. 
 
 I am not fond of fine drawn distinctions in disease, especially when 
 these distinctions are based on some anatomical speciality, and do not 
 lead to any differences in our principles of treatment; and I think 
 we shall arrive at practical results sooner by reviewing some of the 
 more striking cases — I will not say of typhoid pneumonia — but of 
 the acute asthenic diseases of the lung which tend to consolidate that 
 organ. I mean, when using the terms "acute asthenic," to imply a 
 disease which forms more or less rapidly, and is associated with, or 
 secondary to, a condition of the system in which, with fever of some 
 kind, we find evident signs of debility. Leaving refined shades of 
 distinction aside, we may then recognize the following forms of the 
 affection we are now considering: — 
 
 1. Congestion, with more or less consolidation in cases of what is 
 called "diffuse inflammation," "erysipelatous inflammation," or, by 
 some, phlebitis. 
 
 2. Similar or nearly similar conditions (so far, at least, as we are 
 taught by pathological anatomy) in cases of purulent absorption, 
 with or without manifest phlebitis. 
 
 3. The intercurrent disease of the lung in cases of the eruptive 
 fevers, when they are of the low, putrid, or malignant type. 
 
 4. Congestion and semi-consolidations of the lung, as intercurrent 
 affections in fever, and more especially in typhus fever. 
 
 5. Analogous conditions arising in the course of the non-maculated 
 and the so-called typhoid fever. 
 
 6. The disease occurring in connection with delirium tremens from 
 excess. In such cases we will often fined a group of asthenic local 
 diseases, which are generally seated in the stomach, heart, the bronchial 
 membrane, the parenchyma of the lung, and even the pleura and 
 pericardium. In some instances we find that the patient has also 
 typhus fever. 
 
 7. Rapid, extensive, and complete consolidation of the lung occur- 
 ring in the course of a malignant typhus. In some instances the patient 
 dies asphyxiated, while in others a portion of the pulmonary structures 
 falls into sphacelus, and death takes place with the symptoms of acute 
 gangrene of the lung. 
 
 Such are some of the more prominent cases which have been classed 
 under the head of typhoid pneumonia. There is another division of 
 which we have had many examples, and yet I do not wish you to take 
 what I am going to say about it in any other way than in the light of 
 suggestions. The case, as I said before, is by no means uncommon. 
 The patient is attacked with the usual symptoms of typhus fever, and 
 he comes into hospital after two or three days' illness. There is 
 
CRITICAL CONSOLIDATION OF LUNG. Pi 
 
 nothing about him to make one think that his disease will not run the 
 usual course of the epidemic of the day, and we are prepared to 
 expect a fever of at least a fortnight's duration. On admission he 
 may have no symptom which would call attention to his chest; but, as 
 early in some cases as the beginning of the fourth, and in others of the 
 fifth day, it is discovered that the upper lobe of one lung is solid, or 
 nearly so. The clavicle is quite dull on percussion, so is the scapular 
 spine, and the dulness extends to the line of the mamma, with well- 
 marked tubular breathing. This discovery has been so often made 
 accidentally that I am sure many of such cases have passed unnoticed, 
 at least where the attendant is not well informed as to the insidious 
 nature of typhous local diseases, and does not make it a practice and 
 a duty to examine daily, as far as he can, the condition of every 
 organ. 
 
 But the most remarkable circumstance in these cases is that the 
 constitutional disease seems to be cut short. The expression of fever 
 leaves the countenance, the peculiar colour or hue of typhus disappears, 
 the eye becomes bright and intelligent, the tongue cleans, and the pulse 
 comes down to a natural state. And thus we have seen patients so 
 altered in the course of twenty-four hours that one had some difficulty 
 in recognizing them. All the symptoms of typhus were gone, and 
 nothing remained but the consolidation of the lung. And this, too, is 
 not attended with any notable suffering. There may be a little cough, 
 some dull pain, or an inability to lie on one side ; but that is all. The 
 respiration is scarcely, if at all, accelerated ; in fact, it would seem that 
 there was no irritation or excitement of the organ ; and the case is an- 
 other proof of how much less the sufferings in disease are connected 
 with the mechanical than with the vital conditions of organs. 
 
 By the operation of some law, which we do not as yet understands 
 there seems to exist a connection between the cessation of the essen- 
 tial disease and this consolidation of the lung ; the fever appears to 
 abort, and the pulmonary change is critical. Under such circum- 
 stances our prognosis is favourable, the fever having ceased by a well- 
 marked and peculiar mode of crisis. 
 
 This local disease, too, is generally easily managed. Indeed, the 
 cure is often so rapid that I have thought that our remedies had little 
 to do with the result, llow are we to look at such cases ? That they 
 are not examples of inflammation of the lung is plain ; and it appears 
 probable that, if this local disease had not occurred, the patient would 
 have gone through the course of the fever of the day. Does it not seem 
 as if the constitutional disease exhausted itself, as it were, in the pro- 
 duction of the local affection, just as, in certain cases of simple variola, 
 
92 LECTURES ON FEVER. 
 
 we see the fever to subside on the appearance of the pustule ? I do 
 not know whether such cases have been observed elsewhere, but of their 
 existence we have had here abundant proofs. It is worthy of remark, 
 too, that when we compare these cases with the ordinary forms of 
 typhus, attended with secondary disease of the lung, the local affection 
 is developed at an unusally early period ; and it may be that, in the 
 more protracted cases of fevers, the nature of which is to develop local 
 affections, the periods of this development and of the cessation of the 
 fever may also be coincident. We do not, however, find that this is 
 so common as to establish a rule. Let us, assuming that these curious 
 cases were really examples of typhus with a secondary deposit, again 
 compare them with the more ordinary forms of the disease, and we shall 
 find that they want two important characteristics of the longer fevers ; 
 one the successive or simultaneous production of various local dis- 
 eases; and the other, the occurrence of that secondary inflammation 
 or irritation of the parts in which the deposit takes place. That the 
 latter circumstance is one of great weight in relation to the preventing 
 or delaying of crisis, it is impossible to doubt. As to the case of suc- 
 cessive or simultaneous production of local diseases, this, at all events, 
 marks a more severe and complicated disease. 
 
 Gentlemen, I will not here enter into the wide subject of crisis in 
 fever; yet I may point out to you, as a matter well worthy of investi- 
 gation, the possibility of the occurrence of crisis by other modes than 
 those which are generally enumerated; thus we may have a crisis 
 without sweating, diuresis, hemorrhage, or diarrhoea, but which takes 
 place by a silent change in the condition of an organ, and yet a change 
 which will, or may, itself spontaneously disappear. 
 
 Here let me warn you against a common error with respect to cases 
 of disease of the lung arising in the course of some form of consti- 
 tutional malady or fever. They are usually set down as pneumonia, 
 typhoid pneumonia by some. Now, the name itself would be of little 
 moment if its adoption did not lead to errors in practice. And 
 although it cannot be affirmed with certainty that in none of these 
 cases is there pneumonia, yet we have good grounds for believing 
 that, in many of them, inflammation, as the term is commonly under- 
 stood, is either absent from the first, or, if it occurs, that it is only 
 secondary to a special lesion induced by some form of essential 
 disease. 
 
 It is difficult to give any well-defined classification of the various 
 forms of diseases described under the head of typhoid pneumonia, or 
 to draw the line between simple asthenic inflammation of the lungs 
 and those conditions described from an early period under the terms 
 
TYPHOID PNEUMONIA. 93 
 
 of bilious, putrid, or typhoid pneumonia. And observe that when I 
 make use of the term asthenic pneumonia I refer more to the con- 
 dition of the general system than to the activity or inactivity of the 
 local disease. For so far as local inflammatory action is concerned, 
 there is proof that it may originate and proceed with rapidity, and even 
 with vehemence, in the very last periods of life, so that the disease 
 may be sthenic quoad the local condition, and yet the case itself be 
 asthenic in reference to the general state of the economy. Much of 
 the confusion with regard to this subject has arisen from the circum- 
 stance that too great weight was attached to the presence of certain 
 physical signs, which were taken as always indicating similar vital 
 conditions. The succession of the signs of crepitus, dulness, cessation 
 of vesicular breathing, and its replacement by bronchial respiration, 
 is too often held to indicate a simple pneumonia, in which the local 
 disease is the principal condition, and the fever only a secondary one. 
 But it is certain that this train of phenomena, or some modification 
 of them, may occur under exactly opposite circumstances — the local 
 disease being symptomatic of the fever, and not the fever of the local 
 disease. And there is the strongest reason for believing that even 
 though the mere anatomical condition of the lung in the two cases 
 be similar, yet there is an essential, a vital difference, and that practi- 
 cally we cannot deal with the local disease in the latter case as if it 
 were an original affection. This applies to all those cases with the 
 physical signs of pneumonia, which are secondary to any form of 
 fever, whether it be typhus or typhoid, whether it be variola or ery- 
 sipelas, purulent poisoning of the blood, glanders, malignant scarla- 
 tina, or malignant measles. In these cases, even though the physical 
 signs accurately correspond with those of the typical pneumonia — 
 which, by the way, is by no means always the case — we must believe 
 that we are dealing with a special condition of parts, a condition 
 special not only as compared with ordinary pneumonia, but inasmuch 
 as it is derived from the parent malady. 
 
 In the present state of our knowledge, gentlemen, we cannot declare 
 that any special pathological condition exists by which we can dis- 
 tinguish these secondary diseases one from the other. We may say 
 this much, that practically they appear to agree in being indicative 
 of an asthenic state of the system, and therefore, the supervention 
 of their physical signs at any period of those various diseases must 
 not be permitted to divert your attention from the general condition 
 of the patient, or to make you proceed to treat a case as one a 
 sthenic pneumonia because it has some, or even all, of the phys ; ... 
 signs of that condition. Do not suppose that I am taking up your 
 
9-4 LECTURES ON FEVER. 
 
 time unnecessarily by insisting on these points, for they lead us 
 directly to deal with one of the greatest, if not the greatest and most 
 wide-spread error in the practice of medicine — namely, the treatment 
 of all local .acute diseases with feverish symptoms as inflammations. 
 Here is a group of acute local diseases with feverish symptoms, and 
 not only this, but a set of cases exhibiting some or all of the physical 
 phenomena of acute pneumonia; and yet if we subjected them to 
 the ordinary treatment of inflammation, the worst consequences 
 would almost certainly follow. You must learn to look at the ante- 
 cedents and the accompanying general phenomena of these diseases, 
 and set your face against the adoption of any treatment which is 
 based on the doctrine that they are original inflammations. 
 
 I have good reason to believe, and I rejoice at it, that the errone- 
 ous views to which I allude are every day becoming less and less fre- 
 quent, thanks to our improved system of clinical instruction and to 
 the independent spirit of investigation which now animates so many 
 of our students. Notwithstanding, they are still too often acted upon, 
 and over and over again patients who have enough to contend with 
 as the victims of some fell fever or other constitutional disease are 
 lost, or assisted to their death, by the adoption of a local or general 
 antiphlogistic treatment, in consequence of the physical signs of a 
 pneumonia being discovered. Their stimulants are withheld or with- 
 drawn ; tartar emetic, or mercury, or even blood-letting is rashly re- 
 sorted to; and it often happens that, even though the physical signs 
 of the pneumonia are removed or modified, the patient sinks from the 
 combined effect of the original disease and the exhaustion produced 
 by this treatment. I do not think that any of you will fall into these 
 or similar errors, after what I have so often said ; it will, at least, not 
 be my fault if you do. 
 
 Let us now consider the parenchymatous affections of the lung in 
 fever, or, if you will, the typhous disease of the pulmonary structure. 
 It may be stated generally that whatever be the differences in the 
 various cases of this affection in fever, the local disease follows the 
 general law of other lesions secondary to the fever; that is to say, 
 it agrees.with them in its frequent absence, mode of invasion, latency 
 in the earlier periods of its development, spontaneous retrocession, 
 and, lastly, pathological effects. It is quite true that, as compared 
 with the best marked examples of acute sthenic pneumonia, it is not 
 wanting in any of the physical signs of that disease taken singly, but 
 it is generally different from it in the order or arrangement, as it 
 wehe, of these physical signs. And, indeed, I think the rise, pro- 
 gress, and retrocession of a pneumonia which has passed into hepati- 
 
SECONDARY PNEUMONIC COMPLICATION. 95 
 
 zation, as we so continually see in ordinary cases of the disease, is 
 rarely observed in the course of a typhus fever. I have already 
 drawn your attention to those curious cases of consolidation of the 
 upper lobe of the lung. Now, whether these be genuine examples of 
 an arrested typhus, or not, it is difficult to say, but their whole history 
 and progress is vary different from those of ordinary pneumonia; 
 and I repeat that there is nothing rarer than to see in the course of 
 a typhus fever that regular succession of phenomena with which 
 Laennec has made us so familiar, so indicating the several successive 
 stages of an idiopathic acute pneumonia. 
 
 The most common case is the occurrence, generally at an early 
 period, especially iu the maculated forms, and often at a later period in 
 the non- maculated and so-called typhoid fevers, of a well-marked cre- 
 pitating rale in the lower lobes of one or both lungs; it is generally 
 much more extensive and distinctly marked in one lung than in the 
 other. The amount of dulness is seldom very great, and we find the 
 disease, as it were, to linger, and for days together to show no dispo- 
 sition either to produce solidity of the lung on the one hand, or to 
 proceed to resolution on the other. It is often quite latent, and re- 
 cognizable only by careful physical examination ; and its discover}^, as 
 you will readily understand from what I have said before, is sometimes 
 an unfortunate circumstance for the patient. In the present state of 
 our knowledge we must believe this condition of the organ to be 
 either the result of a certain amount of typhous deposit into the lung, 
 or of a special state — an inflammation, if you will — which is, how- 
 ever, under the general law of the fever, partaking of its specific 
 character and capable of spontaneous retrocession. It is seldom 
 attended by pain or by hasmoptysis, and constantly exists without 
 any important modification of the general symptoms of the case. 
 
 The second form of the disease is of a more serious character, and 
 seems to be connected either with an original pyogenic disposition, 
 itself secondary to fever, or we may suppose that the typhous deposit 
 undergoes a rapid purulent transformation, so that in this way a con- 
 dition of the lung is established, having some resemblance to the 
 third stage of pneumonia, as described by Laennec. I have not myself 
 seen a sufficient number of these cases to justify me in speaking very 
 decidedly as to their physical signs; but I think I have seen enough of 
 them to warrant me in believing that the course of the disease is dif- 
 ferent from that of ordinary suppurative pneumonia. We have not 
 observed the intermediate stage of well-marked hepatization between 
 that which is characterized by the occurrence of early rale on the 
 one hand, and the signs of interstitial suppuration on the other. The 
 
9b LECTURES ON FEVER. 
 
 complete dulness and the bronchial respiration which accompany the 
 third stage of pneumonia as described by Laennec we have not ob- 
 served, the physical signs being principally a persisting rale passing 
 from a fine into a large crepitus, and semi-dulness on percussion. On 
 dissection the lung is found soft, friable, of a grayish-red colour, but 
 still very permeable to air, though infiltrated with purulent matter. It 
 is as if the purulent secretion took place coincidently with, or imme- 
 diately after, the first or congestive stage. Some of the patients have 
 had sweatings and a sanguinolent and somewhat sanious expectora- 
 tion ; but we have not hitherto observed the ordinary adhesive prune- 
 juice sputa in these cases. I have seen this disease in connection with 
 purulent deposits in the neck and posterior mediastinum, but it may 
 occur without the formation of purulent matter in any situation other 
 than the lung; it may supervene in the advanced periods of the case, 
 and at a time when the patient seems about to recover, or it may 
 come on much earlier, and when the skin is thickly covered with the 
 petechial eruption. The last case is the most formidable ; but though 
 it is attended with the greatest danger, the disease in it is, however, 
 not always fatal, and we have had several instances in which recovery 
 took place. I need not say that they were all treated upon a tonic and 
 stimulating plan, in addition to which we employed dry cupping and 
 blisters. 
 
 The last case of which I shall speak at present is by far the most 
 acute and formidable of the pulmonary affections of fever ; it is char- 
 acterized by a sudden, complete, and singularly extensive consolida- 
 tion of the lung. In the course of twenty-four, or even sometimes of 
 twelve, hours the most extensive and complete dulness may be pro- 
 duced in a lung which had been previously free from physical signs 
 or at most had only exhibited some ordinary bronchial rales. We 
 have thus the signs of complete hepatization, not preceded by the 
 crepitating rale; the disease begins by consolidation, and then one of 
 two results follows — either the patient dies speedily, generally with 
 loose rales in the opposite lung, combined with tracheal effusion ; or 
 after a day or two he begins to expectorate a horribly fetid matter, 
 and we discover by the stethoscope that a large cavity has formed in 
 the lung. This is a true gangrenous cavity in the very centre of the 
 solidified mass, and the disease has a close pathological analogy to the 
 process of acute mortification which has been described as occurring 
 in some of the worst cases of the typhous disease of the intestinal 
 glands. 
 
 Let us now pass in review the circumstances in which these forms 
 of disease occur ; for when we compare them with the ordinary condi- 
 
DIFFERENTIAL DIAGNOSIS. 97 
 
 tions of aoute primary pneumonia, we cannot but admit that they 
 indicate a lesion of a very different nature. 
 
 In the first place, the physical signs are preceded by fever ; and it 
 may not be until days have elapsed that the symptoms of lung affec- 
 tion as it were spontaneously arise. Secondly, the fever is obviously 
 an essential fever ; it may occur with or without petechia, and other 
 complications may or may not be present. Thirdly, the disease sets 
 in without any apparent external cause. Fourthly, when the puru- 
 lent form is observed, it appears to be, not the third, but the second 
 stage of the affection ; and I may here remark that, on dissection, we 
 rarely, if ever, find what we may term perfectly concocted purulent 
 matter. Lastly, the invasion of one form of the affection may be sud- 
 den, and the signs of extensive and complete consolidation be among 
 its earliest phenomena. It is in this case, too, that if time be allowed, 
 large eschars, forming cavities which may communicate with the 
 bronchial tubes, are liable to occur. 
 
 I may remark here that in two cases of this rapid consolidation the 
 gangrenous eschar did not communicate with the bronchial tubes- 
 One was a case of severe typhus, in a man who had long before 
 suffered from gangrene of the opposite lung; the other occurred in a 
 case of what is termed the erysipelatous or diffuse inflammation. 
 
 The first patient had no gangrenous expectoration. The lower 
 lobe of the left lung presented a very large non-encysted and recent 
 cavity, of a dark colour, filled with fetid grumous- fluid. In the 
 opposite lung was found an old cavity, lined with strong fibrous 
 membrane, and containing a quantity of a substance like putrid flax. 
 It hacl three hollow projections, and communicated with the bronchus. 
 
 In the second patient there was complete and recent solidity 
 throughout the lower anterior part of the right lung. A cavity, the 
 size of a large walnut, without bronchial communication, was found 
 filled with fetid purulent sanies. 
 
LECTURES ON- FEVER, 
 
 LECTURE XIII. 
 
 pneumonic Complications of Fever, continued — "Typhoid pneumonia," so called, is 
 not dependent on a coexistent gastritis — Correct view is that both pulmonary and 
 intestinal lesions spring from the one parent condition, that of fever — Physical 
 signs of ordinary pneumonia are often found, but in an irregular succession, in the 
 secondary pneumonic affection — Sign of tympanitic resonance in latter, first de- 
 scribed by Dr. Hudson — Probable causes of the production of this percussion 
 sound — The author's views — Dr. Lyon's views — Three explanations of the produc- 
 tion of the sign — Frequent absence of crepitus redux in resolution of secondary 
 typhous disease — When inflammatory affections do occur in fever, they are reactive 
 or tertiary in their nature — Typhous affection of the larynx — Rokitausky's 
 " laryngo-typhus." 
 
 I endeavoured to convey to you, at our last lecture, that the 
 conditions which have been described under the head of typhoid 
 pneumonia were probably examples not only of a pathological but 
 of an anatomical state of parts different from that which is found in 
 the simple original inflammation of the lung. And it is a great deal 
 easier to say what they are not than what they are — to state their 
 negative rather than their positive characters. 
 
 Now, I wish to mention here that a certain change has occurred in 
 our opinions as to the origin of the so-called typhoid inflammation 
 of the lung. We at one time held that it was the coexistence of 
 gastritis which gave to the pneumonia the typhoid character. This 
 view was held by us before we had, by that imperceptible power of 
 conviction which arises from experience, admitted the two following 
 principles in their entirety : — 
 
 1st. That symptoms which are diagnostic of local disease, where 
 the patient has not an essential fever, are either altogether valueless 
 or much lessened in value when such a condition exists; and 
 
 2d. That the gastric lesion is rare even as a secondary disease in 
 fever ; so that when irritation of the structures of the stomach occurs 
 it is a tertiary and accidental phenomenon. 
 
 Our present opinion on this matter is in general the following: 
 that in cases in which there are, in connection with the signs of 
 typhoid lesion of the lung, evidences of gastro-intestinal disease, both 
 the pulmonary and abdominal lesions spring from the one parent con- 
 dition, and that, so far from the specialities of the pulmonary being 
 derived from the accidental complication with the abdominal disease, 
 
TYMPANITIC RESONANCE. 99 
 
 both have a common character originating in the same source. I am 
 quite sure that a large proportion of those cases described as 
 examples of asthenic pneumonia depending on gastric complication 
 have been examples of essential fever, with the two affections coexist- 
 ing as secondary lesions. 
 
 We have seen that in these cases, I will not say of typhoid pneu- 
 monia, but of typhous or typhoid affections of the lung, the various 
 physical signs of pneumonia, singly considered, may be present, and 
 are actually often to be found. They fail, however, very frequently 
 to present themselves in that regular order or succession which is 
 observed in true acute pneumonia. 
 
 Now let us inquire whether there is any physical sign peculiar to 
 these cases of typhous pulmonary affections which does not occur, at 
 least as the rule, in idiopathic inflammation of the lung. I do not 
 know of the existence of any such, unless it be the sign of tympani- 
 tic resonance over the diseased lung — a condition first noticed by Dr. 
 Hudson, of this city, and to which much importance is to be attached. 
 Dr. Hudson states that in certain cases of typhous consolidation of 
 the lung the sound on percussion is sometimes very different from 
 that observable in the ordinary condition of hepatization. He de- 
 scribes it as " a tympanitic clearness over the solidified lung without 
 air being present in the pleura ;" indeed, he goes so far as to say that 
 in one case the tympanitic resonance on percussion existed fully to 
 the same degree and was of the same kind as in pneumo-thorax. 
 Here the lung was found perfectly solid throughout, with the excep- 
 tion of a small extent over the anterior and postero-inferior parts 
 which was still crepitating. 
 
 It is very difficult to understand what condition of parts could have 
 caused this singular tympanitic resonance over a solidified lung. 
 When we speak of tympanitic resonance, it must be always borne in 
 mind that the tympanitic sound does not always imply clearness on 
 percussion. When a cavity exists in the centre of a solidified lung, 
 or when hepatization of the left lung is present in connection with 
 flatulent distension of the stomach, the sound on percussion, though 
 dull as compared with that of the healthy lung, has a distinctly tym- 
 panitic character; to this we have long been in the habit of giving 
 the name of tympanitic dulness. I have never found it, however, to 
 simulate the tympanitic resonance which occurs in pneumo-thorax, or 
 in dilatation of the air cells; it is inferior in degree and different in 
 character. It is probable that in cases in which the sound on percus- 
 sion resembled that in pneumo-thorax, there was an actual secretion 
 of air to some extent between the pulmonary and costal pleuras. Dr. 
 
100 LECTURES ON FEVER. 
 
 Hudson met with four cases, in which the observation of tympanitic 
 dulness was followed by dissection. One was that of a man who died 
 of extensive inflammation of the left lung in the Meath Hospital in 
 the spring of 1832. At the close of the case, from the hollow sound 
 on percussion at the lower part of the left side — it had been pre- 
 viously quite dull —a pretty general opinion existed that a pneumonic 
 abscess had formed and burst into the pleura. On dissection, the side 
 having been punctured, no air escaped ; the lung was red and solid ? 
 but without abscess, and the pleura was adherent over two-thirds of 
 its extent. 
 
 I am quite prepared to admit that, with extensive solidification of 
 the lung, the dull sound on percussion may yet have a tympanitic 
 character; but I have seen no case in which this sound could be con- 
 founded with that of pneumothorax, or of dilatation of the air cells. 
 With reference to the bearings of this question upon the signs of 
 typhous pneumonia, I can at this moment remember only two cases 
 which are worth detailing to you. In one tympanitic dulness did 
 occur over the diseased portion of the lung, without our being able 
 to account for it by any accumulation of air either in the pleura or 
 in the stomach. The case was of a low putrid character, and I 
 remember suggesting it as just possible that there might have been a 
 typhous pneumatosis developed in the diseased lung; but I am sure 
 that we were not able to establish the existence of such a condition 
 on dissection ; the case occurred a good many years ago. 
 
 In the second case, which was one of manifest typhus, the posterior 
 portion of the right lung became solid or nearly so, while the ante- 
 rior face of the organ preserved its vesicular respiration. Now, we 
 found that over this portion of the chest — that is, over the front of 
 the thorax on the right side — the sound, as compared with that over 
 the opposite lung, was morbidly clear; it was true tympanitic clear- 
 ness, not dulness, and it continued for three or four days, and gra- 
 dually disappeared with the resolution of the posterior solidity: this 
 case occurred in the Meath Hospital, and was seen by Dr. Hudson 
 himself. I confess I am quite at a loss to explain the nature or mode 
 of production of this phenomenon. Dr. Lyons mentioned to me that 
 in a case of asthenic pneumonia occurring in a patient of intemperate 
 habits, whom we saw in consultation, the anterior superior part of 
 the left lung presented for a couple of days a condition of morbid 
 clearness, but subsequently became engaged in the general consoli- 
 dation of the organ. 
 
 Dr. Lyons is disposed to regard the abnormal clearness which 
 occurs in these cases as the result of the increased pressure of the 
 
SUGGESTED EXPLANATIONS. 101 
 
 respiratory column of air in the still permeable portions of the pul- 
 monary cells, which he considers in certain cases become from this 
 cause expanded beyond their natural volume. His views are that the 
 inspired air presses with a certain force on the whole pulmonary 
 surface, and that if a portion of this surface becomes impermeable to 
 air from solid deposit, occlusion of the tubes, or other cause, the 
 remaining portion of the pulmonary tissue is acted on by the whole 
 of the inspiratory force, before which it is thus made to expand. 
 This portion of the lung may thus be considered to be in a condition 
 of temporary dilatation of the cells, and so gives a correspondingly 
 clear sound on percussion. 
 
 Dr. Hudson's discovery of this sign is of great value in many 
 points of view, but, I think, chiefly as leading not only to the clearer 
 distinction between ordinary pneumonia and the secondary disease of 
 fever, but as a diagnostic of the essential character of the entire 
 malady in the latter instance. In Dr. Hudson's cases the disease 
 seemed to be the typhous affection of the lung, and the facts you will 
 find in his lectures on the "Study of Fever." Many times since his 
 memoir first appeared we have met with cases in our wards present- 
 ing this sign in various degrees of intensity and extent. All these 
 cases were examples of typhous or asthenic consolidations of the 
 lung. His observations are confirmed by Dr. Hayden, in one of 
 whose cases the solidified lung, though it sank in water, gave the 
 same sound on percussion that had been given by the chest during 
 life. 
 
 Now, there seem to be but three explanations of this remarkable 
 sign: first, the secretion of air into the pleura under the influence of 
 the general disease; secondly, compression of the lung while it still 
 is permeable to air; thirdly, an interstitial pneumatosis in connection 
 with the typhous processes. 
 
 Dr. Graves has shown that a temporary pneumo.-thorax without 
 pulmonary fistula, and yet sufficient to displace organs, may occur in 
 pneumonia. We know that a compression of the lung while it still 
 continues permeable — as from liquid effusion into the pericardium or 
 pleura — may cause a partial tympanitic resonance. But looking at 
 Dr. Hudson's cases, at those recorded by Dr. Hayden, and at our own 
 experience, it seems most probable that in the typhous consolidations 
 of the lung there may occur an interstitial secretion of air, recognized 
 by local resonance, and which may disappear with the subsidence of 
 the pulmonary lesion. 
 
 It is not unlikely that this condition is often overlooked in conse- 
 quence of the frequent latency of the pulmonary complications in 
 
102 LECTURES ON FEVER. 
 
 fever, and that the formation of air in the vessels is sometimes a 
 result of fever we have direct proof. It is now some years since a 
 middle-aged man was a patient in the fever ward with maculated 
 typhus of the most severe kind. I cannot now say whether the 
 lungs were greatly engaged, but it was the nervous system which 
 seemed chiefly to suffer. Muttering delirium and deepening coma 
 appeared early. These symptoms were followed by a universal sub- 
 sultus, which increased to an extraordinary degree, and for the last 
 two or three days of life affected, as it were, every little muscular 
 fibre in the face, the incessant twitching of which produced an influ- 
 ence on the expression of the countenance and an appearance I had 
 never before witnessed. This continued up to the time of death. On 
 dissection every vein in the pia mater and in the substance of the 
 brain was found to contain innumerable bubbles of air, which were 
 also present in the sinuses. 
 
 There is a circumstance in connection with the resolution of these 
 typhous diseases of the lung different from what is commonly ob- 
 served in sthenic pneumonia. The true inflammatory hepatization 
 rarely disappears suddenly. It subsides gradually, and the transition 
 state between dulness and clearness on percussion is generally marked 
 by the " crepitus redux." In the cases before us the resolution is often 
 singularly rapid, and unattended by the crepitus of resolution. If, 
 then, we consider the state of solidification simply, we find it on the 
 one hand forming without the crepitus of the first stage of pneu- 
 monia, and on the other disappearing rapidly, and without the rale 
 of resolution. Thus we are permitted, as it were, to witness the silent 
 and spontaneous development and retrocession of one of the secon- 
 dary internal diseases of fever. 
 
 This rapid change from the state of consolidation to that of per- 
 meability to air, unattended by the crepitus of resolution, probably 
 shows that the disease was unconnected with inflammation either as 
 a primary or as a reactive condition. 
 
 You will remember that I suggested to you that some of the cases 
 which have been described as typhoid pneumonia might be held as 
 examples of an aborted typhus. These were characterized by early 
 consolidation, early disappearance of the typhous state, and a rapid 
 and often spontaneous subsidence of the local disease. I cannot help 
 thinking that between such cases and those in which the general 
 disease runs its usual course there is another class in which the pro- 
 gress of the merely pulmonary disease is marked, more or less, by 
 signs of irritation or inflammation of the lung, which is either reac- 
 tive or specific, or both reactive and specific. I apprehend, too, that 
 

 SECONDARY INFLAMMATIONS IN FEVER. 103 
 
 these cases which, as it were, float between the aborted and the perfect 
 typhus, are more numerous than might be supposed ; and in such 
 instances the malady is often treated throughout without a suspicion 
 of its being really an example of typhous disease. 
 
 What has been now said should impress on your minds the prin- 
 ciple T have urged upon you — that the rules of diagnosis of local 
 inflammatory disease which are good in ordinary cases lose their 
 value in a great measure when the patient has fever. This was long 
 ago proved by the researches of Louis on the condition of the brain 
 in fever, and it was the non-recognition of this fact which constituted 
 one of the greatest errors of Broussais. I have told you that if you 
 gained nothing during the session but the knowledge of this prin- 
 ciple, your time would have been well spent. How many cases have 
 we not had of headache, delirium, watchfulness, or its opposite, coma, 
 yet without encephalitis? And so it is with the remaining cavities — 
 symptoms of functional alteration are met with in connection with 
 the cerebral, pulmonary, circulating, and digestive systems in fever. 
 They may or may not be attended by organic change, and that organic 
 change, when it does exist, is not necessarily inflammation. We 
 cannot, I believe, lay down any satisfactory rule of diagnosis which 
 would show that in one case of local functional disturbance there was 
 organic change, and in another there was not. 
 
 I do not seek to teach you that inflammation, with prominent 
 symptoms, and calling for local antiphlogistic treatment, never occurs 
 in fever. You must be cautious in using the word " never" in medi- 
 cine. That true cerebritis has been met with in fever is certain, 
 especially in the form of meningeal inflammation. But it seems prob- 
 able that this occurs less frequently in the head than in the chest or 
 abdomen, and it is almost certain that when it does exist it is not a 
 primary but a reactive inflammation. 
 
 It becomes one of the most difficult problems in practice to distin- 
 guish between the functional and organic affections of the nervous 
 system in fever. The secondary lesions of the brain vary as to their 
 frequency according to the character of the epidemic, as we have seen 
 in the late prevalence of the black fever, or — as it has been called — 
 the cerebro-spinal fever. But the great point to be remembered is 
 that these cerebral lesions have all the characters of the secondary 
 affections— namely, their inconstancy in amount, seat, period of ap- 
 pearance, their mode of 'retrocession, intensity, and incompetence to 
 account for the characters of the general malady. Let this principle 
 be ever present to your minds, for it is impossible to exaggerate its 
 value. Long ago it was acted on empirically by the best physicians, 
 
104 LECTURES ON FEVER. 
 
 who refused to adopt antiphlogistic measures in treating the local 
 symptoms in fever, and who employed stimulants irrespective of them, 
 when the general condition seemed to demand such treatment. It now 
 comes before you as the result of an extended observation, and the 
 study of the pulmonary phenomena, as we have seen, enables us to go 
 a step further, and to declare that not only are the symptoms of local 
 irritation often doubtful or illusive, but that even the physical signs 
 of pneumonia, when occurring in a case of fever, are not to be taken 
 as proof that a local inflammation has occurred. 
 
 If these things be true so far as essential fever is concerned, it 
 would appear probable that in other acute diseases under the influ- 
 ence of a law of periodicity, and, perhaps, in many that arise from 
 the operation of an introduced poison, the same circumstances may 
 be found, so that we might apply to a much larger circle of diseases 
 those principles, as to the secondary local affections, which belong to 
 fever. 
 
 In speaking of the bronchial membrane in fever, we said nothing 
 with respect to lesions of the larynx or trachea as a result of the 
 fever. Taken as a localized disease, I would say that this lesion is 
 not very commonly met with ; and we may safely hold that it is by 
 no means so frequent in the petechial fever of these countries as it- 
 appears to be in the fevers of the Continent. 
 
 This is the condition to which Rokitansky has given the name of 
 laryngo-typhus, by which he means a secondary lesion of the mucous 
 membrane of the larynx and trachea, analogous to that of the bron- 
 chial membrane. It is, then, a secondary affection of the fever de- 
 veloped in the windpipe, and either confined to that part or predomi- 
 nating in it. I think it probable that in most cases of this disease 
 there is an associated affection of the bronchial membrane. But, so 
 far as the fever of this country is concerned, the converse of the 
 proposition does not hold good; for we constantly see the most pro- 
 found bronchial affection without tracheal or laryngeal symptoms. 
 
 We have met a few cases which would answer to the description of 
 Rokitansky's laryngo-typhus. A more proper name for this disease 
 would clearly be "a typhous affection of the larynx." In those cases 
 which we have seen, the symptoms were loss of voice, or a certain 
 degree of hoarseness ; the cough never was the so-called tussis clan- 
 gosa, although it often partook of the laryngeal character, and I do 
 not remember any instance of stridor but orie in connection with the 
 other laryngeal symptoms. In some cases the weakness or hoarse- 
 ness of voice continued for a considerable time, and did not disappear 
 until convalescence was far advanced. 
 
 
LARYNGO-TYPHUS. 105 
 
 I have often thought that, in these cases, the lesion of voice was to 
 be attributed more to the weakness or paralysis of the laryngeal 
 muscles than to any form of irritation or inflammation of the mucous 
 surface. For although we cannot bring any observations from dis- 
 section to throw light on this point, we may fairly believe that the 
 laryngeal muscles are liable to be affected in fever, just as the mus- 
 cular fibres of the heart are often found to be ; that the same process 
 which causes a typhous deposit in the mucous surface may be re- 
 peated in the vocal muscles ; and that a certain time must elapse 
 before these organs recover their healthy condition. They may also 
 be weakened quite independently of any structural change, just as 
 occurs in the heart; for in this latter organ there are doubtless two 
 forms of debility in connection with fever — in the one, we have 
 weakness with actual softening of structure; in the other, a debility 
 which appears to be purely nervous. 
 
 This leads me further to draw your attention to the probable exist- 
 ence of similar conditions in the circular, and perhaps also in the 
 longitudinal, fibres of the bronchial tubes in this secondary disease. 
 I have little doubt that such a condition exists in many instances, 
 and that a weakness, with or without softening of these structures, 
 becomes an important element in the bronchial disease of fever. If, 
 as some modern authorities have urged, these circular fibres are really 
 the expectorating muscles, we can readily see how any weakness or 
 paralysis affecting them would greatly increase the danger of a 
 patient already suffering under copious secretion into the bronchial 
 tubes. We can further understand not only how this condition 
 would superinduce what is termed "effusion into the chest," but also 
 why it is that in the treatment of the bronchial disease of fever there 
 is such danger from the employment of the antiphlogistic method, 
 and how, on the other hand, such admirable results follow from the 
 bold use of tonics and stimulants. 
 
 When we come to speak of the heart in fever, I will draw your 
 attention to the fact that in many of our most remarkable examples 
 of typhous softening of that organ there was a great amount of the 
 secondary bronchial disease; and in such cases you will constantly 
 see the associated diseases of the heart and the lung progressing or 
 retrograding simultaneously, the treatment adapted to the one being 
 suitable also to the other. In the heart, so far as we know, we have 
 to deal with an affection only of the muscular structure; in the lung 
 we have at least two different forms of anatomical structure affected 
 — the muscular and the mucous tissues. But the existence of the 
 essential typhous state so far affects these tissues that their vital con- 
 
106 LECTUKES ON FEVER. 
 
 dition is depressed in a similar manner ; and it happens that what- 
 ever is tonic and stimulant, to the one is equally so to the other, and 
 so by supporting and augmenting the vital energy of both structures 
 we can add the assistance of art to the efforts of nature in throwing 
 off the disease. 
 
 In connection with the subject of laryngo-typhus, I remember a 
 case of complete aphonia without any other laryngeal symptom in a 
 patient suffering from fever for some days. There were no signs of 
 any disease in the upper portions of either lung, and we were at a 
 loss to explain the symptom. After a few days the chest was again 
 examined, when it was discovered that the postero-inferior portions 
 of both lungs had passed into complete consolidation. For this the 
 patient was treated, and resolution was. established in the ordinary 
 way. Simultaneously the voice began to improve, and was shortly 
 quite restored. The explanation of the occurrence of aphonia in this 
 case is difficult, but it may be that the symptom was due to reflex 
 irritation of the pneumo-gastric nerve, dependent on the condition of 
 consolidation in a portion of the lungs. 
 
 LECTURE XIV. 
 
 The Heart in Fever — The state of the pulse, especially iu typhus, not always a 
 reliable guide — Weakening of the heart may coexist with a full, bounding pulse 
 — Slow pulse in convalescence is consequent on a typhous weakening of the heart 
 — Rapid pulse in convalescence is of unfavourable import, pointing to (1) tubercu- 
 losis, or (2) secondary reactive inflammation of the mucous glands of the intestine, or 
 (3) phlegmasia dolens — In such cases the local malady assumes the prominence 
 hitherto presented by the essential disease — Illustrative case of hepatic abscess 
 in convalescence from the yellow fever in 1826-27 — Intermittent fever at close of 
 epidemic of 1827 — Frequency of phlegmasia dolens — Bleedings in cold stage, after 
 Dr. Mackintosh — Failure of quinine in cases of simulative ague, arising from (1) 
 phlegmasia dolens, (2) urinary disease, and (3) the puerperal state. 
 
 Next in order I shall speak of the conditions of the heart in fever 
 — a topic which calls for our most attentive consideration. 
 
 From the. earliest times physicians have been in the habit of rely- 
 ing on the pulse as a guide for the administration or the withholding 
 of stimulants in fever. Now, I must tell you that in typhus at least 
 the pulse is not always to be depended on as a truthful indication. 
 In true typhus one of the most unreliable and illusory symptoms is 
 the state of the pulse, especially in the earlier stages of the disease. 
 
THE HEART IN FEVER. 107 
 
 For instance, in a case of the true petechial character you may find 
 the patient, even on the fourth day, with a full and bounding pulse, 
 while within 24 hours the whole condition will have changed. Now, 
 this state of pulse has too often led to errors in practice both of com- 
 mission and omission — of commission, from the adoption of general 
 or local depletion ; and of omission, from the postponement of the 
 necessary treatment, owing to the apparent inflammatory condition 
 of the system. The opportunity is lost of employing nutrient and 
 stimulant remedies in time. You, gentlemen, educated as you have 
 been, and taught to look on fever with an eye rather to the general 
 aspect of the disease that to its local accompaniments, will not, I 
 trust, fall into this error. I tell you that in typhus fever, at the very 
 time when the pulse has that full, bounding, and seemingly inflam- 
 matory character, debility of the heart, with or without softening, 
 may already have set in. As regards the circulatory system, I will 
 say to you : Examine closely the state of the pulse, and then the 
 character of the heart's action. If both coincide in vigour, so far so 
 well; but you must be prepared to find very often a full and bound- 
 ing radial pulse coinciding with a feebly acting heart — a condition 
 probably progressive. Here we have evidence of the necessity of 
 anticipative treatment, and commonly of its good effects. 
 
 We have now passed in review some of the important typhous 
 affections of the lung. I have told you that in cases of this kind 
 there have been frequently signs of an analogous condition in the 
 muscles of the heart, and to this subject I now crave your attention. 
 
 Long ago Laennec stated that in certain cases of low fever he found 
 the heart in a softened condition — in what he termed Vetat poisseux of 
 the muscles of that organ. He did not recognize the real nature of 
 this condition, but held it to be evidence of the degeneration of the 
 muscular structure of both the voluntary and the involuntary sys- 
 tems, resulting from the dissolution of the fluids in putrid fever. He 
 suggested whether in those cases of fever which exhibit rapidity of 
 pulse during convalescence this symptom is to be attributed to a soft- 
 ening of the heart. This opinion is not well founded, the true 
 typhous softening of the heart, so far from being followed by rapidity 
 of pulse during convalescence, has much more frequently the effect 
 of making it slow — slow not only as considered with reference to the 
 condition of health, but actually falling below the ordinary standard. 
 That rapidity of pulse is commonly associated with typhous affections 
 of the heart, in which there is a weakening of the organs while the 
 fever continues, must be admitted. But this is a different proposition 
 from that advanced by Laennec, who speaks of the symptom during 
 
108 LECTURES ON FEVER. 
 
 convalescence. Many of the greatest triumphs of the stimulant treat- 
 ment in our wards have been seen in cases where the pulse was as 
 high as 140 in the minute, the effect being to lessen its frequency 
 from day to day until the period of convalescence was reached. 
 
 I have little doubt that Laennec met with the true typhous soften- 
 ing of the heart, although he misinterpreted its nature. You may 
 take it as an established fact that in typhus the heart may be softened 
 to the most extreme degree, while the voluntary muscles remain 
 intact. And you may further rest assured that rapidity of pulse in 
 convalescence, so far from indicating any remains of the typhous 
 disease in the muscular structure of the heart, is in most cases a proof 
 of the existence of some lurking disease of some important organ or 
 organs. I say in most cases, for we sometimes meet with instances in 
 which this state of things cannot be discovered, and where the quick- 
 ness of pulse shows that the heart had contracted a habit of rapid 
 action, which it requires time to get rid of. But these cases are 
 exceptional; and whenever you find rapidity of pulse in a patient 
 who has thrown off his fever, you are to take alarm. 
 
 These cases of quickness of pulse are of two kinds. In one class 
 the pulse has never lost the rapidity it attained during the fever; or 
 it has, perhaps, come down fifteen or twenty beats in the minute, and 
 its rate then remains stationary. In the other cases the pulse, which 
 had become quiet, again rises to 100 or 120, or even higher, and 
 remains at that increased rate for days together, without our being 
 able to detect any cause for this rapidity. The latter is, I think, the 
 worse case of the two ; at least it appears oftener to indicate a new 
 pathological change. 
 
 The local diseases which most frequently attend this condition are 
 of two kinds — one of them is tuberculosis in the lungs and other 
 parts; the other is the existence of a secondary reactive inflammation 
 in the mucous glands of the intestines. 
 
 But now suppose that you examine a patient having a quick pulse 
 in convalescence with great care. You percuss his chest ; you ex- 
 amine the state of his respiration in every way ; yet you cannot sat- 
 isfy yourself that there is any disease in his lung ; and you will recol- 
 lect what I mentioned in a former lecture, that in most cases of this 
 tuberculosis after fever there is great local and constitutional suffering. 
 Well, you may make up your mind, from the absence of all these 
 signs, that the patient is not becoming tuberculous at all events. On 
 proceeding to examine the abdomen, you will find, perhaps, that he 
 has a good appetite; that his thirst is gone; that the belly is soft, 
 without any tumefaction ; that there is no tenderness on pressure 
 
QUICK PULSE IN CONVALESCENCE. 109 
 
 anywhere, no throbbing of the abdominal aorta, no tendency to diar- 
 rhoea — in fact, no symptom whatever of disease of the mucous mem- 
 brane of the intestine. And yet, as in the case in the small fever 
 ward, you have a pulse with this unpleasant degree of quickness. 
 Although this patient has convalesced after a long fever, and is now 
 gaining flesh and strength, we have found that the pulse continues 
 rapid. I rather think that it is now quicker than on the 21st day of 
 bis illness, and it makes me extremely uneasy about him. 
 
 Now, gentlemen, suppose that under such circumstances you did 
 not find disease either of the lung or of the abdomen — in this patient 
 the signs of abdominal and pulmonary lesion have disappeared, as 
 well as the characteristic expression of what may be termed the con- 
 dition of fever — what should you suspect? Generally you may look 
 for phlegmasia dolens ; for we have seen many cases in which, after 
 fever, the pulse continuing rapid, this disease exploded. This is, I 
 think, more likely to occur in the non-petechial than in the petechial 
 cases, in the long than in the short fevers ; it is very liable to arise in 
 patients who have had a fever running on beyond twenty-one, thirty, 
 or forty days. These patients, after the true symptoms of fever have 
 subsided, remain with a rapid pulse, and probably in a week or so 
 symptoms of phlegmasia dolens come on. The disposition to this 
 complication is sometimes remarkable, for you will very often find 
 that the patients have two or three distinct attacks of it. It may 
 affect one leg, and the patient may pass through that attack ; still the 
 pulse does not regain its natural rate. After a week or ten days the 
 other extremity will be attacked ; nay, it is even possible that a third 
 seizure may occur — a relapse, as it were, of the disease in the part 
 first affected. In this way patients will go on labouring under the 
 affection and its consequences for months together, although recovery 
 ultimately takes place. 
 
 In most of the cases I have seen there was distinct notice of the 
 invasion of the disease — that is t6 say, the patient was attacked with 
 pain in the calf of the leg. He is seized, say, in the course of the 
 night, and in the morning he exhibits all the characteristics of the 
 disease — a large swelling, pain on pressure, and all the other symp- 
 toms. Sometimes you find a cordy state of the superficial veins; at 
 other times, not. When you can feel a deep-seated vein, you will 
 occasionally find it in a hard and cordy state. 
 
 I think it right to warn you of these contingencies, for I am sure 
 that in the course of your practice you will often have a patient re- 
 covering from fever, and going on in every respect well, except that 
 the pulse does not come down. The rule then is, that, if the most 
 
110 LECTURES ON FEVER. 
 
 minute examination fails to detect disease in the great viscera, the 
 occurrence of this complication may be looked for. 
 
 The term phlegmasia dolens is not always applied correctly, for the 
 disease is not necessarily painful. We have seen a few instances in 
 which the discovery of the local affection was entirely accidental. 
 Of course you will not suppose that T am confident that the patient 
 in the ward will have phlegmasia dolens; all I say is, that he is in 
 that state which would justify you in suspecting something of the 
 kind. 
 
 I have mentioned the rapid deposition of tubercle, ulceration of the 
 intestines, and phlegmasia dolens of the lower extremities, as the dis- 
 eases we have found to occur most commonly in these instances of 
 apparently unaccountable quickness of the pulse after fever. Doubt- 
 less there are many more examples- of local disease arising under 
 these circumstances ; but the general rule will hold good, that this 
 symptom foreshadows a disease which, although at first lament, will 
 before long become manifest. 
 
 These diseases are generally attended with much irritation, and the 
 condition of the patient is one rather of irritation, or inflammation if 
 you will, than of essential fever. And this is one of many illustra- 
 tions of a circumstance often observed by the clinical investigator — 
 namely, the change of character of disease, locally and constitutionally 
 in the same patient, and within a not very extended period. The 
 typhous condition, generally considered, changes into a different state. 
 The essential state disappears, and a local irritation, with its symp- 
 tomatic fever, becomes the prominent malady. Nay, you will find 
 that the very condition of a local disease, formed during the first — 
 the typhous or essential — period, will itself change, and take on the 
 characters of what is termed by some a "healthy inflammation." 
 
 You may sometimes see this well illustrated in that terrible disease, 
 accompanied by purulent deposits in many of the articulations, which 
 may be called "idiopathic pyaemia."' The patients may throw off the 
 typhoid state which attends the earlier periods of the disease, and 
 then the affection of the joints seems to change in its nature, and to 
 take on the characters of ordinary arthritis. I have, however, seen 
 this only where one or two of the larger joints had been affected 
 with the primary disease; and it was most remarkable to witness the 
 changes both in the constitutional state and in the local affection. It 
 was no longer necessary to use general stimulation ; it was no longer 
 improper to employ local antiphlogistic measures. 
 
 You will see in the article on " Hepatic Abscess," in the " Cyclo- 
 pasdia of Practical Medicine," a case which we may well study in 
 
INTERNAL ABSCESS IN YELLOW FEVER. Ill 
 
 connection with this subject. The patient was a middle-aged man, 
 who was attacked with the yellow fever, of which we had such strik- 
 ing examples in the epidemic of 1826 and 1827. A valuable account 
 of this disease is to be met with in Dr. Graves' "Clinical Medicine." 
 This patient was the first who was saved. The treatment which I 
 adopted on the appearance of the jaundice and the spasms of the 
 belly was the free application of leeches to the abdomen, the use of 
 calomel and opium in full doses, and a liberal allowance of wine. 
 The man recovered, to our great surprise ; but whether from the 
 measures employed, or from the circumstance that the epidemic was 
 then losing its malignity, it is difficult to say. However, his recovery 
 seemed perfect ; the pulse became natural ; the yellowness rapidly 
 disappeared ; no gangrene of the limbs or nose had occurred ; and he 
 was finally discharged, to all appearance quite recovered. 
 
 Within a fortnight he again applied for admission. He was evi- 
 dently very ill. The pulse was rapid. He had copious sweats. The 
 breathing was hurried, but not laboured, and he had a hacking dry 
 cough. I at first suspected that his case was one of the acute conse- 
 quent tubercle which I have already described to you. I could dis- 
 cover no sign of abdominal disease, and the physical examination of 
 the chest, repeated with great care from day to day, gave results very 
 different from those observed in the acute deposition of tubercle after 
 fever. There were neither the intense and persisting bronchial rales 
 nor the progressive dulness ; and so I remained in the most unhappy 
 of all positions to which a physician can be exposed — namely, that 
 of having to treat an acute disease of which he knows neither the 
 seat nor the nature. However, the suspense did not last long. In a 
 few days, at the time of visit with the class, I found him coughing 
 up purulent matter, and the nurse showed us a vessel which held 
 more than a quart of the same fluid, which the patient had coughed 
 up during the night. The expectoration had come on suddently. 
 On the day before I had made a most minute examination of the chest, 
 both anteriorly, and posteriorly, and had failed to discover any sign 
 of disease. Yet we now found that the posterior portion of the left 
 side, as far as the scapular spine, was absolutely dull. There was no 
 bronchial respiration, no resonance of the voice, and, I think, no rale. 
 We came to the conclusion that an abscess, probably of the liver, had 
 opened into the chest. I will not go into the details of our treatment, 
 which was that usually employed in cases of internal suppuration. 
 The patient rapidly recovered, and left the hospital without the 
 slightest physical sign of disease in either the chest or belly. During 
 
112 LECTURES ON FEVER. 
 
 the next ten years I had repeated opportunities of seeing this man, 
 who continued to enjoy the most perfect health. 
 
 This case is well worthy of your careful study. It shows, in the 
 first place, that rapidity of pulse, after convalescence, probably indi- 
 cates some profound lesion ; next, that we were right to pause before 
 making the diagnosis of acute tubercle, when there Avas a want of 
 correspondence between the physical signs and the constitutional 
 symptoms. It is an additional illustration of the possible existence 
 of hepatic abscess, without perceptible hepatic tumour; and, lastly, 
 it is remarkable as being the only instance during that singular epi- 
 demic tendency to yellow fever, in which organic change of the liver 
 seemed to occur. Dr. Graves dwells strongly on the point that in 
 none of our dissections did we find hepatitis; and it is quite possible 
 that, even in this case, during the violence of the first attack — that is, 
 when the patient had the yellow fever — the liver was not inflamed, 
 and that its subsequent suppuration may have been owing either to 
 abdominal phlebitis or to a pyogenic diathesis. I assume that the 
 abscess was in the liver; but even this is not absolutely certain. It 
 assuredly was not originally in the chest. Whether the purulent 
 matter made its way into the lung by a perforation of the diaphragm, 
 or whether the case was an example of vicarious action of the lung, 
 thus removing the purulent matter from the liver, are questions which 
 can never be answered. 
 
 As I have alluded to the invasion of phlegmasia dolens after fever, 
 I may mention a case which occurred many years ago in this hospital. 
 You all know that intermittent fever is a rare disease in this country. 
 It is not endemic in our vast mountain districts, nor in our level 
 boggy plains; and, indeed, for many years we never had a case of 
 ague in hospital that did not occur in the person of one of the 
 labourers who went to the fenny districts of England to cut the 
 harvest. These men were often attacked with ague on their way 
 home, the disease being immediately excited by the cold, wet, and 
 fatigue to which they were exposed on their journey. At the close 
 of the epidemic of 1828, intermittent fever became very general; in 
 fact, it was epidemic, and for a time almost every case in our wards 
 was an example of some form of ague. 
 
 It was at that time that I tried the treatment of bleeding, in the 
 cold stage, as recommended by Dr. Mackintosh. Our results, in a 
 very large number of cases, were decidedly opposed to the practice. 
 
 Now, at the time when the wards were filled with intermittent 
 fever, a patient was admitted with symptoms of tertian ague. As 
 was natural when so many cases of the same form of disease were in 
 
SIMULATIVE AGUE. 113 
 
 the house, this did not excite any special attention, and the man was 
 ordered quinine in the usual doses. But the disease did not yield to 
 the specific ; on the contrary, the paroxysms became more severe, and 
 the type of the fever changed to quotidian. I then became alarmed. 
 I stopped the use of bark, and proceeded to make a careful exami- 
 nation of the patient. No signs of disease were found in the chest 
 or belly, but it happened that in throwing off the bed-clothes for the 
 purpose of examining the lower part of the abdomen I accidentally 
 exposed the lower extremities. The thigh and leg at one side proved 
 to be greatly enlarged. The whole extremity was white and elastic, 
 and the saphena vein iu a cordy state. Now, this man had never 
 complained of any local pain or uneasiness, and was as much sur- 
 prised as I was at the state of his limb. He was treated by leeching 
 and the use of calomel and opium, and speedily recovered. He had 
 no paroxysm of the fever after the change of treatment. 
 
 I have hardly a doubt that this patient's life would have been lost 
 but for the circumstance that we omitted the quinine in time. Not that 
 I wish you to suppose that the swollen leg after fever is itself a very 
 dangerous disease ; for we have no reason to think it more so than 
 ordinary phlegmasia dolens ; but I believe that the persistence in the 
 use of bark in cases of simulative ague is fraught with danger. Indeed, 
 there is here a double danger, for we thus not only neglect but exas- 
 perate the acute disease. 
 
 You are all familiar with the intermittent fever, which is symp- 
 tomatic of urinary disease. On this subject, and on the danger of 
 mistaking the affection for ague, and treating the case with bark, the 
 late Mr. Abraham Oolles used to dwell with great force in his lectures 
 on surgery. 
 
 There are, doubtless, many other instances where a local irritation 
 excites a fever, which, for a time at least, has all the characters of a 
 true intermittent. Puerperal women are liable to this disease ; I do 
 not allude to the true puerperal fever, but I have often known women 
 soon after child-birth to be attacked with well marked tertian or 
 quotidian fever, in whom it was difficult, or impossible, to discover 
 any local disease of importance. In some there had been an abortive 
 irritation as it were : perhaps some tenderness of the uterus which 
 had been removed by treatment; or in others a tendency to inflam- 
 mation of the breast — but these had subsided, and the intermittent 
 fever persisted. I have over and over seen bark administered in such 
 cases, and always with bad results. The tertian was changed into 
 quotidian or double tertian, the quotidian into double quotidian, and 
 in one case, where the use of bark was persevered in for a length of 
 
114 LECTURES ON FEVER. 
 
 time, the patient sank with symptoms of inflammation in the abdomen 
 and lungs. I believe that for the treatment of this condition we 
 should trust to change of air, good diet, opium, and nervines. I have 
 known one case in which the practitioner had given bark to a great 
 extent, with the effect of exasperating all the symptoms, in which, 
 when the medicine was omitted, draughts of valerian, ether and opium 
 used, and the air changed, the disease rapidly disappeared. 
 
 LECTURE XV. 
 
 The Heart in Fever, continued — Louis' conclusions, based on post-mortem observations 
 — Typbous softening of tbe beart daring life first studied at the Meath Hospital in 
 epidemic of 1837-39 — As regards state of tbe beart, fever cases fall into three cate- 
 gories : tbose accompanied by (1) no alteration in heart's action, except of rate ; (2) 
 weakness after a few days, consequent on depressed vital power ; (3) cardiac excite- 
 ment — Neither a depressed nor an excited state of the heart in fever necessarily 
 implies organic change — Dynamic condition of the heart a more important indica- 
 tion for treatment than presence or absence of any structural change — True carditis 
 very rare in fever— Typhous weakening predominates in left side of the heart — 
 State of involuntary muscular fibre in acute essential disease is of great importance 
 — Laennec's theory as to typhous softening of heart erroneous, for there is no cor- 
 respondence between the softening of voluntary and involuntary muscular struc- 
 tures — Illustrations from yellow fever of 1826-27 — Exemption of heart from typhous 
 affection is a grouud for a favourable prognosis — Continued excitement of heart 
 equally a ground for a bad prognosis — Excited beart with compressible pulse most 
 unfavourable — Transfusion of blood under these circumstances — Absence of red 
 blood after death, the only noteworthy pathological appearance in this case — Blood- 
 waste in fever to be met by administration of nourishment. 
 
 It may be taken for granted that most, if not all, internal organs of 
 the body are liable to become the seat of the secondary affections of 
 fever ; and the symptoms having a more or less common character, 
 varying only according to the seat of the disease and the liability to 
 reactive irritation, it would be strange if the heart formed an excep- 
 tion to the rule. 
 
 I have shown you that Laennec occasionally observed a softened 
 state of the heart in persons who had died of fever, but that he did 
 not recognize this muscular change as distinct from that general con- 
 dition of the voluntary muscles held to proceed from the dissolution 
 of the fluids. 
 
 Louis, in his great work on the pathological anatomy of fever, 
 corrects the doctrine of Laennec, and shows that in his cases where 
 softening of the heart was met with after death " no similar lesion 
 
OBSEKVATIONS OF LAENNEC AND LOUIS. 115 
 
 was found in any muscular organ, as all the muscles which preside 
 over voluntary motion preserved amid the general disorder their 
 natural colour and consistence." He established the following points 
 as the result of his dissections: First, that the softening he observed 
 was not the consequence of putrefaction ; secondly, that it was often 
 partial, affecting more the systemic than the pulmonary heart; thirdly, 
 that it was to be met with apart from any analogous condition of the 
 voluntary muscles ; and fourthly, that it was not inflammation, but, 
 to use his own words, " something the reverse of inflammation." He 
 further found that the disease was best marked in proportion as the 
 fever was earlier fatal, being much more frequent in those which died 
 from the eighth to the twentieth day than in cases in which life was 
 more prolonged. 
 
 It is to be remarked that neither by Laennec nor by Louis are any 
 observations recorded which would lead to the discovery of this 
 typhous condition during life. I have pointed out that the suggestion 
 of Laennec with reference to a rapidity of pulse during convalescence 
 from fever is not to be accepted. With a view of determining 
 whether, pending the existence of this typhous change in the heart, 
 we could establish its diagnosis — and in the hope of attaining some 
 degree of precision in treatment as regards the employment of stimu- 
 lants, a series of researches was commenced in the wards of the Meath 
 Hospital during the epidemic of 1837-39. These were continued 
 more or less for the next ten or fifteen years. You will see the 
 original memoir in the Dublin Medical Journal, 1 in which it is, I 
 think, sufficiently proved that the typhous secondary condition of the 
 heart is not difficult of diagnosis ; that it is, like the other local con- 
 ditions of fever, inconstant in its occurrence and amount; that its 
 advance and retrocession often follow the corresponding changes in 
 the general malady ; and that by its recognition and study we are 
 greatly assisted in the use of stimulants and of nourishment in the 
 treatment of many cases of fever. 
 
 Now, as regards the state of the heart in fever, you may divide the 
 cases roughly into three categories. In the first there appears to be 
 no alteration whatever in the heart's action beyond the usual increase 
 of rate which belongs to fever. This is a condition which we have 
 found most often in cases of what may be called benign, though they 
 may be well-marked fevers. They are not malignant fevers, and so 
 far as the impulse of the heart and the character of its sounds are 
 concerned, little or no alteration occurs. These cases run a compara- 
 
 1 First series, vol. xv. No. 44, 1839, p. 1. 
 
116 LECTURES ON FEVER. 
 
 tively regular course, unforeseen accidents and complications are rare, 
 and tbe subservience of the disease to the law of periodicity and to 
 judicious treatment are remarkable. The second is that wherein, after 
 a few days, we have weakness of the heart consequent on depressed 
 vital power. The third and worst of all is that in which we find 
 cardiac excitement of more or less violence existing through the entire 
 or a considerable portion of the illness. 
 
 Even in. the case of the two last-named categories — that wherein 
 there is depression of the heart's action, often attended with softening 
 of its substance, and that in which violent excitement of the organ is 
 met with — you must bear in mind that neither the depressed nor the 
 excited condition of the heart in fever is enough to justify the infer- 
 ence that any organic mischief is present. It is true that we not 
 infrequently find a softened state of the muscular structure, yet with- 
 out marks of inflammatory action, in cases where well-marked 
 depression and feeble action of the heart have existed. But where 
 intense excitement of the heart's action has prevailed, we may meet 
 with no evidence of anatomical change, with no sign of inflammation. 
 The softened state which is associated with the weakened dynamic 
 condition is wanting, and the heart has a perfectly normal and healthy 
 aspect. 
 
 What I wish to convey to you is this, that as regards prognosis and 
 treatment we have to look rather to the dynamic condition of the 
 heart than to any structural change in its tissues. Thus we may have 
 all the signs of extreme weakness of the heart without the occurrence 
 of any softening ; and, on the other hand, the heart's action may be 
 excited to an extreme degree where inflammation will be completely 
 absent. You are, therefore, not to have recourse to antiphlogistic 
 measures merely because the heart is excited ; and, again, you are not 
 to infer that there is actual softening where the heart's action is 
 depressed. It is true that feebleness of sounds and impulse attends 
 softening of the heart, yet in certain cases their rapid reappearance 
 under stimulants seems to show that a depressed innervation may 
 exist for a time independent of the softening of the organ. 
 
 As regards the use of stimulants in fever, you are to look more to 
 the vital than to the organic changes of the organ. We have deter- 
 mined that signs of a well-marked and continued depression of the 
 heart's energy are commonly associated with actual softening — at least 
 it was so in one epidemic — and, on the other hand, that even a con- 
 tinuous excitement in fever may occur without any carditis. In fact, 
 true carditis seems to be extremely rare in fever; and this might be 
 expected when we remember how seldom the serous membranes are 
 
DEGREES OF SECONDARY CARDIAC LESION. 117 
 
 affected in the disease. I have before spoken of the rarity of organic 
 disease of the heart traceable to an attack of typhus or typhoid fever 
 — which contrasts so remarkably with what is seen in rheumatic fever. 
 This will prepare you for believing that the excited state of the heart 
 in fever, when it does occur, rarely calls for any interference. And 
 experience shows that we must be very cautious in the use of stimu- 
 lants in such cases, not from their exciting influence on the heart itself, 
 but from their disagreement with the nervous system. 
 
 In cases of convalescence, where the heart has been depressed, and 
 probably softened, the returning vigour of the organ is an indication 
 that the stimulants should be lessened or given up. 
 
 It is, then, with the depressed condition of the heart that we have 
 principally to do. As I have said to you already, this state is com- 
 monly associated with a softening of the muscular structure due to 
 the secondary influence of the fever poison. It arises, as it were, 
 silently in the course of the fever, and it subsides spontaneously, 
 leaving the structure — organically at least — in a state of health. 
 
 In regard to the weakening with or without softening, we find that 
 it predominates in the left side .of the heart, so that our researches 
 confirm those of Louis. We have, it is true, found a very few cases 
 in which, both the ventricles being engaged, the right appeared more 
 softened than the left, but this was entirely exceptional. Although 
 in our typhus fever debility and softening of the heart predominate 
 in the left ventricle, yet — when it is more accurately compared with 
 the fever of the Continent — future observations may show that the 
 softening of the right ventricle is of more frequent occurrence than 
 in the cases observed by Louis. 
 
 The investigations as to the state of the heart in typhus may be 
 said to belong to our own time. The pathological anatomists of the 
 Continent, although they investigated so closely the post-mortem 
 appearances in fever, neglected the examination of certain portions 
 of the system, the reason being that they were seeking rather to estab- 
 lish a theory than to arrive at the whole truth. Hence the condition of 
 the muscular fibre in a number of diseases has been much neglected. 
 Even at the present day the best works give us very imperfect infor- 
 mation as to the abnormal conditions of muscular fibre, whether of 
 the voluntary or of the involuntary systems. Much remains to be 
 discovered upon this point. 
 
 In connection with acute disease of the internal parts the state of 
 the voluntary muscles is, probably, not of much importance, but 
 with regard to the involuntary muscles it is far otherwise. 
 
 The larynx, trachea, and lung arc muscular organs, so also is the 
 
118 LECTURES ON FEVER. 
 
 digestive tube, and there is reason to believe that muscular fibre exists 
 in other places where it has not as yet been described. But of all the 
 involuntary muscles the heart is the most remarkable, both from a 
 physiological point of view and in the manifest changes which it may 
 exhibit in the course of an essential fever. 
 
 I have mentioned that Laennec considered the softening of the heart 
 in fever an example of general muscular softening depending on the 
 dissolution of the fluids. Now, you may believe that neither in fever 
 nor, I apprehend, in any other disease, acute or chronic, is there any 
 necessary connection between the state of the voluntary and that of 
 the involuntary muscles. Louis has shown that the softening of the 
 left ventricle and its friability were sometimes so great as to cause 
 the heart to break down on the slightest pressure, while the voluntary 
 muscles preserved their firmness, and were in a perfectly healthy 
 state. 
 
 Our observations are strikingly confirmatory of this. We have 
 seen patients with every one of the conditions termed putrescent — 
 with black petechias, gangrenous sores on the back, sordes on the 
 teeth, and fetid and bloody discharges — and nevertheless when we 
 came to examine the voluntary muscular system after death, it 
 appeared perfectly red and firm, exhibiting well-marked cadaveric 
 rigidity. I remember very well that when those frightful cases of 
 yellow fever occurred in this hospital, the disease commonly attacked 
 the strongest young men — models of muscular development. In 
 these subjects, notwithstanding the malignity of the disease, the black 
 vomit, and the gangrene of the extremities, the condition of cadaveric 
 rigidity was most remarkable and long continued. 
 
 In a very small proportion of cases in which we found the typhous 
 softening of the heart, we did observe something analogous to such a 
 change in a class of muscles which may be termed " mixed " or 
 "semi-involuntary." Thus in two or three instances where the heart 
 was softened we found a certain amount of softening of the pectoral 
 muscles, but except in this portion of the voluntary system there was 
 no departure from health. 
 
 Now, looking at the action of the heart in fever, you will see cases 
 in which, for a time at least, nothing abnormal exists; even the rate 
 of the pulse may be long unaffected, though this is rare. This often 
 varies, being sometimes quicker and sometimes slower, but with this 
 exception there is nothing abnormal observed in the whole course of 
 the case. There is neither increase nor loss of impulse, no lessening 
 of either sound of the heart, no unusual preponderance of one sound 
 over the other; in fact, if you except the alteration of rate, there is 
 
ESCAPE OF MUSCULAR SYSTEM. 119 
 
 nothing abnormal as regards the heart; yet, though this condition 
 may continue all through the case, and is a ground of a good prog- 
 nosis, there are examples where it has continued for three weeks, and 
 then a complication of bad symptoms has appeared. This we have 
 observed more in typhoid than in maculated typhus. 
 
 That this occasional escape or exemption of the heart from mischief 
 is a favourable circumstance there can be no doubt ; it shows that, 
 like other organs in fever, it may be untouched in certain cases by the 
 secondary processes of the disease. This bears on the point we have so 
 often insisted on — the variableness of all local affections as to seat, 
 intensity, and time of appearance in essential disease. One patient 
 may have the heart engaged ; in another with the same character of 
 fever it escapes. That is all we can say. 
 
 In the next category we place the cases of excitement of the heart 
 — a condition justifying an unfavourable prognosis, especially when 
 it is a continued one. It may exist in the earlier periods of the 
 fever, and continue after the symptoms of prostration have set in, 
 when the heat of the body falls and the pulse becomes feeble, con- 
 trasting strongly with the force or vivacity of the heart's action. 
 This is a very strange condition, but one full of danger. It is not 
 yet understood, and we have failed to connect it with any anatomical 
 change in the heart. In some patients it may continue all through 
 the case; in others it is ephemeral — that is to say, it exists for two or 
 three days and then subsides, though it may return. 
 
 In others, and these seem to be the worst cases, the heart during 
 the early and even the middle period of the fever has not been affected 
 with depression or the signs of softening, when we observe the terrible 
 symptom of an increasing excitement of the organ with an increasing 
 weakness of the patient. When you apply your hand over the heart 
 you find it acting violently and with a jerking character, similar to 
 that of ordinary nervous palpitation — a quick, sudden, violent action 
 — while both sounds are loud, sharp, and distinct. Any of you not 
 accustomed to such cases would expect to find a strong resisting pulse, 
 but it is not so ; you may find it extremely small ; it may be just per- 
 ceptible and easily compressible, and it is a fact that this excited action 
 of the heart may continue for days when every trace of pulse at the 
 wrist has disappeared. This condition of the heart, whether it has 
 existed all through, whether it is intercurrent or ephemeral, or, as we 
 say, terminal — coining on at the close of the case — or lasting many 
 days, is, I need not tell you, of the worst augury. 
 
 You will ask, What is this affection ? Is it inflammation ? We have 
 every reason for believing that it is not so. Is it an example of that 
 
120 LECTURES ON FEVER. 
 
 functional state of organs in fever of which I have spoken ? Certain 
 it is that in our dissections in these cases we do not find anything 
 abnormal in the heart — no vascularity, no lymph, no alteration of the 
 valves, no inflammation of the aorta, not a single anatomical evidence 
 of inflammation. 
 
 A good many years ago we had a case of excited action of the 
 heart with progressive failure of the pulse. A woman had been 
 employed in washing the clothes and bed linen in a case of severe 
 maculated typhus. She was admitted in a bad form of fever, with 
 great prostration. The heart soon assumed the excited and jerking 
 action ; the pulse was rapid and weak. "Wine had no good effect, and 
 about the twelfth day her condition seemed hopeless. N pulse could 
 be found at the wrist, and the skin was cool, as was also the breath. 
 None of the ordinary local diseases could be detected, though the 
 excitement of the heart continued. Under these circumstances I 
 determined to try the transfusion of blood, and the operation was 
 performed by the late Mr. Smyly. About twelve ounces of freshly 
 drawn blood, not defibrinated, were thrown in, with the effect of 
 restoring the pulse, so that it could be reckoned, and of making the 
 breath warm. The action of the heart remained unchanged, but the 
 patient sank in about thirty hours after the operation. 
 
 On dissection, conducted with great care, no anatomical change or 
 lesion whatever could be detected in any of the cavities. The heart 
 was empty and the ventricles firm, while the posterior portions of the 
 lung presented nothing of the congested state common in fever. The 
 whole lung posteriorly as well as anteriorly was perfectly white, dry, 
 and apparently bloodless. It seemed as if all the blood, at least the 
 red blood of the body, had disappeared in the course of the fever, a 
 condition which I believe was first noticed by Laennec. 1 
 
 1 It is now some years since Dr. George Harley was led to believe that in certain 
 cases the colouring matter of the blood was to be found in the urine, under the guise 
 of what he termed uroKcematin. This substance closely resembles the hsematin of the 
 blood in appearance and properties, and especially in the fact that it contains iron. 
 If the quantity of urohsematin is in excess, its presence is readily detected by a 
 deepening of the colour of the urine on the addition of some nitric acid, the effect 
 being heightened when the mixture is heated. From his investigations, Dr. Harley 
 is inclined to regard urohaBmatin as the debris or the product of the colouring matter 
 of the red blood corpuscles, and he considers the amount of the substance present 
 to be to some extent a gauge of the destruction of red blood corpuscles in health or 
 in disease. I need scarcely say how interesting the examination of the urine would 
 be in a case similar to the one just detailed. The discovery of a very marked excess 
 of urohsematin under such circumstances would have supplied a missing link in the 
 diagnosis of an extreme blood-waste. 
 
THE HEART IN FEVER. 121 
 
 It has ever since been a cause of sorrow to me, remembering the 
 law of periodicity in fever, that in this case we did not repeat the 
 transfusion. The restoration of the pulse in the radial artery, and of 
 the warmth of the breath, showed that by the operation we had gained 
 time. 
 
 T have little doubt that this lessening of the quantity of the blood 
 in fever occurs more or less in many cases independent of local disease 
 or excessive discharges, and this you will at once see bears strongly 
 on the point of the careful and continuous giving of nourishment in 
 the course of fevers. I believe that this is beside the question of the 
 use of wine or other stimulants in fever. 
 
 LECTURE XVI. 
 
 The Heart in Fever, continued — Depression of the heart, more marked in typhus 
 than in typhoid — Signs of the change connected with (J.) the impulse, (B) the 
 sounds — The phenomena attending depression are variable — Description of their 
 development, generally from the fourth day. 
 
 A. Impulse: — Possible sources of error in diagnosis: (1) constitutionally feeble 
 impulse, (2) emphysema of lungs — Necessity for comparison of condition of heart 
 from day to day — Peculiar modification of impulse in certain cases — Vermicular 
 action — Effect of position on impulse of heart — Loss of impulse generally progres- 
 sive, sometimes rapid — " Where differential diagnosis is difficult or impossible it 
 is often unnecessary as a guide to immediate practice" — Retrocession of the local 
 malady is gradual. 
 
 B. Sounds : — First phase of lesion : second sound becomes relatively, but not posi- 
 tively, augmented. Second phase : disappearance of first sound. Third phase : 
 disappearance of both sounds (a condition of most unhopeful augury) — Foetal 
 character of the sounds in some cases — Speculations as to failure of second sound 
 — Loss of impulse and failure of sounds generally advance pari passu, but not in- 
 varibly so — As failure of sounds begins at the left side, so in recovery the pheno- 
 mena follow the inverse course. 
 
 We must now speak of the third and most important condition — 
 as regards treatment — of the heart in continued fever. We have 
 spoken of its quiescence and its excitement, and we are now to study, 
 first, the signs of depression of the heart in fever ; secondly, how far 
 those signs are diagnostic of the softened state described by Louis; 
 and, thirdly, the general nature of that change. 
 
 The phenomena attending depression of the heart are of more 
 importance in the maculated typhus than in the typhoid fever; at 
 least they appear earlier — often much earlier — and seem to be more 
 connected with softening in the former. As you might expect, the 
 
122 LECTURES ON FEVER. 
 
 state of depression is recognized by the characters of impulse and of 
 sounds. Now, after what I have so often impressed on you in the 
 wards, I need not urge the importance of the principle that, in de- 
 ducting practical conclusions from the phenomena of the heart, their 
 value will be derived not from the comparison or contrast of one 
 patient's case with that of another, but rather from the study of each 
 case with itself at different stages of the disease from its commence- 
 ment to its termination. 
 
 Now, as regards the action of the heart in fever there are many 
 interesting phenomena to be studied. You will, of course, understand 
 that they will not prove to be constant in future epidemics or in all 
 countries. I have no doubt that the secondary affections of the heart 
 are under the same rule of variability as to occurrence and intensity 
 as are the other lesions in fever. Now, I suppose that you have a 
 case of maculated typhus, in which this secondary affection sets in. 
 You will often find after the third or fourth day that the impulse of 
 the heart has diminished to a remarkable extent, and this may happen 
 gradually, but we have observed it within twelve or eighteen hours — 
 that is, in a patient whose heart was beating naturally yesterday its 
 impulse is hardly perceptible to-day. Generally, however, we find 
 that the vivacity of the heart's action is progressively and gradually 
 lessened, and that the change is plainly perceptible about the fourth 
 day. Instead of the normal healthy beat of the heart, there is a 
 sluggish, laboured, and heavy motion. The diminution or cessation 
 of its impulse is first observable at the apex, when the stroke of the 
 heart is either not to be felt or scarcely perceptible. As the disease 
 goes on, you will have to make pressure in the direction of the base 
 of the heart or in the region of the xiphoid cartilage, in order to be 
 sensible of its action at all. It will be generally found on close 
 investigation that this cessation of impulse commences at the left side 
 — a fact again confirmatory of the researches of Louis, that softening 
 of the heart in fever begins in the left ventricle. Recollect, however, 
 that there are not a few persons who, although enjoying average 
 health, have hearts with a really feeble action, or apparently without, 
 or with very little, impulse, and this may save you from the error of 
 necessarily attributing to the typhous weakening or softening pheno- 
 mena which may be simply natural or constitutional. Bear in mind 
 also that feebleness of the sound and impulse may be caused by an 
 emphysematous state of the lung, which has the effect, as it were, of 
 burying the heart deep in the thorax. 
 
 Now, remember what I said to you about the advantage of the test 
 of comparison, not so much of one patient with another as of the 
 
VERMICULAR IMPULSE. 123 
 
 state of the same patient at different periods. If you find the heart's 
 impulse lessened or gone, and know that it was present on the day or 
 two previously, you have evidence that the change in the impulse is 
 owing to the influence of the fever. Also, if you perceive the loss of 
 impulse to be progressive — that is, that it becomes daily feebler and 
 less perceptible — you may set this down as the result of the typhous 
 weakening of the heart. Under such circumstances, on giving stimu- 
 lants and nutrients, you may be suprised at finding the impulse greatly 
 restored ; yet this effect, I must observe, is commonly transitory in its 
 nature, for it is only when the disease has run through its stages and 
 has been safely passed that you can look with any certainty for a 
 permanent restoration of the vigour of the heart. The restoration, 
 however temporary, of the impulse under the use of stimulants goes 
 so far to indicate that its weakness was one of the secondary condi- 
 tions of the essential disease, and as fully subject to the law of peri- 
 odicity as the petechial eruption, the discoloration of the skin, or 
 any of the other local secondary phenomena of fever. 
 
 I have told you that the loss of impulse is generally first observed 
 at the left side of the heart, but you will meet with cases where it 
 commences over the right cavities. But whether the signs first appear 
 here or on the opposite side, when both cavities are engaged the 
 impulse becomes undiscernible from the languor of the contractile 
 power of the entire heart. If, say on the fourth day of fever, the 
 impulse begins to languish and grows progressively weaker each day, 
 you need entertain no doubt of its typhous character. 
 
 In these cases of diminution and at last extinction of perceptible 
 impulse we have often observed a modification of the impulse that is 
 interesting. It marks a feeble action of the ventricles in which the 
 contraction is, as it were, not sudden but progressive. Instead of the 
 suddenly occurring, promptly ceasing, and well defined beat of the 
 heart, the impulse has a beat of a vermicular character, as if all the 
 contractile muscles of the ventricle did not act at the same moment. 
 In cases where the feeble impulse is visible you can sometimes satisfy 
 yourself of this vermicular action by the eye, and, as you might 
 expect, there is a certain prolongation of the first sound at the apex 
 approaching bellows murmur. 
 
 Now, under such circumstances the heart is about to be, or has been, 
 greatly weakened, and accordingly you may find this physical sign 
 in the earlier periods, when the process of softening is on the advance, 
 or again at a later period, when the organ is recovering. I think it 
 is an important indication that actual softening has occurred, and that 
 the feebleness of the impulse and sounds implied something more 
 
124: LECTURES ON FEVER. 
 
 than failure of nervous power of the organ. It may be present, 
 especially as a sign of recovery, for one or two days, and this is seen 
 in cases of slow convalescence from a state of extreme prostration. 
 
 In estimating the amount of failure of the impulse I must give you 
 some cautions before you conclude that there is no impulse. While 
 the patient lies on his back it may happen that the mere application 
 of the hand below the mamma will lead you to believe that impulse has 
 ceased, yet you are not at once to conclude that this is so. You must 
 make pressure downwards with the hand, and if still you do not get 
 impulse you are to apply the tips of your fingers to the intercostal 
 space firmly, and you may then feel the action. Nor are you to 
 declare that there is no perceptible impulse until you examine the 
 patient, turning him well on the left side and applying the hand as 
 before. If this fails to detect the stroke you may believe that the 
 most extreme weakness of the organ exists. 
 
 The loss of impulse is generally progressive, though sometimes 
 rapid. You will find it at first difficult to distinguish between weak- 
 ness combined with a process of softening, and simple debility with- 
 out organic change. But this is of no great practical importance, at 
 least so far as immediate action goes ; it illustrates the great principle 
 in clinical medicine, of which you have seen so many examples, that 
 where differential diagnosis is difficult or impossible, it is often unne- 
 cessary as a guide to immediate practice. The process, like other 
 secondary affections in fever, begins silently, without preceding signs 
 of excitement, except perhaps rapidity of action. 
 
 There is nothing more interesting than to observe from day to day 
 the retrocession of the local malady and the restoration of the organ 
 to health. In general the return of the impulse is attended with that 
 of the sounds, though we have seen exceptions to this. Thus the 
 sounds may return before the impulse, while we have had cases in 
 which eight days elapsed after its return before the sounds were re- 
 established. 
 
 Let me again impress on you that the value of the lessening or the t 
 want of impulse of the heart in fever as an indication of depression, 
 without softening, depends on the observation of a good impulse 
 during the earlier period of the case, as this will prove that the 
 feebleness or want of impulse was not the natural condition. 
 
 Now, as to the character of the sounds — looking at the circum- 
 stances connected with the impulse, and at the pathological state of the 
 heart, you will be able to predicate the results of auscultation. As 
 the impulse is lessened, it may be to extinction, so it is as to the 
 sounds. The change appearing first, at least in the great majority of 
 
DIMINUTION OF SOUNDS. 125 
 
 cases, in the arterial side of the heart, the sound of contraction of the 
 left ventricle becomes feebler and feebler, while that of the right, 
 though it may be lessened, continues. The second sound becomes 
 relatively, though not positively, augmented, and this may be taken 
 as showing the first phase of the lesion. 
 
 Next we may have a similar state of things as to the right ventricle, 
 and then it commonly happens that we find the heart acting with but 
 a single sound, and that sound the second. In a few extreme cases 
 all systolic and diastolic sounds cease, and we have the strange condi- 
 tion of a heart acting, yet so feebly that it has neither impulse nor 
 sounds — even in this state the pulse may continue perceptible. 
 
 But there are variations of these signs in different cases, all, how 
 ever, showing a depressed and probably a softened state of the organ. 
 Both ventricles may be engaged, causing diminution of their sounds, 
 while the second is also lessened. Neither sound is extinguished, but 
 both are greatly and apparently equably reduced. In this case, when 
 the pulse is rapid — say 130 or 140 in the minute — the resemblance 
 of the sounds to those of the heart of the foetus in utero is singular. 
 So similar are they that I believe if an observer was blindfolded, 
 brought to the bedside, and made to use the stethoscope, he would 
 think he was examining the abdomen of a merely pregnant woman, 
 and not the thorax of a male subject in typhus fever. 
 
 Were we to speculate on the causes of the lessening of the second 
 sound, we might ask, Does it depend on the condition of the heart 
 itself, or on that of diminished resiliency of the aorta and pulmonary 
 artery — a secondary effect of the fever? But it is unnecessary in the 
 present state of our knowledge to discuss such points. It is enough 
 to know that this condition is one, though an exceptional one, of the 
 signs of debility of the heart in fever. 
 
 Now, touching the sounds of the heart, you may take it as a general 
 rule that the diminution of impulse and the feebleness of the sounds 
 advance pari passu. Yet this is not invariably the case, and I must 
 tell you that you are not always to infer the loss of impulse from the 
 disappearance of the heart's sounds. It is certain that in fever we 
 may have a good impulse, apparently a healthy one, although the 
 cardiac sounds may be very obscure. Ou the' other hand, the sounds 
 of the heart may be found natural and satisfactory while there still 
 exists a decided loss of impulse. Generally, however', the two groups 
 of phenomena are found to go together, the one being indicative of 
 the other. 
 
 We may, for the sake of perspicuity, consider the phenomena of 
 the sounds of the heart in fever under three forms. In the first there 
 
126 LECTURES ON FEVER. 
 
 is a departure from the normal proportion — as to force, clearness, and 
 persistence — which the first sound should bear* towards the second. 
 In the second we have the diminution of both first and second sounds. 
 You will perceive that in the first form the inequality arises from 
 weakened action at one side of the heart, while the other remains 
 unaffected. Here both are partially enfeebled. In the third form the 
 sounds at both sides cease to be discernible even to the keenest ear. 
 This last change involves a condition in which successful treatment is 
 rare, and it may supervene on one or other of the former two changes 
 already described. Either of the first two may terminate in the last, 
 or total cessation of both sounds of the heart. 
 
 Now, all these signs — including those which go to make up the 
 third group of phenomena detailed — seem to indicate that the vital 
 power, and frequently the organic structure of the heart, are pro- 
 foundly affected. 
 
 It is, however, to the characters of the first sound and to the impulse 
 that your attention in practice is chiefly to be turned. During the 
 whole range of an investigation into these phenomena in fever, which 
 has extended over a long series of years, neither I myself nor the 
 gifted students who have laboured with me could ever say that we 
 met with a single case of fever in which the peculiar phenomena of 
 cardiac debility began with diminution or cessation of the second 
 sound of the heart. Whatever may be the cause which produces the 
 second sound, one thing is clear — that it has much less relation to the 
 vital character and condition of the heart than has the first sound. 
 
 I have mentioned that where the sounds of the heart become altered 
 in the course of a fever the change begins in the left ventricle and 
 travels towards the right side of the heart ; the systolic sound first 
 becomes diminished towards the left, and afterwards towards the right. 
 In cases of recovery the phenomena follow the inverse course, as we 
 might naturally expect. We find the returning first sound audible, 
 first over the right, and then over the left ventricle. 
 
THE HEART IN FEVER. 127 
 
 LECTURE XVII. 
 
 The Heart in Fevee, continued — Post-mortem appearances in extreme typhous softening 
 — This affection not followed by chronic disease of the heart — Periods of invasion 
 and of retrocession — Diagnosis of actual softening depends on (1) the character 
 of the fever, and (2) the persistence of physical signs of failure of the heart — 
 Simultaneous lessening of both sounds (fetal heart) — Its bearing on the treatment 
 by stimulants — Slowness of pulse in convalescence from typhous softening — An- 
 alogy to fatty degeneration of heart with slow pulse — In latter case the phenome- 
 non, however, is constant — Occasional reversal of the order in which the signs of 
 typhous softening show themselves — Prognosis more favourable with depressed 
 than with excited heart — Former condition is more amenable to treatment — Report 
 on an epidemic of typhus at Stockholm in 1841, by Professor Huss — Cardiac Mur- 
 murs in fever, especially in advanced stages of typhoid and relapsing fever, are 
 generally basic and systolic, functional in character, and occasionally accompanied 
 by venous murmurs in the neck — Difficulty of distinguishing the first and second 
 sounds of the heart in certain cases of disease : (1) chronic bronchitis, with weak 
 and irregular heart and congested liver ; (2) late stages of some forms of fever — 
 Example of the latter — Diagnosis drawn from a want of accordance in the symptoms. 
 
 Before we proceed to consider some of the remaining secondary 
 conditions of fever it will be right to return, in this lecture at least, 
 to its influence on the heart, not so much as a question of pathological 
 anatomy, but as having an important bearing on the two great objects 
 of medical science, the cure and the prevention of disease. 
 
 We have studied some of the signs of typhous affection of the heart 
 — a state commonly one of depressed vital energy, attended with a 
 softened condition varying in its amount and extent, and following 
 the laws of the secondary organic and functional affections in fever. 
 Many of you have had an opportunity of studying this condition 
 during life and after death. It may be described as a change in the 
 muscular structure, which is certainly not inflammatory. There is 
 but little, if any, change in the volume of the organ, which latter is 
 often more or less livid, as you may see in other structures in fever. 
 Serum is sometimes found effused into the pericardium, but beyond 
 this there is no affection of the external covering, the endocardium, 
 or valves. The structure of the heart, most often of the left ventricle, 
 becomes homogeneous, and in it to the naked eye the muscular fibre 
 can hardly be detected. It is of a dark colour, and has some resem- 
 blance to the cortical structure of the kidneys. It seems infiltrated 
 with an adhesive secretion, and is softened and friable, breaking down 
 
128 LECTURES ON FEVER. 
 
 under a slight pressure. This change may be more or less general, 
 though it commonly predominates in the left ventricle, where it may 
 occur in patches from a quarter to an eighth of an inch in breadth 
 and an eighth in depth. So great is the softening in extreme cases 
 that where both ventricles are almost equally engaged, on grasping 
 the great vessels and turning up the apex of the heart, we find the 
 whole organ to fall over the hand like the cap of a large mushroom. 
 
 That this is a special and secondary local disease in fever there can 
 be no doubt. I have spoken of its variations in intensity, extent, and 
 time of retrocession. Like other secondary diseases, its frequency 
 varies according to the epidemic character, for though it has for many 
 years been observed in our wards and studied in connection with the 
 necessity for and employment of stimulation, yet it was certainly 
 more frequent before the epidemic of 1847 than it has been since that 
 time. It was not a very prominent symptom in the famine fever of 
 1847 and 1848, and its subsequent rarity, as compared with what was 
 observed in the decade following 1837, may have been connected with 
 the general disappearance of fever in Ireland for some years after the 
 famine fever. Like the other secondary affections, too, it often exhibits 
 retrocession without consequent disorganization. In fact, there is no 
 example of reactive irritation or inflammation, such as we see in the 
 lungs or intestines, having ever occurred in the heart. Out of many 
 hundreds of cases observed since 1837 to the present time, we have 
 had no example of chronic organic disease of the heart traceable to 
 the typhous affection. 
 
 The period of invasion of this manifestation appears to be between 
 the fourth and sixth day of the fever, and its retrocession takes place 
 at varying times between the tenth and the fifteenth day. The physical 
 signs of weakness may be said to continue for about eight days. 
 
 The diagnosis of actual softening, as distinguished from simple de- 
 bility, will depend on the character of the fever and the time during 
 which the physical signs of failure of the heart have been present. 
 Experience, again, shows that the progressive diminution of the impulse 
 and sounds of the heart, which may proceed to their extinction, is 
 sufficiently often connected with the actual softening to justify the 
 diagnosis of this lesion. 
 
 The energy of both sounds may be simultaneously lessened, and 
 where this takes place to a certain degree they resemble those of the 
 fcetal heart. This, we have thought, in some instances showed an 
 irregular and anomalous case, in which the stimulating treatment, 
 although manifestly indicated, was not so successful as in the ordinary 
 
SLOW PULSE. 129 
 
 case of diminution or obliteration of the first sound while the second 
 remained. 
 
 A remarkable character of the pulse — one to which allusion has 
 already been made — during convalescence, in cases of unquestionable 
 softening of the heart, which had been treated by free stimulation, is 
 the progressive diminution of its rate even below the normal standard. 
 In these cases, when convalescence is already advanced, when the 
 heart's impulse has been restored and its sounds have again become 
 audible, the pulse, having fallen to 72, on the next day will be found 
 to beat but 60 times a minute. This lowering of rate may go ou for 
 several days afterwards, until at length the pulse will have fallen per- 
 haps to 48, 40, or even 36, when once more it rises in a similarly 
 gradual way to the natural standard of health, at which it finally re- 
 mains. The return to the natural standard, however, though progres- 
 sive, is effected in a shorter time than was the gradual fall in the first 
 instance. It js difficult to assign a cause for this peculiarity of pulse, 
 but a similar slowness of the pulse undoubtedly exists in many cases 
 of fatty degeneration of the heart. 
 
 It is very difficult to account for this slowness of pulse supervening 
 when convalescence is all but established, not only as to the general 
 symptoms, but as to the heart itself, which exhibits a return of its 
 natural vigour. In the fatty degeneration of the heart the pulse, which 
 we have found as low as 28 in the minute, is more or less perma- 
 nently slow. The rate may rise to 36, but the power of attaining 
 the natural standard seems lost. You will remember, however, that 
 in this condition the muscular structure is permanently damaged, 
 while the typhous affection is under the law of periodicity. 
 
 I must tell you that although in the majority of cases the typhous 
 change is marked in the first instance by the failure of impulse, and of 
 the ventricular sound — these signs being most developed at the left 
 side of the heart — you may meet cases in which they vary in their 
 seat and order of occurrence. I have impressed upon you that fever 
 is an essential condition. Yet when you study it in a number of 
 cases, even during the same epidemic, though you may find among 
 them a generic resemblance, they present infinite varieties in the local 
 symptoms and signs — varieties as to seat, intensity, the occurrence, 
 amount, nature, time, and complication of the secondary affections. 
 Hence you may expect to meet with departures from the usual suc- 
 cession of phenomena as to the functional as well as the organic changes 
 of the heart. The former may be ephemeral, the latter variable as to 
 their retrocession. Signs of excitement may alternate with those of 
 depression, and the order of phenomena as regards the first and second 
 
130 LECTURES ON FEVER. 
 
 sounds of the heart may (though this is rare) be reversed. This great 
 principle remains, that the disturbances of the heart in fever, even 
 when it shows excitement, are very rarely indicative of inflammation, 
 while the nature of the morbid change is truly "something the re- 
 verse of inflammation." 
 
 Turning to prognosis, it is clearly to be more favourable in the case 
 of depression than in that of excitement of the heart, and looking at 
 the frequency of softening, you arrive at the conclusion — which seems 
 a strange one — that the existence of such a change in one of the most 
 important organs of the body may lead to a better prognosis than 
 under opposite circumstances. The reason of this, however, is obvious. 
 In the case of the typhous softening we can safely and advantage- 
 ously employ stimulants, which are comparatively ineffective, and 
 often inadmissible where the heart is excited. The condition of de- 
 pression of the heart is certainly more frequent in the well-marked 
 maculated fever than in the typhoid form. It begins,, at all events, 
 earlier, and the signs of progressive softening and recovery are much 
 better defined. Still it would be wrong to say that in the typhoid 
 cases the examination of the heart is not of great importance. When 
 we shall speak of treatment and of the use of stimulants, you will find 
 that in the advanced stages of typhoid a very great amount of stim- 
 ulation is often borne with the best results. 
 
 Before passing from the subject of the state of the heart in fever, I 
 wish to draw attention to a very interesting report upon an epidemic 
 of fever which occurred in a corps of gens d J armes stationed at 
 Stockholm in the winter of 1841. The observations made in this re- 
 port by Professor Huss are very confirmatory of our researches at the 
 Meath Hospital. The disease in this outbreak had most, if not all, the 
 characters of our typhus. 
 
 The skin was maculated, with the usual accompanying symptoms 
 of prostration, delirium, stupor, and secondary affections of the pul- 
 monary and gastro-intestinal systems. Daring the earlier periods of 
 the fever, varying from five to nine days, the sounds of the heart, 
 particularly the first, became enfeebled. In the more advanced stages 
 of the abdominal cases, the first sound would become similar to the 
 second, and grow feebler until the second alone was to be heard. In 
 convalescence the first sound was again heard faintly; then it became 
 similar to the second, and the action of the heart was restored with the 
 inverse series of phenomena. 
 
 In this epidemic wine does not seem to have been used by Professor 
 Huss, but he gave tonics, such as the mineral acids, and nervine stim- 
 ulants — musk, camphor, and so on ; and in the employment of these 
 
FIRST AND SECOND CARDIAC SOUNDS. 131 
 
 remedies he acted on precisely the same principle that we adopt in the 
 use of wine — that is to say, he was guided by the enfeebling of the 
 first sound and impulse of the heart, and by the other signs of a 
 depressed vital condition. 
 
 There is one other point on which I have not touched — the existence 
 and nature of cardiac murmurs in the advanced stages of fever. 
 These are more frequently met with in the enteric or typhoid fever 
 and in the relapsing forms of the disease than in maculated typhus, 
 although even in the last-named they have been observed in the early 
 stages of convalescence. Generally speaking they occur at the base 
 of the heart, and are always systolic. In a few cases, however, they 
 seem to be developed towards the apex, or they may occur in both 
 situations at once. They are by no means so frequent or so prominent 
 as in convalescence from rheumatic fever, in which we have observed 
 them throughout the course of both the thoracic and the abdominal 
 aorta. We need not here inquire whether they are anaemic or spa- 
 nasrnic ; it is enough to know that they are not organic, and that they 
 indicate the use of iron and a restorative treatment. In a few cases, 
 but by no means in all, they are accompanied by venous murmurs in 
 the neck. 
 
 I was observing just now, in the ward, at the bedside of the boy who 
 had the pulmonary lesion (I will not call it pneumonia), with a low 
 typhoid fever (he is under the care of Mr. Daly), how well his case 
 illustrates the advantage of clinical study. If you take up works 
 upon disease of the heart, you find that it is assumed by almost every 
 writer that the first and second sounds of the heart are to be easily 
 distinguished from each other. There are some persons who, if you 
 were to say to them, in any given case, "I have had considerable diffi- 
 culty in saying which was the first and which the second sound of the 
 heart," would set you down as very deficient indeed, and as one who 
 had not been properly taught. But the fact is, gentlemen, that there 
 are many cases in which at first it is very difficult indeed to say which 
 is the first and which the second sound of the heart. Occasionally the 
 most experienced man will require repeated observation before he can 
 make up his mind. 
 
 It has repeatedly happened to me that, after thinking I had settled 
 the point, I was again thrown into doubt on moving the stethoscope 
 an inch or two. 
 
 I mention this to show you how diffident we should be in our 
 opinions upon these subjects, how slow we should be to condemn 
 men because they do not come up to the mark laid down in books. 
 
132 LECTURES ON FEVER. 
 
 The truth, in fact, is, that they may go beyond it — that they are 
 wiser than the authors of such books. 
 
 There are two eases in which it is often extremely difficult to say 
 which is the first and which the second sound of the heart. One 
 of these is that triple combination of local disease which is so common, 
 especially in private practice, where the patient has chronic bronchitis, 
 a weak and irregular heart, and congestion and enlargement of the 
 liver. But there is another element very commonly to be found in 
 connection with this combination, and that is the gouty element; so 
 that you may have a gouty man with chronic bronchitis, with a weak 
 and irregular heart, and with an enlarged liver. In such a case it is 
 sometimes extremely difficult to say which is the first and which the 
 second sound. They are closely similar ; and the action is so irregular, 
 so uncertain, that you may often apply the stethoscope for minutes 
 together most carefully and yet not be able to make up your mind. 
 This is one case. Well, take another — such as that of the boy above 
 stairs. 
 
 This boy presents some very curious phenomena ; and illustrates 
 difficulties which you would not anticipate, if you depended merely 
 upon the text-books for a diagnosis of disease of the heart. It is 
 difficult to say whether the murmur which he has belongs to the first or 
 to the second sound. But there is a greater and a still more impor- 
 tant difficulty in this case — namely, to determine whether this is an 
 organic or an ansemic murmur — and I am not ashamed to say that 
 my own mind is not made up on the subject. It would be very easy 
 to adopt one theory or the other, and to argue upon it ; but I know 
 thoroughly the difficulties of the subject; and I think, at this moment, 
 it would be hardly possible to say whether this boy has disease of the 
 valves of his heart or not. There is one consideration connected with 
 the case which is drawn, not from physical examination at all, but 
 from the general history of the patient, and it is this, that while 
 organic murmurs are rare — very rare in the form of disease which 
 he has had — inorganic murmurs are comparatively common in it. 
 
 This is a very strong point. We are here under this difficulty — a 
 difficulty which you may meet with every day in private practice 
 — that we are called on to give an opinion when the data that should 
 guide us in that opinion are deficient. We want to know the pre- 
 vious history of this boy. If, instead of being in hospital, he were 
 a private patient under your care, or if you had been the attendant 
 on his family for years together, were familiar with him and intimate 
 with the state of his heart, you would be able to say, first, if he ever 
 had carditis; next, whether, before his late attack, he had cardiac 
 
CARDIAC MURMURS. 133 
 
 murmur or not. But we know nothing of all this; and the only fact 
 we have to go on is the observation of Mr. Daly that when the boy 
 was first examined this murmur was not there at all. I myself 
 have no doubt as to the correctness of this observation of Mr. Daly, 
 and believe that whether the murmur be organic or inorganic, it 
 has been developed since the patient came into the house. Can 
 we distinguish by acoustic signs alone, gentlemen — and this is a 
 point which bears on the subject of fever in a most important man- 
 ner — the inorganic from the organic murmur ? The answer to this 
 question is simply that, in the present state of our knowledge, there are 
 many cases in which we cannot do so; that there is no special acoustic 
 character by which we can distinguish one of these phenomena from 
 the other. This looks like a depreciating statement, as far as our skill 
 in diagnosis is concerned; but the cause of diagnosis would be much 
 more injured by attributing to it powers which it does not possess 
 than by confessing its deficiencies. The diagnosis in the case in 
 question is to be drawn from other sources — generally speaking, from 
 circumstances connected with the condition of the patient, the absence 
 of the signs of inflammation, and a variety of other points. 
 
 As regards cardiac murmur in fever, the observation has been 
 frequently made that valvular murmur, when the patient is made to sit 
 up, does not disappear ; but we have found in this hospital that, in many 
 cases in which a murmur was observed after fever, it was ascertained 
 that, in an upright position, the abnormal sound disappeared, or, if it 
 did not cease altogether, it became much less intense; so that the 
 disappearance of the murmur in the upright position is in favour of its 
 inorganic nature, while its persistence or aggravation points to an or- 
 ganic origin. So far so well. But, you will ask, is this rule absolute ? 
 This is a question which must be answered in the negative; for you will 
 meet with anasmic murmurs which are not influenced by position; and 
 I believe there are, on the other hand, organic murmurs which are 
 influenced by position. There are, doubtless, some organic murmurs 
 in which, when the heart is made to act rapidly, the murmur either 
 disappears or becomes lost in the other cardiac sounds, so that you 
 cannot distinguish it. 
 
 My own impression about the patient whose case we are at present 
 studying is that the murmur is inorganic. I trust it is; but I would 
 not say so positively, because the sound, although strongly marked — ■ 
 although approaching very closely indeed to the inorganic murmur — 
 is similar to a kind of murmur which we in this hospital have met 
 with in cases where the heart has been weakened. It is a true mus- 
 cular murmur — a sound produced simply by the non-synchronous 
 
134 LECTURES ON FEVER. 
 
 contraction of the muscular fibres — when they act vermicularl}', as it 
 were. The murmur in our patient possesses more of this character 
 than of that of the true valvular murmur. There is another point 
 connected with it which is of importance. If this murmur was valvular, 
 it would imply a great deal of disease; a rough, almost rasping bruit 
 in the situation of the aortic valve, implies generally a great amount 
 of disease, commonly chronic; and, under these circumstances, you 
 might expect that the patient would show other signs of disease of 
 the heart. So that we here have a diagnosis drawn, as I often ob- 
 served to you before, from that important source — the want of ac- 
 cordance of the symptoms. Supposing the murmur here to be 
 organic, we should expect to find with this amount of valvular disease 
 signs of dilatation of the left ventricle, or of the whole heart. And 
 yet even when this boy had one of his lungs almost entirely 
 obstructed — a condition which often acts in developing latent cardiac 
 disease — the symptoms of cardiac suffering were not at all remarkable. 
 So that there is here, to a great degree, this want of accordance in the 
 symptoms — a condition which is against the opinion of the murmur 
 being organic, and in favour of its being functional. A mistake, gen- 
 tlemen, was often made in connection with auscultation generally — 
 I am happy to say that it is but seldom made now — that of supposing 
 that every disease had its special acoustic sign. Consequently the 
 attention of students and physicians was directed to the study of 
 physical signs from a purely mechanical point of view — to the 
 observation merely of their acoustic characters. 
 
 There can be no doubt that it is of the greatest importance to study 
 carefully everything connected with a diseased organ — both its physical 
 and its vital phenomena; but what you have to learn specially is not 
 so much how to detect or recognize a particular sign, as to know how 
 to reason upon it when you have discovered it. It is here that the 
 clinical student of practical experience has the greatest superiority 
 over the mere reader. His mind is trained to reason upon the phe- 
 nomena which he observes. Here we have a group of phenomena; 
 and if we did not give ourselves the trouble to turn every possible 
 point of the case over in our minds, we should come to an imperfect 
 and erroneous conclusion about it. 
 
 Bear this in mind always, that there is no absolutely pathognomonic 
 physical sign of any disease whatsoever. This cannot be too strongly 
 stated; and I believe that we might go further, and say that there is no 
 combination of mere physical signs which, excluding the history and 
 vital symptoms, can be justly considered as pathognomonic; at all 
 events, if there be such a combination, it is one of extreme rarity. We 
 
SECONDARY INTESTINAL COMPLICATIONS OF FEVER. 135 
 
 hear of certain murmurs being pathognomonic of this and of that dis- 
 ease of the heart — friction sounds being pathognomonic of pleurisy 
 — crepitating rales, of pneumonia — amphoric sounds, of effusion of air 
 and fluid into the pleura. All this is wrong; it is based upon 
 error ; and you must expunge it altogether from your minds, if you 
 wish to be good physicians and faithful observers of 
 
 LECTURE XVIII. 
 
 Secondary Intestinal Complications of Fevek — General and introductory remarks — 
 A generic resemblance between tbe various forms of fever — Secondary abdominal 
 complications are more frequently observed in typhoid fever, but do not exist as 
 its necessary anatomical character — Dothinenteritis was largely prevalent in 
 the typhus epidemic of 1826-28 — Fever must be observed independently in each 
 epidemic and in every country — Typhoid fever almost without characteristic 
 symptoms — Illustrative case ; extensive intestinal ulcerations found after death — 
 Vital symptoms of intestinal complications: (1) thirst, (2) swelling of belly, 
 (3) diarrhoea, (4) ileo-caecal tenderness, (5) increased action of abdominal aorta 
 (6) rigidity of abdominal muscles — Three forms of abdominal swelling : (1) early 
 and moderate tympany, (2) doughy condition, (3) slight ascites — Increased action of 
 abdominal aorta — Case of, in perforation of the stomach — Analogous local arterial 
 excitement in (1) whitlow, (2) rheumatism — Diagnosis from aneurism — Intestinal 
 complications seem to interfere largely with action of the law of periodicity — Early 
 alleviation of local irritation checks deposit, and so prevents future mischief — Hence 
 relief of symptoms by early depletion as practised by Broussais, who misinterpret- 
 ed the matter, and was led to look upon the general fever as but symptomatic of a 
 local lesion. 
 
 Gentlemen, I hope that none of you will misunderstand me and 
 suppose that I do not recognize the differences between the various 
 forms of fever, about which so much has been written in latter times by 
 excellent observers. That a case of fever answering to the description 
 of the pythogenic fever of Dr. Murchison — the typhoid of Sir William 
 Jenner and Dr. Hudson — runs a different course from a maculated 
 typhus or a relapsing synocha, is to be admitted. All these forms vary, 
 whether in isolated cases or in the multiplied examples which occur 
 in epidemics. As a rule they differ as to their apparent exciting 
 causes, their local complications, their mortality, their attendant phe- 
 nomena, and their consequent effects on the economy. That follicular 
 disease of the intestines is commonly met with in typhoid as 
 compared with typhus may be admitted, as well as the rule that the 
 laws of periodicity in the former are not so well marked as in the 
 latter. But what I want you to perceive is that there is between them 
 
136 LECTURES OX FEVER. 
 
 a great generic resemblance. The greater your intimacy with fever — 
 the more it is observed upon a large scale, the less attention you will 
 pay in your diagnosis, prognosis, and treatment to the question 
 whether the disease belongs to this or to that categorv. This is 
 true at all events as to the typhus and typhoid fever. Much has been 
 written to prove that dothinenteritis may be taken as the anatomical 
 character of the latter disease, and some go so far as to deny the 
 occurrence of ulceration of the intestine in maculated typhus. Yet no 
 man who has observed this fever in an Irish hospital will subscribe 
 to such a doctrine. Dothinenteritis is, or has been, a common occur- 
 rence in the last-named form of the disease, its frequency and amount 
 varying in different epidemics. In such a case are there two diseases, 
 different in identity, existing together in the system ? and what becomes 
 of the alleged differences, when the management of the case is con- 
 sidered ? 
 
 The theatre of a hospital is not the place for a systematic course of 
 lectures. We can be here better employed, and the teacher's business 
 is to say, like Mark Antony, " that which he knows," and to prove it by 
 demonstration, referring to cases with which his hearers are familiar. 
 
 When we consider fever in relation to pathological anatomy, symp- 
 toms, exciting causes, and treatment, we find it a complex and ever- 
 varying condition, with certain generic resemblances in the relations 
 between it and the secondary affections which impress on it particular 
 and varying characters ; but to lay down rules by which each type of 
 fever can be proved to have a separate identity is to go too far. I have 
 told you that no two epidemics are exactly alike either as regards their 
 essential symptoms or local complications. The results of the most 
 careful and extended researches will enable us to lay down principles 
 — as to pathology, prognosis, and treatment — applicable when the 
 disease occurs in different countries and climates and affects different 
 races of men. 
 
 I have said that this is not the place to go into the history of every 
 observed form of fever, and into the various controversial questions 
 that have arisen regarding them. Study the excellent works of Dr. 
 Murchison, Dr. Hudson, Sir William Jenner, and Dr. Stewart, and use 
 your own judgment as to how far your experience bears on the great 
 questions therein discussed. In the mean time let us continue to study 
 the local complications, after which we shall be in a position to deal 
 with the question of the treatment, if not the prevention, of the 
 disease. 
 
 It will not be necessary after these observations to take up your time 
 by going over the beaten ground of the pathological anatomy of the 
 
NO SPECIAL ANATOMICAL CHANGE. 137 
 
 digestive tube in fever You will meet with descriptions of the tume- 
 factions and ulcerations of the glands in every modern work on the 
 subject. Let us rather take a general view of the symptoms attendant 
 on fever with reference to the digestive system, and as we have studied 
 the various conditions of the lungs and heart under the influence of 
 the disease, let us now consider its secondary abdominal complications. 
 
 What I have to say on this subject must be held to apply to the 
 several varieties of fever. Although the symptoms now to be studied 
 are not equally developed in all these varieties, yet when I speak of 
 " local lesion " I intend my remarks to apply to fevers of every kind. 
 We have spoken of the alleged anatomical distinction between 
 typhus and typhoid — the one being free from intestinal disease, the 
 other always presenting it. Now, it would be more philosophical, 
 to say that no form of fever has any special anatomical change ; that 
 where such does take place it is of a secondary character ; and that 
 when it arises in the digestive system, it is more frequently observed 
 in one form of fever than in another. Such a proposition might be 
 accepted. 
 
 The frequency of dothinenteritis as regards fever is, or has been, 
 greater on the Continent than in this country. The typhoid is more 
 common abroad than the true maculated typhus. Hence in proportion 
 as true typhus is epidemic, we find fewer instances of the secondary 
 intestinal lesion, which becomes more frequent when typhoid fever 
 extensively prevails. But the local disease is not necessarily charac- 
 teristic of any peculiar type of epidemic. In the outbreak of 1826-28 
 (if ever there was a true typhus epidemic it was then) in a very 
 large number of cases the secondary local disease of the intestine, con- 
 sidered to belong to the typhoid form, was present. In fact, there 
 was an observable tendency towards an extreme amount of disease of 
 the digestive organs. It was in this epidemic that the yellow fever 
 appeared, with peculiar symptoms of very severe gastro-intestinal 
 disturbance. I cannot too earnestly impress on you all that, as re- 
 gards fever and its treatment, you are not to trust implicitly to the 
 statements of other observers, no matter how eminent they may be, 
 in forming your judgment as to the cases at the time under your charge 
 Recollect that all such statements are to be accepted only as bearing 
 on outbreaks of fever as observed in different places and at different 
 times; for both the locality and the period of an outbreak are con- 
 siderations which must be taken into account. 
 
 It was a grave medical error on the part of Broussais and his disci- 
 ples to declare the constancy of gastro-enteritis over the world from 
 observing fever in France. The same remark applies to theories as 
 
138 LECTURES ON FEVER. 
 
 to symptoms and treatment — doctrines formed and adopted without 
 reference to the period and place of observation and the prevailing 
 epidemic character. You may admit the disease of the digestive organs 
 to be met with less frequently in typhus than in typhoid, but if you 
 were to conclude that in typhoid fever intestinal lesion was a special 
 and constant result, or that it was not met with in typhus, you would 
 be wrong. Eecollect what I have already told you as to the variable 
 and inconstant characters of the local affections in fever. Cases of 
 typhoid fever will come under observation wherein there is an 
 absence of any direct symptom, or of any change whatever in the 
 anatomical structure. This is an important fact, and a single case of 
 the kind is of great value and interest. 
 
 Again, we may have typhoid fever with intestinal lesion, but with- 
 out any direct symptom beyond mere loss of appetite, and malaise — 
 nay, even these symptoms may be absent. I will detail for you a re- 
 markable instance of this. The disease ran a course of forty-three 
 days without break or alteration. There were at first some slight 
 respiratory symptoms, but subsequently the case seemed to be one 
 of a purely nervous character. Towards the termination, symptoms 
 of engorgement of the air passages and of weakness of the heart 
 appeared. At no stage of the disease was there any swelling of the 
 belly or tenderness there. There was no throbbing of the abdominal 
 aorta, no rigidity of the recti muscles, no diarrhoea; the evacuations 
 were all through healthy in character. In fact, so far as the belly 
 was concerned, not a single symptom could be detected from beginning 
 to end. I put the state of the tongue out of the question, as in fever 
 it is no evidence of disease of the digestive system. Not only was 
 there a complete absence of any direct symptom of intestinal disease 
 in this perfectly marked case of typhoid, but also the patient took his 
 food well and it seemed to perfectly agree with him. On dissection 
 the lower third of the ileum showed a sheet of suppurating ulcers, 
 with extensive destruction of the mucous membrane. 
 
 The junior members of the class will learn from this case that in 
 fever the symptoms of the secondary disease of the intestines may be 
 singularly obscure, especially as compared with those in the lungs, 
 heart, or brain, and when they do occur they do not give any reliable 
 measure of the extent of disease. When the brain is affected, the 
 nervous symptoms of pain, delirium, subsultus, coma, and so on, gen- 
 erally reveal the disease. The disease of the lung, and especially of 
 the heart in its softened condition, though partaking to a certain 
 degree of the (so to speak) silence of the secondary affections, is ascer- 
 tainable by physical examination — which in the lung discovers rale 
 
INTESTINAL AFFECTION PAINLESS. 139 
 
 and dulness, and in the heart diminution or extinction of sound and 
 impulse. 
 
 Even the vital symptoms of these forms of disease often reveal the 
 mischief. You may find dyspnoea, lividity, rapidity and feebleness of 
 pulse, and so on ; but in the case of the digestive system matters are 
 different. I think we owe to Broussais the knowledge of the fact 
 that in fever inflammation and ulceration of the bowels may almost 
 be described as a painless disease, the symptoms affording no reliable 
 evidence as to the nature and extent of the local mischief. There 
 may be thirst, some tympany, or moderate diarrhoea, and on dissection 
 you may find ulceration, even having gone on to perforation — yet the 
 symptoms of thirst, tympany, and diarrhoea will be insufficient to 
 enable you to declare the amount of local disease. 
 
 The most important vital symptoms, which all vary in their amount 
 and intensity, are thirst, swelling of the belly, diarrhoea, and tenderness 
 of the ileo-csecal region, and often of the epigastrium. Pain is rarely 
 complained of. The abdominal muscles may be more or less rigid, 
 and there is sometimes increased pulsation of the abdominal aorta. 
 
 Three forms of abdominal swelling may be noted. You may find 
 an early but moderate tympany affecting apparently the small rather 
 than the large intestines. Again, especially in advanced cases, you 
 may have a doughy-like condition of the belly yielding little or no 
 tympanitic sound, and conveying to the hand a sensation as if the in- 
 teguments were thickened and agglutinated to the organs beneath. 
 I think I have observed another kind of swelling, caused by a 
 slight liquid effusion into the peritoneum. This can be detected by 
 the feeling of fluctuation when the patient is placed upright. Gen- 
 erally, however, the abdominal swelling is principally tympanitic, 
 while in some advanced cases the belly becomes collapsed. 
 
 About the middle period of the disease you may often find diar- 
 rhoea with or without morbid stools. The tenderness on pressure dif- 
 fers from that of peritonitis in not being at all so well marked. This 
 tenderness may be general, although most commonly it is best per- 
 ceived in the ileo-csecal and epigastric regions. I would caution you, 
 however, against using any but the gentlest pressure in seeking for 
 this symptom ; the great rule in all examinations is to avoid giving 
 the patient any cause of complaint or the least inconvenience. 
 
 You are also to look for increased action of the abdominal aorta — 
 an interesting symptom, of which the analogue maybe seen in the 
 increased action of the radial artery in whitlow. I have observed that 
 in this local manifestation of fever the pulsation of the vessel is often 
 more equable than in ordinary nervous throbbing of the aorta. It 
 
140 LECTURES ON FEVER. 
 
 disappears with the subsidence of the disease, and I have seen it do 
 so after an application of leeches and poultices to the belly. 
 
 In cases where its existence is doubtful we sometimes find a marked 
 disproportion between the beat of the radial and femoral arteries. 
 This is a very interesting subject, and the symptom in question led 
 us some years ago to the diagnosis of rupture of the intestinal tube. 
 A middle-aged man, who for more than a year had suffered from ab- 
 dominal pains attributed to dyspepsia, fell down in the street, and was 
 brought into our wards in a state of collapse. The surface was cold, 
 and the pulse at the wrist had ceased. The belly was moderately full, 
 but painless to pressure. 
 
 These symptoms, connected with the previous abdominal pains, had 
 all the characters of hemorrhage into the peritoneum from rupture of 
 an aneurism. But we came to the conclusion that the case was one of 
 perforation of the intestine from this circumstance — that while the 
 pulse had ceased at the wrist, it-was distinct and jerking in the groin. 
 The freedom from pain on pressure seemed to favour the diagnosis of 
 rupture of an aneurism, but you must remember that the patient 
 was in a state of extreme collapse. 
 
 On dissection, the diagnosis of perforation of the digestive tube 
 proved to have been correct. The solution of continuity was not, as 
 we had supposed, in the small intestine, but in the great curvature of 
 the stomach. The accident seemed to have occurred immediately 
 after the man had taken a full meal, the ingesta having escaped almost 
 wholly into the peritoneal cavity. The serous membrane presented 
 a diffused red tinge, seen principally in the hypogastric region, appa- 
 rently a very early stage of peritonitis, and as such sufficient to 
 account for the increased local arterial action. 
 
 While I am on this subject T may mention that iu certain cases of 
 chronic aortic patency, with the usual arterial throb, in which the 
 patient experiences an attack of rheumatic arthritis, say of the wrist, 
 the force and vehemence of the corresponding radial artery become 
 so exaggerated as to make it difficult to convey an adequate impres- 
 sion of it. It may be compared to the blow of a steel hammer on an 
 anvil — so greatly exaggerated by the local irritation is the ordinary 
 increased impulse of the vessel. According as each joint becomes 
 attacked under the influence of metastasis, the violent pulsation is 
 found in the corresponding artery. I have known this temporarily 
 intensified impulse, when its seat was the abdominal aorta, to lead to 
 the wrong diagnosis of aneurism, the signs of which disappeared with 
 the subsidence of the intestinal disorder. 
 
 The diagnosis is to be drawn from the history of the case, as a 
 
SYMPTOMS OF INTESTINAL AFFECTION. 141 
 
 violently acting abdominal aneurism is not developed in a short period 
 of time without previous symptoms. The combination of abdominal 
 aneurism with permanent patency of the aortic valves is rare indeed, 
 and the existence even of a large aneurism has little if any influence 
 on the action of the vessel above and below it. Constitutional dis- 
 turbance resulting from the local irritation also aids the diagnosis, for 
 there is nothing more remarkable than the long preservation of the 
 general health in a case even of large abdominal aneurism. 
 
 In enteric fever you may often find a rigid state of the muscles of 
 the belly. It seems principally to affect the recti muscles and, I think, 
 preponderates at the right side. It may vary from day to day, and 
 apparently corresponds with the phases of the local malady. How far 
 this condition is related to the signs of gurgling in the ileo-csecal region 
 may be questioned. But this latter sign, unless when plainly localized, 
 is not of great value. 
 
 As to the state of the tongue, you cannot in a case of fever place 
 much, if any, dependence on it as a measure of intestinal secondary 
 disease; you are to look on it as an index less of the local than of 
 the essential malady. The morbidly clean, bright red, and glazed 
 tongue may change and assume a natural appearance under strong 
 stimulation. 
 
 Looking at the secondary disease of the intestine and its liability to 
 reactive inflammation, I think it probable that it interferes more with 
 the periodic laws of fever than do the respiratory affections, and many 
 cases of protracted fever may be thus looked on as examples of an 
 essential combined with a symptomatic condition — the first causing 
 the special deposit, and the second resulting from the reactive irrita- 
 tion which may terminate in ulceration, or suppuration, and thus sus- 
 pend the action of the law of periodicity. Hence the sooner we can 
 detect and alleviate the local irritation the less will be the deposit, and 
 the less also will be the interference with the periodic laws. The 
 amount of deposit in essential disease, as we see in variola, seems to 
 be influenced by that of the cutaneous vascularity and irritation. By 
 early local depletion we can greatly diminish the degree of pustulation 
 and its virulence. In fact, its occurrence in particular situations, say 
 the face, can be all but suspended. 
 
 Now, this point was never considered by the school of Broussais, or 
 they misinterpreted the mutter. A patient had fever, and the appli- 
 cation of leeches to the belly was followed by great relief of symp- 
 toms, and soon by the subsidence of the fever. Here, they said, is a 
 proof that the fever was only symptomatic of the gastro-enteritis, and 
 so the idea of essentiality must be given up. No, say the more careful 
 
142 LECTURES ON FEVER. 
 
 observers; the relief in this case is from the diminution of a secondary 
 reactive irritation interfering with the law of periodicity, which was 
 again permitted to act on the removal or modification of that irrita- 
 tion. 
 
 You cannot sufficiently study in fever the relations between its 
 secondary and its essential conditions, or the influence which the latter 
 have on the former when a process of reactive local inflammation is 
 set up, giving rise to symptomatic irritation, and interfering with 
 the periodic laws. In some cases of enteric fever these laws are 
 permitted to act, and an abortive attempt at recovery takes place. 
 In those described by Dr. Cheyne in the "Dublin Hospital Reports" 
 the general characters of fever subsided, the pulse fell, and appetite 
 returned ; but after a time symptoms of intestinal disease became 
 developed, and the patient sank after the false crisis with extensive 
 disease of the mucous membrane. It was suggested by Dr. Todd that 
 in such cases a state of pyasmia was induced by the absorption of pus 
 from the intestinal ulcers; but the symptoms in the second stage of 
 Dr. Cheyne's cases were more likely due to irritation of the intestine, 
 which interfered with the retrocession of the secondary disease and 
 prevented crisis. No doubt in abdominal typhus you may find the 
 mesenteric glands filled with pus, but in fever, as in variola, there 
 seems to exist a power of disposing of purulent secretion in vast 
 quantities, which if retained would act as a poison. 
 
 LECTURE XIX. 
 
 Intestinal Complications of Fever, continued — They resemble all the other secondary 
 affections of fever in their general characteristics and relations to the primary 
 essential malady — More frequent in typhoid, but occurring in typhus also, as, for 
 example, in the epidemic of 1826-27 — Pathological appearances observed in the 
 intestinal tract in that fever — Yet these appearances were not necessarily found 
 after death even where sever* abdominal symptoms existed in life — Eruption of rose 
 spots in fever. 
 
 When we review the lesions of the abdominal organs in fever, we 
 find that in their relation to the essential malady they are subject to the 
 same general laws which govern the other secondary affections. They 
 are — and it cannot be repeated too often — not the cause, but the result 
 of the essential disease, whether that exists in the form of bad typhus 
 or of enteric fever. They are various in their amount and intensity, 
 
fever of 1826-27. 143 
 
 and this so remarkably that even when looked on as secondary affec- 
 tions they fail to furnish an anatomical expression for the malady. 
 The vital symptoms of the local affection are rarely prominent, so 
 that the attention of the physician may never be called to them by 
 the patient. This is more especially the case in proportion as the 
 fever partakes of the characters of typhus rather than of typhoid. 
 
 But we cannot predicate in any given case or in any epidemic 
 under what conditions or in what degrees the local affection may 
 present itself, how far it will modify the general symptoms, or what 
 other seats of secondary lesion the case may exhibit. 
 
 In the great epidemic of 1826 and 1827 the disease, as I have told 
 you, was clearly a typhus fever, with every character of the affection. 
 It was highly contagious, with abundant and well-marked petechial 
 eruption and prominent secondary affections of both the respiratory 
 and digestive systems. The tumefaction and ulcerations of the ileum 
 were found well marked in numerous cases, so that if those who advo- 
 cate the doctrine that such a lesion does not occur in typhus had been 
 here at the time, and had made dissections in this hospital, they would 
 never have defended this opinion. Let me again impress upon you 
 that the very occurrence, or amount, or intensity of this or that secon- 
 dary affection in fever varies according to the epidemic. In this fever 
 we had all the anatomical characters of the intestinal disease — the 
 tumefaction of the mucous glands, their vascularity and ulceration; 
 the filling of the mesenteric lymphatics with pus, and its deposit in the 
 mesenteric glands; sloughing of the glands of the intestines, and so 
 on. You must be careful not to infer the symptoms and the anatom- 
 ical results of disease from the observations of a single epidemic. 
 
 Discard altogether the idea which has been put forward by many 
 persons who make too fine distinctions in medicine that this disease, 
 of which I have given you now a rough sketch, is, or has in itself, any 
 great value as an anatomical distinction between different kinds of 
 fever. This is a favourite doctrine of those writers who hold that 
 there is an essential difference — a complete difference — between the 
 typhus fever of these countries and the fever of the Continent. The 
 real state of the case is that, although this complication is more fre- 
 quently met with on the Continent than it is here, it is not infrequently 
 met with here also. It is also true that, although it belongs more to 
 the non-petechial cases than to the petechial, yet it may occur in the 
 latter and it may be absent in the former. 
 
 The tendency to this affection varies greatly with the epidemic 
 character of the disease. In one year we may have extremely well- 
 marked petechial typhus without the slightest appearance of ulcer- 
 
144 LECTURES ON FEVER. 
 
 ation or disease of the mucous membrane of the intestine — and if one 
 who advocated the doctrines I spoke of came to this county and made 
 his dissections during that period, he would probably find abundant 
 cases to establish his doctrine. But it might happen that if he re- 
 turned after a few years he would find occasion to change his opinion, 
 for he would then see a fever in all its external characters the same 
 that he had seen before — a fever with true petechia and all the 
 characters of essentiality — but, further, a fever with the intestine 
 extensively ulcerated. It is incorrect, then, to say typhus fever may 
 not be attended with this anatomical change in the intestine ; this I 
 wish strongly to impress upon you. The occurrence of it is, so far as 
 we know, accidental ; at all events, it is not a necessary consequence 
 either of the non-petechial or of the petechial fever; but in some 
 epidemics we may have petechial fever with it. And, again, even in 
 the same epidemic we may have cases with the whole intestinal tract 
 perfectly free from disease, and also cases in which it exhibits the 
 affection extensively. 
 
 Now, in illustration of this I will read the particulars of some 
 dissections of fever which were observed in the epidemic of 1826 and 
 1827. I have stated that this was a very singular epidemic, and one 
 which, apparently, is unknown to the Continental writers. It was a 
 very extensive and prevalent outbreak ; it infected many hundreds of 
 thousands of persons in this country. I think there were something 
 like 3000 beds for fever open in Dublin, and I am quite sure that if 
 there had been 10,000 beds, they would have been all filled. There 
 were in this hospital alone 300 beds, so that we had a very good op- 
 portunity of observing it. It was a true typhus fever, a maculated 
 fever — this I wish to impress strongly upon you — and yet in a very 
 large number of cases indeed there was follicular disease of the intes- 
 tine. Now, such is the state of prejudice on this subject on the Con- 
 tinent and elsewhere, that when you mention such a simple fact as 
 that we had in this country an epidemic of typhus fever — of maculated 
 fever with ulceration of the intestine — a large number of the best 
 informed Continental pathologists will shrug their shoulders and 
 politely express a doubt as to the fact that you have told them. 
 
 But in order to show the great variety presented by the secondary 
 intestinal affections in one epid'emic, I will briefly describe the patho- 
 logical conditions observed. 
 
 The most usual appearances were extensive ulcerations in the lower 
 third of the ileum. These ulcers were either isolated and circular — 
 as large as a sixpence, with raised edges and very deep — or running 
 all around the intestinal tube. There was also great enlargement of 
 
ERUPTION OF ROSE SPOTS. 145 
 
 the lymphatics of the mesentery — the vessels containing purulent fluid, 
 and the mesenteric glands themselves in a state of suppuration and 
 destroyed. These were the common anatomical changes as far as the 
 abdomen was concerned. There were also, in a large number of 
 cases, typhous affections of the bronchial system. The bronchial and 
 the intestinal tracts were the two points on which the force of the 
 secondary affections of the disease seemed to be thrown. But in this 
 very epidemic other cases occurred in which ulcers of the intestine 
 were not found, and yet the disease was fatal, and fatal with abdomi- 
 nal symptoms. This was seen in those terrible cases of yellow fever 
 which I shall presently describe. So that here we find a general ten- 
 dency to secondary abdominal affections, but a variation in their 
 nature ; and if this be true, what becomes of the special anatomical 
 character of the fever? 
 
 You will not forget that with regard to the symptoms of disease of 
 the mucous membrane and glands in fever, and especially in that form 
 called typhoid, enteric, or pythogenic fever, or abdominal typhus, 
 though these symptoms are more often present, yet the absence of 
 one or many of them is not uncommon. Much attention has been 
 paid by various observers to the eruption of rose spots, supposed to 
 be peculiar to typhoid fever. Although we do not know anything of 
 the rationale of this symptom, its frequency must be admitted. But, 
 as regards its appearance, the condition of inconstancy must also be 
 admitted, nor is its existence to be taken alone as a clear distinction 
 between fever with, and fever without, the intestinal affection. Like 
 all the other local symptoms of continued fever, it is not constant in 
 its occurrence, its amount, its successive appearances, its relation to 
 the stage of the disease, its complication with other cutaneous erup- 
 tions — measly eruptions or petechias, or its connection with symptoms 
 of progression or renewal of the abdominal lesion. In the course of a 
 protracted fever three or more distinct eruptions of rose spots may 
 take place and you may observe the latter ones even when the con- 
 stitutional state and local symptoms of fever have nearly if not alto- 
 gether subsided. 
 
 10 
 
146 LECTURES ON FEVER. 
 
 LECTURE XX. 
 
 Intestinal Complications of Fevek, continued— Division into three categories, with 
 reference to the vital symptoms : I. These symptoms are absent, although the silent 
 disease may be great in amount ; II. Local symptoms are evident ; III. Symptoms 
 and pathological changes are both well marked— Further description of the epi- 
 demic of 1826-27— Sudden access of intense abdominal pain, followed by icterus 
 and gangrene— Fatality of this complication— Splenic(?) abscess occurring in the 
 first case of recovery, and discharging through the lung— Resemblance of this form 
 of fever to the yellow fever of the tropics— Dr. Lawrence's observations— Dr. Graves' 
 observations. 
 
 With reference to the vital symptoms, we divide cases of fever 
 with abdominal secondary complication into three categories. 
 
 In the first it may be said that the local disease is silent — although, 
 us in a case I detailed to you, its amount be great, no direct local 
 symptoms exist, and the patient does not draw your attention to it. 
 This may occur in petechial or in non-petechial fevers, or, to use 
 another expression, in typhus or in typhoid. The amount of the so- 
 called characteristic affection varies in different cases and different 
 epidemics from a very few small ulcers to extensive disease and de- 
 struction of tissue. 
 
 In the second category there are evident local symptoms, such as 
 early tympany, tenderness on pressure, arterial throbbing, diarrhoea, 
 and rigidity of the recti muscles. These symptoms may occur in both 
 forms of the disease, but are more common in non-petechial than in 
 petechial fevers. 
 
 In the third category we place those cases observed in the epidemic 
 of 1826-27, in which the abdominal complication widely differed in 
 the violence of the symptoms and in the pathological changes from 
 anything we had seen before or have seen since. 
 
 In this third class abdominal complication is attended with mani- 
 fest and violent symptoms, the nature of the affection in many respects 
 differing from the ordinary dothinenteritis in typhoid, and even as it 
 occasionally occurs in typhus. 
 
 In the epidemic of 1826 and 1827, as I have said, the secondary 
 affections were often marked by a great activity and severity. I 
 have spoken to you before of this epidemic, but it is a remarkable 
 circumstance that while the follicular disease of the intestine was 
 
YULLOW FEVER OF 1826-27. 147 
 
 extremely frequent throughout its course, yet in the particular group 
 of cases of which I am now about to speak it was absent. 
 
 In the course of this epidemic the following extraordinary circum- 
 stance occurred : Patients who had precisely the symptoms of the 
 general fever — whose symptoms presented nothing to draw particular 
 attention to them more than to others — would be suddenly seized 
 about the seventh day with extraordinary abdominal spasms — the 
 spasms so severe that they could be likened only to the worst cases of 
 painters' colic. In some cases the pain was so great as to make the 
 patient scream out, and, just like the spasms in painters' colic, there 
 was great relief given to the patient by making strong pressure upon 
 the abdomen. In the course of a very short space of time — I believe 
 within an hour or less — it was observed that the patient's face began 
 to turn yellow. A jaundiced tint rapidly spread over the whole 
 body, so that on the day on which the patient was attacked he was 
 universally jaundiced. The kind of jaundice was curious too. It 
 never amounted to the extreme degree of yellowness seen in true 
 jaundice. The patient was very yellow certainly, but he had not that 
 intense yellowness which you see in cases of mechanical obstruction 
 of the gall ducts, or of cancer of the liver, and so on. 
 
 The horrible spasms continued for several hours. The patient then 
 began to vomit black matter — matter at first like coffee grounds, but 
 afterwards quite black. In a few instances he passed the same matter 
 from his bowels, but in most cases the bowels were constipated. Then 
 began another class of symptoms. The tip of the nose grew cold ; 
 it became pale, livid, purple. The same appearance was presented by 
 the toes. A gangrene — true gangrene — of the uares and of the toes 
 preceded death. In some cases death took place with the whole of 
 these symptoms within six hours from the invasion of the attack of 
 spasms; in others the patients lived for twenty-four or thirty-six 
 hours. I believe few lived for more than thirty-six hours. 
 
 This disease attacked the finest and best developed men ; young 
 men from twenty-five to thirty years of age were very commonly 
 struck down. The first sixteen of these cases died ; not one was 
 saved. The outbreak excited the greatest possible consternation ; it 
 was thought that the yellow fever was about to break out in these 
 countries. 
 
 The post-mortem appearances in these patients were the same in all, 
 and they were different — remarkably different — from those in other 
 patients who died in this epidemic, but without these symptoms. In 
 these cases we did not find follicular ulcers of the intestine. It is a 
 very curious fact that the so-called anatomical character of typhoid 
 
148 LECTURES ON FEVER. 
 
 according to many writers, was not here. What did we find ? We 
 found in the first place that the peritoneum was not inflamed, notwith- 
 standing the dreadful pain. It had just the appearance that we see in 
 many cases of bad fever— a certain lividity of colour. In every dis- 
 section we found intussusceptions to the most extraordinary extent, 
 invaginations of the intestiues in every direction upwards and down- 
 wards ; in some patients as many as six were observed. In all of 
 them there was an enormously enlarged spleen, in a condition of ex- 
 treme softening, so that in some patients it was difficult to take this 
 viscus out of the body without rupturing it. In none, however, did 
 it appear that actual rupture of the spleen had occurred during life. 
 In none did we find any inflammation of the liver, and with respect 
 to the mucous membrane of the stomach and of the intestines, all 
 that can be said was that there was extreme lividity and softening in 
 different portions of the intestine. Now I mention this fact particu- 
 larly, to show that in an epidemic of our. typhus fever where there is 
 a tendency to abdominal symptoms we may have essentially different 
 anatomical results. 
 
 I have told you that in none of these cases was the liver inflamed, 
 and the close similarity of the anatomical appearances with those ob- 
 served in the yellow fever in the Southern States of North America 
 is very remarkable. An American physician, Dr. Lawrence, has 
 published a series of dissections in cases of yellow fever, which 
 exactly correspond to the post-mortem appearances in the outbreak I 
 have described. I believe that inflammation of the liver is rarely 
 observed in the yellow fever of tropical climates; and this is also true 
 of the fever we experienced here in 1827. 
 
 But while dwelling on this subject, I may mention that the seven- 
 teenth patient was the first to recover. I do not say that his recovery 
 was owing to the treatment adopted. It is more likely that it was due 
 to the decreasing violence of the morbific cause; for in every great 
 and extraordinary epidemic the first cases, generally speaking, are the 
 most violent, and it is probable that the result of this seventeenth case 
 was owing mainly to the fact that the intensity of the disease was on 
 the decline. Afterwards others recovered, and the disease lost a great 
 deal of its violent character. 
 
 One patient made a good recovery even after having lost the left ala 
 nasi and one of her toes; but in the case just spoken of the following 
 circumstances occurred— and it is interesting to note them in connec- 
 tion with the question of yellow fever generally. The patient was 
 treated on this plan : He was allowed wine with extreme liberality. 
 Sixteen leeches were applied to the epigastrium. He also used mer- 
 
CASE OF ABDOMINAL ABSCESS. 149 
 
 cury and opium freely and after a time left the hospital to all appear- 
 ances perfectly well. In the course of about two weeks he expressed 
 a great desire to be readmitted into the hospital, stating that he was 
 very ill: 
 
 On readmission he looked miserable. His respiration was very 
 quick ; he had a dry cough and a rapid, small pulse, with severe 
 sweating at night ; and he presented all the appearances of n person 
 in acute phthisis. Upon a careful examination, however, we were 
 surprised to find that there were little or no stethoscopic signs of dis- 
 ease of the lung. The chest everywhere sounded well, and there was 
 hardly any rale to be found; a little sibilant rale here and there 
 might be discovered. I may mention to such of you as have, not 
 studied the subject of acute tubercle following fever, that in almost 
 all instances of this affection there are intense signs of pulmonary irri- 
 tation. In the present case the absence of these signs led us, after a 
 day or two, to doubt that the patient was getting tubercle, as we had 
 at first supposed. I repeatedly examined him with extreme care over 
 the whole chest. One morning I found nothing; next day, upon 
 entering the ward, I saw the patient sitting up in a state of orthopnoea 
 with a large vessel beside him completely filled with pus. There 
 were, I am sure, three pints of purulent matter in the vessel. Upon 
 examination I found an extraordinary change. While his chest had 
 been quite clear the day before, the entire of the left side posteri- 
 orly was now absolutely dull; there was no resonance of the voice or 
 tubular breathing on this side. 
 
 The patient gradually recovered, and the whole progress of the case 
 indicated that an abscess had formed and had opened through the left 
 lung. Whether it was a case of actual communication between an 
 abdominal abscess and the lung, with escape of the pus into the latter; 
 or whether it was one of those extraordinary cases of vicarious action 
 of the lung relieving the abscess, is a matter we cannot tell, for the 
 patient recovered and lived afterwards for many years in perfect 
 health. 
 
 For a long time I was in the habit of looking at this ease as an 
 exceptional one in the epidemic, in which, you may remember, we 
 did not find any example of acute hepatitis. I have since come to 
 the conclusion that the case was, in all probability, abscess of the 
 spleen. You will recollect that enlargement and softening of the 
 spleen were constantly present, and this may be held to have pre 
 pared the organ for suppuration after convalcsence from the f j ver. 
 
 Recollecting also that the sudden flow of pus took place through 
 the left lung, it seems most probable that splenic abscess formed,, 
 
150 LECTURES ON FEVER. 
 
 which perforated the diaphragm, crossed the pleura by means of ad- 
 hesions, and was finally discharged into the lung. It is possible that 
 when the patient came into hospital the second time the spleen was a 
 mere sac of purulent matter, and hence its condition would more 
 easily have escaped detection from the fluid character of its contents. 
 A case has been placed on record of abscess of the spleen in fever in 
 which, although perforation into the lung did not take place, such an 
 accident would have occurred had the patient survived a few days 
 longer ; for the part of the diaphragm in contiguity to the abscess 
 was found nearly penetrated. 
 
 It is possible that this diseased condition of the spleen began to be 
 developed during the acute stage of the fever; and taking into ac- 
 count the peculiar character of the epidemic, distinguished as it was 
 by extreme activity of all the organic processes; it is most likely that 
 the spleen passed from the softening into the suppurative condition 
 during the patient's convalescence. Dr. Hudson, in speaking of the 
 vomiting which so often occurs in relapsing fever, mentions a re- 
 markable case reported by Dr. Law. In the course of less than two 
 days the patient passed from a slightly jaundiced hue into deep jaun- 
 dice, with delirium, lethargy, coma, and death. The liver and spleen 
 were found much enlarged and congested, and so softened that they 
 seemed as if they had been soaked in blood. May we not suppose 
 that, if life had been prolonged, such a condition of these viscera would 
 have ended in suppuration and the formation of abscess ? 
 
 The case which I have described above was the only one in which 
 suppuration of a large viscus came under our notice in convalescence 
 from this fever, but it is an interesting fact that a very few years sub 
 sequent to this epidemic the occurrence of hepatic abscess was fre- 
 quently noticed in this hospital, and, indeed, in most of the hospitals 
 in Dublin. This you will see from a report, by Dr. Graves and 
 myself, in the fifth volume of the " Dublin Hospital Reports." 
 
 With regard to the identity of these extraordinary cases of fever 
 with the yellow fever of tropical climates, you will remember that I 
 spoke of the dissections made by Dr. Lawrence, of America, and the 
 close correspondence of his results with ours. Without entering at 
 length into the question, which is fully discussed by Dr. Graves in 
 his twenty-first lecture, I will merely say that in my own opinion 
 the view taken by him is correct — namely, that the diseases differ 
 only in degree. Certain it is that the most prominent symptoms of 
 the tropical yellow fever were present in the outbreak which occurred 
 here — black vomiting, epigastric tenderness, jaundice, and enlarge- 
 . ment of the spleen. 
 
INTESTINAL COMPLICATIONS OF FEVER. 151 
 
 LECTURE XXI. 
 
 Intestinal Complications op Fever, continued — Organic changes— Perforation of 
 intestine — Of common occurrence in 1826-29 : (1) Generally rapidly followed by 
 symptoms of peritonitis ; (2) hut may be unattended by local symptoms in pro- 
 gressive cases, or again may induce only limited peritonitis (adhesions) ; (3) 
 Symptoms of perforation may be veiled by the co-existence of intense irritation 
 in another cavity of the body — Illustrative case — Time of occurrence of perforation 
 as observed in six cases — Diagnosis of internal solutions of continuity is based on 
 sudden development, without apparent exciting cause, of new, local, violent, and 
 often rapidly fatal symptoms — Cases to which this rule of diagnosis is applicable — 
 In effusion into a serous sac the degree of resulting inflammation is determined 
 chiefly by the quality of the effused fluid — Examples — Influence of an irruption 
 of pus in producing serous inflammation contrasted with that of an irruption of 
 blood — Physiological difference between pus corpuscle and white blood cell — The 
 formation of conservative adhesions seems to be rarer in peritonitis than in 
 pleuritis — Case of hepatic abscess in which adhesions occurred and recovery 
 followed (diagnosis from abdominal aneurism). 
 
 We have to-day to study another of the results of abdominal 
 complication in fever, where the ulcerative process in the mucous 
 glands of the intestine goes on to perforation of the tube, generally 
 resulting in effusion of its contents into the peritoneal sac. You are 
 not, however, to suppose that this ulceration in all cases is the result 
 of an attack of fever — it may arise under other circumstances. 
 
 Still the follicular ulceration in fever is more likely to induce per- 
 foration than other forms of this affection. You all know how common 
 ulceration of the mucous membranes is in phthisis with diarrhoea, yet 
 how very rarely do we meet with perforation in this case ? 
 
 I have spoken of the epidemic of 1826 and 1829 as being remark- 
 able for the activity of the secondary organic changes. At the close 
 of this epidemic we had several cases of perforation of the intestine 
 in our wards, though before and since that time this accident has 
 been rarely observed. You will see reports of these cases in the fifth 
 volume of the "Dublin Hospital Reports" 
 
 Thus, in a large proportion of the cases observed by Dr. Graves and 
 myself, the symptoms were those of a sudden and violent attack of 
 peritonitis, which proved rapidly fatal, so that there was little difficulty 
 as to the diagnosis. 
 
 But, as in other internal solutions of continuity, there may be latency 
 as regards the accident. Perforation by no means implies escape of the 
 
152 LECTURES ON FEVER. 
 
 contents of the tube into the peritoneal sac, and little or no local 
 symptoms may attend the progressive ulceration — as in the case I 
 mentioned to yon. 1 In this way several perforations may occur with- 
 out general peritonitis. 
 
 In other cases the inflammation of the serous membrane seems to 
 be limited to the seat of the lesion, where the contiguous folds of the 
 intestine become agglutinated by adhesion, which thus prevents the 
 escape of the faecal matter and the production of sudden and general 
 peritonitis. 
 
 But there is a third class of cases, in which the latency of even an 
 extensive amount of peritonitis attending the perforation, seems to be 
 owing to the coexistence of intense irritation in another cavity of the 
 body. A young woman was admitted with fever and severe secondary 
 bronchial affection. In the course of five days she had some epigas- 
 tric pain, which was removed by leeching. The belly became some- 
 what tympanitic, and the condition of the lungs got worse. The fever 
 ran on, and in about nine days symptoms and signs of pneumonia 
 appeared in the left lung, with tenderness of the epigastrium, for which 
 she was again Keched over this region and also on the left side. Tar- 
 tar emetic was ordered, and in a few days the pneumonia seemed to 
 subside, but recurred. The skin then became cool, and we had hopes 
 of her recovery ; but the thoracic symptoms returned with violence, 
 and she died after an illness of about three weeks' duration. 
 
 This was a case of tubercular fever combined with dothinenteritis. 
 The substance of the lung was of a bright vermilion colour, perfectly 
 fluffed with recent miliary and granular tubercles, and with intense 
 redness of the bronchial membrane. Some puriform fluid was found 
 in the peritoneum, and the small intestines were generally glued to- 
 gether by soft exudation, which, on being removed, allowed us to see 
 no less than four perforations capable of admitting a quill in the lower 
 portion of the ileum. Many of the follicular glands were enlarged, 
 and — in the lower portion of the gut — ulcerated in different degrees, 
 so that in some the bottom of the ulcer was the muscular, while in 
 others it was merely the serous, coat. In the arch of the colon were 
 two small ulcerations. No faecal matter appeared to have escaped 
 through the perforations. 
 
 This case shows how the symptoms of a severe affection in one 
 cavity may be masked by the existence of violent irritation in another. 
 You may see something of the same kind in delirium tremens from 
 excess, which may be complicated with a group of local irritations of 
 
 1 Page 138. 
 
INTESTINAL PERFORATION. 153 
 
 the heart, lungs, stomach, and brain, no one of which diseases pre- 
 sents the usual prominent local symptoms. 
 
 It is interesting to inquire respecting the period of the fever at 
 which the perforation and consequent fatal peritonitis take place, for 
 by this we may learn something as to the rapidity of intestinal ulcer- 
 ations. You are to remember that our cases occurred at the time 
 when the epidemic was dying out, and we may hold that the activity 
 of the organic process for which it was so remarkable was on the 
 decline. 
 
 In our first case — that of a man aged 36 — the symptoms resembled 
 those of ileus: great pain, violent spasms of the abdominal muscles, 
 and tympanites. These set in on the seventh day ; great aggravation 
 of pain took place on the eighth, and he died on the thirteenth day. 
 A perforating ulcer capable of admitting the finger was found about 
 three inches above the ileo-caecal valve ; the mucous membrane above 
 and below the valve was intensely red and softened ; the bladder was 
 inflamed — inability to pass water, which yielded to treatment, having 
 been amongst the early symptoms. 
 
 In the second case — that of a man aged 32 — violent pain followed 
 a severe debauch. It returned in the course of two days, having been 
 at first relieved by purgatives. On the return of the pain, though the 
 belly was swelled, it was not very tender on pressure. The pulse was 
 full and the bowels obstinately costive. In consultation with the late 
 Dr. Beauchamp, bleeding, purgatives, and injections were ordered, the 
 pulse continuing full and strong. During the night excruciating pain 
 came on, with green vomiting, and the man died next morning. 
 
 A perforation was found in the last twelve inches of the ileum, 
 corresponding with a follicular ulceration. Many similar but non- 
 perforating ulcerations were found. 
 
 In the case of tuberculous fever which I have just now related it is 
 impossible to fix the time of the perforation, but you will remember 
 that there was no escape of feculent matter into the peritoneum. It 
 would seem that a mere perforation not followed by this occurrence 
 is, like the ulceration of the mucous membrane, a silent process as far 
 as relates to pain. 
 
 In another case of perforation the accident seemed to occur on the 
 fifth day. The patient had headache, for which he took two doses of 
 epsom salts, by each of which he was briskly purged. On the fifth day 
 violent pain, prostration, and vomiting came on. He was at once 
 admitted with fecal vomiting, collapse and pain, and tenderness of 
 the abdomen. He died on the sixth day, all pain and tenderness of the 
 abdomen having dissappeared for many hours hfore death. The usual 
 
154 LECTURES ON FEVER. 
 
 appearances of perforating ulcer, general peritonitis, and disease of 
 the mucous glands of the ileum were found. 
 
 In our fifth case, which was a mild enteric fever with epigastric 
 tenderness, the countenance became anxious on the thirteenth day, 
 the tongue glazed and dry, and the patient, a man aged 21, complained 
 of pain in the belly. Soon afterwards hemorrhage from the bowels 
 showed itself, and the abdominal pain became intense. Next day he 
 had all the symptoms of severe peritonitis, and he died the following 
 morning. The peritoneal cavity was filled with sero-purulent matter. 
 About two inches from the ileo-csecal valve an open perforation was 
 found, and the mucous glands in its vicinity were in various stages of 
 ulceration. 
 
 The last case I shall notice was that of a man aged 46, who a year 
 previously had contracted ague. The paroxysms were stopped by 
 bark, but thirst, anorexia, soreness in the epigastrium, and yellow 
 slimy dejections continued. Twelve days before admission he was 
 attacked by shivering, followed by vomiting and severe pain about 
 the umbilical region. A bilious diarrhoea succeeded, which lasted for 
 ten days ; then it ceased, and the pain became suddenly intense, with 
 retention of urine. The belly swelled, and the pain and tenderness 
 were general. He sank on the third day after admission. 
 
 The peritoneal cavity being opened, a rush of foetid air took place, 
 the sac being found to contain much yellow fluid mixed with fsecal 
 matter and lymph ; a thin false membrane covered the peritoneum of 
 the liver and the abdominal parietes. The small intestines were livid 
 and covered with coagulable lymph. 
 
 One more example of perforation without effusion of the contents 
 of the tube, and consequent fatal peritonitis, has been observed in our 
 wards. Here the perforation appeared to be closed by merely the 
 serous membrane of the contiguous fold of intestine, which was not ad- 
 herent, and which showed only a slight patch of lividity. Do not forget 
 this, as it illustrates the importance in these cases of seeking to lessen the 
 peristaltic action of the intestine. When I speak of treatment we shall 
 return to this subject. 
 
 The diagnosis of internal solutions of continuity is based upon the 
 occurrence of sudden, perfectly new, local, violent, and in many cases 
 rapidly fatal symptoms, all this often happening without manifest ex- 
 citing cause. The violence of the symptoms seems to depend on 
 changes in the mechanical state of organs, on the production of acute 
 local inflammatory action, and on internal losses of blood, causing 
 syncope with or without convulsions. Here the embolic pathology 
 confirms principles already in use so far as the solids are concerned, 
 
INTESTINAL PERFORATION. 155 
 
 and extends their application to the fluids ; for there is in one sense 
 a solution of continuity, not indeed of the, tissues of the suffering 
 organ, but in the current of the fluids which supply it. 
 
 The same general rules of diagnosis apply to many different cases, 
 such as rupture of the heart or of an internal aneurism ; perforation 
 of the pulmonary serous membrane from the lung ; opening of an 
 empyema into the lung, causing expectoration of pus and pneumo- 
 thorax ; perforating ulcer of any portion of the digestive tube; rup- 
 ture of the urinary bladder, uterus, or gall-bladder; the opening of an 
 abscess of the liver into the peritoneum, pleura, or pericardium : and 
 rupture of a vessel in the brain. 
 
 The cases of peritonitis from perforation we have been considering 
 are examples of an acute local inflammatory action, the result of a solu- 
 tion of continuity. 
 
 Now, as regards the diagnosis from sudden inflammation of the 
 perforated organ, much depends on the quality of the fluid which 
 escapes into the sac. The effusion of the contents of the intestinal 
 tube, urinary bladder, or gall bladder, is commonly attended with new 
 and violent inflammation ; while more bland fluids, such as blood or 
 the contents of an hydatid sac, do not produce these violent effects. 
 The sudden effusion of purulent matter, on the other hand, is often 
 followed by intense inflammation of a serous sac — as we see in phthisis 
 with pulmonary fistula, and in hepatic abscess opening into the peri- 
 toneum. 
 
 Of this latter accident we had a remarkable example in our wards 
 many years ago. It occurred in 1828, when abscess of the liver was 
 observed in many instances. The early symptoms of hepatic irritation 
 were rather obscure, but three weeks before admission the patient had 
 sweatings and nocturnal perspirations. The right side was dilated, 
 but the intercostal spaces were well marked. There were all the signs 
 of hepatic tumour. In the course of a fortnight the swelling increased, 
 and as the symptoms indicated abscess, although there was no fluctu- 
 ation, Dr. Graves' operation was performed. In the course of a week 
 a fluctuating tumour appeared between the median line at the epigas- 
 trium and the lower end of the wound. The patient was greatly 
 prostrated. A lancet was pushed from the wound into the tumour, 
 when in place of the expected matter there was an effusion of dark 
 bile. No jaundice existed at the time. The circumscribed tumour 
 subsided, but the fulness of the side remained. In the course of four 
 hours the patient had two very copious motions, consisting of purulent 
 matter tinged with bilious and fluid feces. It was plain that the ab- 
 scess had opened into the intestine. Next morning the improvement 
 
156 LECTURES ON FEVER. 
 
 was remarkable: the swelling had much diminished, and in a few 
 days had altogether subsided. The patient improved so much as to 
 take exercise, but continued to be affected with an obstinate diarrhoea. 
 
 In little more than three weeks from the subsidence of the tumour 
 a small hard swelling appeared in the epigastrium : it rapidly increased 
 and became fluctuating. The diarrhoea continued. Thirteen days 
 having elapsed, he was suddenly seized with excruciating pain in the 
 epigastrium. It was so severe as to produce an almost convulsive 
 state. He now had the usual symptoms of perforation and of peri- 
 tonitis, with this exception, that the disease, after its first violence was 
 spent, ran a course of eight days before death took place. 
 
 We found the peritoneum filled with fluid, intermixed with large 
 masses of gelatinous exudation, which in some places showed a com- 
 mencing organization. This exudation was laminated, and its interior 
 was traversed by bloodvessels of a deep blue colour. An abscess, 
 the size of an orange, communicating with the peritoneal sac by an 
 opening capable of admitting a quill, was found in the left lobe of the 
 liver. In the right lobe was a cavity lined with a dense membrane, 
 and communicating with the duodenum by an opening which admit- 
 ted the finger with ease. This accounted for the consequent diarrhoea 
 on the subsidence of the first tumour. 
 
 In another case, in which a vast hepatic abscess existed, the opera- 
 tion of puncture was immediately followed by dreadful pain in the 
 lower part of the belly, and a sensation as if matter was escaping into 
 the peritoneum. In a few hours the patient, a woman, showed every 
 symptom of acute peritonitis. There were vomiting and screaming, 
 the pulse 140, small and wiry ; and the knees drawn up. These symp- 
 toms all subsided in a few days under the opium treatment, but she 
 sank exhausted in nearly a month from the operation. Universal 
 adhesion was found, and the abscess contained nearly four pints of 
 purulent matter. 
 
 The influence of an eruption of purulent matter in exciting serous 
 inflammation, so far as we have observed it, differs very much from 
 the effects of hemorrhage into a serous sac. I have seen a case in 
 which, from a rent at the origin of the aorta, a gush of blood into the 
 pericardium took place on three separate occasions. • After death no 
 evidences of pericarditis were discernible. In a second instance, where 
 an aneurism of the abdominal aorta opened into the pleura on three 
 occasions, with a considerable interval between the first and second 
 and between the second and third hemorrhages, uo trace of pleuritis 
 could be discovered. 
 
 This character of the blood is in direct contrast to the irritative 
 
PUS AND WHITfi BLOOD CELLS. 157 
 
 effect of a purulent fluid on a serous membrane, and goes far to show 
 that there must be some essential physiological difference between 
 pus and the white corpuscles of the blood. Here, as in many other 
 points, physiological conclusions are to be tested by the facts of path- 
 ology, and no matter how similar the white blood corpuscle and the 
 pus cell may appear under the microscope, we must believe that the 
 vital characters of the two are different. 
 
 Since perforation of the peritoneum occurs more frequently than 
 perforation of the pleura, it is interesting to consider whether adhesive 
 inflammation is a less frequent occurrence in the former than in the 
 latter lesion — at least when we speah of cases where the irritation is 
 prolonged from the underlying tissues to the serous surface. That this 
 seems to be the case in chronic disease there can be little doubt. In 
 the ordinary tuberculous disease of the lung, partial adhesions of the 
 pleura are almost constant, and consequently empyema and pneumo- 
 thorax are very exceptional. "We know little of perforation in acute 
 suppurative disease of the lung, and it is certain that in chronic ulcer- 
 ations of the intestine, as in phthisical diarrhoea, it is very rare. 
 Adhesion may be absent in hepatic abscess — as is seen in India, where 
 the abscess may come forward so as to cause discoloration of the 
 integument and yet the peritoneum be not adherent over it. This 
 comparative insusceptibility of the peritoneum to the adhesive process 
 is mentioned by Mr. Annesley. 
 
 That adhesion of the serous membrane in cases of fever with ulcer- 
 ated intestine is rare seems certain when we consider the frequency 
 of the complication and the number of recoveries in cases where per- 
 foration has never occurred. Yet this accident, like every other 
 complication in fever, varies in frequency with the epidemic con- 
 stitution. 
 
 Still, were you to hold that adhesion and local inflammation of the 
 peritoneum never attended cases of underlying suppuration, you 
 would be wrong. At the time of the prevalence of hepatic abscess 
 in this hospital the disease was often observed as a primary and idio- 
 pathic affection, and we had a case in which the signs of adhesive 
 inflammation assisted in the diagnosis. 
 
 The patient, a young and strong man, after exposure to cold and 
 damp from sleeping on the grass, was next day attacked with intolera- 
 ble pain in the loins. He had fever of an inflammatory type. After 
 some days the pain in the back ceased, and a tumour with excentric 
 and strong pulsation made its appearance in the right hypochondrium. 
 The pulse became more rapid, and copious sweatings set in. 
 
 The case was considered to be one of aneurism of the hepatic or 
 
158 
 
 LECTURES ON FEVER. 
 
 of the abdominal aorta. We came, however, to a different conclusion, 
 and looked on it as one of acute hepatic abscess, for the following 
 reasons: — 
 
 1st. The history of the case and the time of life of the patient. 
 
 2d. The existence of fever, at first of an inflammatory and then of 
 a hectic type. Such a condition, so far as we are aware, is 
 unknown in aneurism. 
 
 3d. The pulsation was indeed excentric, and so far like that of 
 aneurism. Yet we knew that a pulsation communicated to a 
 sac filled with fluid and lying upon an artery acquires this char- 
 acter. This fact, therefore, did not exclude the possibility of 
 hepatic abscess. 
 
 4th. That when the hand was laid on the tumour a deep inspiration 
 enabled us to feel well-marked friction. This was very important, 
 as aneurism of the abdominal aorta has little, if any, iufluence 
 in causing adhesion of the peritoneum, though aneurism of the 
 thoracic may be attended with local pleuritis and adhesion. 
 
 In a few days the contents of a large abscess were discharged per 
 anum, and the patient recovered. 
 
 We have seen that the ordinary chronic ulceration of the intestine 
 in phthisis rarely spreads to the serous membrane. The comparative 
 insusceptibility of the peritoneum to adhesive inflammation in acute 
 secondary disease of the intestine increases the obscurity of the diag- 
 nosis of this lesion in fever. 
 
 Dr. Beatty 1 details cases of inflammation in ovarian and splenic 
 tumours, in which the frottement of peritonitis was plainly felt. He 
 also quotes Dr. Bright, and then remarks: "It would appear that 
 this method of diagnosis of disease of a serous membrane is applica- 
 ble only in those situations where one at least of the opposed surfaces 
 is adherent to a solid existing body. I am not aware that such phe- 
 nomena as have been mentioned can be perceived in inflammation of 
 the peritoneum under ordinary circumstances, where the soft, pliable 
 walls of the abdomen are in contact with the mass of the intestines." 
 
 1 Contributions to Medicine and Midwifery, p. 298. 
 
SEROUS MEMBRANES IN FEVER. 159 
 
 LECTURE XXII. 
 
 Secondary Nervous or Cerebro-spinal Complications op Fever — when they predomi- 
 nate, prognosis is unfavourable — Of all secondary typhous affections they are' least 
 connected with organic change — Probable reason : mucous membranes and skin 
 undergo anatomical change more readily than serous membranes — Cerebral inflam- 
 mation rarely observed in fever — Purpuric fever of 1867 an exception — Absence 
 of organic change in typhous cerebral derangement does not lessen its importance 
 as regards prognosis and treatment — Inadmissibility of routine treatment either 
 antiphlogistic or by stimulation, in fever — Results obtained by Louis as to relation 
 between head symptoms and pathological change in fever — Actual cerebritis, 
 when it does occur in fever, is a tertiary phenomenon — Dr. Hudson's cases — Study 
 of analogies is of importance in essential diseases ; thus relief of headache in 
 early stage of some cases of smallpox by leeching is analogous to good results of 
 moderate depletion in early stages of some cases of fever — Further examples of 
 the effect of lessening vascular supply in controlling development of smallpox 
 eruption — Analogy in case of secondary affections of fever — Nervous symptoms 
 arise from three conditions : (1) influence of fever-poison, (2) ursemia, (3) specific 
 secondary inflammation, probably erysipelatous in character. 
 
 We are to-day to study the nervous or cerebro-spinal symptoms of 
 fever. I believe it may be held, that, of the various symptoms indica- 
 tive of suffering of organs in fever, these are the most remarkable; 
 and, when developed to a certain point, the grounds of a worse prog- 
 nosis than any others. And yet, so far as investigation has gone, 
 they are less often connected with organic change than those belong- 
 ing to the digestive, respiratory, or circulatory systems. 
 
 Is there any reason for this ? Not that the question should mate- 
 rially influence our practice. Yet, looking at the results of dissection 
 in fever, it may be held that the surfaces of relation — the mucous 
 membranes and skin — undergo anatomical change far more frequently 
 than the serous membranes. Of the three great cavities of the body 
 the cerebro-spinal is the least liable to secondary anatomical change; 
 an interesting fact when we reflect on the number of violent and extra- 
 ordinary nervous affections — epilepsy, chorea, tetanus, hydrophobia, 
 mania, and others — on all of which anatomy sheds but a negative 
 light. 
 
 The first thing to be laid down is that, as regards fever in this 
 country, or rather as it has hitherto occurred in this country, inflam- 
 mation, either of the substance of the brain or of its serous covering, 
 is rarely observed. The researches of Louis show how little cerebral 
 symptoms in fever are to be relied on as indicative of the presence of 
 
160 LECTURES ON FEVER. 
 
 inflammation. Dr. Murchison 1 says that he has repeatedly known 
 the most severe cerebral symptoms during life without abnormal 
 vascularity of the membranes after death, and, further, that he has 
 met with only two instances where the appearances would justify the 
 opinion that inflammation had occurred in typhus. Tn another place, 
 in speaking of the diagnosis between cerebritis and the delirium of 
 fever, he adduces the existence of the eruption in the latter disease. 
 
 But you will be ready to admit that the cerebral symptoms in fever, 
 in regard to their connection with organic change, are under the same 
 law as those of the digestive and pulmonary systems, and that they 
 share with these the characters of inconstancy in occurrence, in amount, 
 and in their connection with organic change. This inconstancy you 
 will see influenced by the epidemic character and in isolated cases ; and 
 whether the symptoms are or are not associated with organic change, 
 they also show a subjection to the law of periodicity. 
 
 I can add my testimony to that of Dr. Murchison as to the rarity of 
 cerebritis in fever; indeed I never saw an example of it in the dead 
 body before or after 1867, when the epidemic (if it may be so called) 
 of the purpuric fever with cerebro-spinal symptoms furnished many 
 cases to our wards. This was an example, as it were, of an epidemic 
 within an epidemic — like the occurrence of the yellow fever of which 
 I have already spoken. Arachnitis as a secondary affection of the 
 brain and spinal cord was then common enough, so that the name of 
 cerebro-spinal fever could be justified, if the existence of organic 
 change of the nervous centres is to be made the ground of nosological 
 distinction. 
 
 It is, then, to be admitted that, so far as the actual state of our 
 knowledge of the affections of the three great cavities in fever is a 
 guide, those of the brain are the least connected with anatomical 
 change. It is possible that at some future day chemical or microscopi- 
 cal research will succeed in discerning anatomical change corre- 
 sponding with the manifold nervous conditions of fever. As yet, 
 however, this has not been done. On the other hand, if you were to 
 conclude that nervous symptoms are of less importance because we 
 cannot connect them with ascertained organic states, you would fall 
 into great error — as regards treatment and prognosis they are of the 
 greatest importance, for they reveal a state of deranged function 
 which may be, and often is, fatal, although there is neither inflamma- 
 tion, nor deposit, nor any known constant or distinctive anatomical 
 change. 
 
 The assumption of inflammation of the brain in the presence of 
 
 1 Continued Fevers of Great Britain. Second edition, p. 2(J0. 
 
IMPORTANCE OF CEREBRAL SYMPTOMS. 161 
 
 violent nervous symptoms in fever constitutes one of the greatest 
 dangers to which young physicians are exposed, when they come to 
 deal with the most formidable complication of the disease ; aye, and 
 old physicians, too, whose clinical education has been imperfect. I 
 have known of the application of leeches to the head in an advanced 
 case of cerebral fever with delirium ferox to be followed by sudden 
 sinking and death. I have told you how an eminent apothecary in 
 this city, the late excellent Mr. Packenham, while he was an appren- 
 tice in one of the first establishments in Dublin, would be commonly 
 sent to remove the leeches from the temples on the death of the 
 patient. The doctrines of the anatomical school — a school which 
 denied essentialities, and with which all diseases were symptomatic 
 of a local irritation — naturally led to a routine practice. The more 
 violent the local symptoms, the more intense the inflammation was 
 held to be, and in consequence the more vigorously and continuously 
 the antiphlogistic treatment was pursued. I once saw in Paris a 
 caricature in which a patient was stretched in bed in articulo mortis 
 surrounded by three physicians. His countenance was hippocratic, 
 and it was plain that the hour of deliverance from the disease by 
 death was at hand. The principal figure among the attendant physi- 
 cians, intended for Broussais, exclaims, "Encore des sangsues. " 
 
 But the doctrines of Broussais, of Bouillaud, of Clutterbuck, and 
 of Armstrong are now matters of history, thanks to the researches 
 of Louis and of Andral into the pathological anatomy of fever — 
 " that disease" (to use the words of Louis) "called gastro-enteritis" 
 — and thanks to the influence of the writings of the fathers of British 
 medicine — of Sydenham, Hay garth, Fothergill, and Heberden — and 
 on the Continent of John Peter Frank. Truth, though for a time 
 obscured, conquers in the end. The teaching of these great men has 
 triumphed over the innovations of the so-called physiological medicine. 
 A more accurate observation, a truer interpretation of phenomena, 
 a greater respect for the recorded experience of such men as those 
 I have mentioned, have resumed their sway over the medical mind, 
 and every day the routine application of the antiphlogistic or the 
 stimulant treatment is less and less seen. It is right, however, to 
 observe that the disuse of the routine antiphlogistic treatment is not 
 altogether to be attributed to more modern research. 
 
 When studying fever, you will find that what applies to one 
 symptom applies more or less to all. Thus, when we study the 
 relation between organic change and delirium, we may safely adopl 
 the same conclusion with regard to all the nervous symptoms, such as 
 coma, convulsions, and so on. Louis, in his work Recherches sur la 
 11 
 
1'02J 
 
 LECTURES ON FEVER. 
 
 G astro- Entente (page 155), compares the results of twelve dissections 
 in cases of fever where delirium was absent, or only passing and 
 slight, with those of twelve other dissections where this symptom was 
 most violent and persistent. In a former lecture I have given the 
 results of his observations, but I may be pardoned for reproducing 
 them here in a tabular form. 
 
 Delirium absent. 
 
 Cases 
 Redness of cortical substance of the 
 
 brain 4 
 
 Inflammation of optic thalamus . 1 
 Slight softening of brain . . .1 
 
 Brain anatomically healthy . .< 6 
 
 12 
 
 Delirium present and violent. 
 
 Cases 
 
 Slight reddening of cortical substance 
 Slight softening of brain . 
 Livid venous injection of mem- 
 branes of the brain 
 Brain perfectly healthy 
 
 12 
 
 Now, looking at these tables, it is impossible to avoid seeing that 
 there is no constant relation between the anatomical changes of the 
 brain and the symptoms. In the general progress of fever, as I have 
 told you, the nervous symptoms may be considered of the greatest 
 importance, and in the present state of our knowledge we must refer 
 them to the effects of the poison of fever. Whether that poison acts 
 directly and in the first instance on the nervous centres, or indirectly 
 on them through the medium of the blood, is a question which may 
 still be asked. They are, at all events, in their early stages to be 
 looked on more as functional than as organic symptoms. But, in the 
 nervous as in the pulmonary and abdominal symptoms, we find incon- 
 stancy and irregularity in the visible alteration of the organ. It 
 would in any case, however, be an error to assert that there are no 
 cases of secondary nervous engagement, in which local antiphlogistic 
 treatment is to be used. We might as well say that there are no cases 
 in which cupping of the chest, or the application of leeches to the 
 ileo-ca3cal region, was useful. 
 
 That actual cerebritis does occasionally occur in fever is certain. 
 It is very probable that it is a tertiary phenomenon in the case — the 
 steps being, first, fever; then, deposit ; and, lastly, reactive inflamma- 
 tion. I do not apply the observations I now make to the cerebro- 
 spinal or purpuric fever, although when cerebritis does occur in fever 
 it seems to depend on an epidemic tendency. You. will see in Dr. 
 Hudson's work 1 an account of three cases in which true inflammation 
 of the brain and its membranes was proved on post-mortem examination 
 to have occurred in the course of fever. In one case head symptoms 
 
 Lectures on the Study of Fever. Second edition, p. 252. 
 
CEREBRITIS IN FEVER. 163 
 
 of a very severe nature became developed about the eleventh day 
 of maculated typhus. Four days later the patient died. On exam- 
 ination the dura mater was found sensibly thickened, the sub- 
 arachnoid fluid considerably increased in quantity, and the vessels of 
 the brain and its membranes much congested. The cerebellum and 
 medulla oblongata were to some extent softened. The second patient 
 from the time of his admission lay in a state of increasing stupor, 
 with ptosis of one eye, strabismus, retention of urine, and finally 
 dysphagia. Here there was intense venous congestion of the cere- 
 bellum and upper part of the cord and a circumscribed collection of 
 yellowish- green pus lay included beween the arachnoid and the 
 under surface of the cerebellum. The arachnoid itself bore traces of 
 inflammation. In a third case similar appearances were observed. 
 
 Dr. Hudson also quotes some cases of a like kind which were 
 communicated to the Pathological Society by Sir Dominic Corrigan. 
 " While," says Dr. Hudson, "you must endeavour, on the one hand, to 
 avoid the mistake of ascribing the nervous derangements caused by 
 the toxic action of the fever poison to cerebral inflammation, you 
 must, on the other, avoid the opposite error of ignoring the existence of 
 true inflammation, when this is indicated by the groups of symptoms 
 enumerated above, whether it occurs in the form of acute congestion 
 of the brain, as in some epidemics of typhus, of epidemic cerebro- 
 spinal arachnitis, of arachnitis, or as the effect of previous injury, or of , 
 reactive irritation and inflammation, set up in the advanced period of 
 typhoid fever." 
 
 In the investigation of disease, especially in that of fevers, the 
 study of analogies is of great importance; and looking at the lia- 
 bility of essential affections to induce secondary local conditions, we 
 may expect the brain also to be subject to this liability, the result 
 being a neurotic or functional condition followed or not by anatomi- 
 cal change. Why it is that the latter result seems so rare we have 
 as yet no means of determining. It may indeed, unless reactive irrita- 
 tion occurs, be overlooked in examinations after death. It is not 
 easy to distinguish the toxic influence of fever from the signs of 
 primary or of reactive inflammation. Yet, although it be admitted 
 that the nervous symptoms are generally functional, the relief afford- 
 ed in certain cases by a few leeches, the cold affusion, and the use of 
 ice to the head, indicates a condition which — if not actual meningitis — 
 is related to or may possibly be a precursor of it. And it may be 
 asked whether the secondary effect of fever may be locally modified 
 or arrested by a lessening of the blood supply. I have published a 
 
164 LECTUKES ON FEVER. 
 
 case of variola which illustrates the arrest of local development of the 
 pustules. 
 
 A young and healthy woman was admitted with severe fever of a 
 sthenic type. She was about three days ill, and complained of intense 
 headache, far more violent than that met with in the early periods of 
 ordinary fever. The face was flushed and turgid. Looking on the 
 case as exceptional, we applied leeches freely to the temples. This 
 was followed by relief of pain ; the redness of the face disappeared, 
 as did the fulness. Next day smallpox vesicles appeared, on the 
 breast and arms', and there was soon a plentiful crop of pustules 
 running into confluence over the entire body, with the exception of the 
 face, where but one or two small and aborted pustules formed. 
 
 We have found, too, in variola, that where the appearance of the 
 vesicles on the face was attended with heat and vascularity, the appli- 
 cation of leeches rendered the after-pustulation so much more benign 
 that this mode, together with the use of light poultices, has been 
 found most efficacious in preventing the subsequent pitting of the 
 face, and we have therefore commonly employed it. 
 
 In a remarkable case of severe confluent smallpox the patient had 
 been an inmate of the surgical ward for a chronic affection of the 
 knee, for which the joint was strapped with mercurial plaster. Of 
 this I was not aware till the stage of decrustation arrived, when the 
 strips of plaster which had tightly bound the knee fell off, and this 
 singular appearance was seen. The face and body generally presented 
 black, thick, and fetid crusts, but the knee for a space of seven 
 inches was of a pearly whiteness, without a trace of pustulation, and 
 contrasting strangely with the condition of the skin above and below 
 the joint. Here the pressure by the straps had lessened the vascular 
 supply. 
 
 Now, regarding the eruption of smallpox as a secondary and local 
 manifestation of that disease, as there is no doubt it is, we see it, in 
 the instances just quoted, controlled by local depletion or lessening of 
 the blood supply. The similar relation between the nervous symp- 
 toms in fever and the local treatment I have referred to is at once 
 interesting and suggestive. 
 
 We may hold in practice that the nervous symptoms in fever arise 
 from the following conditions : — 
 
 a. The influence of the poison of fever. 
 
 b. The occurrence of the urosmic condition. 
 
 c. The occurrence of an inflammation, probably of an erysipelatous 
 and also of a specific nature, analogous to that in the other 
 secondary affections of fever. 
 
EPIDEMICS WITHIN EPIDEMICS. 165 
 
 Of these the first two may be considered as functional or neurotic, 
 and, remembering the quality of inconstancy as to the period of 
 appearance of the secondary symptoms in fever, we find that any, or 
 any combination, of these may occur at various stages of the disease. 
 
 LECTURE XXIII. 
 
 Nervous Complications of Fever, continued — Cerebrospinal fever — Phenomena of fever 
 inconstant and variable, except, perhaps, the phenomenon of increased tempera- 
 ture — Type of fever also varies in different epidemics — -Two examples : (1) yellow 
 fever of 1826-27, (2) malignant purpuric, or cerebrospinal fever of 1867 — Dr. E. W. 
 Collins' report on latter — There exists a " constitutional element" in the disease, so 
 that the cerebro-spinal arachnitis can hardly be held to be a primary, idiopathic 
 affection — Evidences of essentiality from presence of other phenomena in connec- 
 tion with the skin, etc. — Reports to the Medical Society of the King and Queen's 
 College of Physicians in Ireland on the epidemic of 1867 — Inconstancy and variabil- 
 ity of the symptoms in the outbreak — Dr. H. Kennedy's views — Symptoms of the 
 disease — Petechias — Early setting in of putrefraction — Retraction of head: some- 
 times persistent after disappearance of other local and general symptoms, and 
 sometimes persistent after death — Recapitulation : Points to be considered in 
 connection with epidemic of 1867 : (1) yellow fever of 1826-27, (2) cerebro-spinal 
 arachnitis of 1846 (Dr. Mayne), (3) coincidence of cases of malignant measles in 
 1867, and (4) hsemorrhagic and purpuric smallpox iu epidemic of 1S71-72. 
 
 I have on many occasions sought to impress on you that fever is a 
 condition which, though possessing a generic character, exhibits 
 infinite varieties in most of its aspects, whether it be looked on in 
 its sporadic cases or as occurring in great epidemics. There is no 
 point of view in which any of its phenomena can be regarded as con- 
 stant, except perhaps that of increased temperature. The epidemic 
 of one period is found to differ from that of another, whether we look 
 at its commencement or decline, its intensity or mortality, or the in- 
 fluence of remedies. And this quality of variability applies to the spo- 
 radic cases also, whether considered individually or collectively. The 
 disease varies in its contagiousness in different epidemics as the con- 
 dition of receptivity in healthy bodies varies, and this state of recep- 
 tivity is different according to the period. It is changeable as to its 
 degree of intensity, the number and nature of its complications, and 
 the vital phenomena of the secondary affections, their progress and 
 their influence on the disease as to its danger and its periodic laws, 
 and all this whether local symptoms are merely functional or reveal 
 organic change. 
 
166 LECTURES ON FEVER. 
 
 This will prepare you for the occurrence at irregular intervals of 
 time of groups of unusual cases having on the one hand a generic 
 resemblance, yet varying as to their local manifestations, and this is 
 what we mean by the term of epidemics within epidemics. 
 
 Now, the variation from the type of the general and coexisting 
 epidemic may be seen in both the essential and the local characters. 
 We have had two most remarkable examples of this in Dublin. 
 One of these was the yellow fever of which I have already spoken, 
 characterized by violent and sudden abdominal spasms, followed 
 rapidly by jaundice and mortification of the nose and toes; and the 
 other the disease which has so many names — the cerebro-spinal fever, 
 the malignant purpuric fever, epidemic cerebro-spinal meningitis, 
 febris nigra, etc. 
 
 Now, I recommend all of you to carefully study the report on this 
 disease by Dr. Collins in the Dublin Quarterly Journal, 1 which may 
 be taken as a model of what a scientific and faithful medical report 
 should be. This variety of fever appears first to have attracted atten- 
 tion in America early in this century. Dr. Collins shows that the 
 first account of the cerebro-spinal fever is that of an epidemic which 
 prevailed in Geneva in 1805. The disease showed itself in various 
 places in Europe and in America. Then it continued in America, and 
 in 1837 it became a widespread epidemic, occurring in Germany, Eng- 
 land, Ireland, and Denmark, and appearing at many ports in Spain, 
 North Africa, and Italy. In the British and Foreign Medico- 
 Ghirurgical Review, 2 you will find an excellent resume of the reports 
 of the American, German, and British physicians. This article is 
 written in that philosophical spirit which has so long distinguished 
 the periodical just mentioned. The name in use in America for this 
 disease was the spotted fever. Discussions arose about the nature of 
 the disease, some holding it to be an essential fever related to typhus, 
 if not typhus itself; others, a true cerebro-spinal meningitis. But it 
 is plain that the relation between the nervous symptoms — and also 
 the state of the brain and spinal cord — and the general symptoms 
 was not fully understood. The great fact of the secondary lesions in 
 fever varying in amount, prominence, seat, result, time of appearance, 
 was not yet appreciated, while the doctrine of the anatomical school, 
 that fever was symptomatic of a local irritation, made men look upon 
 the structural change as the cause of all the symptoms, while it was 
 truly the effect, though when it occurred it produced special pheno- 
 mena of a striking kind. It is true that Dr. Gordon found the marks 
 of cerebro-spinal inflammation within five hours from the occurrence 
 
 1 Vol. xlvi. August, lS6S,p. 170. 2 Vol. xlii. p. 389, and vol. xliii. p. 1 32 
 
NATUKE OF THE AFFECTION. 167 
 
 of the first symptoms of the constitutional malady, though the special 
 signs of cerebro-spinal irritation were wanting, and Levy has recorded 
 another case of singular rapidity of morbid action. Arguing from 
 these cases and from another in which extensive exudation in the 
 meninges was found after thirty hours of illness, Dr. Collins, while 
 admitting a constitutional element in the disease, holds that, since the 
 products of inflammation became developed in so short a period of 
 time, the inflammation itself from which they sprang cannot be con- 
 sidered other than primary and as forming along with the constitutional 
 element the pathological essence of the disease. 
 
 Now, the admission of the constitutional element is to give up the 
 doctrine of primary cerebro-spinal meningitis ; for what is this but 
 fever, with secondary nervous symptoms and organic states ? 
 
 "Congestions," writes Dr. Collins; 1 "plastic, purulent, sero-purulent, 
 or serous exudations; sometimes even alterations of the nervous sub- 
 stance itself, of ever-varying extent, singly or together, bear their 
 testimony to the nature of these inflammatory processes. But these 
 inflammatory changes, constant though they be, are not the only, nor 
 are they always the most important, features of the disease. Behind 
 them all, as in other affections, modifying and at times predominating, 
 lies another, a constitutional element, which gives to the disease so 
 many of its varied and. most appalling characters. This constitutional 
 element, the importance of which cannot be over-estimated, is re- 
 markably exemplified in those malignant and rapidly fatal cases of 
 meningite foudroyante, so called, which occurred within the past two 
 years throughout this island. The lesions here found, in many 
 instances, have been only varying degrees of congestion of the pia 
 mater, and similar experience is not wanting from the records of other 
 epidemics, so that some French writers have even given to this form 
 of the malady the title of forme canrjestionelk." 
 
 Now, this term " meningite foudroyante" is improper. It conveys a 
 false idea of the whole disease, leading to the belief that all its symp- 
 toms, the rapidity of its progress, and its fatal results are only measures 
 of the intensity of a primary local inflammation. But that the 
 "constitutional state" of Dr. Collins is of the nature of fever generat- 
 ing local disease — as scarlatina commonly generates sore throat; 
 measles, bronchial irritation ; and typhus and typhoid, pulmonary 
 and abdominal diseases — is obvious when the relation between the 
 local and constitutional state is considered. Its amount is variable, 
 and does not necessarily correspond to the violence of the symptoms. 
 In some of the most rapid cuses there is nothing observable but 
 
 I Loc. oit. p. 201. 
 
168 LECTURES ON FEVER. 
 
 congestion of the pia mater, and the degree of meningeal inflammation 
 has been found, as in the secondary affections of fever, to vary accord- 
 ing to locality and time — in other words, according to the local 
 epidemic. 
 
 To show that the cerebro-spinal arachnitis can hardly be considered 
 a primary idiopathic affection in this disease, the coexistence of other 
 local affections is to be noticed. Thus, great swelling of the eyelids 
 and conjunctivitis, with deep-seated injury of the eye; deafness, often 
 without, but occasionally with, purulent discharge; aphthae; swelling 
 of the parotid, submaxillary, and cervical glands, with or without 
 consequent suppuration, have been described. Epistaxis, meteorism, 
 diarrhoea, enlargement of the spleen, broncho-pneumonia, and occa- 
 sionally pericarditis, have been noticed by various observers in differ- 
 ent localities and at different periods. 
 
 Yet there are other evidences of its analogies to essential disease — 
 the occurrence of herpes; of a dusky discoloration of the skin, as in 
 typhus; of extraordinary petechial spots running occasionally into 
 vast ecchymoses, so as to evoke the designation of black death, and 
 the occurrence of a condition of the joints similar to that described 
 long since by the late Dr. MacDovvel. This at first simulates rheu- 
 matic arthritis, but soon shows the signs of purulent deposit. All this 
 confirms the view which was long ago taken in this hospital, and more 
 lately set forth by Stille, that this disease is a combination of an essen 
 tial specific condition, analogous to fever, with an important local and 
 consequent lesion of the nervous centres. The variations of pheno- 
 mena, both essential and local, though these present a generic resem- 
 blance, the differences of results of post-mortem examination — all are 
 plainly referable to the laws of essential epidemic disease occurring 
 at various times and in various parts of the world. 
 
 That the remarkable local affection, which gave a name to the epi- 
 demic we are considering, agrees in its general characters with the 
 secondary lesions of other varieties of fever, is evident from the truly 
 able and practical paper by Dr. Gordon in the forty-third volume of the 
 Dublin Quarterly Journal; and also from the records of two succes- 
 sive meetings of the Medical Society of the King and Queen's College 
 of Physicians in 1867. At these meetings not less than twenty-seven 
 observers of the disease in Ireland during the epidemic of 1866 and 
 1867 recorded their experience of it. I do not know of any greater 
 illustration of the healthy state of medical opinion in Ireland than 
 that afforded on this remarkable occasion. Most of those who gave 
 reports of cases and the results of their experience were physicians 
 
ESSENTIALITY OF THE DISEASE. 169 
 
 to some of the Dublin hospitals, while reports were also read by some 
 military surgeons then quartered in Ireland. 
 
 The occurrence of the nervous symptoms and the condition of the 
 nervous centres had received great attention from most of the ob- 
 servers. I may state that these meetings were more for the purpose 
 of recording individual experience than for discussion, of which there 
 was very little ; and when among the reporters were men of such mark 
 as Drs. Hudson, Gordon, Lyons, Hayden, Law, Banks, Henry Ken- 
 nedy, and Moore, you can understand the great importance of the oc- 
 casion. 
 
 Now, I claim no originality for the views I have submitted as to 
 the primary or the secondary nature of the cerebro-spinal disease. 
 Gentlemen, there is nothing more deplorable than the contests among 
 our brethren respecting priorit}' in observation and doctrine. I have 
 spoken of this in my lecture on medical ethics, and have shown you 
 that when several observers are working for the same object and at 
 the same time — similar views will occur to many of them simulta- 
 neously. This applies to all investigations. It is of the first import- 
 ance that the truth should be made known, but by whom it was first 
 suggested matters little indeed. 
 
 If you study the cases brought forward at the College of Physicians, 
 you will find that the character of inconstancy attended the symptoms 
 of meningitis, and also the structural alteration. In one of the very 
 worst cases which I saw with Dr. Lyons death took place in little 
 more than twenty-four hours. The patient was a fine young man, an 
 officer in a cavalry regiment. There was no retraction of the head. 
 Dr. Lyons recorded two other fatal cases in which the peculiar cere- 
 bro-spinal symptoms were absent. In the 52d Regiment five cases 
 were reported by Mr. Haverty. The third case proved fatal in sixteen 
 hours after admission. There was no pain in the head, no retraction ; 
 nothing unusual was found in the brain, but at its base an increased 
 quantity of serum, which was of a dark colour. In a case which oc- 
 curred in this hospital with recovery, there was no retraction of the 
 head. The patient had slight converging strabismus and dilated pu- 
 pils. In a case by Dr. MacSwiney no lesion of the brain or spinal 
 cord was discovered, and Dr. Kennedy stated that many similar in- 
 stances had been met with by others, in which, as in Dr. MacSwiney's 
 case, there were no symptoms of arachnitis and no lesion of the nerv- 
 ous centres found after death. Dr. Banks, also, said that in many 
 fatal cases in this epidemic no signs of cerebro-spinal meningitis were 
 discovered after death. 
 
 Dr. Kennedy remarks on this subject as follows: "Taking, then, 
 
170 LECTURES ON FEVER. 
 
 all the facts at present known, and more particularly the one that our 
 typhus fever has, within these two years (he spoke in 1867), been fre- 
 quently complicated by spinal arachnitis, into consideration, it ap- 
 pears to me that no other conclusion can be arrived at than that the 
 late terrible disease which has visited us is a specific fever, and that . 
 the spinal arachnitis is but a complication, which may or may not be 
 present." 
 
 It is needless to insist on the importance of all this, as showing 
 (what might have been predicated) that the disease in its essence was 
 not primary inflammation of the cerebrospinal meninges. We have 
 seen fatal cases in which it might have been said that there were 
 never any symptoms of inflammation of the nervous centres, while, 
 on the other hand, every shade or degree of such symptoms have 
 been met with. We had one case here in which convulsions contin- 
 ued through the whole illness; and the state of the brain and spinal 
 marrow varied from the condition of freedom from disease in some in- 
 stances to one in which the base of the brain and spinal cord were 
 bathed in pus. 
 
 This variability in the amount of the local disease is thus strictly 
 analogous to what we observe in the secondary intestinal lesions of 
 typhoid. 
 
 It appears, then, that a form of cerebro-spinal disease with menin- 
 geal inflammation has been observed to commonly but not universally 
 attend this singular malady in America and in Europe. It has been 
 revealed by pain in the head, rachialgia, opisthotonos, trismus, and 
 occasionally convulsions. Yet it throws no light on the constitutional 
 state to which it appears secondary. It is variable in its occurrence, 
 inconstant in its amount, and incompetent to account for the general 
 malady. In short, it has all the characteristics of a secondary rather 
 than of a primary local malady. It is often associated with other 
 forms of local visceral disease. 
 
 There is nothing more appalling than the appearance of many pa- 
 tients in this affection — the dark petechial spots soon become confluent, 
 and vast black ecchymoses form. In a patient who m I saw with Dr. 
 Croly a few petechial spots appeared on the neck on the first day of 
 illness. Next morning these had become black, and increased in size 
 so rapidly that they seemed to grow under the eye of the observer. 
 At eleven o'clock the spots were extremely large, and in the course 
 of two hours the entire right arm and half of the right side of the chest 
 had become continuously black, with large patches over the rest of the 
 body. Soon after this a fit of convulsions came on, and the patient 
 
RETRACTION OF HEAD. 171 
 
 died at half-past two. The duration of the illness was about thirty 
 hours. 
 
 Another case is given by Dr. Croly in which the disease set in with 
 vomiting, followed by severe diarrhoea. On the second day blue spots, 
 soon becoming black, appeared on the sufferer's legs, and shortly be- 
 fore death on her arms and face. She died in convulsions with forci- 
 ble retraction of the head. The duration of illness was twenty-eight 
 hours. 
 
 In some instances, where this terrible disease had run a rapid course, 
 putrefaction appeared to have set in at a very early period after, or 
 even before, death. I was called to see a patient in whom the symp- 
 toms had first developed themselves but twenty-eight hours before. 
 He had just died as I entered the room, and I shall not soon forget 
 the overpowering stench of putrescence which rose from the still warm 
 body. The ordinary medical attendant assured me that the stench 
 had been observed some time previously to death. 
 
 Two interesting facts in connection with a remarkable symptom of 
 this disease — I allude to the retraction of the head — deserve to be 
 mentioned here. The first is the occasional long continuance of the 
 rigidity after all constitutional and local symptoms have disappeared. 
 I saw a boy in whom the retraction was so great that he could lie only 
 on his belly, and in this position he remained for several weeks, dur- 
 ing which time his general health was excellent; he took much nourish- 
 ment and gained flesh. In another case the retraction did not appear 
 until just at the subsidence of the constitutional condition. It in- 
 creased with the patient's convalescence until at last, when all febrile 
 condition had ceased, it became so extreme that his head was bent 
 backwards almost at a right angle with his body. This extraordinary 
 retraction subsided with remarkable rapidity, and had quite vanished 
 within 48 hours. 
 
 The second point is the occasional persistence of the rigidity after 
 death. It has been supposed that the muscles which have been thus 
 contracted during life are not liable to the rigor mortis, but in a re- 
 markable case published by Dr. Gordon in his Report on Gases of 
 Fever icith Cerebro -sinned Meningitis 1 all the constitutional and local 
 symptoms of the disease were present, opisthotonos being extreme, and 
 continuing after death. On the fifth day of the disease the patient, a 
 girl aged 15, lay on her abdomen, and refused to allow herself to be 
 moved on the back, or on either side. Her spine presented a most 
 wonderful and uniform curve, concave backwards; her head was also 
 curved backwards on the spine of the neck. Dr. Gordon had not seen 
 
 1 Dublin Quarterly Journal, vol. xl. p. 412. 
 
172 LECTURES ON FEVER. 
 
 so much opisthotonos in the worst cases of tetanus. She had no pain 
 or tenderness on pressure on any point of the spine. She died on the 
 ninth day of her illness, and after death the body presented a very 
 frightful appearance. It was still prominently arched forward. It 
 was of a dusky blue colour, with a copious eruption of black spots, of 
 various sizes, from that of a small pea to a crownpiece; some small and 
 circular, others large and irregular in form. 
 
 Now, in reviewing the results of our experience in this hospital, to- 
 gether with the published reports of the disease in Ireland, Germany, 
 and America, we must, I think, agree with all the best observers that 
 to look upon the affection as simple and idiopathic cerebro-spinal 
 meningitis would be erroneous. It is quite true that the frequency of 
 actual disease of the cerebro-spinal centres is a most striking peculiar- 
 ity, yet that this condition should be placed in the category of local 
 affections secondary to an essential malady is more than probable. 
 Like this class of diseases generally, even where it shows itself early 
 in the case, the cerebro-spinal complication does not seem to take the 
 initiative. We have had examples here in which the symptoms of the 
 local malady failed to appear until after the seventh or even the ninth 
 day, although the other characters of the disease were strongly marked. 
 I have already spoken to you of the character of inconstancy in 
 amount which it has in common with other secondary lesions, and not 
 only in amount but in intensity. Like them, too, it may occasionally 
 be absent. Nor can we attribute the remaining phenomena of the 
 disease — the enormous ecchymoses, the rapidly increasing and dark 
 petechias, the gangrene of the skin, and the tendency to general putres- 
 cence — to the occurrence of a primary cerebro-spinal inflammation. 
 
 In connection with the extraordinary epidemic in Ireland of which 
 I have been speaking, the following circumstances are worthy of re- 
 membrance : — 
 
 First. The occurrence of the cases of so-called yellow fever, de. 
 scribed by Dr. Graves, in the epidemic of 1826 to 1830, in 
 which there was blackening and mortification of the feet and 
 the nose, with jaundice, black vomit, and splenic enlargement. 
 Secondly. The outbreak of cerebro-spinal arachnitis in Dublin and 
 its neighbourhood in 1846, an account of which is given by 
 Dr. Mayne in the Dublin Quarterly Journal, vol. ii. p. 95. The 
 collapse stage in the worst cases he describes as closely resem- 
 bling cholera. This stage was ushered in by violent pain in the 
 abdomen, rapidly followed by vomiting, and not infrequently 
 by purging. The extremities then became cold and bluish, and 
 the pulse a mere thread. There was no cutaneous eruption or 
 hemorrhage. 
 
ANALOGIES. 173 
 
 Although Dr. Mayne does not deal with these eases as examples of 
 essential disease, but rather looks upon them as primary inflammation, 
 yet analogy and the history of the febris nigra make it highly probable 
 that the cerebro-spinal inflammation was not a primary affection in the 
 strict sense of the word. In the collapse cases noticed by him, after 
 the lapse of a few hours, reaction, more or less perfect, ensued ; the sur- 
 face became hot, the pulse full and frequent (from 120 to 140) ; the 
 stomach often continued irritable, whilst an intolerable thirst torment- 
 ed the sufferer. 
 
 Thirdly. The coincidence of cases of malignant measles with the 
 recent epidemic of cerebro-spinal fever — a fact noticed by Dr. 
 Gordon, and of which I have recorded a remarkable example 
 in the Transactions of the Medical Society of the College of Phy- 
 sicians. 
 And, fourthly. The extraordinary prevalence of purpuric and 
 hemorrhagic smallpox in the late terrible epidemic in Dublin. 
 I think that when you reflect on what has been now said, and on 
 these latter remarkable facts, the doctrine of a cerebro-spinal menin- 
 gitis independent of the general causes of essential disease, whatever 
 these may be, cannot be entertained. 
 
 LECTURE XXIV. 
 
 Nervous Complications op Fever, continued— Hysteria— Occurrence of hysteria, espe- 
 cially at an early stage, of unfavourable import— View that hysteria is always symp- 
 tomatic of uterine excitement is quite erroneous — Nymphomania only a local and 
 accidental manifestation — Hysteria is observed in males as well as in females in 
 fever — Case of erotic symptoms in typhoid fever occurring in a young girl, reported 
 by Dr. A. W. Foot — In early stage of fever hysteria generally is the precursor of 
 severe nervous symptoms— Its appearance may lead to serious complications later in 
 the disease — Illustrative cases— Hysterical symptoms are sometimes connected with 
 actual or organic disease, especially in acute affections — Dr. Cheyne's observation: 
 Hysteria a ground for a good prognosis in every disease, fever alone excepted — Outbreak of 
 hysteria, affecting the abdomen, in female fever ward of Meath Hospital — Anoma- 
 lous symptoms in advanced stages of fever often due to hysterical state— Case of 
 typhous hysteria in the male followed by cerebritis. 
 
 One of the nervous conditions in fever still remains to be considered. 
 I refer to hysteria, the occurrence of which, especially in the early 
 periods of fever, should always excite apprehension as to the result. 
 I have often told you that you are to reject the common notion that 
 hysteria is always symptomatic of uterine irritatiou, and that the oc- 
 
174 LECTURES ON FEVER. 
 
 currence of hysteria in a woman was owing to ungratified desires. 
 I would advise you not to enter practice, whether your patients be in 
 the humbler ranks of life or in the more refined walks of society, with 
 this gross, degrading, and ignorant idea. 
 
 We cannot doubt that in certain cases of hysteria there is evidence 
 of excitement of the genital system, but this result of the general disease 
 is only one — it may be — of a series of local excitements. The hys- 
 teric condition may affect the brain, and you may have intense pain, 
 coma, mania, and convulsions. If the lung be affected, dyspnoea, 
 cough, expectoration, even haemoptysis, may be observed. Hysteric 
 palpitation and syncope occur when the disease falls on the heart, vo. 
 miting when it affects the stomach, paralysis when the bladder is 
 engaged, and so on. It is easy to understand that if the disease fastens 
 itself upon the uterus and the genital system, symptoms of nympho- 
 mania may be produced. 
 
 In fact, in cases of hysteria with excitement of the genital system it 
 has merely happened, and accidentally, that upon that system the brunt 
 of the disease has fallen, while, if any other organ had been affected, 
 there would have been no symptoms of nymphomania; but mania, 
 convulsions, palpitation, cough — the tussis ferina — or uncontrollable 
 vomiting might have been present, according to circumstances. 
 
 Indeed, the occurrence of hysteric symptoms in fever in the male 
 as in the female is almost conclusive that it is a special nervous affec- 
 tion, the origin of which is unknown — an affection which may engage 
 every great organ in the body, which is not symptomatic of irritation 
 of any one of them, and whose seat is in the nerves of animal and 
 organic life. 
 
 Let me again impress upon you that the old and still too common 
 view of hysteria is to be rejected as one based on ignorance of the 
 female constitution and of medicine. You will hear it advocated only 
 by men of gross and prurient ideas. It is true, that, when the genital 
 system happens to be engaged in the hysteric state, there is a liability 
 to nymphomania, and you may hear expressions and witness actions 
 in the purest females that may surprise you ; but remember that these 
 are but the symptoms of a secondary local manifestation of a general 
 malady. Hysteria, as its name implies, was held to be symptomatic 
 of irritation of the uterus, just as fever was considered as symptomatic 
 of cerebritis or muco enteritis. 
 
 It is true that in fever we have not yet observed any erotic symptoms 
 in the male subject, but in the young female they are oceasionally met 
 with. A case of this kind recently occurred in these wards under the 
 care of Dr. Foot. A young woman was admitted on the eighth day 
 
CASE OF HYSTERICAL COMPLICATION. 175 
 
 of an enteric fever. Her pulse was 100 and temperature 99.5°. She 
 was talking and gesticulating in such an erotic manner that the nurse 
 suggested her separation from the other patients. She laughed in- 
 cessantly, and exhibited all the symptoms and action of violent excite- 
 ment of the genital system. This continued all that day and night. 
 Next morning the pulse was 114 and the temperature 101.3°. The 
 head, hands, and feet were very cold and livid. The heart's action 
 was weak. This patient was a blonde, with very light hair and blue 
 eyes. She hid her face from the physician, then jerked it round, took 
 a look at the class, and hid it again. She took a double meaning out 
 of every question put to her. In reply to ordinary questions as to 
 headache, etc., she said, with a knowing laugh, "I know you all well. 
 I won't let you; you won't succeed. I know what you're about." In 
 words such as these she addressed both the physician and the class in 
 general. It was impossible to get an answer from her. Her manner 
 and conversation were jocular, immodest, and disrespectfully familiar. 
 
 She was ordered 30 grains of chloral at once, and immediately went 
 to sleep. After the effects of the chloral had passed off she was ordered 
 30 grains of bromide of potassium every third hour. Next morning 
 she was a different person — timid, respectful, gentle — and she did not 
 recollect a word of what she had said the day before. This fact was 
 further ascertained through the nurse to be true, as shame might have 
 led her to feign forgetfulness to the students. On this day, the 10th 
 of her illness, several rose spots appeared for the first time on her 
 chest. She subsequently went through a well-marked enteric fever, 
 on the 28th day of which her temperature permanently fell, having 
 ranged during her illness between 101.8° and 97.2°. As there was 
 constant and characteristic diarrhoea, and as t,he lungs became the seat 
 of congestion at one period, the case afforded an example of secondary 
 complication of the three great cavities of the body. 
 
 The patient's manner subsequent to the hysterical attack was most 
 decorous. She did not appear to possess a particle of what is called 
 the " hysterical temperament." So far from seeking for or seeming to 
 like any attention, she was so distant and indifferent to the pupils as 
 sometimes to appear impolite. She bore an excellent character prior 
 to admission, and her parents intended to have nursed her at home, 
 but got alarmed "when she got out of her mind," and brought her to 
 the hospital. 
 
 Many a time I have known of a deep wound inflicted on the delicacy 
 of the purest girl by the expression of these — T may call them brutal 
 — views on the part of the attendant — views which show that he is at 
 once ignorant of the physiology and of the pathology of the female 
 
176 LECTURES ON FEVER. 
 
 constitution, and of the moral nature of that sex, which is the deposi- 
 tary of all that is pure and delicate and moral in this life. That man 
 is unworthy of confidence or of the name of a ph ysician who thus 
 drags his profession into the mire. 
 
 In the early periods of fever hysterical symptoms generally usher 
 in a great severity of many of the nervous conditions of the disease, 
 while their later occurrence gives rise to singular and often embarrass- 
 ing complications even after the fever has run its course. 
 
 This is illustrated by the case in the wards. The girl had recovered 
 from fever, when she was agitated at seeing one of her friends brought 
 sick into the ward, and soon fell into her present condition. She lies 
 in a prostrate and stupid state, though answering questions rationally. 
 She complains of pain at the top of her head. The breathing is 
 natural, but at times hurried and croupy. Any attempt to examine 
 the throat brings on the most violent spasms, attended by hysterical 
 singultus. Now, has this patient irritation of the brain or of the 
 larynx ? It is most probable she has neither, but you must remember 
 that she has recently had a continued fever, and so we must act as if 
 she were threatened with cerebral or laryngeal irritation, although of 
 course in a very tentative way. 
 
 A case which left a deep impression on my mind occurred with us 
 some years ago. It shows how actual organic change may be masked 
 by the hysterical complication. A young woman was an inmate of 
 this hospital for many months, presenting a succession of the most 
 violeut and various local symptoms of hysteria. In fact, almost every 
 organ of her body was in turn attacked. She had long-continued 
 and incessant vomiting. For many weeks she took no food, although 
 with little if any emaciation. She had hemiplegia, palpitation, rapid- 
 ity of pulse, constipation, tympany, and retention of urine, and these 
 symptoms succeeded one another or were present in various combi- 
 nations. But the most prominent symptom was a spasmodic and 
 unceasing cough, so loud as to be heard through the house ; indeed, I 
 have often heard it at the gate of the hospital. This was attended by 
 frequent attacks of stridor — so severe as to threaten life — and these 
 would alternate with convulsions, or some other symptom. During 
 the latter the stridor would completely disappear. Many months 
 passed by, during which this girl left and was readmitted into hospital 
 on several occasions. Soon after her last admission she showed for 
 the first time symptoms of fever, which eventuated in an attack of 
 general though modified smallpox. During the continuance of this 
 attack all the hysterical symptoms completely subsided. Some weeks 
 elapsed, during which she continued well, when the tussis ferina and 
 
OUTBREAK OF HYSTERIA. 177 
 
 the fits of stridor returned exactly as before. We looked on it simply 
 as a renewal of the old condition, and, as many and various remedies 
 had been tried before, the case was regarded as one which might be 
 left to nature. In a few days she died, asphyxiated. On dissection, 
 to our surprise, we found a great amount of inflammation and deep 
 ulceration of the larynx, with total destruction of its ventricles. 
 
 I do not think highly of that man's mind or heart to whom the death 
 of a poor patient with recent, unrecognized, and probably remediable 
 disease is a matter of indifference. Did the ulcerative disease coexist 
 with the hysteria? It is not likely that it did, for the latter was of 
 long continuance, while this laryngeal ulceration was obviously acute. 
 Were its symptoms occasionally suspended during the convulsive 
 paroxysms ? Did the variolous disease, by its derivation, cause a lull 
 in the laryngeal condition, or did the hyperassthetic state of the larynx 
 predispose it to organic change consequent on the exanthem? Un- 
 happily we cannot solve these questions now, but there is one lesson 
 to be learned from this sad case, and it is this: that, in dealing with 
 hysterical patients, we must not fall into the common mistake of 
 considering their local symptoms as in all cases unconnected with 
 organic disease. 
 
 We are not, then, to neglect local symptoms, and to consider them 
 as merely neurotic in the hysterical condition. That they may he, 
 and commonly are so, is certain, especially in cases of chronic disease. 
 But in an acute disease like fever the occurrence of hysteria should 
 make us especially cautious in our prognosis as to coming nervous 
 symptoms. The late Dr. Oheyne, of this city, used to say that the 
 hysterical complication was a ground of a good prognosis in every 
 disease, fever alone excepted, and this observation may apply to all 
 forms of essential and of symptomatic fever. 
 
 Some time ago we had a remarkable manifestation of the hysterical 
 state in fever. A young woman who was all but convalescent, and 
 who had nearly passed through her disease before admission, was 
 suddenly attacked with violent pain in the belly, which was swollen 
 and tympanitic, with extreme hyperassthesia on pressure. But the 
 corresponding symptoms of peritonitis were absent. There were loud 
 and constant screaming and all the other evidences of a violent hys- 
 terical attack. In the course of two or three days five other patients 
 in the same ward became successively and similarly affected, and you 
 can well imagine the scene presented by six women in the same ward 
 and for several days and nights in this state. It seemed as if they were 
 possessed, and labouring under the most violent form of demoniacal 
 mania. There was nothing remarkable in the character of the fever 
 12 
 
178 LECTURES ON FEVER. 
 
 at the time. Some of them had simple continued and others typhus 
 fever. Convalescence followed in all the cases, though in two of them, 
 and in one especially, symptoms of enteric inflammation supervened, 
 and were met by the usual treatment. 
 
 These facts show how even in a fever ward hysteria will spread by 
 contiguity. 
 
 The most common form of the combination of the hysterical state 
 with fever is met with generally in an advanced stage of the disease, 
 when the patient shows signs of the hysterical state by complaining of 
 anomalous symptoms, the alleged severity of which is in no way in 
 accordance with the constitutional condition. She becomes unrea- 
 sonable, capricious, and complaining. She watches for sympathy, re- 
 fuses sustenance, and may be detected in feigning symptoms. Re- 
 tention of urine is common, so as to require catheterism — an operation 
 which should be, if possible, performed by a female attendant. 
 
 But it is in cases where the nervous symptoms which properly belong 
 to fever are preceded by a well marked hysterical state that head 
 symptoms of a severe kind may be anticipated. In one of the most 
 severe cases of typhus fever with cerebral symptoms that I have seen, 
 the patient, a middle-aged man, of excellent physical development 
 and the most splendid intellectual attainments, exhibited perfectly 
 formed hysterical symptoms for thirty-six hours after sickening of 
 fever. Symptoms of violent head-affection then set in, which were 
 treated by local depletion. The case terminated favourably. 
 
PART II. 
 
 TREATMENT OF FEVER. 
 
 LECTURE XXV. 
 
 Introductory Remarks — Principles on which the treatment of fever is to be based — 
 True meanirig of the word empiric. Historical retrospect — The Symptomological, 
 the Anatomical, the Rational or Eclectic Schools — Essence of fever cannot be de- 
 termined by pathological anatomy — Etiology of fever is indefinite. 
 
 Before entering on the treatment of fever it may be well to consider 
 the principles on which it is to be based, and which the best physicians 
 from the earliest times have followed. Though the application of 
 these principles has varied according to the prevalence of this or that 
 theory of disease, still, when we look at the recorded experience of 
 practical men, we shall find that there has been in the main an agree- 
 ment as to questions of prognosis and of treatment. Notwithstanding 
 all that has been done in the morbid anatomy of fever, including the 
 results of the microscope and of chemical research, I believe that our 
 predecessors were, as a r.ule, as good physicians in fever as we are 
 ourselves. Indeed, it may be held that in the highest quality of the 
 medical mind, the almost intuitive perception of what is right to do 
 under existing circumstances, they were — notwithstanding all our 
 boasted advance in pathology — our equals, if not our superiors. The 
 older British physicians — Sydenham, Haygarth, Heberden, Fordyce, 
 and Fothergill in England; Gregory, Cullen, and Alison in Scotland; 
 and Harvey, Cheyne, and Graves in Ireland — were all great physicians, 
 whose practice was based on a study of the history and symptoms 
 rather than the organic changes. These true lights of medicine were 
 eclectics, and so were not wedded to any exclusive doctrine or practice. 
 As I have said before, they were more symptomatologists than morbid 
 anatomists — that is, their practice was founded rather on the general 
 vital conditions than on the supposed state of any particular system. 
 They looked on a case of fever as a whole, and dealt with it as a whole. 
 They did not, like Paracelsus, advise their followers to burn the 
 writings of Hippocrates, Galen, and Avicenna; or, like Broussais and 
 
180 LECTURES ON FEVER. 
 
 some more modern professors, impugn the morality or the intellectual 
 powers of the great men who preceded them. 
 
 The class of physicians to which I allude did not assume any dis- 
 tinguishing name. They were all imbued with the modesty of science, 
 and did not affect to be the apostles of any new doctrine. They were, 
 however, agreed on some great points, of which that of essentiality of 
 disease was the chief one. This view of fever is well expressed by For- 
 dyce, whom I have long since quoted in speaking of fever. "Fever," 
 he says, " is a disease which affects the whole system ; it affects the head, 
 trunk, and extremities; it affects the circulation, absorption, and the 
 nervous system; it affects the body and it affects the mind: it is 
 therefore a disease of the whole system in the fullest sense of the term. 
 It does not, however, affect the various parts of the system uniformly 
 and equally, but, on the contrary, sometimes one part is more affected 
 than another." 
 
 AW the great observers whom I have enumerated believed — and 
 acted on that belief — that our knowledge of the nature of fever is of a 
 negative character, and though the earlier of them did not fully appre- 
 hend the history of the organic secondary lesions, yet it can be in- 
 ferred from their writings and their practice that they looked on them 
 less as the cause than the consequence of fever. To all intents and 
 purposes, then, they recognized what we now call the secondary 
 affections of fever, and met them as they arose, always keeping in view 
 the previous and associated constitutional state so commonly marked 
 by prostration of nervous energy. They recognized the laws of 
 periodicity. In a word, their principles of management of fever were 
 based on "observation rendered fruitful by study;" the recorded expe- 
 rience of the past was to them a light in the wilderness, not a matter to 
 be ridiculed or sneered at; and so, though unassisted by the scalpel, 
 the microscope, or chemical research, they worked out the true prin- 
 ciples of treatment by studying the living rather than the dead. Their 
 treatment has been called empiricism, as if this term was necessarily 
 one of reproach. 
 
 I address myself now to the junior members of this class. I wish 
 to impress upon them that those who so use the term display igno- 
 rance alike of its meaning and of its derivation. The class of men of 
 whom I speak practised empirically — that is, they practised from ob- 
 servation and experience. Their empiricism was an enlightened empiri- 
 cism, based on a just appreciation of facts as regards the living, rather 
 than of those concerning either post-mortem changes or therapeutic 
 influences. In truth, the term empiric has been applied to one who 
 is truly not an empiric — to one who, ignorant of the natural history 
 
TRUE EMPIRICISM. 181 
 
 of disease and of the influence of his so-called remedies on the health 
 or life of his patient, practises recklessly and for his own profit, not for 
 the benefit of the sick. To such a class the old-fashioned word " quack" 
 applies, rather than that of " empiric." You may ask me : Are we all 
 to be empirics? 1 answer: Yes, in the true sense of the word, for the 
 benefit of our patients, not ignorantly or for our own advantage. The 
 great men whose names I have mentioned were empirics of this kind. 
 They had learned from long experience that the adoption of certain 
 modes of treatment, differing according to circumstances, would be 
 attended with beneficial results, although even the most gifted of them 
 could not tell why it was that such effects were produced. 
 
 All they professed to know was that such was the fact, and the line 
 of treatment was adopted simply because it was proved to be useful. 
 This was pure empiricism ; but who will refuse to say that the practice 
 of it was not only justifiable but commendable? In fact, in the 
 present state of medical knowledge we must all be more or less 
 empirical in our practice. The gentleman who has the case of dumb 
 ague under his charge in the wards prescribed cinchona, and therefore 
 is an empiric; for he cannot explain, any more than I can myself, 
 why the remedy is useful in such cases. He knows only that cincho- 
 na exerts a specific remedial effect on the disease, and so he employs 
 it empirically, yet conscientiously and wisely. 
 
 The symptomological school of physicians in their treatment of 
 fever invariably looked to the general condition of the patient first, 
 and afterwards to the state of his local organs. And so these men, 
 acting mainly by the light of their own genius, sagacity, and experi- 
 ence, adopted the same principles of treatment which we advocate 
 here, and which are now endorsed by the best men in Europe, aided 
 as they are by all the appliances of modern science. These old physi- 
 cians, to use the impressive words of Dr. Graves, "fed fever" liberally, 
 yet judiciously, with nutriment, with wine, with tonics, and with dif- 
 fusible stimulants. 
 
 We now come to a school of practitioners who adopted a diametri- 
 cally opposite plan of treatment in fever, who looked less to the pa- 
 tient's general condition and more to the secondary and local affections 
 of the disease under which he was suffering. They discovered, or 
 thought they discovered, cerebritis, gastritis, hepatitis, pneumonia, and 
 so on. according as symptoms arose indicative of engagement of the 
 brain, the intestinal or the respiratory system; and they asserted 
 that those physicians who dared to treat such symptoms of local in- 
 flammation by the administration of food, wine, and bark were nothing 
 short of privileged assassins, to be denounced as legalized murderers. 
 
182 LECTURES ON FEVER. 
 
 Shortly after my election to this hospital, at a time when the fever 
 wards were under the charge of Dr. Graves, a gentleman fresh from 
 the schools of Paris, an ardent believer in the so-called physiological 
 doctrines of Broussais, called on me to say that he could no longer 
 continue to attend in the fever wards. I asked his reasons for this 
 determination. He said, "I cannot longer witness such wholesale 
 murder. I every day see Dr. Graves, in manifest cases of gastro entente, 
 administering wine, brandy, and nutritive food, when the tongue is 
 red and all the symptoms of enteric inflammation are present." "Bat," 
 I said, "when you speak of 'wholesale murder' have you seen any 
 cases in which this practice had fatal results?" "No," he replied; 
 " that's the extraordinary thing ; but I suppose your Irish constitutions 
 are peculiar. Yet I cannot bear to see it any more ; I must go away." 
 And so this fettered doctrinaire lost the clinical teaching of the " great 
 Dublin practitioner," as Graves was called by Trousseau many years 
 later. 
 
 This second school of physicians we may fairly designate "The 
 Anatomical School," who denied essentialism and mistook the effect 
 for the cause, and whose simple treatment was starvation and local 
 depletion. I may here observe that the practitioners of this class 
 used to style themselves " The Physiological School," but their physi- 
 ology was very bad indeed. They based their theory and practice in 
 fever on morbid anatomy rather than on pathology. They sought 
 to explain all the symptoms of the disease, local and general, by re- 
 ferring them to the sympathies of a part of the digestive system when 
 under inflammation ; while they failed to recognize that this inflam- 
 mation was not the first link in the chain of morbid phenomena, but 
 was reactive and secondary in its nature. 
 
 "We now come to the Rational School, though its disciples have not 
 assumed any such distinctive name. It might be termed " The Patho- 
 logical School," for pathology signifies only the physiology of disease. 
 It is this school, shadowed out by the old English writers, still more 
 developed by John Peter Frank, its views and doctrines long taught 
 by Graves, which has been now followed by most right-thinking men 
 at home and abroad. It is in this school that so man}' of our country- 
 men have been educated, who in various parts of the world have so 
 nobly upheld the repute of British and Irish medicine. It may be 
 termed "The Eclectic School," for it adopts whatever is true in the 
 teaching of the past, and rejects whatever is mischievous, erroneous, 
 and bad. It admits the essentiality of fever — that strange but gen- 
 eral condition which — it cannot be too often repeated — differs from 
 any other condition of the living body, varying in form, in intensity, 
 
QUESTION OF ANATOMICAL CHANGES. 183 
 
 duration, and secondary complications, subject to the laws of perio- 
 dicity, and in which the rules of diagnosis of local diseases applicable 
 in other cases must be modified. 
 
 Now, if we inquire to which of the preceding schools, the sympto- 
 mological or the anatomical, the present rational or eclectic system 
 more nearly approaches, you will find that it is far more closely 
 related to the first than to the second. In the present healthier state 
 of medical opinion, the general condition of the patient in fever is 
 looked on as of more importance than the local affections. "The whole 
 is more than the pari 1 ' 1 is the golden principle to be recognized in the 
 treatment of all essential diseases. You are not to adopt any exclu- 
 sive theory from the condition of one part, and you are never to per- 
 mit the occurrence of a local affection to sway you overmuch in your 
 management of the general disease, if from your knowledge of the epi- 
 demic character and the actual condition of the patient, you deter- 
 mine that a decisive mode of treatment is necessary — for example, the 
 use of food and stimulants. You are not to be stopped from giving 
 them because some local affection might seem to prohibit their use, 
 for I believe in ninety-nine out of a hundred cases you may override 
 this seeming objection with safety and advantage. 
 
 The anatomical school, as I have shown you, fell into the great error 
 of regarding the local diseases in fever not only as primary but as 
 necessary affections. You are to hold a diametrically opposite 
 opinion ; it is in the higher knowledge of the laws affecting the local 
 diseases in fever — its consequence, not its cause — that the rational 
 and eclectic school has its chief merit. We of that school know well 
 that, although these local diseases are so common that their occur- 
 rence is the rule rather than the exception, yet they vary according 
 to many circumstances. Some of these are utterly unknown to us, 
 while of those the existence of which seems probable — such as climate 
 and epidemic influence — the modus operandi is hidden from us. 
 
 I have shown you that the so-called anatomical or physiological 
 school explained the various symptoms in fever on the principle of 
 organic sympathies, but they cannot be thus accounted for. Fever 
 may exist without the presence of any notable anatomical change. A 
 single case of this kind would overturn the entire theory, and 1 believe 
 that the more you see of fever the more readily will you admit, 
 especially in typhus, that the severity and the mortality of the disease 
 are directly in proportion to the toxic effect of the poison and the 
 freedom from anatomical change. 
 
 I have brought before you examples of the cessation of fever coin- 
 cident with structural change. The general principle which comes 
 
184 LECTURES ON FEVER. 
 
 into view on looking at the most wide-spread epidemic affections is, 
 that their victims do not die of local organic disease; or, to put it in 
 other words, that the destructiveness of these affections is in the in- 
 verse ratio to the amount of anatomical change produced by them. 
 If this be so, it furnishes a crushing argument against the anatomical 
 theory of fever, and recommends to our minds the paramount impor- 
 tance of considering the vital rather than the organic state. 
 
 One more important consideration I beg to recommend to you. 
 The anatomical school held that between the local affections in fever 
 and idiopathic inflammation there was no difference, but we hold fast 
 to the opinion that, though similar in physical signs and in anatomi- 
 cal character— at least to a great degree — to primary disease, they are 
 widely distinct in their vital characters. Although to the eye, even 
 when armed by the microscope, the character of these secondary 
 changes may be precisely similar to those of idiopathic lesions, yet 
 similarity of physical aspect by no means implies identity of vital 
 character. Consider two cases of iritis apparently the same: you 
 have an opportunity of examining the structures after death ; will you 
 then find an anatomical difference between the two? Or if you do, 
 will this explain the fact that in one case simple antiphlogistic meas- 
 ures would suffice to subdue the disease, while in the others a specific 
 treatment is necessary ? 
 
 Gentlemen, you will perceive the vast importance of recognizing 
 the vital characters which are extended to the products of disease, 
 and this applies to all physiology. 
 
 In Goethe's drama of Faust the Devil possesses himself of the pro- 
 fessor's gown, and sitting in his chair is consulted by some of the 
 students as to their objects of study. He decries anatomy as a means 
 for clearing up the problem of life. I have often thought that the 
 words of the great German poet and philosopher, which I have pre- 
 viously quoted, are strangely applicable to the question of the vital 
 character of disease, which is something varied, although hidden, not 
 to be seen, measured, weighed, or analyzed. 
 
 Before passing now to speak of the treatment of fever in detail, I 
 would remind you that we cannot by pathological anatomy determine 
 the essence of fever. We may even go further and say that no post- 
 mortem or ante-mortem investigation has discovered what is its cause, 
 why this condition presents itself in so many forms — some of them 
 sufficiently distinct and, as it were, concrete, others more or less inde- 
 finable — one form passing into another, varying at different times in 
 history, apparent exciting cause, epidemic character, degree of conta- 
 giousness, mortality, and the amount and nature of the secondary 
 
NO SPECIFIC TREATMENT. 185 
 
 changes. It may be that destitution has been often attended with, re- 
 lapsing fever, that decomposing human exuvise may induce typhoid 
 or enteric fever, that typhus springs from overcrowding; yet I would 
 exhort you to avoid all exclusive doctrines as to fever, whether you 
 deal with its exciting causes, its classification, its pathology, or its 
 results. 
 
 As far as we can judge, the relation between the particular form of 
 fever and its apparent exciting cause is by no means constant. Desti- 
 tution is followed by every form of fever. The presumed exciting 
 causes of typhoid — such as impure water, defective drainage, putrid 
 emanations — will be followed by typhus in one case and by typhoid 
 in another. While saying this, I believe it to be sufficiently made 
 out that typhus is more immediately connected with overcrowding than 
 typhoid, and that the latter form of fever is more related to the defective 
 sanitary conditions I have just specified. But all this has little to do 
 with treatment, the great principles of which are constant, while their 
 application varies in the individual case or in the special epidemic. 
 
 LECTURE XXVI. 
 
 No specific line of treatment — Respect to be had (1) to the essential disease, (2) to 
 its local and secondary effects — Failure of specifics in early stage of fevers — Want 
 of success in the endeavour to found a science of therapeutics on experimental 
 physiology or pathology — Effects of the action of the law of periodicity wrongly 
 attributed to the adoption of therapeutical measures — Sustenance by food and 
 stimulants — Two sources of danger to the fever patient; (1) primary effects of the 
 fever poison in causing depression, (2) supervention of secondary local disease — 
 Views of Dr. Graves on the subject of giving food in fever. 
 
 In our study of the treatment of fever we shall best consider the 
 question first in regard to the essential element of the disease, and 
 next in reference to its local and secondary effects. You will meet 
 with a certain number of cases in which your attention will be com- 
 pelled more especially to the constitutional state, and this throughout 
 the whole course of the malady; while even in the most prominent 
 local complications you are not, in your treatment and prognosis, to 
 overlook the essential condition. Lot us apply ourselves to the first 
 of these questions. 
 
 Is {"ever, independent of local complications, a condition which can 
 be cut short, or can its duration be materially abridged ? In other 
 words, is there any known specific treatment for any kind of con- 
 
186 LECTURES ON FEVER. 
 
 tinued fever? — has any means been discovered of cutting the process 
 of fever short, or of anticipating the time when, by the law of period- 
 icity, the peculiar condition of organic life which we call fever will 
 cease, and the system be again governed by its natural laws? 
 
 Now, I believe that no direct or specific treatment which would 
 have these effects has been as yet discovered. When 1 was a younger 
 man, some idea that a fever might be cut short, particularly if it were 
 dealt with in its earlier periods, influenced most, or at least many, 
 practitioners. Each physician had, according to the teaching he had 
 received or to the theories he had formed — less from experience than 
 from a priori reasoning — his own favourite and routine method of 
 proceeding. Some employed emetics to effect the object in view; 
 others, diaphoretics ; many used purgation, blood-letting, or even the 
 exhibition of mercury, while each appealed to examples of recovery 
 after such proceedings in justification of them. 
 
 I believe that all these courses of proceeding were not only futile, 
 but harmful — futile in this, that they did not arrest the fever, and 
 harmful because their effect too often was, in ordinary words, to spoil 
 the case : that is to say, to interfere with the pathological laws which 
 govern disease as physiological laws govern health. Among these 
 laws that of periodicity is chiefly to be mentioned. There were other 
 bad effects. Copious sweating or venesection produced debility. Pur- 
 gatives predisposed, as we have seen, to dangerous disease of the di- 
 gestive tube, while the use of mercury, especially in rheumatic fever, 
 clearly increased the cachectic and anaemic condition in convalescence. 
 Some of the worst cases of recovery from rheumatic fever which I 
 witnessed were those in which the system had been saturated with 
 mercury in the early stages of the disease. 
 
 The error involved in the adoption of any of these practices was 
 that of not recognizing the natural history of fever. These men acted 
 vigorously in the first period of the disease, and thereby commonly 
 tended to exhaust the system, not knowing what the duration of the 
 case might be, when all the powers of nature would be called on to 
 induce a favourable result. You, gentlemen, have not had an oppor- 
 tunity of becoming practically acquainted with what I am about to 
 tell you. It often happened that, after the employment of some of 
 these measures, a remarkable lull in the symptoms followed ; the febrile 
 state was greatly ameliorated and sometimes almost disappeared, the 
 patient expressed relief, and everything seemed to justify the course 
 which had been adopted. But the "snake was scotched, not killed," 
 and in a short time the disease showed itself again, running its course 
 unaffected — except for evil — by what had been done. 
 
FALLACY IN THERAPEUTIC RESEARCH. 187 
 
 I have spoken of rheumatic fever. See the number of specifics 
 that have been proposed for its treatment — mercury, opium, bark, iron, 
 alkalies > acids, and so on. I will say nothing of the system of Bouil- 
 laud — the bleeding coup sur coup. The very number and variety 
 of the so-called specifics for the disease leads to a conviction of their 
 little value as remedies. But it would be well were their effects only 
 negative, for experience shows that they are too often injurious by 
 their interference with, the ordinary and normal laws of the disease. 
 As I have just said, rheumatic fever was commonly treated by mer- 
 curialization, with the result that convalescence was in almost every 
 case protracted and uncertain. 
 
 In truth, gentlemen, that part of medicine which involves therapeu- 
 tics has always been — and we may say, is still — in the most unsatis- 
 factory condition. There is no part of medical science in which the 
 principles of right reasoning have been so largely and so continu- 
 ously neglected or outraged ; and though in our own time experimental 
 physiology or pathology has been had recourse to as a basis for a ra- 
 tional therapeutical science, yet how very far are we from any satis- 
 factory conclusion on the matter? This is to be accounted for from 
 various reasons. Experiments have been made on animals, and the 
 results have been held to apply to man, not only in his normal but 
 in his diseased condition. For example, to determine whether a mer- 
 curial is ever efficacious in bilious derangement, calomel is given to 
 a dog, in whose gall-bladder an open fistula has been made; and the 
 question of its fitness in man, when in disease, is tested by the quantity 
 of bile which flows from a canula in the gallbladder of a healthy dog. 
 
 But it is in relation to our immediate subject, and especially to the 
 periodicity of disease, that the most fruitful source of error in modern 
 therapeutics exists. The essential disease, as well as its secondary 
 effect, is subject to periodic law. Both spontaneously subside, and 
 when that subsidence follows on the exhibition of this or that remedy, 
 a therapeutic fact is held to be discovered. Yet this subsidence may 
 be in no way connected with the effect of the remedy. It probably 
 would have occurred without it; it may have been delayed or other- 
 wise interfered with by the action of the medicine itself; nay, further, 
 the subsidence of the essential or of the local part of the disease will 
 occur even after the use of many and different remedies. The false 
 reasoning which has been held to apply to one applies equally to all, 
 and so the therapeutic experiments lead to erroneous conclusions. 
 
 I have shown you that the study of the diseased or healthy organ- 
 ism reveals more of the effects than of the essence of disease. Hence 
 you must be cautious in adopting any therapeutical system based 
 
188 LECTURES ON FEVER. 
 
 upon visible organic change. In the study of therapeutics we should 
 depend principally upon experiment and induction in disease as ob- 
 served in man. Professor Acland has observed that if but a few well- 
 instructed men were to take up any one remedy, and continue to 
 record the character and history of the case, and the results of the 
 particular agent, making as it were their hospitals medical observa- 
 tories, we should in time have such a mass of facts— the results of un- 
 biassed observation — as would enable us to draw safe conclusions. 
 
 The therapeutist of the present day has great advantages over his 
 predecessors, particularly in the assistance which is now given by 
 chemical and microscopical research. But he must also possess as- 
 sistance of other kinds. He must know the principles of accurate 
 reasoning, he must deal with vital phenomena, of which our know- 
 ledge is so deficient that we have to study their modifications experi- 
 mentally, as yet without any direct reference to structure or to vital 
 chemistry. 
 
 The laws of periodic action must be considered, and — as he pro- 
 ceeds — he must inquire whether the simplest local, as well as the 
 most complex general, affection is not more or less subject to some of 
 these wonderful laws. He must study the question how far medical 
 interference is capable of extinguishing morbid action, of merely post- 
 poning it, or, lastly, of deranging a process which was to end in its 
 removal. He must well understand how certainty in medicine is to 
 be approached only by the balance of probabilities, and he must be 
 thoroughly acquainted with the difficulties which are involved in those 
 medical statistics which result from the labours of more than one 
 observer. Other circumstances will suggest themselves — such as 
 locality, race, habit, age, sex, and previous history. 
 
 In dealing with the treatment of fever, and looking upon the disease 
 in its aspect of essentiality — that is, as a condition independent of 
 local disease and capable, after a period, of spontaneous disappear- 
 ance — the question of the use of sustenance by food or stimulants 
 should first engage our attention. 
 
 We have seen that there are two prominent sources of danger to 
 the patient in fever — one, exhaustion from the direct influence of the 
 fever poison in depressing the vital energy ; and the other, the frequent 
 development of local disease. But we are never to forget that when 
 fever assumes the typoid form its duration is very uncertain. It may 
 last from three to six weeks, so that if the sustenance of the patient 
 be not attended to he may sink from inanition. On this point you 
 should read Dr. Graves' ninth lecture, in which he teaches how to feed 
 a patient in fever. I remember ouce, when he and I were going 
 
CHOICE OP FOOD IN FEVER. 189 
 
 through the convalescent wards, he expatiated on the healthy appear- 
 ance of the patients, many of whom had gone through long fevers. 
 "This is all owing to our good feeding, " he said. " Will you, when 
 the time comes, write my epitaph, and let it be — 'He fed fevers'?" 
 
 Now, this expression of one who was the representative man in 
 medicine in Ireland has been carped at by some of those whose criti- 
 cism means only fault- finding — a wide-spread class like the critic in 
 Goldsmith's Citizen of the World. " The work might have been better 
 if the artist had taken more pains." It has been supposed that Graves 
 advocated high feeding in fever indiscriminately, but you know too 
 much to believe this. lie speaks of the danger of the starving system, 
 and shows how the practice arose from the doctrines of those who 
 taught that fever was only symptomatic of inflammation. He shows 
 the effect of abstinence in producing symptoms similar to those of 
 the worst fevers, as exemplified in the wreck of the " Alceste" and 
 of the " Medusa." " You may," he says, " think that it is unnecessary 
 to give food, as the patient appears to have no appetite and does not 
 care for it. You might as well think of allowing the urine to accu- 
 mulate in the bladder, because the patient feels no desire to pass 
 it. You are called on to interfere, where the sensibility is impaired, 
 and the natural appetite is dormant; and you are not to permit your 
 patient to encounter the horrible consequences of inanition, because 
 he does not ask fur nutriment. I never do so. After the third or 
 fourth day of fever, I always prescribe mild nourishment, and this is 
 steadily and perseveringly continued through the whole course of the 
 disease." 
 
 He continues: "An attentive consideration of the foregoing argu- 
 ments has led me, in the treatment of long fevers, to adopt the advice 
 of a country physician of great shrewdness, who advised me never to 
 let my patients die of starvation. If I have more success than others 
 in the treatment of fever, I think it is owing in a great degree to the 
 adoption of this advice. I must, however, observe that great dis- 
 crimination is required in the choice of food. Although you will not 
 let your patient starve, do not fall into the opposite extreme: you 
 must take care not to overload the stomach. When this is done, 
 gastroenteric irritation, tympanites, inflammation and exasperated 
 febrile action are the consequences. I have witnessed many instances 
 of the danger of repletion in febrile diseases. A case of this kind oc- 
 curred some time ago in this hospital, in a boy who was recovering 
 from peritonitis. \n another case, in private practice, an incautious 
 indulgence in the use of animal food was followed by a fatal result. 
 A young lady ate some beefsteak, contrary to my orders, at an early 
 
190 LECTURES ON FEVER. 
 
 period of convalescence from fever, relapsed almost immediately, and 
 died of enteritis in thirty-six hours." 
 
 He then speaks of the care and judgment which are necessary in 
 giving food, particularly in the beginning of fever. He recommends 
 well-boiled gruel made of groats and flavoured with sugar, thin pa- 
 nado, and, as the fever advances, speaks of good and well-made chicken 
 broth as one of the best of nutriments — to be employed, however, at 
 first experimentally. He advises that. " all kinds of food and nutri- 
 ment should be given by day, and the patient should, if possible, be 
 restricted to the use of fluids by night. The natural habit is to take 
 food by day and not by night, and in sickness as well as in health we 
 should observe the diurnal revolution of the economy." Again, the 
 usual period of meals should be observed, and the space of time for 
 giving chicken broth, jelly, arrowroot, and other mild articles of diet 
 should be from eight o'clock in the morning to eight in the evening. 
 
 With respect to drinks, he considers that the patients are generally 
 allowed to drink too much. "It may be urged that they have a 
 strong desire for fluids; but they should not be gratified in everything 
 they wish for. The continued swilling of even the most innocent 
 fluids will bring on heaviness of stomach, nausea, pain, and flatulence, 
 and predisposes to congestion and intestinal irritation." Further on 
 he says: "You should never allow them to take a large quantity of 
 fluid at a time; you should impress upon them the danger attendant 
 on such a practice, and tell them that a spoonful or two, swallowed 
 slowly, allays thirst more effectually than drinking a pint at a time." 
 Again: "The abuse of ordinary drinks — as common water, whey, 
 barley water, soda and seltzer waters, and effervescing draughts— is a 
 frequent source of tympanitic swelling in fever." 
 
 I have now shown you that Dr. Graves was no advocate for the in- 
 discriminate and too liberal employment of food in fever, and that he 
 was fully alive to the dangers both of the want and the excess of food 
 even in convalescence. 
 
 In addition to the prejudices with which the inflammatory doctrine 
 imbued so many minds, with respect to the use of food in fever, a 
 new set of arguments was raised against it, in consequence of the ex- 
 periments of an American physician. I allude to the case observed 
 by Dr. Beaumont, and so often quoted since. In this remarkable case 
 various medicinal substances and articles of food were introduced 
 through an external fistula into the stomach; their effects were noted, 
 and also the conditions of temperature, vascularity, etc. The results 
 were subsequently published in connection with the action of the sto- 
 mach upon food. One of the results stated to have been thus obtained 
 
DIGESTION IN FEVER. 191 
 
 was, that the existence of the state of fever altogether suspended the 
 process of digestion. Here was a statement which had the appearance 
 of being founded upon strict observation. It influenced a number of 
 young men ; but did it influence those who had once been in charge of 
 a fever hospital ? Not at all ; because such men knew well that, no 
 matter what Beaumont might say about the stomach not digesting 
 when the patient had fever, in thousands of cases patients in fever 
 digested remarkably well, required food, and derived benefit from it. 
 In a large number of cases of typhus fever the stomach has an excel- 
 lent power of digestion; and, I believe, if we were bold enough, we 
 should find that many articles of food usually forbidden to fever 
 patients might be given to them with safety. 
 
 A remarkable incident was related to me which shows that the sto- 
 mach in fever is capable of digesting even a rather coarse article of 
 food. A lady who had been recently married was attacked with ex- 
 tremely severe petechial fever ; she was covered with dark-coloured 
 maculas, and disease had run to about the twelfth or thirteenth day. 
 She was attended by several eminent physicians. Her case w r as an 
 extremely bad one, and her life was all but despaired of. She was 
 violently delirious. Her husband, himself a physician, had occasion 
 to leave the house on some business. At the period of the dinner hour 
 of the family the servants were cooking a rump of beef and cabbage, 
 and the odour of it filled the house. In her delirium the patient 
 called for some of the dish. Her sister, who was attending her, be- 
 lieving she was dying, determined to indulge her, from the feeling 
 that it was right to accede to the request of a dying person. She 
 proceeded to the kitchen, and, as soon as the beef was boiled, brought 
 up a very large mess, smoking hot, to the lady's bedside, when she 
 devoured it with great avidity. Shortly afterwards her husband 
 came in, and was told what had happened. He became terrified, and 
 sent for physicians in every direction. Four or five assembled ; time 
 was pressing, and all agreed that something should be at once done. 
 
 Each of these physicians had his own suggestion to offer — one re- 
 commended an immediate emetic; another, a drastic purgative; a 
 third, a purgative injection ; a fourth, a large dose of calomel ; a fifth, 
 a powerful blister. At length the late Dr. Harvey, then Physician- 
 General and a man of the greatest practical knowledge in medicine, 
 joined the consultation, all members of which except himself were in 
 a state of intense excitement. At the time the stomach pump was 
 not in fashion, but every one agreed that some great effort should be 
 made to get the corned beef and cabbage out of the lady's stomach. Dr. 
 Harvey was entreated to go upstairs immediately to see the patient, 
 
192 LECTURES ON FEVER. 
 
 who was declared to be in coma. His first observation was charac- 
 teristic of the man. "Some of you," lie said, "help me off with my 
 coat." He proceeded leisurely to the bedside, where he remained for 
 some minutes, which appeared to the anxious consultants below an 
 inordinate period of time. He came downstairs slowly, and on en- 
 tering. the room was again surrounded, all of them declaring their 
 willingness to forego their individual opinions and to abide by his 
 decision, for not a moment further was to be lost. 
 
 He was quite unmoved by the situation, and simply said, " By , 
 
 I\\ let her sleep it out I" and took his departure. She did sleep it 
 out, and in the course of some hours awoke much better. Her re- 
 covery was perfect. 
 
 Now, I do not tell you this anecdote to induce you to feed your 
 patients with salt beef and cabbage in fever, but it is very important 
 as showing that in the advanced stage of a maculated typhus fever the 
 stomach is capable of digesting such an article of food as salt beef, 
 and that it proved in the particular case innocuous. Dr. Harvey 
 was too good a physician not to understand the evils of the nimia di- 
 ligenlia medicorum in fever, and the result showed the value of his 
 practical knowledge. The supposed coma was natural sleep — a most 
 favourable circumstance, and he knew his art too well not to decry 
 any interference with it. 
 
 There can be little doubt that in many cases of advanced fever a 
 greater latitude in the use of food might be adopted with advantage. 
 But you must remember that, in the lower ranks of life, the power 
 of the stomach to deal with a variety of food becomes less and less. 
 Ordinary nourishment commonly answers well where greater delica- 
 cies would be rejected or would disagree. 
 
STIMULANTS IN FEVER. 193 
 
 LECTURE XXVII. 
 
 Stimulants in fever — Views as to the nutrient properties of stimulants are to be 
 received with caution — Anticipative use of stimulants — Meaning of the term — Con- 
 siderations to be taken into account in resolving upon this method of treatment : (1) 
 prevailing epidemic character of the disease, (2) previous condition of the patient 
 (" Sinking of vital power" — Illustrative case — Stimulation often unsuccessful in the 
 intemperate, and in those whose brains are overworked), (3) development of symp- 
 toms of severe typhus, (4) development of fever odour — Contrast between typhus 
 and typhoid as regards period at which stimulation is called for — Condition of the 
 heart, a guide — Physical signs of cardiac weakening. 
 
 Following- the consideration of food in fever we shall next take 
 up that of diffusible stimulants. Their employment we have had to- 
 gether a full opportunity of studying, and those of you who are prac- 
 tising pupils have learned to prove their value and importance in 
 every form of fever. You have learned also to avoid routinism, and 
 you well know that when we speak of every form of fever we do not 
 mean every case of the disease. We have had cases in which no 
 wine was used, in which it was sparingly employed, where it was not 
 used until after the middle period of the fever. In many cases, too, 
 you had to use it and other stimulants with great boldness and for 
 many days, beginning at an early stage of the disease. Again, wine 
 had sometimes to be omitted, though the disease still was running on ; 
 and, lastly, its exhibition or its withdrawal had to be alternated sev- 
 eral times in the course of the disease. 
 
 Many of you have also learned that in fever the common error of 
 delaying the giving of stimulants to a very late period of the case is 
 a practice fraught with mischief, attributable to the prevalence of the 
 doctrine that fever and all its local symptoms were induced by in- 
 flammation. By this system all the good of the anticipative use of 
 stimulants is lost. 
 
 Any unbiassed observer of fever will admit that between the con- 
 dition of vital prostration and what is termed " waste of animal tissue" 
 there is no constant relation. We cannot deny the occurrence of 
 metamorphosis of tissue and waste of organic substance as incidental 
 to fever; on the contrary, we believe that these phenomena are re- 
 markably perceptible. But we must also hold that there is a prostra- 
 tion of vital energy — a tiling per se } which is totally unconnected with 
 loss of organic substance. Do not for a moment forget this — that the 
 13 
 
194 LECTURES ON FEVER. 
 
 forms of disease in which we find the greatest prostration of vital 
 power are those wherein we discover least signs of organic mischief. 
 A striking example of this is found in cholera, and in the various 
 forms of continued fever. 
 
 Now, I must tell you that the views of my lamented friend Dr- 
 Todd are to be received with caution. One thing is certain — that 
 whether we look on wine and brandy as food or simply as stimulants, 
 the great point is to know when and how to administer them bene- 
 ficially. We have not indeed attempted to decide the question ex- 
 perimentally as to whether stimulants act as food by repairing the 
 wasted tissues, for in all our cases food and stimulants were given to- 
 gether — our object being rather to save life than to settle an abstract 
 physiological question ; and many of you had cases of weakened heart 
 in fever where the influence of stimulants was too rapid to be ac- 
 counted for except on the principle of a direct action on the nervous 
 system. 
 
 It is true that we have seen life prolonged for several weeks by 
 stimulants alone. Some years ago a patient in one of the small wards 
 had long used a fabulous amount of spirits. He lived on brandy or 
 whiskey for a month, during which time he swallowed nothing else, and 
 cost the hospital a good deal more than his life was probably worth. 
 
 If Dr. Todd's views were to be carried out in every case of disease, 
 essential or otherwise; if, in short, we were to administer stimulants 
 on the routine principle — regarding them as nutrient substances, cal- 
 culated to supply the waste of animal tissue, and as it were rebuilding 
 the organic structure, we should find ourselves lamentably disap- 
 pointed. The adoption of such a system found very few supporters 
 among experienced physicians. 
 
 But let us do justice to Dr. Todd's memory. As practical men, in 
 the present state of our knowledge, we have little to do with questions 
 of physiology, and to him belongs the merit of showing that the use 
 of alcohol may be resorted to or at least borne in states of disease 
 where it was held to be dangerous. He has still further shown the error 
 of the anatomical school, which referred everything in acute disease to 
 inflammation ; and though he may have fallen into a routine practice, 
 we should be slow in holding him answerable for the errors of some 
 of his followers. 
 
 Even in many essential diseases you will find that stimulants are 
 contra-indicated or badly borne. I do not say that in such, an oppo- 
 site mode of treatment will succeed, but there are many cases of es- 
 sential disease — of puerperal fever, pyaemia, malignant scarlatina, small- 
 pox, and others — in which, though the vital strength is fearfully pros- 
 
ANTICIPATIVE STIMULATION. 195 
 
 trated, for some reason which we cannot explain stimulants are too 
 often powerless for good. There can be no doubt that the efficacy of 
 stimulation is closely connected with the prevailing epidemic character 
 of disease, and thus it was observed in our late visitation of small- 
 pox that wine and brandy were often productive of good effects. 
 But still the proposition is true that stimulants in the class of diseases 
 I have mentioned are not followed by the same happy and almost 
 heroic effects which we so often witness in typhus fever. 
 
 We may dwell upon the question of the use of stimulants in fever 
 as regards, first, the anticipative treatment, and next the treatment 
 urgently called for by the circumstances of the case. By the term 
 anticipative treatment you are to understand the administration of stim- 
 ulants at an early stage of fever, when, although there may be no 
 very pressing vital symptoms calling for their use, the sagacity of 
 the physician enables him to foretell the occurrence of great prostra- 
 tion of vital energy. Under such circumstances he gives stimulants 
 by anticipation. 
 
 In comparing the relative value of these two modes of proceeding, 
 I am of opinion that the anticipative method is that which will tend 
 most to the saving of human life. In adopting this line of practice 
 the physician does not wait until the patient has been labouring for 
 many days under the exhausting influence of the disease. He does 
 not withhold the needful aid until the 10th or 12th day, when the 
 prostration of vital energy has assumed a formidable aspect, when the 
 prompt use of stimulants is suggested by common sense, and when 
 often, unfortunately, the system is incapable of responding to the 
 remedy. For you will learn that where the powers of life have re- 
 mained long without support, a downward process may commence 
 from which no effort can rescue the sufferer. 
 
 In the anticipative treatment we follow the old maxim, " venienti 
 occurrite morbo," and he who knows when to adopt it has gained a 
 high place in practical medicine. 
 
 In determining on the employment or the contrary of the anticipa- 
 tive treatment, the following considerations must be present to you 
 
 First, the epidemic character or habit of the disease; secondly, the 
 previous condition of the patient. 
 
 What we have to guard against is a sudden sinking of the vital 
 energy, shown by special conditions of the nervous and the circula- 
 tory systems. I have told you, that, with respect to these and the other 
 systems in fever where the strength has been unsupported, the down- 
 ward tendency goes on until a point is peached from which there is 
 no revival. In these eases there is between the heart and the nervous 
 
196 LECTURES ON FEVER. 
 
 centres a great sympathy, and the condition of the one — which is re- 
 vealed by manifest physical signs, and with which you are all now 
 familiar — gives you a clear conception of the state of the brain and 
 the spinal marrow. 
 
 This failure of the heart, like the other secondary affections, is 
 under the law of periodicity, yet I believe it may occur in chronic 
 cases, but with this difference — that having become established it 
 continues until the end. A gentleman of energetic and industrious 
 habits, who lived well and took his bottle of wine daily, and who 
 never showed any disease of the heart, became subject to attacks of 
 ordinary gout. He was persuaded to undergo a protracted course of 
 hydropathy, during which the candle was burned at both ends, for 
 no wine or stimulant was allowed for more than a month. His con- 
 dition was remarkable; he had no pains, no fever, the pulse was about 
 sixty, weak but regular, and when asked to describe his symptoms he 
 said, "I have no complaint to make, but of a strange weakness of 
 body and mind which is quite new to me." He lived for several 
 weeks, the failure of the heart increasing every day, while no amount 
 of stimulation had any effect in restoring its vigour, and he died 
 without any ascertainable cause beyond mere nervous exhaustion. 
 The process of death was peculiarly slow. 
 
 This sinking of the vital power, not accounted for by any apparent 
 loss of organic tissue, takes place in fever, and it is with a view of 
 arresting its progress that we have recourse to the anticipative treat- 
 ment. But there are various grounds for adopting this line of con- 
 duct; for example, if you know that in the epidemic, a great number 
 of cases assume well-marked symptoms of prostration, say on the 
 seventh, eighth, or ninth day, you will on the fourth or fifth anticipate 
 their occurrence by commencing the use of stimulants. Even in the 
 middle of the course of a fever case, or at any period of its progress, 
 you will do right to guard against the occurrence of sudden prostra- 
 tion, which, when once it has set in, especially in mature age, may 
 resist the most active stimulation. 
 
 But there are collateral circumstances to which you must look — 
 such as the previous history of your patient, his habits of life, his 
 previous health, in short, whether he brings into this contest with a 
 formidable disease a constitution affected by previous illness, bad 
 habits, or nervous exhaustion. You will also ascertain whether any 
 ignorant attempts to cut short the fever had been made ; the patient 
 may have been bled for supposed inflammation, he may have had 
 cathartics, mercury, tartar emetic, or powerful diaphoretics. In such 
 cases you have solid reasons for adopting the anticipative method, 
 
INDICATIONS FOR STIMULATION. 197 
 
 though the patient may not as yet have fallen into a state of pros- 
 tration. 
 
 The fall administration of stimulants is generally called for when 
 the patient has passed the age of eighteen or twenty. In children 
 we are obliged to have recourse to stimulants, but we employ them 
 in a modified manner; their energetic use is indicated principally 
 in adults between the age of twenty-five and forty-five, and here we 
 employ them at an early period, not so much to combat existing 
 prostration, but to anticipate the depression of vital power which 
 sooner or latter is almost certain to ensue. 
 
 In estimating the chances that the employment of stimulants will 
 be followed by success, much will depend on the previous habits of 
 the patient. We have long found that the greatest triumphs of the 
 stimulating treatment were seen in patients of strictly temperate 
 habits, who seem more capable in fever of bearing large quantities of 
 stimulants without intoxication. In private practice we often find 
 that stimulation cannot be carried on so boldly as in hospital ; and 
 this appears to be connected with the previous habits of the patient, 
 not in the way of intemperance in the use of wine, but in that of over 
 exercise of the brain. Men engaged in anxious callings, or in intense 
 mental exertion, are bad subjects in fever, and bear the stimulating 
 treatment imperfectly. Thus it is that professional men so frequently 
 succumb — witness the frightful mortality among the medical men of 
 Ireland in the famine fever. In many such cases, with symptoms of 
 profound adynamia, stimulants are badly borne, and hence — when the 
 disease, as too often happens, is of a malignant character — the patient 
 makes but a poor fight, and adds to the list of victims who have fallen 
 in the discharge of their duty. 
 
 For the first few days your patient may make little complaint. 
 There are often remissions in which he declares himself much better; 
 but if the symptoms of essential fever are gradually developing them- 
 selves, if petechial spots begin to appearand particularly if the skin 
 exhibits the dusky discoloration so characteristic of typhus, you may 
 expect severity of symptoms. This discoloration appears, and after 
 a time recedes, as the petechia come and vanish, and like them too is 
 subject to the law of periodicity. 
 
 Another indication for the early exhibition of stimulants is the 
 peculiar fever-odour sometimes present from a very early period. 
 Benign fevers rarely are attended with this peculiar odour, which 
 belongs to more malignant forms of disease. 
 
 You will observe that the symptoms I have particularized are more 
 closely connected with typhus and with typhoid fever, and- accord- 
 
198 LECTURES ON FEVER. 
 
 ingly we find that early stimulation is much more frequently indicated 
 in the former than in the latter; in other words, the free use of stimu- 
 lants, when necessary, is called for at a later stage of the disease in 
 typhoid than in typhus. It is right, however, for us to bear in mind 
 that some of the cases requiring the most powerful stimulation have 
 been of typhoid fever in its advanced and complicated condition. 
 
 It is in petechial typhus that the anticipative treatment is most 
 frequently called for, and will be found to answer best. In typhoid 
 fever the occurrence of prostration is commonly later observed, and is 
 of more gradual development. As we have already seen, this form 
 of fever is less manifestly under the law of periodicity than true 
 typhus, and the character of its secondary affections is more variable. 
 
 Physicians have from the earliest times been in the habit of deter- 
 mining on the administration or withholding of stimulants in fever by 
 the state of the pulse. But — at least in the early periods of fever — 
 the pulse taken alone is not to be depended on. It may be, up to the 
 fourth day, full, throbbing, and resisting, and this has often led to 
 errors in practice of both commission and omission. I have shown 
 you that even under these circumstances an examination of the 
 heart may reveal the commencement of a change in the vital condi- 
 tion of that organ. It was this temporary excitement of the pulse 
 that led to the practice of bleeding, and of employing other depleting 
 measures, by which the vital power was expended at an early stage 
 of the case, and the influence of the law of periodicity was interfered 
 with. 
 
 This ephemeral state of arterial excitement led, on the other hand, 
 to errors of omission. The apparently inflammatory condition caused 
 apprehension — the existing state was alone attended to, and the prob- 
 able future in the case disregarded. You will not fall into these 
 errors. The secondary debility of the heart may have commenced at 
 a time when this pseudo-inflammatory state still existed, while in fact 
 the pulse continued full and bounding, and the temperature high. 
 
 Take this rule with you into practice — that in the treatment of 
 fever, and at almost any period of fever, you are not to be guided by 
 the pulse alone. It must be observed in relation to the action of the 
 heart — remembering that a full and good pulse may coincide with a 
 feebly acting heart — a heart under the influence of the fever poison, 
 often as it were on its way to the state of softening. All this you see 
 bears on the question of the anticipative treatment. 
 
 Now among the most reliable indications for the early use of this 
 treatment are the physical signs of weakness of the heart. 
 
 A man, aged 30, was admitted on the sixth day of typhus fever. 
 
WEAKNESS OF THE HEART. 199 
 
 He was the fifth of his family who within a short time had severe 
 maculated typhus. The impulse of the heart was scarcely perceptible, 
 and there was already a distinct preponderance of the second sound. 
 On the next day the impulse was imperceptible, even when he lay on 
 the left side. He was ordered twenty ounces of wine, a blister over 
 the heart, and beef-tea. The following day the impulse could be felt, 
 but the sounds resembled those of a foetal heart. The wine was 
 increased, and two glasses of brandy were also administered. On the 
 12th day the pulse had fallen to 80, and the sounds of the heart were 
 greatly improved ; on the 13th day the impulse of the heart was re- 
 stored, its sounds were proportionate, and the pulse had fallen to 76. 
 The diminution of the first sound of the heart led us to the exhibition 
 of stimulants boldly, and at an early period of the case. On the 7th 
 day the impulse was imperceptible, while on the 8th the first sound 
 had disappeared ; and although the other symptoms did not seem to 
 call for active stimulation, wine was ordered in free doses from this 
 indication alone. The symptoms of cardiac debility were observed at 
 so early a period as the sixth day, but it is probable that the typhous 
 affection of the heart had commenced even before admission to 
 hospital. 
 
 So far as the heart is concerned, the following are the physical signs 
 which seem to indicate the anticipative use of stimulants. I have put 
 them down in their chronological order: — 
 
 (1.) Early subsidence of the first sound, observed over the left 
 
 ventricle. 
 (2.) Diminution of the first sound over the right ventricle. 
 (3.) The heart acting with a single, and that the second sound. 
 (4.) Both sounds being audible, but their relative intensity being 
 changed so as to represent the action of the heart of a foetus 
 in utero. 
 (5.) With these signs, a progressive diminution of impulse, which 
 occasionally becomes imperceptible, even when the patient 
 lies on the left side. 
 During convalescence, as we have seen, the signs of recovery of the 
 heart are usually observed first on the right side, and afterwards over 
 the left side. 
 
 With reference to the anticipative treatment, we have spoken 
 principally of the results of physical examination, as indicative of 
 the typhous weakening of the heart in the early stages of fever. I 
 have stated, that, although in the commencement of a typhoid fever 
 any bold exhibition of stimulants is not often called for, yet in its 
 advanced stages we have sometimes to make free use of stimulation. 
 
200 LECTURES ON FEVER. 
 
 I have observed that students were occasionally under a misappre- 
 hension about the doctrines which we have long held in this hospital 
 with respect to the condition of the heart as a guide for the use of 
 wine. They have come to the erroneous opinion that we are to give 
 wine only when we find the want or diminution of the first sound of the 
 heart, and that we are not to give wine where the heart is acting well. 
 This is a mistaken view. As to the state of the heart in connection 
 with the effect of stimulants, we have ascertained that the efficacy of 
 stimulants is often directly as the debility of the organ. It has also 
 been ascertained that the power of bearing stimulants, their effect 
 upon the nervous system, their good effects on the general condition, 
 are directly as the weakness of the heart. 
 
 We may lay down as a rule, that there are three conditions of the 
 heart to be looked at by the practical man in the treatment of fever. 
 
 In one, we have an excited heart — a violently excited heart all 
 through the case; and this, although the symptoms be those of extreme 
 adynamia, although the surface be cold, the breath cold, and the pulse so 
 feeble that it cannot be discovered. Nay, the heart may act with great 
 force for several days, and yet there may be no pulse at the wrist. 
 This is one case. 
 
 In the next case, we find an exactly opposite condition, in which the 
 systolic force of the heart is diminished. This is shown by loss of 
 impulse, by diminution — and, in certain cases, by extinction — of the 
 first sound of the heart, while the second remains. This is a case 
 which calls for wine, and in which you should give it; it is a case in 
 which, in the vast majority of instances, wine will agree with the 
 patient. 
 
 There is a third set of cases in which the heart does not seem to be 
 implicated at all in the course of the disease — in which, notwithstand- 
 ing the existence of the most extraordinary group of symptoms affecting 
 various organs, the heart, in the middle of the storm, seems to be in a 
 state of calm and quiet. 
 
 If we compare these three conditions with a view to prognosis, we 
 may arrange them in this way. The excited heart all through, with 
 feeble pulse and with adynamia, is unquestionably the worst. There 
 is no worse symptom in fever than an excited heart. It is especially 
 a bad symptom when, with that excitement, we find a feeble pulse. 
 Next will be the case of sinking of the heart ; and the most favour- 
 able condition is that in which, as I said before, the heart seems to 
 escape disease. 
 
 You are not, however, to suppose that because you have an ex- 
 cited heart you are not to give wine ; or that, because the heart is not 
 
STIMULANTS IN FEVEE. 201 
 
 affected at all, you are to withhold wine if in either case the general 
 symptoms of the patient require it. You are not to found your ex- 
 hibition of wine or other stimulants upon any one thing; you are to 
 take the general state of the patient into consideration. What we 
 have done is to discover an intelligible practical rule which will 
 guide you in the use of wine in certain, I think in many, cases; but 
 you are not to suppose that because a man has a clear first sound of 
 the heart, therefore you are not to give him wine. You are not to 
 suppose that because the heart is safe you can do without wine. Now, 
 in a case recently under your observation, although the heart seemed 
 to escape, or was at most only feeble through the course of the dis- 
 ease, frightful adynamia existed; day after day the patient's face was 
 Hippocratic, or almost so ; the general character of the disease was 
 that of the most terrible putrescent fever — yet his heart escaped. 
 And here is the result. We have given that man upwards of twenty 
 bottles of wine and twenty-four ounces of brandy, and now, on the 
 twenty-eighth or thirtieth day of the disease, we have the satisfaction 
 of feeling that his case may be set down as among the triumphs of 
 medicine. 
 
 I wish also strongly to impress on you the great importance of the 
 use of other forms of nourishment in this disease ; for we must not 
 only keep up the nervous energy of the system by wine, but we must 
 support nature by food. There is no greater mistake in fever than 
 that of the withholding; of food. 
 
 LECTURE XXV ITT. 
 
 Stimulants in Fever, continued — Signs in connection with the heart of the agreement 
 of stimulants : (1) return of impulse, (i) return of first sound, (3) gradual fall hi 
 the rate of the pulse— In cases of " foetal heart" great boldness in stimulation is 
 Deeded — No certain rules as to quantity of wine and whiskey or brandy required — 
 Examples of free use of stimulants in malignant typhus — Case of Hardoastle (ty- 
 phoid fever) — Eruption of vesicles as a secondary complication — Bed-sores. 
 
 We arc today to consider practically the use of stimulants in fever. 
 This is a matter difficult to be taught orally. The exhibition and the. 
 management of stimulants in ^cvcv are among those points in practice 
 which are best learned at the bedside, so that when I am addressing 
 the advanced students — men who themselves have already largely 
 shared in the responsibilities of the fever wards — I do so as a fellow- 
 student on the one hand, and a brother practitioner on the other. 
 
202 LECTURES ON FEVER. 
 
 Many medical men who have received little beyond a surgical edu- 
 cation, or who have not had a case of fever on their hands before 
 they entered into practice, and who probably have never attended in 
 the wards of a fever hospital, on their first meeting with the disease, 
 are timid in the use of wine in fever, and have not learned that in 
 this disease the symptoms of inflammation are commonly fallacious. 
 This, as I have before said, is from the nature of their medical educa- 
 tion. Here we see the wisdom of that regulation of the University 
 of Dublin, in accordance with which all candidates for the degree of 
 Bachelor of Medicine must show that they have personally attended 
 at least five cases of fever before being admitted to examination. 
 
 As experience increases, men become less timid in the use of wine, 
 and accordingly we find that those physicians who are sneeringly 
 termed men of the old school, are often the best practitioners in fever ; 
 they have learned by experience in middle life what you have been 
 taught in your student days, and they know, by their perception of 
 the vital phenomena, when to give or not to give stimulants, when to 
 increase, to diminish, or to omit them. 
 
 Now it is a great thing to possess a simple rule which will guide 
 the practitioner who has had little or no experience in this matter, in 
 the exhibition of wine — and I believe that in the observation of the 
 ph} r sical signs of the heart, he will obtain such assistance. You will 
 not suppose that I advise you to be guided solely by the state of the 
 heart, but I say that in solving the question as to the use and the 
 management of stimulants, you are to ascertain and consider in every 
 case the condition of the organ plus the general symptoms and his- 
 tory. 
 
 We have already studied the anticipative use of wine. Let us sup- 
 pose we have a case of maculated typhus, say on the sixth or eighth 
 day — the pulse not very weak, and at 115 or 125 in the minute; you 
 find that the impulse is not strong, or it may be absent, unless when 
 the patient lies on the left side — the first or ventricular sound is les- 
 sened. Under such circumstances the use of wine is called for, and 
 there is a strong probability that it will agree. You begin with six 
 or eight ounces of good port in the day — given in divided- doses, 
 together with proper food. 
 
 It will always be right that in such a case you should see the 
 patient in the course of six or eight hours, to judge whether the stim- 
 ulant has agreed ; in a few cases even at this period of the fever the 
 depression of the heart goes on rapidly, and if so, the stimulant will 
 have to be increased. Should things on the next day remain without 
 change, and should there be no signs of the stimulant having dis- 
 
AGREEMENT OF STIMULANTS. 203 
 
 agreed, you may continue. By-and-by it may happen that the first 
 sound of the heart disappears, so that the organ acts with a single 
 sound, even over both ventricles. This indicates increasing debility, 
 and calls for a free use of the stimulant, and, in many cases, the em- 
 ployment of brandy, for which a good vehicle is warmed milk with a 
 little sugar. 
 
 Now, in most cases of typhus fever in this country with favourable 
 result, the prostration of the patient, of which the heart is commonly 
 so good an index, begins to disappear at about the twelfth day, but 
 you may find evidences that the wine has agreed even before that 
 period. Of these the principal are :— 
 
 1st. The return of impulse. 
 
 2d. The commencing re-establishment of the first sound. 
 
 3d. The gradual coming down of the rate of the pulse. 
 
 Of these, the second and the third are the most important, for the 
 return of impulse is sometimes the commencement of an excited state 
 of the heart— always an unfavourable symptom in fever. When the 
 first sound is restored in its normal manner, the process is gradual, 
 being commonly first perceived over the right ventricle, and when 
 completed it has its natural character. 
 
 But with regard to prognosis, the best indication of the agreement 
 of stimulants is the lessened rate of the pulse; even a slight diminu 
 tion, say of two or three beats in the minute, is of great importance. 
 If -at your next visit the diminution of rate goes on, it is a great en- 
 couragement to a good prognosis. Remember how often we have 
 seen a good result when the only favourable point in the case was that 
 the pulse became slower and slower while stimulants were being freely 
 used. Still, to say that the falling of the pulse under stimulants is a 
 certain ground for a good prognosis would not be justifiable, as Ave 
 shall see presently. 
 
 In cases of extreme nervous prostration and debility of the heart, 
 as shown by the foetal character of the sounds — or in some instances 
 by the extinction of all sound, while the pulse continues — great bold- 
 ness may be used in the administration of stimulants. It is true that 
 in examples of the "foetal" heart the ventricular sound continues. 
 Yet we have found that the lessening of the second sound is an im- 
 portant sign of generally deficient vital energy, and the necessity of 
 free stimulation. Of this I offer no explanation, but of the fact I am 
 certain. 
 
 It is very difficult to lay down rules as to the quantity of wine or 
 other stimulants that may be required by circumstances, and you 
 have seen cases in which the patients took a quantity of stimulants, 
 
204 LECTURES ON FEVER. 
 
 which in the state of health would have produced intoxication. We 
 have commonly given from 16 to 21 ounces of wine with half a pint 
 of brandy in the day; and in many cases we might have given more, 
 and with advantage. 
 
 In a severe case of maculated typhus with extinction of the first 
 sound over both ventricles from the seventh day, 96 ounces of wine 
 with five ounces of brandy were exhibited. The coming down of the 
 pulse was remarkable. 
 
 Thus on the 7th day it was at 124 
 8th " 120 
 
 11th " 116 
 
 12th " 96 
 
 18th " SO 
 
 15th " 76 
 
 On this last day the skin was cool, the impulse perceptible, and the 
 sounds proportionate. 
 
 This case also showed that peculiar character of pulse which we 
 have observed in many examples of the debilitated heart in fever 
 treated by free stimulation, the pulse having been restored to its natu- 
 ral rate, and convalscence all but established. It continued to fall 
 even as low as 32 in the minute, when it rose progressively to its 
 natural standard. 
 
 Thus in this case the pulse was — 
 
 17th day 60 
 
 18th " 50 
 
 22d " 32 
 
 25th " 60 
 
 The convalescence was perfect on the 18th day. 
 
 This case was a model example of typhus, in which recovery was 
 not interfered with by any secondary lesion. The falling of the 
 pulse so far below the natural standard is not constant, but I have 
 always looked on it as showing that the heart had been greatly weak- 
 ened, with or without muscular softening. 
 
 I have told you that no rule can be laid down as to the actual 
 quantity of stimulants to be exhibited. Every case has its own pe- 
 culiarities even in the same epidemic. You will have differences in 
 the necessity for stimulation, differences in the degree of vital pros- 
 tration, in local complication, and in all the physical signs of the 
 heart as to their nature, combination, mode of subsidence, and be- 
 haviour under treatment. As a general rule the freer the case is 
 from manifest local complication, apart from the vital depression of the 
 
ILLUSTRATIVE CASES. 205 
 
 heart, the bolder may you be in stimulation. But you are not to 
 allow the local complications — except that of active irritation of the 
 brain — to deter you ; and even in certain cerebral cases, where cir- 
 cumstances call for it, you may use stimulants tentatively. 
 
 Two cases of most malignant typhus occurred to me some years 
 ago. Both the patients were medical men; one was a young man of 
 a non-excitable and phlegmatic temperament. In this case the use 
 of stimulants was commenced at about the eighth day, and ran on 
 for more than a week. The symptoms were extreme prostration, con- 
 tinued — though not profound — coma, weakness of circulation, cold- 
 ness of breath, enormous vibices, a general purpling of the skin, and 
 paralysis of the bladder. A worse case so far as the essential disease 
 was concerned could hardly be conceived. Fortunately the power of 
 swallowing was unaffected, and you are not to despair of any case of 
 fever as long as deglutition remains. During ten days the stimulants 
 given were so varied and in such large quantity that his friends 
 refused to continue them, thinking it would be a dreadful thing that 
 the patient should leave the world in a state of intoxication. We 
 could not persuade them that we knew better, and we had to send 
 one of the class of this hospital to mount guard over the case, and to 
 administer the wine and brandy perforce. By the twenty-first day. 
 when the disease subsided, he had taken at least two dozen of wine, 
 including port, Madeira, and champagne, with six large bottles of 
 brandy. The recovery was perfect and without any accident, and the 
 gentleman has since enjoyed many years of the best health. 
 
 In the second case I did not see the patient until the twelfth day. 
 He was a man of high mental culture and activity of mind and body. 
 He had been attended by a physician of the anatomical and antiphlo- 
 gistic school. In place of food he had got mercury, and in place of 
 wine, tartar emetic. A glass of claret had been permitted on the day 
 before we saw him. There was no disturbance of the brain, but he 
 was covered with a petechial eruption approaching to purpura. The 
 surface was cold, and the pulse almost imperceptible. From the mid- 
 dle of the calf of each leg downwards, and over both feet, the surface 
 was black, the skin hanging in loose wrinkles, giving an appearance 
 as if the patient had on a pair of black socks. We expected mortifi- 
 cation of the legs and feet, but, within twenty-four hours from the 
 commencement of the stimulating treatment, the circulation was fully 
 re-established, the blackness had disappeared, the feet had become 
 warm, and the fulness of the limbs had returned. I need not tell you 
 that stimulants were used boldly. In the first eight hours sixteen 
 
206 LECTURES ON FEVER. 
 
 ounces of brandy were given. The patient made an excellent re- 
 covery, and is still in the best health. 
 
 In both these cases the patients had been of very temperate habits. 
 The disease was a most severe but uncomplicated typhus, the nervous 
 system not excited, and the stimulants agreed throughout. Both 
 cases were thus well adapted for the bold and continued use of the 
 stimulant treatment. 
 
 Gentlemen, there is at present in our wards a patient whose case I 
 would commend to your most attentive study. I refer to the young 
 man Hardcastle, in whom the general symptoms of fever are presented 
 in their most aggravated and appalling form. This patient is a native 
 of England, and had been but a short time in Dublin. His case is 
 full of instruction. 
 
 I have mentioned that he is not a native of Ireland because it is 
 probable that this circumstance has acted in modifying the symptoms 
 of his disease. Had this patient been attacked with fever in his 
 native place, he probably would have shown the symptoms of ordi- 
 nary typhoid fever, and the case would have been a comparatively 
 mild one. But at all events, this much we may believe, that different 
 countries present endemic, sporadic, and even epidemic fevers, with 
 characters in some degree peculiar to themselves; and we are not yet 
 able to explain why fever in one country differs so much from fever 
 in another — why maculated typhus should be so common in Ireland, 
 and comparatively rare in England — or why the fever in Paris should 
 so commonly present a particular local lesion. Many causes doubt 
 less act; and I suppose among others, such as climate, diet, soil, and 
 so on, the race and temperament are to be reckoned. 
 
 I have suggested that if various families of mankind have a physio- 
 logical stamp, they probably have also their pathological peculiarities. 
 However this may be, it becomes a curious subject of inquiry, to de- 
 termine what are the modifications of the symptoms of the fever in 
 Ireland or in any other country, when the patient is not a native of 
 the country, and especially if he has not been long resident in it. The 
 most extraordinary case I ever witnessed was that of a gentleman, a 
 native of France, who, after a long exposure to contagion during the 
 famine fever, contracted maculated typhus here. He was a man of a 
 sanguineo-nervous temperament, and exhibited during his illness a 
 succession of symptoms widely different from those which we com- 
 monly see in the spotted typhus of this country. He was profusely 
 maculated, and the peculiarity of the case consisted in the irregular 
 manifestations of various local symptoms — principally engaging the 
 nervous system— and the inconstancy of the general condition, espe- 
 
RACE AND TEMPERAMENT. 207 
 
 cially with, reference to excitement or collapse. This gentleman 
 happily recovered, after passing through a storm of disease such as I 
 and his other attendant, Dr. O'Ferral. had never seen before. 
 
 Hardcastle is a young man who has been well educated, and he is 
 evidently above the rank of the ordinary hospital patient. His symp- 
 toms have been, from an early period of the disease, alarming in the 
 highest degree. You will seldom see a worse case of adynamic fever. 
 We may safely say, that for the last fortnight, both by day and by 
 night, there has been an uninterrupted struggle between medical art 
 and the fell disease which is upon him. During that time he has been 
 lying more like a decomposing corpse than a living man ; but he has 
 been kept from dying by the bold and constant exhibition of stimu- 
 lants, by tonics, and by food. 
 
 Some of you may wonder why it is that we thus go on with the 
 increasing exhibition of stimulants — the untiring efforts to support 
 life — although for the last ten days, at least, we have been hourly ex- 
 pecting his death. The answer is, that we believe his disease to be 
 one which may subside, sooner or later, under the law of periodic 
 action. His recovery will then take place — not in consequence of 
 the action of any specific which has the power of curing fever, but 
 from causes the nature of which is hidden from us. We are like the 
 defenders of a post attacked by a powerful enemy, but yet expecting 
 succour, and we seek to hold the place until that succour arrives. 
 
 There are two points in this case worthy of notice. One is that 
 the nervous system has been so little engaged. He has had occasion- 
 ally a slight delirium, and latterly some agitation and slight subsultus 
 tendinum ; but though he generally appears sunk in stupor, it is not 
 true coma, but rather the stupor of exhaustion, for, when you rouse 
 him, his intelligence appears to be good. Is this escape of the brain 
 to be looked on as favourable, or the contrary? According to an old 
 and well-founded opinion, all anomalous circumstances in fever are to 
 be feared. You know the aphorism, "Pulsus, vullus, et urina bona: et 
 eager morilur." This contains an important truth ; but, in typhus, the 
 want of nervous symptoms is in general favourable; for of the symp- 
 toms referrible to one of the three cavities, doubtless those indicating 
 nervous lesion are the most formidable. 
 
 The second [joint to which I wish to direct your attention is, that, 
 although this patient presents the symptoms of typhus so decidedly, 
 he cannot be said to have any rnaculas or petechia:. In fact, his skin 
 has been unaffected; there has been none of the so-called exanthema- 
 tous eruption of typhus; and, even at this advanced period, the 
 existence of petechia? is so doubtful, that I would not say that lie has 
 
208 LECTURES ON FEVER. 
 
 them. Yet, if ever a man had the typhus gravior, this man has it. 
 His surface exhales the peculiar odour of typhus, strongly marked ; 
 he is prostrated to the last degree ; he has been kept alive by the most 
 powerful stimulation ; he has a feeble heart, and well-marked second- 
 ary affections of the intestinal and bronchial surfaces; his mouth is 
 full of sordes ; his tongue black, dry, and cracked ; his breath fetid. 
 The stethoscope indicates a general and severe bronchial affection, 
 and there is a wasting diarrhoea. 
 
 I am not going to take up your time by a discussion as to the dis- 
 tinctive characters of typhus and typhoid fever. But it would be, I 
 think, difficult even to the advocates of the distinction, to declare in 
 which class this case should be placed. In this instance, as in most 
 others, the settlement of the question is of little value; for, whether 
 the disease be typhus or typhoid fever, the treatment should be no other 
 than that which we have so far carried out. I may say this much, 
 however, that the presence or absence of an early eruption having 
 some similarity to an exanthem, or, again, the presence of petechias, 
 appears to be insufficient to justify our drawing a strong line of dis- 
 tinction between these diseases. I would advise you to receive with 
 more than caution the doctrine, that the early eruption in typhus is a 
 true exanthem, and that its absence in any given case points out that 
 the disease is not typhus, but typhoid fever. 
 
 Again, it is stated that the non-maculated fevers are often protracted 
 and dangerous ; so they are, but not so often as they are short and 
 easily managed. And I have not seen that relief of organs in typhus, 
 which some describe as the rule, when the eruption appears. How, 
 then, are we to look on the eruption. Certainly not as a distinctive 
 mark between two different diseases. Gentlemen, we know that 
 typhus fever will run its course and destroy life, without the necessary 
 production of any hitherto ascertained anatomical change. We know 
 further, that in many cases local alterations are formed, but that there 
 is the greatest inconstancy in different epidemics, and in different 
 patients during the same epidemic, in the seat, amount, time of appear- 
 ance, and results of these local changes. The cutaneous rash is 
 plainly one of this group of secondary affections ; and its absence or 
 presence can no more be said to distinguish the disease, than the 
 absence or presence of any other of these affections. I think we may 
 admit that an early and florid eruption is often met with in typhus, 
 which is well marked in other respects also; and again, that such 
 cases generally require and bear stimulation. 
 
 To return to the case of Hardcastle. We observe that there has 
 been as yet no tendency to the critical or periodical retrocession either 
 
BED-SORES. 209 
 
 of the secondary diseases or of the general affection. The fourteenth 
 day passed by without any crisis, or without any subsidence of the 
 disease ; the eighteenth day passed by ; the twenty-first day has 
 passed by; and he is now in the twenty -fourth day of this terrible 
 disease, kept alive by the use of wine, administered every hour, and 
 also by the free use of hot brandy punch. He presents an appearance 
 to-day to which I wish specially to direct your attention. You may 
 remember that Saturday last was the twenty-first day, and it was 
 then reported to me that the patient was getting a bed-sore. Upon 
 examining him, we found in the ordinary situation of bed-sores a 
 blush of redness and a slight degree of oedema ; but beyond that there 
 was nothing remarkable. There was this point, however, which I 
 observed at the time, although it was not until to-day that I thought 
 it of importance, namely, that there was already a solution of continuity 
 of the skin. Now, this is remarkable, and if such a case should occur 
 to me again it would awaken my attention. In the ordinary cases of 
 bed-sores we seldom see a solution of continuity of the skin at an 
 early period; we see lividity, blackness if you will; but a solution of 
 continuity of the skin before the ordinary appearances of mortification 
 have occurred, is extremely rare. 
 
 In this patient, on Saturday, just at the very centre of the livid 
 patch on the skin, there was a slight solution of continuity. During 
 the evening the nurse observed that several dark-coloured vesicles or 
 pustules were making their appearance on various parts of his body. 
 Mr. Parr saw these on Sunday, and he found that between the shoulders 
 there was an eruption of livid tumours, which appeared to be some- 
 thing between vesicles and pustules. To-day (Tuesday) such of you 
 as saw the patient will not soon forget the extraordinary appearance 
 of his back. I have been attending on fever in this hospital since 
 1827, and I never saw anything of this kind before. 
 
 Now, it is a very remarkable circumstance, that this eruption of 
 gangrenous vesicles or pustules should have occurred upon the twen- 
 ty-first day; and this case, as far as it goes, appears to strengthen an 
 opinion, which I have long held — that we were in error in attributing 
 what are termed bed-sores in fever, simply to mechanical causes. The 
 general idea is, you know, that they are simply the result of pressure 
 long continued on a particular part of the body, from the neglect of 
 turning the patient in bed — of pressure combined with the effects of 
 position. Now there can be no doubt that these are predisposing 
 causes, but whether they are the sole and entire causes is another 
 matter ; and I am almost convinced that the bed-sore in fever is often 
 one of the group of secondary affections analogous to the ulceration, 
 14 
 
210 LECTURES ON FEVER. 
 
 or the tumefaction and ulceration, of the glands of the intestine — or 
 to the bronchial affection which occurs in the middle stages of the 
 disease — or to the other secondary organic diseases of fever. And if 
 analogous to them, it should be more or less observed to be under the 
 law of periodicity; it should appear and disappear at a certain time, 
 or, at least, exhibit a tendency to do so. We have observed this very 
 curious fact. There are cases in which the system seems to be in such 
 a state that bed-sores will form from the slightest possible causes — 
 that is to say, whenever there is any irritation or pressure, no matter 
 how slight, a bed-sore will form in any part of the body. Some years 
 ago we had a patient in this hospital, who, after the twelfth day, 
 showed this tendency. She had bed-sores on the nates, and one on 
 each shoulder. Then the tendency to the multiplication of these sores 
 increased, and every morning two or three new ones were discovered. 
 Wherever there was the slightest possible pressure, we found a gan- 
 grenous spot — in the fold of the arm ; in the fold of the pectoral 
 muscle; where the mamma leant upon the arm ; where the head leant 
 upon the hand in sleep; where one leg lay on the other — the mark of 
 a black hand was stamped upon the surface. In every possible posi- 
 tion in which anything like pressure was made, or irritation excited, 
 there were bed-sores ; and this tendency went on day after day, up 
 to a certain day, until there were about thirty sloughs in different 
 parts of the body. From that day — I might say from an hour of that 
 day — no more bed-sores formed, although the constitutional symp- 
 toms had not subsided. The patient then had to go through the 
 process of throwing off all these sloughs, of granulation of the cavities 
 from below, and of their cicatrization. She was kept lying on her 
 face for upwards of a month, and finally recovered. 
 
 Now what I want to draw your attention to in the case of Hardcastle 
 is, that this extraordinary eruption of gangrenous patches on his back 
 is not of the nature of bed-sores in the ordinary sense of the word. 
 These patches are not produced by pressure. We find them in great 
 abundance in the hollow of the back, where pressure is relieved by 
 the pelvis and by the shoulders. We find them in abundance in the 
 interscapular region ; but if we wanted additional proof it is this — 
 that we find them on the anterior portion of the thorax. They came 
 out as vesicles. These vesicles became hard at the top, then black, 
 and soon the mass dropped out ; and this patient's back is now as if 
 you took a sharp gouge and punched out circular portions of the flesh 
 in a vast number of spots. Now it can hardly be doubted that this 
 singular appearance is an example of a secondary disease affecting 
 the surface ; and it is very remarkable that it should have appeared 
 
NATURE OF BED-SORES IN FEVER. 211 
 
 on one of the critical days — upon the day when, in the ordinary 
 course of fever, the disease should have subsided. It strengthens 
 greatly the opinion, that not only is the general disease under the 
 law of periodicity, but that the secondary alterations are so too. 
 
 As a general rule, gentlemen, in prognosis, the occurrence of any 
 vesicular eruption whatsoever in fever is bad. We have in fever 
 several forms of vesicular eruptions. But suppose you take a patient's 
 hand to feel his pulse, on the eighth or tenth day of fever, when he is 
 otherwise going on well, and you are surprised at seeing a vesicle 
 upon his arm. Do not neglect this-— do not overlook it. The mere 
 circumstance of that solitary vesicle forming so silently, without any 
 pain, without any notice, points out that there is mischief before you 
 — that the case is likely to go wrong. It is a very important prog- 
 nostic. Here we have on this patient an eruption of vesicles running 
 rapidly to deep gangrenous destruction of the part, for some of the 
 cavities formed by them are singularly deep, though circumscribed. 
 
 Now, suppose that in place of that disease attacking the skin, upon 
 the fourteenth day, or whatever day you please, it should attack the 
 intestine. Suppose that the typhous matter suddenly infiltrated a 
 gland in the intestine, which should fall as suddenly to gangrene, and 
 that there was a solution of continuity ; you will at once see the pro- 
 gress of the worst form of the typhous secondary disease of the 
 intestine. You may look on this man as at this moment turned 
 inside out. On the surface of his skin you are able to learn the 
 history of the worst form of the typhous ulceration of the intestine. 
 This extraordinary condition of his surface no one will say is inflam- 
 mation of his skin. Apply the same view, and will you say that the 
 disease of the intestine is inflammation of that part ? Certainly not. 
 
 Whether this man is to live, gentlemen, or to die, I believe none 
 of us can venture to say. Of course the chances are enormously 
 against him; but I have said that in the treatment of fever you are 
 never to despair so long as the patient can swallow. So long as he 
 is able to take nourishment, or to swallow wine, no matter how dread- 
 ful or apparently hopeless the symptoms may be, you are not to 
 desert him, but — to use the phrase of our glorious sailors — you are 
 to fight the ship while she swims. In a disease under the mysterious 
 law of periodicity, every hour of compelled life is a clear gain. And, 
 over and over again, you will find that your efforts will be crowned 
 with success. You will see a patient lying with his back icy cold; 
 you will see him pulseless — his lungs filled with secretion — his belly 
 tympanitic — with dreadful diarrhoea — the lower extremities gangre- 
 nous — himself in a state of insensibility — and yet, even under these 
 
212 LECTUKES ON FEVER. 
 
 circumstances, a recovery is possible. But that recovery can be 
 effected only by the steadfast determination of the physician not to 
 desert his post until the vital spark has actually fled; and, if you 
 commit an error in holding on — in hoping against hope — at all events 
 it is an error on the right side. 
 
 LECTURE XXIX. 
 
 Stimulants in Fever, continued — Case of Hardcastle, continued — Treatment by food 
 and stimulants in extreme cases — Presence of cerebral symptoms to a great extent 
 unfavourable to tbe exhibition of stimulants — Necessity for daily observation of the 
 effects of the treatment in each case — Signs of disagreement of stimulants — Routine 
 practice is in every instance to be deprecated — Fallacies of the numerical system 
 in therapeutics — History of routinism — Its results — Description of routinism in the 
 treatment of fever. 
 
 With reference to the case of Hardcastle, with which we were occu- 
 pied at our last lecture, we may hope that the symptoms have at last 
 yielded. The great interest of this case consists in its having been 
 an example of a fever in which the patient was scarcely maculated, 
 yet in which the stimulating treatment had to be pursued with an 
 activity as great or greater than that which we are called on to employ 
 in the worst cases of spotted typhus. 
 
 On looking over my notes I find that on his admission, which was 
 on or about the seventh day, he had a few scattered maculae on the 
 abdomen, of a large size, and of a leaden gray colour. He then had 
 diarrhoea, abdominal tenderness, and ileo-caecal gurgling; and the 
 sounds of the heart, though weak, preserved their natural mutual 
 relations as to force and duration. Doubtless the patient at this 
 period might have been well described as labouring under typhoid 
 and not typhus fever, according to the distinctions now in vogue ; 
 but on the 14th, or the 21st, or the 24th day, he would be a bold 
 man who would declare that the case was not typhus of the worst 
 description. 
 
 He is now at the 28th or 30th day of his illness, and we have 
 every reason to believe that all will now go well. Since the eruption 
 of gangrenous vesicles or pustules, which occurred on the 21st day, 
 there have been no new appearances of this form of disease, there has 
 been no new bed-sore, nor have the gangrenous patches spread, as 
 might have been expected ; two of them are in the form of sinuous 
 cavities, but even these show signs of healing. 
 
MANAGEMENT OF BED-SORES. 213 
 
 These sores were treated first, you will remember, by the simple, 
 and afterwards by the fermenting, poultice ; but as the latter gave 
 considerable pain, the nurse returned to the simple poulticing, and 
 now we have changed our plan, and are using stimulating dressings 
 to the ulcerated surfaces. 
 
 In the management of these sores, whether they be the ordinary 
 bed-sores or examples of the gangrenous pustules, both of which 
 appear to be of the nature of the secondary affections of typhus under 
 the law of periodicity, it sometimes happens that we have to deal with 
 extensive sinuses. I have seen them at times of not less than six 
 inches in length. In most cases the best treatment for them will be 
 stimulating injections, using the vulcanized India-rubber bottle with 
 a long and slender ivory pipe. It is generally requisite at first to 
 wash out the sinus with tepid water, and afterwards to inject some of 
 the metallic solutions — diluted solutions of sulphate of copper, nitrate 
 of silver, or sulphate of zinc — and when the discharge is very fetid, 
 you may use the decoction of bark, or solutions of chloride of lime or 
 soda. An excellent dressing when the sore is open is the Canada 
 balsam combined with oil, or a mixture of equal parts of castor oil 
 and balsam of copaiba. You will derive advantage, also, from the 
 employment of pressure by means of flat compresses of lint, and a 
 roller when it is possible to apply it, or in other cases you may 
 employ strapping with adhesive plaster. When the sinus is in a 
 depending position, and matter accumulates in its lower portions, it 
 is sometimes necessary to make a counter opening; but this operation 
 should rather be delayed until the system has improved; the case is 
 then to be treated as an ordinary surgical one. 
 
 Now let me draw your attention to the diligence with which the 
 administration of wine has been pursued in this case. We began its 
 exhibition on the 2d of November, which was the eighth day of the 
 disease ; on that and the next four days, the quantity administered 
 was six ounces daily. The wine used all through was port, of an 
 excellent quality. From the 6th to the 11th he had twelve ounces 
 daily, and from the 11th to the 18th his daily allowance was twenty- 
 four ounces. During the next three days it was reduced to eighteen 
 ounces; and from the 21st to the 25th, to twelve ounces per diem. 
 On the 26th and succeeding days he had ten ounces; on the 28th the 
 quantity was reduced to eight; on the 4th of December he had but 
 four ounces; and the wine was omitted altogether on the 5th. Be- 
 sides all this, a tumbler of hot brandy-punch, containing two ounces 
 of the best brandy, was administered whenever the patient's state 
 seemed to require it. In this way we used about twenty-four ounces 
 
214 LECTURES ON FEVER. 
 
 of brand j, seven bottles of porter, and 432 ounces of wine, while, in 
 addition, bark, musk, and ammonia were freely exhibited. 
 
 Some may suppose that this quantity of wine was excessive. Such 
 is not my opinion, nor will it be yours when you come to treat the 
 typhus of this country in a large hospital. I am sure we might have 
 given him with safety much more, and I doubt if we could have done 
 with less. The result of the case confirms what I have said to you 
 before, that in fever, no matter how terrible the group of symptoms 
 may be, you are not to despair so long as the patient can swallow. Bear 
 in mind, too, that Hardcastle has been carefully fed throughout with 
 chicken broth, beef-tea, and jelly ; and we have now passed that period 
 when, under the law of periodicity, his terrible disease should sub- 
 side. 
 
 The principal symptoms were extraordinary prostration, coldness 
 of the surface, and feebleness and irregularity of the heart's action ; 
 and it was not until the end of the eighth day of the exhibition of 
 stimulants in great quantities that any favourable influence was pro- 
 duced on the circulation. The case strongly illustrates the advantage 
 of persisting in the use of stimulants, although for days together no 
 amendment seems to follow their employment. 
 
 I cannot too strongly impress upon you that even under appa- 
 rently desperate circumstances life may be saved by the repeated 
 introduction of small quantities of food and stimulants. Here we 
 see the advantage of skilled nurse-tending. In the practice of a 
 friend of mine a case occurred in which the power of deglutition was 
 all but lost, the vital powers were sunken to an extreme degree, the 
 action of the heart almost imperceptible, the eyes staring, with con- 
 tracted pupils; while the symptom of lachrymation, regarded by 
 experienced men as one of the worst in fever, was present. It was 
 thought by all except the physician that the patient should be left to 
 die. He, however, did not utterly despair. A large blister was 
 applied to the occiput and nape of the neck, and a teaspoonful of 
 brandy and beef-tea was administered every ten minutes during many 
 hours. A slight motion of the eyelids was at last perceived. This 
 was followed by deglutition, and after some time reaction had taken 
 place. 
 
 Some would say that in this most severe case the recovery was 
 to be attributed to the blistering. It is more probable that it was 
 connected with the action of the periodic laws, favoured by the 
 continued introduction of stimulants. In such a case the use of 
 enemata of beef-tea or of milk, containing in addition a small quan- 
 
INFLUENCE OF PREVIOUS HABITS. 215 
 
 tity of brandy, aud also quinine, as recommended by Dr. Graves, is 
 indicated. 
 
 As to the employment of wine in a case seen for the first time, 
 you will remember that in fever those who have been previously of 
 temperate habits are generally the best subjects for the stimulating 
 treatment. In our wards great quantities of wine have produced the 
 best effects in the peasant class. Such men are by no means habitually 
 intemperate. They may exceed now and then on the occasion of a fair 
 or a wake, but their habitual drinks are milk, water, or tea. It is not 
 so with the artisan class, who indulge in ardent spirits. Here I beg 
 of you to remember what we have seen as to the anticipative treat- 
 ment, and also that having to deal with a case of fever — say, in its 
 first week — you cannot predicate how long it will continue. This is 
 particularly true in the typhoid form, especially when affecting the 
 adult. 
 
 It would seem as if the frequent habit of alcoholic stimulation in 
 health rendered the brain less capable of supporting wine under the 
 condition of fever. At all events, you have seen that the use of 
 stimulants where the patient had been a drunkard has by no means 
 the same admirable result observed in men of a different habit. 
 
 The freedom from symptoms of cerebral excitement, particularly 
 when attended by heat of the head and increased action of the 
 cerebral arteries, is of course favourable to the use of wine. 
 
 But there is another cerebral condition which renders the use of 
 wine in fever less often advantageous. It is met with in those whose 
 occupation has long entailed a close and intense mental labour. Such 
 subjects you will meet more frequently in the middle classes of 
 society than among hospital patients, and in them we find that, while 
 other circumstances indicate the free use of stimulants, their tran- 
 quillizing effect is not seen, and they have to be omitted or used 
 only at intervals. This is one out of many reasons why the over- 
 worked professional man, especially if he be a physician, is so bad a 
 subject for fever. Indeed, whenever you are called to treat a medical 
 brother in typhus or in typhoid, you may lay your account at having 
 a rock ahead. 
 
 In the course of a case of typhus or the more prolonged examples 
 of severe typhoid, in which you are giving wine, you must every day 
 be on the look-out for symptoms that the stimulant is no Longer 
 necessary or is disagreeing. Such a change is coin non, showing that 
 the period has arrived when the stimulant is beginning to have the 
 intoxicating effect which it would have were the patient not in fever. 
 It is not easy to describe accurately this state, and you must learn it 
 
216 LECTURES ON FEVER. 
 
 by observation. There is an undefined general excitement, some- 
 times with heaviness and even a degree of delirium, often of a novel 
 kind, together with loss of sleep. Symptoms not unlike many of 
 those in the earlier stages of the case appear, while the pulse is more 
 resisting and the patient complains of thirst and general malaise. 
 Now, some of you have seen this group of symptoms in the advanced 
 stages of fever where stimulants had been employed at first with 
 great advantage, and you will remember the benefit which followed 
 their disuse or diminution. This is a most important point of 
 practice. Coincident with the use of wine or other stimulants you 
 may have observed a gradual subsidence of the symptoms of fever, 
 the re establishment of the heart's action, the coming down of the 
 pulse, the cleaning of the tongue, and an improvement in the nervous 
 symptoms. Under these circumstances the wine may be diminished 
 gradually. 
 
 But where there are indications that it is beginning to disagree, and 
 that, in place of having a calming, it has a disturbing, effect on the 
 brain and heart, although at first the opposite state had been induced — 
 then the omission of the stimulant may take place at once, and the 
 p.irient be supported on bland and unstimulating nourishment. You 
 must have seen examples in our wards of the happy effects which 
 followed the disuse of stimulants. 
 
 When, in a protracted fever in which stimulants had been clearly 
 indicated and had manifestly agreed in full quantity, symptoms of a 
 more general disturbance of the system supervene, you must consider 
 whether this condition is owing to an exacerbation of the essential 
 disease or to the influence of stimulants ; in other words, whether the 
 time has not arrived when their sanative action has given place to an 
 opposite effect. Under such circumstances your course may be often, 
 and safely, a tentative one. Such a course is recommended by Dr. 
 Murchison when there is a question as to the giving of stimulants in 
 the early stages of fever ; and here likewise you may feel your way 
 in an opposite direction and watch the effect of a certain diminution 
 of the remedy. 
 
 Now, gentlemen, before concluding this lecture, I wish to say to 
 the junior members of the class, and indeed to you all, that physicians 
 are to be met with who boast that they do not give stimulants in 
 fever, while, on the other hand, there are men in whose practice their 
 use is a matter of routine. In either of these categories you may 
 meet those who refer to and compare the numerical results of their 
 practice. But these men have not learned how inconsequential are 
 such comparisons. They have not learned how fallacious the results of 
 
KOUTINISM TO BE AVOIDED. 217 
 
 the numerical system are in indicating a line of practice to be adopted 
 in all cases. They have not perceived that life may be saved or lost 
 by the adoption of this or that system— the advocates of stimulation 
 saving those cases which required it, and their opponents those where 
 it was injurious or unnecessary. 
 
 It is true that the observations of the numerical school have been 
 directed to determine what treatment in a certain disease will be 
 followed with success in the greatest out of a given number. But this 
 is not what the practical physician wants to know. Is it not rather 
 what is best for him to do in the case of A, B, or C ? A certain 
 treatment may have been successful in 75 per cent, of a group of 
 cases, but he knows that this will not justify him in adopting it ex- 
 clusively in all or in any of the remaining 25 per cent. 
 
 He has learned that fever, in the general acceptation of the term, 
 is a condition with laws of periodicity, and that, therefore, all thera- 
 peutic conclusions as regards it will have to be estimated by a 
 reference to this characteristic ; and, lastly, that fever is a varying 
 condition, its cases — although capable of being arranged into groups 
 — having certain similarities, but also infinite varieties, in local and 
 essential symptoms; in amount, period, and degree of complications ; 
 in the influence of remedies and in the epidemic character. Therefore 
 in its treatment, and with reference to therapeutics, each case must be 
 considered by itself. 
 
 It is plain that dependence on the numerical system will encourage 
 routinism — a line of conduct so opposed to the proper dealing with 
 disease; for to adopt a practice deduced from the results of com- 
 parison of numbers is but to justify routinism under the show of 
 authority. 
 
 It is hardly necessary to observe to the senior members of this 
 class that the use of wine and other stimulants in our wards is in no 
 way a practice of routine. Gentlemen, you have seen many cases 
 during the last year in which wine was sparingly or not at all used 
 in the course of the fever, simply because it was not required. Food 
 was regularly given, while careful watching was practised, so as to 
 detect early any sign of failure of the energy of the brain or circu- 
 lation. 
 
 It will be well to look at the various illustrations of routinism in 
 the treatment of fever which we have known in this country. The 
 Irish physicians of the last century might be called routinists in one 
 respect — namely, that they employed wine and tonics in most cases 
 liberally, if not indiscriminately. Like the old English physicians, 
 however, they were eclectics, and so did not fall into many of the 
 
2^3 LECTURES ON FEVER. 
 
 errors of their successors. Their doctrine of putrescence merely im- 
 plied prostration of the system— in other words, debility was the 
 condition to be guarded against and met; and doubtless, in the whole 
 class of adynamic and essential diseases, if they erred, the error in 
 practice was one on the right side. Drs. Quin, Plunket, and Harvey, 
 all used wine freely in maculated typhus. Indeed, a bottle of Ma- 
 deira daily was commonly ordered by them. To a certain extent 
 they used it anticipatively, for they did not wait for the advent of 
 extreme prostration. 
 
 The next phase of routinism was of a different and opposite nature. 
 The doctrines of Broussais, which taught that the essential disease was 
 symptomatic of local inflammation, while the reverse was true, turned 
 the minds of men into a wrong direction. The idea of inflammation 
 was opposed to the exhibition of stimulants and tonics, and the 
 practice of medicine was reduced to using direct or indirect de- 
 pletion. 
 
 The theories of Clutterbuck and of Armstrong supplemented those 
 of Broussais as to inflammatory action being the cause of fevers, and 
 so that new routinism in practice was generated, of which the leading 
 characters were starvation and evacuation. The laws of periodicity 
 in fevers were ignored, as was also the great fact in medicine that 
 symptoms diagnostic of local disease when the patient has not essen- 
 tial fever cease to be so when he has. 
 
 Thus was established the routine practice of the adoption of eva- 
 cuants, of bleeding, of diaphoresis, and even of purgatives. The 
 system was pertinaciously reduced through every outlet, while little 
 or nothing was introduced to supply the deficiency. The disciples 
 of Broussais by applying leeches to the abdomen and by starvation 
 reduced the patient to a state of inanition. Those of Clutterbuck 
 did the same by depletion of the head for imagined cerebritis, and 
 those of Armstrong operated similarly for the reduction of a supposed 
 inflammatory diathesis. The depleting effect of acute disease, the re- 
 duction of the volume of blood by the fever itself, the waste of tissue 
 —were overlooked, while every new interference with the powers of 
 nature more and more impaired the vis medicatnx. 
 
 We may attribute to the same cause that timidity in the use of 
 wine in fever whicli is still observable in the practice of some of our 
 brethren, especially those who during their student lives have not 
 been brought into daily bedside contact with the disease. I re- 
 member some few years ago receiving an urgent call to see a 
 lady in fever. I was entreated to lose no time in going, as the patient 
 was so low, so far gone, that she had actually been ordered wine ! I 
 
HISTORY OF ROUTINISM. 219 
 
 found the lady at about the fourteenth day of a low enteric or typhoid 
 fever. She was extremely weak, and suffering under great mental 
 depression and physical exhaustion, which had been present from 
 the commencement of the attack. I recommended the immediate 
 use of wine. "Oh," was the answer, "she has been ordered wine, 
 and is now taking it." On inquiry it turned out that what had been 
 ordered was light claret, the quantity being one or two teaspoonfuls 
 in cold water twice or thrice a day. Now, this was the treatment of a 
 physician whose opinion was in general not to be despised, but who 
 had, like many of his contemporaries, been brought up not only in 
 ignorance of the use of wine, but in a terror as to its effects on the 
 supposed inflammatory condition of fever. My advice as to the 
 quantity and quality of the wine was looked on as daring and inno- 
 vating, but was nevertheless followed, and with full success. 
 
 Closely following on the routine local and general antiphlogistic 
 treatment in fever was a method which seemed to spring from the 
 adoption of the views of Abernethy as to the influence of derange- 
 ment of the chylopoietic viscera in introducing disease. A patient 
 might or might not have a continued essential fever, but the intestinal 
 and renal secretions showed derangement. Here the treatment 
 recommended itself by its simplicity — a mercurial pill at night, 
 followed in the morning by doses of infusion of senna, with rhubarb 
 and gentian and Epsom salts, the care of the attendant being mainly 
 directed to the appearance of the tongue and the inspection of 
 the evacuations. This practice would be continued for days, the 
 digestive organs obstinately refusing to right themselves, notwith- 
 standing the treatment, until the patient began to sink, and was 
 perhaps attacked with peritonitis, the result of perforation. Let me 
 tell you a case of this kind. 
 
 A gentleman previously healthy was attacked with symptoms of 
 fever, and attended by two professional men long since dead, one a 
 physician, the other a surgeon. He was treated for many days on 
 the mercurial and purgative plan. I need not say that the fever 
 continued, and as at last there was considerable sinking of the vital 
 powers, a consultation was asked for by the patient's friends, and an 
 eminent consulting physician of Dublin saw the case. He suggested 
 that the treatment had been carried sufficiently far, and recommended 
 chicken broth and a moderate use of wine. A light tonic, consisting 
 of an infusion of cascarilla with a few drops of dilute muriatic acid, 
 was also ordered. 
 
 This was in the morning, and within two hours, the consulting 
 physician having to leave town, I was hurriedly summoned to the 
 
220 LECTURES ON FEVER. 
 
 case, it being alleged that the patient had been poisoned by the 
 medicine. Violent pain had supervened just at the moment of swallow- 
 ing the first dose of medicine. It was easy to see that perforation and 
 peritonitis from long-continued intestinal disease had taken place. 
 Nothing that I could say would induce the friends to take this view 
 of the case, and to my surprise they were backed up by the medical 
 attendants. I even drank some of the mixture in their presence. 
 The patient sank in the course of some hours, and it was only by my 
 declaring that a coroner's inquest should be held that I got permission 
 to examine the body. The ileum was extensively ulcerated, and 
 complete perforation had occurred in no less than four places. In 
 one, probably that which caused the effusion into the peritoneum, 
 the opening was the size of a fourpenny piece. 
 
 The coincidence in time of swallowing the first dose and of the 
 effusion into the peritoneum was singular. It was hardly down when 
 the patient cried out, "I am poisoned! I am poisoned!" and re- 
 mained in terrible pain until he was moribund. 
 
 Here was a case of enteric or typhoid fever in which the intestinal 
 disease was doubtless aggravated by the continued catharsis for many 
 days. In the Report of the Meath Hospital, by Dr. Graves and 
 myself, many cases of intestinal perforation are given where at thft 
 commencement of the fever hypercatharsis had been induced by the 
 exhibition of doses of saline purgatives. Looking at the routinism 
 then prevalent, the case I have detailed was probably not an excep- 
 tional one, and curiously illustrates that a knowledge of medicine is 
 not necessarily implied in the legal qualification for practice. 
 
 But as the principles of right reasoning in medicine are better 
 inculcated and understood, and as larger views of the pathology of 
 fever — such as those taught by John Peter Frank, by the fathers of 
 British medicine, and by modern writers, like Christison, Graves, 
 "Watson, Murchison, Jenner, and Tweedie — are more generally known 
 and made use of in medical education, the older as well as the newer 
 forms of routinism will disappear. The time is coming rapidly when 
 routinism in its successive phases will be forgotten, and the state of 
 fever be dealt with in a philosophical spirit. 
 
 Before concluding this lecture let me give you an extract from one 
 of the writings of a witty medical satirist, the late Dr. Brennan, of 
 Dublin, commonly called " The Wrestling" and sometimes " The 
 Turpentine Doctor." It is entitled "A Receipt to Make a Fever," 
 and is a picture of the practice of the day three-quarters of a century 
 ago — unhappily, not yet extinct: — 
 
A RECEIPT TO MAKE A FEVER. 221 
 
 Any patient, when you get him, 
 First of all, be sure you sweat him : 
 The next day you need not heed him, 
 But the third take care to bleed him. 
 When he's sweated and he's bled, 
 Then, of course, you'll shave his head ; 
 Clap on five-and-twenty leeches, 
 Tho' the first cost a crown each is. 
 
 When to sink he does incline, 
 Blister legs and give him wine. 
 Tell his uncle or his brother 
 That you'd like to see another — 
 
 Yet let nobody approach 
 
 But a doctor in a coach ; 
 
 For a coach does mighty wonders 
 
 In concealing doctors' blunders. 
 
 The writer then passes in satirical review the different consulting 
 physicians of Dublin, concluding with himself: — 
 
 If they talk of Brennan's knowledge, 
 Say, "He is not of the College," 
 Or, to joke if you incline, 
 Smiling mention — Turpentine — 
 And you may throw in — by dad ! — 
 That you know he's wrestling mad. 
 
 The patient dies 
 
 When with drugs you well have swilled him, 
 
 Tell his friends the fever killed him ; 
 
 All that could be done was done — 
 
 The worst you ever saw, but one : 
 
 And this is a mighty consolation 
 
 In such an awful visitation. 
 
LECTURES ON FEVER. 
 
 LECTURE XXX. 
 
 Treatment of the Local Secondary Affections in Fever — Relative importance of 
 these affections as regards prognosis — Bronchial Affections — Necessity for ad- 
 ministration of stimulants and nourishment — Danger of exhibition of tartar emetic 
 — Failure of emetics— Turpentiue-puncli — Dry-cupping, poulticing, blistering — 
 Internal remedies: bark, ammonia, spirit of chloroform, turpentine — Acute Con- 
 solidation of the Lung — Its three forms — Treatmeut of the first form by dry-cupping, 
 blisters, quinine, turpentine, and wine — Of the second form by local depletion 
 simultaneously with the administration of wine — Of the third form, externally by 
 iodine and blisters, internally by tonics and iodide of potassium. 
 
 Following the plan which 1 have laid down in this course of lec- 
 tures, I shall to-day direct your attention to the management of the 
 secondary local affections of fever. We may classify these under four 
 headings, according as they involve the nervous, circulatory, pulmo- 
 nary, or digestive systems. 
 
 Were we to attempt to classify these local affections with respect 
 to their importance as regards the parent disease and the safety of the 
 patient, it would be difficult to determine whether the nervous, circu- 
 latory, pulmonary, or digestive symptoms should be considered as 
 entitled to the first place. 
 
 In reference to prognosis, the predominance of cerebral symptoms 
 may certainly be held to be of unfavourable import, and one reason 
 for this is that their presence often interferes so materially with the 
 attempt to combat prostration by the administration of stimulants. 
 But, apart from this consideration, the preponderance of cerebral symp- 
 toms is more serious as always indicating — not necessarily organic 
 change in the nervous centres — but a functional disturbance in them 
 which reacts on all the other systems of the body. 
 
 If, however, we were to classify the various phenomena connected 
 with the different systems of the body in fever according to the 
 amount of their corresponding anatomical changes, we should say 
 that the pulmonary affections are the most liable to changes of this 
 description. 
 
 Thus, notwithstanding all the researches which have been insti- 
 tuted respecting the anatomical changes in typhus and typhoid fevers, 
 no one can at present venture to say what condition of brain corre- 
 sponds to this or to that symptom in these diseases ; no one can 
 accurately determine the state of the brain as regards its anatomical 
 
CHARACTER OF CEREBRAL SYMPTOMS. 223 
 
 changes from the observation and study of any symptom. We may 
 recognize a condition of brain in fever in which stimulants will not 
 be borne, and another wherein they are useful, but we may be unable 
 to reduce either of these to an anatomical expression. As we have 
 seen in a former lecture, there is no symptom in ordinary fever 
 whereby we can determine the presence of actual and progressive 
 cerebritis or arachnitis. One patient will be in a state of high delirium, 
 with injected brain, another will have an injected brain in the absence 
 of any such symptom. 
 
 These are important facts, most necessary to be kept in mind ; but 
 you are not to infer from this that we are altogether powerless in the 
 treatment of the cerebral symptoms of fever. All that has been said 
 shows only, that, in dealing with the special condition of existence to 
 which we give the name "fever." our pathology must not be too 
 material in its character or tendency, and that the symptoms of merely 
 functional suffering are infinitely varied in nature, time of appearance, 
 intensity, and their degree of combination with organic change. 
 
 I have said that of all the secondary diseases of fever those affecting 
 the pulmonary system are the most frequently attended by anatomical 
 change, and among these — the bronchial affection — for primary 
 bronchitis it does not seem to be — most especially so. 
 
 It is remarkable how silently this affection will be developed in 
 proportion to the severity of the fever. From superficial observation 
 the presence of serious bronchial disease might never be suspected, 
 but on exploring the chest morbid sounds may be heard universally 
 in front and behind. Yet there may be no severe cough, no extreme 
 dyspnoea, or lividity of countenance. 
 
 Frequently with this secondary disease in malignant typhus an ex- 
 treme degree of weakening of the heart, with softening of that organ, 
 will be found associated. By having regard to this complication we 
 obtain the key to the treatment which is especially indicated in these 
 cases — namely, the free administration of stimulants and nourishment. 
 Here, also, the anticipative method of treatment is often indicated, 
 for the secondary bronchial affection with a weakened heart places 
 the patient in a position— it may be — of the most imminent peril. The 
 heart grows weaker, and there can be little doubt that its weakened 
 condition is repeated in the muscular fibre of the lungs and bronchi. 
 The bronchial tubes are loaded, mucus is copiously secreted, the 
 muscles which assist the act of expectoration become paralyzed, and, 
 should relief not be afforded, the almost inevitable result is asphyxia 
 and death. 
 
 These observations arc simply suggestive of the necessity of adopt- 
 
224 LECTURES ON FEVER. 
 
 iDg a decided and active system of treatment. The more closely you 
 investigate cases of this kind, the more convinced will you be that 
 paralysis of the circular fibres of the expectorant muscles takes 
 place; and here we have one — perhaps the principal — reason why 
 the liberal administration of stimulants is found so successful under 
 such circumstances. It may be that even after recovery from the 
 primary disease death will ensue from purely mechanical obstruction 
 in the lungs and air-passages. This is another reason for adopting 
 the principle of meeting the disease early. I never saw a case of 
 death from secondary bronchial effusion except where the disease had 
 been overlooked at first. 
 
 Now let us advert to the general mode of treatment of this com- 
 plication. Suppose you are called in to a patient, say on the fourth 
 or fifth day of typhus. You find a rale in the large bronchial tubes, 
 extending next day into the smaller tubes. Will you call this " bron- 
 chitis" and treat it as such? Certainly not. You have before you a 
 patient in a certain condition as regards the respiratory functions, 
 which condition is under the influence of the parent malady. If 
 there be any inflammation present in such cases, it is specific, 
 asthenic, and reactive, not to be treated by antiphlogistic means. 
 The presence of the rale is not to induce you to bleed or to apply 
 leeches, but what you have to trust to is active and energetic stimulant 
 derivative treatment. Some physicians recommend in such cases 
 the exhibition of tartar emetic. Where this course is followed the 
 patient may sink. 
 
 Now, the inveterate habit with which men in our own time were 
 imbued, of attributing every local symptom in fever to inflammation, 
 led to the practice of giving mercury in this condition. But you will 
 easily see the unfitness of such a course when time is pressing and it 
 is absolutely necessary to modify the vital, and relieve the mechanical, 
 state of the lung which threatens asphyxia. My friend Dr. Mackin- 
 tosh, of Edinburgh, strongly advocated the use of emetics in this 
 condition ; but I do not recommend them — at least they have not been 
 hitherto successful in our hands. You will meet cases in which they 
 will not act at all. I have seen the most powerful emetics, of various 
 kinds, exhibited without any vomiting whatever being produced. I 
 have known cases in which, after milder remedies had been used, the 
 sulphates of zinc and copper utterly failed. Or the full action of the 
 emetic may occur, and be followed by great relief of the chest; yet in 
 a short time the suffocative state will return, and, the sensibility of 
 the stomach being destroyed, the patient sinks asphyxiated. 
 
 But the course of treatment under these circumstances long 
 
TREATMENT OF BRONCHIAL AFFECTION. 225 
 
 followed in our wards is dry cupping, blistering, and the free exhibi- 
 tion of turpentine in whiskey-punch. By this course our late 
 excellent apothecary, Mr. Parr, saved many a life when the patient 
 was almost in articulo mortis. He would administer a tumbler of 
 strong punch with two or three drachms of spirit of turpentine, and 
 repeat the dose, if necessary, in a short time. Often has he said to 
 me in the morning, "Sir, I had. to punch three cases last night — they 
 are all doing well." The effects were simply wonderful, and illustrate 
 the principle that you are not to despair in a case of fever so long as 
 your patient can swallow. 
 
 This reminds me of a translation by Dr. Brennan in the Milesian 
 Magazine : — 
 
 Si quid novisti reetius, istud candidus imperti. 
 Si non, his utere mecuni. 
 
 Doctors ! if you have better drugs than mine, 
 Say where they're hid ; if not, use turpentine. 
 
 In this theatre my late colleague, Dr. Graves, dwelt largely on the 
 value of this medicine in the secondary affection of the lungs in 
 fever, and he has been followed emphatically by Huss of Stockholm. 
 
 In the less urgent cases you are not to forget that the disease may 
 show a sudden and violent exacerbation ; and I have often heard 
 practitioners account for the occurrence of tracheal rattle and fatal 
 asphyxia and excuse themselves on the supposition of a sudden effu- 
 sion into the chest, when, in truth, the bronchial tubes had for days 
 been engaged, and the affection unrecognized and neglected. 
 
 I repeat that in fever, especially in typhus, with a weakened heart, 
 the affection of the bronchial tubes may be developed insidiously and 
 to a great extent. 
 
 With respect to external and local applications in ordinary cases 
 of this secondary affection, I have already spoken of the use of 
 dry- cupping. Amongst other means may be mentioned the repeated 
 application of turpentine fomentations; of poultices consisting 
 wholly of linseed meal, or of linseed meal and mustard in varying 
 proportions; and of moderate-sized blisters, covered with a linseed 
 poultice, so that the vesicating action shall be favoured by the 
 warmth and moisture of the poultice. 
 
 Of internal remedies, the decoction of bark, with ammonia and 
 spirit of chloroform, is most frequently indicated : or moderate doses 
 of turpentine may be employed with good effect. The confection of 
 turpentine administered in peppermint water is found to be a valuable 
 preparation. But above all it will be necessary to support our patient's 
 15 
 
226 LECTURES ON FEVER. 
 
 strength by the judicious administration of suitable nourishment, and 
 wine or other stimulants. 
 
 Acute consolidation of the lung in fever may be considered, 
 with regard to practice, under several forms: First, that in which 
 symptoms and signs of anything like acute or sthenic inflammation 
 do not occur. The disease is in these cases more or less silent or 
 latent, and recognizable chiefly by physical signs. You are to treat 
 this affection by dry-cupping, blisters, quinine, turpentine, and wine. 
 
 But between these cases and others where a greater activity of the 
 ordinary inflammatory symptoms is observed, indicating that a local 
 antiphlogistic treatment may be employed with advantage, there 
 exists an intermediate form which includes cases of almost infinite 
 shades and varieties of character. 
 
 In cases of the secondary pneumonic affection which possess 
 many of the characters of acute sthenic pneumonia, there may be 
 pain in the side, great local increase of temperature, and distress of 
 respiration. Here the application of a few leeches, or of the scarifi- 
 cator and cupping-glass, may be followed by immediate and marked 
 relief to the patient. In many such instances the use of wine is not 
 to be intermitted on account of the practice of local depletion. There 
 is a point of great importance in practical medicine — one which I 
 wish to impress strongly upon you — namely, that lines of treatment 
 apparently opposite or antagonistic may, under certain circumstances, 
 be employed simultaneously with success. Your treatment is to be 
 influenced not by the name of a disease, but by the condition of your 
 patient; and you may relieve local irritation by local blood-letting 
 while you support the general system, and deal with the essential 
 disease by the use of stimulants. 
 
 When describing in a former lecture those consolidations of the 
 lung, especially of its upper lobe, in fever, which seemed to partake 
 of the nature of a crisis, I said that it was often a matter of doubt 
 whether the clearing of the lung was to be attributed to the remedial 
 measures employed or to the spontaneous subsidence of the condition 
 in obedience to the law of periodicity. However, a small blister or 
 two may be used, and the application of the tincture of iodine ex- 
 ternally, with the exhibition of iodide of potassium in combination 
 with a tonic, may be of advantage. 
 
 I need not say to the students of large bedside experience that it 
 is sometimes difficult to distinguish between a primary pneumonia 
 with a symptomatic fever and states of the lung secondary to typhus 
 or to typhoid. You will, also, be prepared to hear that this difficulty 
 has been more commonly met with since the period of change of type 
 
TREATMENT OF INTESTINAL SECONDARY AFFECTIONS. 227 
 
 in disease. Still, during the last few years, several cases of primary 
 pneumonia have come under our notice, in which, though with less of 
 the general violence of symptoms once so familiar to us, we have 
 used the lancet — moderately, it is true, but with the most rapid suc- 
 cess. The pain, the adhesive red expectoration, the state of the heart, 
 and the early appearance of the symptoms, were our chief guides. 
 
 The dreadful occurrence of sphacelus in consolidation of the lung 
 in typhus is to be met by the antiseptic and stimulant treatment. 
 
 That recovery is possible in this catastrophe I have already shown 
 you. The patient in question died after a lapse of some years from 
 the first attack. We found recent sphacelus in one lung, and a 
 cavity containing a dry slough, and with a firm lining membrane in 
 the other. 
 
 LECTURE XXXI. 
 
 Treatment of Intestinal Secondary Affections. — Two chief indications : (1) allevia- 
 tion of symptoms, (2) modification of typhous deposition — Poulticing — Local de- 
 pletion in early stage — Analogy in variolous eruption — Danger of alterative or 
 purgative treatment at the outset of Continued Fever — Necessity for caution — Con- 
 stipation — Diarrhtza — Poultices, demulcents, sedative astringents, injections of flax- 
 seed tea — Tympany — Turpentine injection — Diet in diarrhoea — Perforative peritonitis 
 — Opium our sheet-anchor — Danger of the antiphlogistic method — Dr. Murchison 
 on the treatment of this accident — Bran poultices and warm fomentations — Hemor- 
 rhage from the intestine in fever — Not to be interfered with unless continued and 
 excessive — Treatment by astringents, opium — Illustrative case. 
 
 In a case of enteric fever, or of a well marked typhus with more or 
 less of intestinal affection, your efforts in reference to the treatment 
 of the local secondary disease will be directed less to the cure than to 
 the palliation of the symptoms, and to diminishing the activity of that 
 process under which the mucous membrane and glands become the 
 seat of the typhous deposit. 
 
 We seek to lessen the amount of change by modifying the specific 
 and afterwards the reactive irritation. 
 
 Local bleeding and diligent poulticing are the measures on which 
 reliance is to be placed in the first instance, while everything which 
 might excite overaction or hypersecretion of the intestines is to be 
 avoided. The first of these remedial measures is best effected by- 
 moderate leeching of the ileo-caecal, and in some cases the epigastric 
 regions, due regard being paid to the strength of the patient and to 
 
228 LECTURES ON FEVER. 
 
 the period of the case at which the local symptoms become manifest. 
 In the earlier periods from six to ten leeches may be applied first to 
 one and then to the other situation, and this will be often followed by 
 the relief of local suffering and — as regards the general symptoms — 
 by the best effects. The repetition of this local bleeding will depend 
 on circumstances. But if tenderness, local fulness, increased arterial 
 action of the belly, or muscular rigidity be wholly or in part removed 
 or modified, it is not often necessary to repeat the application. I 
 need scarcely say that the presence of these symptoms affords an in- 
 dication for this early use of local depletion. 
 
 I have shown you that Broussais, in defence of the doctrine that 
 fever was only symptomatic of gastroenteritis, appealed to the fact of 
 the relief which often follows local depletion, and I have suggested a 
 more probable interpretation of the entire matter. Local depletion, if 
 employed sufficiently early in the case, may prevent altogether, or 
 greatly modify the development of intestinal symptoms. Here it 
 would seem that the lessening of the blood supply interfered with the 
 deposition of typhous material along the intestinal tract in the agmi- 
 nated and solitary glands. This is strikingly analogous to what is 
 observed in certain cases of variola, where the local development of 
 the secondary eruption on the face or elsewhere is largety under 
 control by the application of leeches or by strapping the part at an 
 early stage of the disease. This point T have already illustrated in a 
 former lecture. 
 
 Again the analogy holds good with respect to the pustular eruption 
 of variola, and the secondary typhous deposits of fever in the intesti- 
 nal tract. For even where there is good reason for supposing that 
 these deposits have already taken place, and are passing on to ulcera- 
 tion, it is found that local depletion may be of the greatest use in 
 allaying irritation and so preventing the violence of a reactive inflam- 
 mation. 
 
 All this goes to prove that the influence of local depletion cannot 
 be taken as an evidence of the primary nature of the local malady ; 
 for in the first place it receives a similar and easier explanation from 
 the hypothesis of an essential disease with a secondary local affection ; 
 and in the next place the argument from analogy is altogether in sup- 
 port of this hypothesis, and against the views of Broussais. 
 
 It is still necessary —I regret to say it — to warn you against follow- 
 ing the routine practice of giving what is called " alterative," combined 
 with purgative, medicine, in the early periods of fever — a' course too 
 commonly followed, even while the practitioner is unaware of the 
 nature of the disease he is treating. In this way a threefold injury 
 
CONSTIPATION AND DIARRHCEA. 229 
 
 is inflicted. The strength of the patient is exhausted at a time when 
 it should be husbanded ; the normal course of the fever is interfered 
 with ; and, should there be any tendency to the intestinal affection, it 
 is doubtless augmented and exasperated by measures which determine 
 to the part of the economy most likely to be the seat of lesion. This 
 is analogous to what is often observed in constitutional maladies. 
 Thus, in cancerous cachexia the local organic change is frequently 
 determined by the receipt of some injury. In acute essential diseases, 
 again, the same thing is noticed, as for example in variola, where the 
 application of rubefacients will be followed by an increased develop- 
 ment of the eruption, while a contrary effect will, as we have seen in 
 a former lecture, be produced by local depletive measures. 
 
 In a large proportion of our cases of perforative peritonitis, hyper- 
 catharsis by saline purgatives had been induced at an early period 
 with the mistaken view of seeking to cut the fever short. 
 
 We have spoken of the use of leeches and of light poulticing. 
 Should there be constipation, with swelling of the abdomen, to such 
 an extent as to render it advisable to free the bowels, mild enemata 
 may be employed, and turpentine fomentations applied to the surface. 
 The enemata must be composed of the blandest fluids, to which, if 
 there be any troublesome tympany, a little turpentine made into an 
 emulsion with yolk of egg may be added. 
 
 I am ready to admit that cases will constantly present themselves, 
 in which the practitioner will be at a loss to determine whether con- 
 tinued fever is threatening, or the symptoms are to be referred merely 
 to the presence of a " feverish cold." Under these circumstances I 
 would still inculcate the necessity for caution, and would recommend 
 that the smallest doses of aperient medicines likely to effect the ob- 
 jects in view should be employed. 
 
 But when you have symptoms of irritation of the intestine attended 
 by diarrhoea, the use of poultices and of demulcents may be combined 
 with that of astringents of a sedative nature. I know no better 
 remedy than the acetate of lead given with some preparation of opium. 
 In the form of pill these two drugs may be conveniently given ; but 
 if ordered in a mixture, it will be necessary to substitute the acetate 
 of morphia for crude opium. I have never seen any bad result from 
 lessening or checking the diarrhoea, or any symptoms of lead-poison- 
 ing, even when this medicine had been continued for many days. 
 
 Here I may allude to the fact, that, in the first two epidemics of 
 cholera in this city, the use of the " pilula plumbi cum opio" was intro- 
 duced by Dr. Graves, following the recommendation as to the value 
 of the acetate of lead in the diarrhoea of Continued Fever by Sir 
 
230 LECTUKES ON FEVER. 
 
 James Bardsley. 1 The remedy, in the hands of Dr. Graves and of 
 many others, was employed in a vast number of cases, and I believe 
 that during this great clinical experiment not a single case of lead- 
 poisoning occurred either in the earlier stages of the case or in the 
 later period of convalescence. We must, of course, remember that the 
 acetate of lead is by no means so poisonous as the carbonate ; but I 
 would caution you against its possible change into this latter salt. If, 
 for instance, it is compounded in a mixture with water containing 
 carbonate of lime, it may be decomposed. This is still more likely 
 to occur in the use of lead-lotions. The most violent and long- 
 continued case of lead-colic I ever saw was that of a woman who had 
 suffered from an extensive burn of the abdomen. Lead-lotion was 
 applied to the injured surface for weeks together, and we must sup- 
 pose that a considerable quantity of carbonate of lead was formed and 
 absorbed, for symptoms of poisoning soon showed themselves. 
 
 To return — you are to use demulcents either by the mouth or in 
 the form of injection. I remember, when a student, that a remedy 
 called the " mistura olei et opii," was extensively employed in this 
 hospital, and with the best effect. It was an emulsion of oil, 
 gum arabic, and cinnamon water, to which a little laudanum was 
 added. We used to believe that it acted mainly in lubricating the 
 irritated surfaces. The injection which we have employed with 
 greatest advantage in diarrhoea in fever has been one of flaxseed tea, 
 to which a few drops of laudanum may be added. The infusion of 
 flaxseed should be made with unbruised seed, and its effect in pro- 
 ducing a sensation of general soothing, perceived throughout the 
 intestinal tract, is most remarkable. 
 
 I have already spoken of the value of a turpentine injection in cases 
 of constipation with tympany, but when this latter symptom accom- 
 panies diarrhoea, and becomes very extreme, the same remedy is often 
 indicated. You might suppose that given by the mouth the turpen- 
 tine would act as a purgative ; but if it is given in small and repeated 
 doses — as, for example, from 15 minims to half a drachm every two 
 or three hours — the result may be just the opposite. 
 
 Nor is the mere symptom of tympany to be neglected, for although 
 it is by no means commonly of much importance in the early stages 
 of intestinal lesion in fever, it may assume dangerous proportions. 
 
 Some years ago a case occurred in these wards in which abdominal 
 tympany seemed to be the direct cause of death. It resisted all 
 
 1 Clinical Lectures on the Practice of Medicine, reprinted from the second edition, 
 1864, p. 317. 
 
PERFORATIVE PERITONITIS. 231 
 
 remedies, and we failed in the attempt to pass the long tube beyond 
 the sigmoid flexure. On dissection the small intestine and the colon 
 were found enormously distended — the large intestine being turned 
 over and obstructed by the formation of a complete fold at the com- 
 mencement of the sigmoid flexure. 
 
 Two points connected with the treatment of diarrhoea in fever 
 remain to be considered. In the first place, we have to deal with the 
 question of diet. We have already spoken of diet generally in fever, 
 and you will remember the rules which were laid down for your gui- 
 dance. It is occasionally found that beef-tea tends to increase the 
 diarrhoea. Should this occur, we must either give it in smaller quan- 
 tities, or suspend, its administration. Chicken broth may be substi- 
 tuted, or farinaceous foods employed. Arrowroot with port wine, sago, 
 tapioca, rice, rice milk, plain or boiled milk, and milk and lime-water 
 in varying proportions are articles of diet to which recourse may be 
 had. I have also used eggs, and have found them to agree perfectly. 
 They may be boiled, or beaten up raw with milk sweetened with 
 sugar. " Egg-flip," or the " mistura spiritus vini Gallici" of the " British 
 Pharmacopoeia," is one of the most valuable stimulant and nutritive 
 preparations we possess. 
 
 The second point relates to the exhibition of other astringents than 
 those already mentioned. These are " chalk mixture," gallic and 
 tannic acids, the astringent tinctures (kino, rhatany, logwood, and so 
 on), and dilute sulphuric acid. They are, I believe, all useful in their 
 \va} r . I have given pills of tannic acid combined with Dover's pow- 
 der with good effect; but the most valuable of the remedies I have 
 just named is undoubtedly the dilute sulphuric acid. It has a three- 
 fold value — it allays thirst, acts as a tonic, and possesses powerfully 
 astringent properties. It may be administered frequently, and in 
 doses of from 15 to 25 or 30 minims well diluted ; or the aromatic 
 sulphuric may be substituted. 
 
 We shall now speak of peritonitis resulting from perforation of the 
 intestine, the occurrence of which may be explained by that insuscep- 
 tibility of the peritoneum to adhesive inflammation which we have 
 already considered. Eemember how rarely we meet with general 
 adhesions of the peritoneum in comparison with the frequency of such 
 a condition in the pleura. Now, it would appear that the violent 
 symptoms of perforation depend, less on a localized serous inflamma- 
 tion corresponding to a perforating ulcer of the intestine, than on the 
 fact that an effusion of the contents of the tube into the general cavity 
 .causes suddenly an extreme and commonly fatal inflammation. You 
 may occasionally meet cases where, although the serous membrane is 
 
232 LECTURES ON FEVER. 
 
 perforated, no general inflammation occurs— the process is circum- 
 scribed, and is not attended with any effect on the constitutional 
 symptoms. In fact, there is occlusion of the opening — the base of the 
 ulcer being formed by the serous membrane of the adjacent fold of 
 intestine, so that no effusion of the contents takes place. And we 
 have seen that the effect of intense irritation in another cavity may 
 be to render latent even a general inflammation from effusion, as in 
 gastro-catarrhal fever or in cases of cerebral complication. 
 
 Dr. Murchison 1 gives a remarkable example of the latter. A young 
 man aged 19, in enteric fever with acute delirium, suffered from pro- 
 fuse intestinal hemorrhage, but there were no symptoms of peritonitis. 
 After death, on the 19th day, there were found ulceration of the 
 intestine, perforation, and peritonitis. 
 
 Now, if we compare this terrible accident with the analogous con- 
 dition of empyema and pneumothorax from perforation of the pleura, 
 it seems to be more rapidly and certainly fatal. For, although in the 
 chest the accident is often attended by violent symptoms, these are 
 attributable rather to the frequently consequent and sudden collapse 
 of the lung than to the influence of the resulting pleuritis on the 
 nervous system. 
 
 It frequently happens in pneumothorax, that, after the first storm 
 of suffering is past, there comes an interval of calm — often prolonged 
 — while occasionally many of the vital symptoms of pulmonary dis- 
 ease disappear. The condition of collapse and compression seems, 
 even for a long time, to suspend the diseased process in the lung, so 
 that its constitutional symptoms may actually subside and disappear 
 temporarily. 
 
 It was long believed, and is by some still held, that general peri- 
 tonitis from perforation in fever is invariably fatal. But we have in 
 this hospital arrived at a different conclusion. It is now many years 
 since a female suffering from ascites, and under the care of Dr. Graves, 
 underwent the operation of paracentesis, soon after which she was 
 seized with symptoms of acute peritonitis. In those days, I may tell 
 you, such an accident in the operation of tapping was not uncommon, 
 and no wonder. A very large trocar and canula were employed, and 
 efforts made to get rid of every drop of fluid. With this view the 
 abdomen, while the canula remained in the wound, was compressed 
 and kneaded in various places — the mouth of the hard instrument 
 thus scraping against the serous membrane of the intestines — and a 
 tight bandage afterwards applied. Besides the effect of all this vio- 
 
 1 Continued Fevers of Great Britain, second edition, page 571. 
 
OPIUM IN INTESTINAL PERFOEATION. 233 
 
 lence, the serous surfaces, long separated from the effusion, were 
 rapidly brought into contact, so that you can easily understand the 
 frequency of peritonitis. The accident is now comparatively rare. 
 
 In the case before us the strength was greatly reduced, and no 
 remedial measure was proposed by the operator. The woman being 
 in extreme pain, Dr. Graves administered a full opiate, with the best 
 effect. Sleep soon followed, and after a few hours the patient awoke 
 with the symptoms greatly alleviated. The opium was repeated in 
 diminished doses, and after a few days all the symptoms of acute 
 peritonitis had subsided. She made an excellent recovery. 
 
 The success in this case determined us to employ opium in free 
 doses in the first example of perforative peritonitis which occurred, 
 and the practice has since then proved in many instances successful. 
 
 The two great indications of relieving pain and of controlling the 
 peristaltic action have been in these wards and in the practice of 
 several of my friends fulfilled with the happiest effects, while the 
 interesting result of the tolerance of opium in large quantities in 
 acute peritonitis has been established. Thus a grain of opium, 
 exhibited every hour, has been often given without any poisonous 
 effect whatever. 
 
 A case occurred here which illustrates the danger which may 
 follow any excitement of the peristaltic action even after recovery 
 from the first access of peritonitis has ensued. A young man, in an 
 enteric fever, was suddenly seized with the most violent symptoms 
 of peritonitis. The pulse became small, rapid, and wiry — the abdo- 
 men swollen and exquisitely tender. No doubt was entertained as 
 to the occurrence of a perforation, and the opium treatment was at 
 once resorted to and continued for twenty-four hours. Next day the 
 symptoms were greatly lessened in intensity, and we continued the 
 remedy at longer intervals for a few days. All symptoms of perito- 
 nitis disappeared, the abdomen felt natural, and the pulse had returned 
 almost to its normal standard. The patient's condition improved 
 daily, he took nourishment freely, when, the bowels having been 
 confined for many days, a very mild saline laxative was unfortunately 
 given. It acted gently, when the former symptoms at once returned, 
 and the patient sank in the course of some hours. On dissection, 
 well-formed but recent adhesions were found in different portions of 
 the peritoneum — evidently the result of the first, all-but-cured attack. 
 The perforation was in the ascending colon. It was patulous, while 
 bilious and feculent fluid existed in the serous cavity. 
 
 Now, that this patient would have been saved, had the laxative 
 
234 LECTURES ON FEVER. 
 
 been withheld, there can be little doubt, and the case is full of instruc- 
 tion and warning. 
 
 There are few more interesting and important facts in therapeutics 
 than the tolerance of opium in repeated doses in this form of perito- 
 nitis, and the remedy has been found applicable in other cases besides 
 those of intestinal perforation. It has succeeded in a rupture from 
 an over-distended bladder, in which immediately after the accident 
 no urine could be found by the catheter. In a case in which an he- 
 patic abscess had opened into the peritoneum, the inflammatory symp- 
 toms entirely subsided after a few days of the opium treatment. On 
 dissection, after death from another abscess, numerous organized 
 adhesions were observed between the convolutions of the intestine and 
 the parietal peritoneum. 
 
 In connection with this subject of the treatment of perforative peri- 
 tonitis, it may be well to remind you that this complication of fever, 
 like the other secondary affections, varies in frequency according to 
 the prevailing epidemic characters of the disease. Thus previously 
 to 1827 Dr. Graves observed but one instance of the lesion out of 
 more than 1000 cases of fever, while during the session of 1828-29 
 the occurrence was frequent in Dublin. At the present day, again, 
 even though enteric fever has increased in prevalence, this terrible 
 accident is comparatively rare. 
 
 Dr. Graves and I 1 have shown that the antiphlogistic method of 
 treatment is not so applicable in these cases as in examples of idio- 
 pathic peritonitis. In the first place, the perforation occurs at an 
 advanced period of some other disease, when the constitution is 
 enfeebled, and, at the time you will be called on to interfere, the 
 patient is suffering not merely from general peritonits but from the 
 collapse which attends the accident. The disease runs its course with 
 such rapidity that in a comparatively short time the patient is brought 
 into the last stage. Under these circumstances the antiphlogistic 
 plan only accelerates the fatal termination. No doubt in ordinary 
 peritonitis bleeding may check the increase or extension of the dis- 
 ease ; but in these cases the affection is immediately extensive and 
 severe, and the indications are not to withdraw blood from the already 
 enfeebled frame, but rather to relieve pain, control the peristaltic 
 action of the bowel, and to support the strength until nature shall 
 have completed the organization of the false membrane. 
 
 In the epidemic of 1827 the antiphlogistic method in these cases 
 signally failed in our wards, while the exhibition of opium and wine, 
 
 1 "Clinical Report of the Meath Hospital," Dublin Hospital Reports, vol. v. 
 
INTESTINAL HEMORRHAGE. 235 
 
 or of opium in full doses, was attended by satisfactory results. More 
 recent experience testifies largely to the truth of these observations. 
 
 Dr. Samuel Ousack, in speaking of puerperal fever, long ago bore 
 witness to the efficacy of wine and opium in puerperal peritonitis, 
 where the powers of life were greatly sunken, and any form of blood- 
 letting or of depletion was inadmissible. His observations were fully 
 confirmed by Dr. Gooch. 
 
 I would commend to your most attentive consideration the following 
 admirable remarks by Dr. Murchison on the treatment of peritonitis 
 in fever. He says: — 1 
 
 " Although the cause of peritonitis cannot always be determined with 
 certainty, in the great majority of instances it is perforation of the bowel. 
 The case, though desperate, is not altogether hopeless. Opium is the only 
 remedy to be relied on in such cases ; but, to be of service, it must be given 
 immediately and boldly. To an adult, two grains of solid opium may be 
 given at once, followed by one grain every second or third hour, till slight 
 stupor is induced. When the stomach is irritable, the subcutaneous injection 
 of morphia is preferable to opium by the mouth. The doses will vary with 
 the age and other conditions of the patient, but the amount of opium tole- 
 rated is often extraordinary ; as much as sixty grains have been taken in 
 three days with benefit. The opium is to be given alone, and not in combi- 
 nation with calomel, which brings down more bile into the lower bowel, and 
 so excites peristaltic action. The object is not to produce absorption of 
 lymph (even if the mercury had power to do this), but to paralyze the 
 movements of the bowels, so as to prevent the escape of their contents into 
 the peritoneum, and favour the formation of adhesions. 
 
 " Many writers have recommended the application of leeches to the abdo- 
 men on the supervention of peritonitis, but the extreme prostration, and the 
 circumstance that the tendency is to death by asthenia, contraindicate such 
 a practice. The pain and tension of the abdomen will also be relieved by 
 warm fomentations, bran poultices, and turpentine stupes ; but a much more 
 certain method of subduing the inflammation is covering the abdomen with 
 a bladder of ice, or with the ice poultice referred to under the treatment of 
 tympanites. At the same time the patient must be kept in a state of absolute 
 rest, and on no account raised in bed, and the ingesta ought to be liquid, 
 and given in such small quantities at a time that they can be absorbed by 
 the stomach. A tablespoonful of milk or of iced brandy and water may be 
 given every hour, or every half-hour. The large quantities of food and 
 stimulants sometimes given cannot fail, in my opinion, to be injurious." 
 
 He adds : — 
 
 " If the case does well, we must beware of interfering with the constipation 
 induced by the opium : cases are recorded where the incautious administra- 
 tion of a purge appeared to break up the adhesions and produce a fresh and 
 fatal attack of peritonitis." 
 
 Hemorrhage from the intestine in fever is not of very uncommon 
 occurrence. It may sometimes be regarded as to some extent a cr'dl- 
 
 « ' Loc. cit., page 655. 
 
236 LECTURES ON FEVER. 
 
 cal phenomenon, and it often produces a beneficial and curative effect, 
 lessening the local determination and irritation. Under these condi- 
 tions it should not be interfered with. 
 
 But cases are met with in which, from the amount, continuance, or 
 recurrence of the bleeding, the patient's life is placed in jeopardy, 
 and then we are called on to check the flow if possible. 
 
 The manner of the hemorrhage is twofold. Sometimes it consists 
 in a weeping from the mucous membrane. More rarely a vessel of 
 some size is opened by ulceration — this especially happens in the 
 second or third week of enteric fever. Fortunately, the treatment 
 likely to be of use is nearly the same in both cases. Rest is of para- 
 mount importance. Cold drinks and ice may be given. Turpentine, 
 in small doses, is particularly useful where the hemorrhage is associated 
 with much tympany. Acetate of lead and opium sometimes act well; 
 or opium may be given in full doses if there are strong grounds for 
 supposing that the source of the bleeding is an eroded artery. The 
 points in favour of such a view will be the suddenness of the occur- 
 rence of the bleeding, its large amount, the advanced period of the 
 illness, and the absence of hemorrhages in other parts of the body. 
 
 A man, of middle age, was almost convalescent from a compara- 
 tively mild enteric fever, when in the middle of the night he was 
 seized with sudden diarrhoea. The resident clinical clerk was hastily 
 summoned. He soon found that the motions consisted principally of 
 blood, at first dark and tar-like, then of a more florid and arterial 
 appearance. The quantity passing from the patient was so large that 
 no time was to be lost. The clinical clerk accordingly at once ad- 
 ministered a full opiate; in an hour he gave a grain of opium with 
 acetate of lead, and he repeated this dose every two hours until the 
 patient had taken 7 or 8 grains of crude opium. The hemorrhage 
 was soon checked, and the curious thing is that the patient showed 
 the same remarkable tolerance of the opium which we have already 
 spoken of in connection with peritonitis. He made a good and rapid 
 recovery. Of course the utmost caution should be employed in these 
 cases, aud the effect of every dose should be attentively watched. 
 
 Among other remedies in this complication may be mentioned tan- 
 nin, tincture of the perchloride of iron, and ergot. The last is highly 
 commended by such authorities as Dr. Murchison, and Dr. J. B. Rus- 
 sell, of Glasgow. The former has used it subcutaneously with excel- 
 lent effect. 
 
NERVOUS SECONDARY SYMPTOMS OF FEVER. 237 
 
 LECTURE XX XII. 
 
 Treatment of the Nervous Secondary Symptoms of Fever — Headache— Cold lotions, 
 warm fomentations, moderate leeching, shaving the head, cold affusion, ice — 
 Delirium — Treatment depends on (1) period of case, (2) presence of hyperemia 
 of the brain, or otherwise — Ice, leeches, shaving the head, cold affusion in active 
 delirium — Nourishment and wine in passive or anaemic delirium — Sleeplessness — 
 Moderate leeching, cold affusion, ice— Turpentine in constipation and tympany — 
 Catheterism in distended bladder — Sedatives — Opium, tartar emetic and opium, 
 hyoscyamus, bromide of potassium, chloral, wine — Convulsions — Most formidable 
 in fever — TJrsemic, due to (1) retention of urine: catheterism; (2) suppression of 
 urine : dry-cupping and poulticing over kidneys, diluents, diuretics, aperient ene- 
 mata, promotion of action of the skin. 
 
 Among- the earliest, most frequent, and often most prominent of 
 the nervous symptoms in fever is headache. At first it is seldom 
 very violent, and no important or vigorous measures are required 
 for its relief at this period. It is generally a symptom which sub- 
 sides early in the case, and is rarely indicative of anything beyond 
 functional derangement, or incipient or progressive affection of the 
 brain. The intensity of the symptom is more marked in typhus 
 than in typhoid; but in neither form of fever is it often accompanied 
 by indications of active determination to the head, and in both it 
 commonly subsides without any interference beyond the application 
 of a cold lotion, such as vinegar and water, or chloride of ammonium 
 (sal ammoniac) and water. 
 
 But should it be severe, and attended with more or less heat of the 
 head, you may employ with advantage warm stuping of the forehead 
 and temples. These warm fomentations may be repeated according 
 to circumstances, and you have often seen the marked relief afforded 
 by them. Should this measure fail, the application of two or three 
 small leeches to the temples or behind the ears will be followed by 
 relief — a relief out of proportion to the quantity of blood taken. You 
 will, however, remember that the pain generally subsides by itself 
 after the lapse of a few days. Yet it sometimes continues, and resists 
 even the treatment I have suggested; and then, when it is severe and 
 attended with heat and fulness of the head, you may adopt more 
 active measures. You may apply a larger number of leeches in 
 relays for two or three times. It used to be the practice in this city, 
 when the pain was obstinate, with heat of the head, sleeplessness, and 
 
238 LECTURES ON FEVER. 
 
 commencing delirium, to open the temporal artery — a proceeding 
 often followed by excellent results. It should be remembered that T 
 speak of a time at the commencement of the change of type in 
 disease; yet the general adoption of this measure is not to be advised, 
 as the wearing of a tight ligature round the head is often distressing, 
 to say nothing of the accidental re-opening of the wound or the for- 
 mation of a small traumatic aneurism. I should tell you that the 
 quantity of blood removed in this procedure was never excessive, 
 varying from six to ten or twelve ounces. 
 
 Now, I believe that by shaving the head, the cold affusion, and, if 
 necessary, the application of ice, you will do all that arteriotomy 
 could effect. 
 
 Yet shaving the head should not be a matter of routine, especially 
 among hospital patients. You must not forget that the poor conva- 
 lescent cannot afford to purchase a wig, and that in consequence he 
 may become liable to otitis and other accidents, such as rheumatism 
 or neuralgia of the head. And this reminds me that in the epidemic 
 of 1826 and 1828 one of the physicians of our large temporary hos- 
 pital adopted the routine practice of shaving the head of almost all 
 his patients. Dr. Graves and I, on the other hand, had very rarely 
 occasion to direct the operation, so that when the shorn and the 
 unshorn patients met in the convalescent wards the former became 
 greatly dissatisfied. But this was not all, for soon those whose heads 
 had escaped the routine razor turned on the shaved ones such a 
 battery of Irish satire on their appearance that on one occasion it 
 proved too much for endurance, and a general engagement took 
 place in the convalescent ward, which was quelled with the greatest 
 difficulty. 
 
 Cold affusion is best carried out in the following manner : The 
 patient's head is held over a basin, while cold water is allowed to 
 pour slowly from a jug holding a quart or two, and held at no great 
 height above the head. It is necessary to let the stream fall on 
 different parts of the head from time to time, for otherwise a very 
 painful sensation may be produced. The almost instantaneous relief 
 afforded in this way is often remarkable. 
 
 Now as to the application of ice: This is frequently most clumsily 
 and ineffectually performed. A bladder containing fragments of ice 
 is placed on the vertex and allowed to remain there. The effect of 
 the cold thus locally employed on the shaved head gives such distress 
 as to be at times intolerable until the ice is all melted, when you may 
 frequently find your patient's head covered for hours with a bag of 
 water at fever heat. Of course you will not permit such an error to 
 
TREATMENT OF DELIRIUM. 239 
 
 happen — the frequency of which showed how much we were in want 
 of skilled nurse-tending. The proper method of proceeding is to place 
 a piece of ice, rubbed smooth with the hand, in a cup-sponge of con- 
 venient size, and by inverting the sponge to bring the ice into contact 
 with the shaved scalp, keeping it in gentle motion round the head. 
 The sponge absorbs the water, and when it is saturated it can be 
 squeezed out, the ice replaced, and the application recommenced. In 
 this way no pain is caused, and the proceeding is grateful to the 
 patient, while the entire head is cooled. Of course, in many cases the 
 application must be renewed at shorter or longer intervals. 
 
 Before passing from the treatment of headache I wish to mention 
 the influence for good on the general condition of the patient often 
 observed on cooling of the head by some of the means I have described. 
 At times, in advanced fever with continued determination to the head, 
 you may see a rapid improvement (which continues to recovery) of 
 the patient when the heat and fulness of the head have been allayed 
 by appropriate measures. It seems as if the influence of periodicity, 
 which had been interrupted by the local malady, was again permitted 
 to act. There can be no doubt of the existence in fever of a condition 
 more or less persistent, in which various influences may bring about 
 a cessation or subsidence of the morbid phenomena. Thus we read 
 of cases of camp fever subsiding on any forced removal of the patients. 
 You will find marked benefit to follow the removal of a patient in 
 protracted fever to another ward; and even crisis has been observed 
 closely following a simpler proceeding, such as a change into a fresh 
 bed, the washing and shaving of the patient's face, sponging the sur- 
 face, and so on. 
 
 In considering delirium in fever, strive to keep the great patho- 
 logical principle before you of the rarity of actual cerebritis in essen- 
 tial disease. Also that when it does occur it is in most cases specific 
 and reactive, and as such, not to be treated as a simple primary in- 
 flammation. You will do well to study Dr. Collins' history of the 
 epidemic of cerebro-spinal fever in Dublin — the so-called "cerebro- 
 spinal arachnitis" — and you will perceive, I do not doubt, that the 
 condition of the brain and spinal cord was strictly analogous to 
 that of the ordinary secondary diseases in typhus and typhoid fevers; 
 tbat it bore the same relation to the essential malady; and that 
 in all things — treatment included — there was an analogy between 
 the local and predominant affections of these forms of disease. They 
 differed only as to symptoms referable to the organs which bore the 
 weight of the secondary malady, and agreed in inconstancy of occur- 
 rence, variety in degree, and incompetency of the local phenomena 
 to account for the general symptoms. 
 
2-10 LECTURES ON FEVER. 
 
 A key to the treatment of delirium is to be obtained by having 
 regard mainly to two considerations. First, the period of the case at 
 which this symptom is developed. The earlier the period, the greater 
 the chance of relief by remedial measures, such as the cold affusion 
 and leeching. Secondly, the presence, the degree, or the absence of 
 signs of active hyperemia of the brain. 
 
 Now, the symptom may be actively developed at an early period, 
 making it probable that it is still of toxic and functional origin; or 
 it may occur at a more advanced stage, when — if signs of active 
 determination to the head .be present—it may be supposed that re- 
 active irritation is already set up. It is in this latter condition that 
 Dr. Hudson advocates the practice of arteriotomy, but this measure 
 is seldom necessary if leeches are judiciously used, and the cold 
 affusion or the application of ice to the head properly carried out. 
 
 Ice is especially useful under such circumstances. I remember 
 attending a professional man, who with a very large head was of a 
 highly nervous and choleric temperament. He had a well-marked 
 typhus fever with severe cerebral symptoms, such as frequently-vio- 
 lent delirium, long-continued want of sleep, and extreme heat of the 
 head. Leeches had been freely applied, and followed by shaving the 
 scalp and cold affusion. I recommended the application of ice in 
 the way I have detailed to you. There had been no sleep for several 
 days and nights. A proper supply of ice having been obtained, his 
 wife commenced to move the sponge with ice slowly and steadily 
 round and round and over the great head. The patient at once 
 became quiet, and soon fell into tranquil sleep. So long as the appli- 
 cation was continued he remained asleep, but awoke suddenly and 
 delirious whenever from fatigue his wife rested her arm. In this 
 way he used to get continuous sleep for half an hour or an hour. 
 For three days and three nights she hardly ever intermitted her labour 
 of love, and might be seen kneeling at the bedside while a cloud of 
 vapour was rising from the head. Her unwearied efforts were re- 
 warded, and her husband recovered. 
 
 The devotion of woman is truly wonderful. In another case — one 
 of putrid typhus fever — the disease, from the condition of the skin 
 and the discharges, was of a most loathsome nature, and the patient, 
 also a medical man, in his wild delirium could not be kept in bed 
 unless his wife undressed and lay down beside him. This, I ascer- 
 tained, she continued to do during the long course of the disease, for 
 in this way alone could any sleep be obtained. At our daily visit 
 this lady received us in a fresh and elegant morning costume. She 
 too had her well-earned reward, and we cannot doubt that her noble 
 
DELIRIUM AND SLEEPLESSNESS. 241 
 
 indifference to personal risk went far to protect her in the dreadful 
 exposure to contagion. A lesson taught us is that contagion is one 
 thing, the state of receptivity of the body another. 
 
 Gentlemen, you will learn many things in your future practice 
 besides medicine, and will be taught what a woman will do when the 
 object of her love lies prostrate in disease, in shame, in sorrow, or in 
 madness. This is indeed the bravery of devotion. In one of the 
 Ballads of the Cid, he is represented as rescuing from death by drown- 
 ing a leper whom none of his train would approach. He mounts him 
 on his horse, brings him to a place of refuge, and even shares his bed 
 with him at night. He is awakened by a sensation as if a sword 
 passed through him, to find his companion gone. Soon afterwards 
 the room is suddenly filled with light, and the holy Lazarus stands 
 effulgent by his side, bringing a message from the Throne of God, 
 that all honour will be given to him in this world, death in victory, 
 and life eternal in the world to come. 
 
 The form of delirium I have just been speaking of is that accom- 
 panied, by high arterial tension and other active symptoms. If, on 
 the other hand, such signs are wanting, you must be very cautious in 
 bleeding locally, or even in the application of cold. An opposite line 
 of treatment is in this case generally indicated. If we have delirium, 
 even violent, without heat, fulness, or increased arterial action, the 
 treatment by leeching and cold may be in the highest degree danger- 
 ous. This we have often witnessed in pure delirium tremens, and in 
 the frequent affection in Dublin called "the whiskey-fever," when 
 these are combated by depletion of the head. 
 
 It is now many years since I was called to see a Polish officer in an 
 advanced stage of typhus fever. He had been very delirious, and at 
 my visit I found him with his shaven head covered by a bladder of 
 ice, while in each axilla a large mass of ice was fixed, and his hands 
 were clasped as in prayer. He was perfectly pale, and with great 
 feebleness of pulse; but he recognized me, and turning towards me 
 he mournfully said, " I think I am one of the lost ones." I need not 
 say the ice was all removed, warm and dry clothing supplied, while 
 wine and nourishment were given. The result of the change of 
 treatment was in every way satisfactory. 
 
 In administering stimulants in delirium you must in every case 
 begin tentatively, watching their effect from hour to hour. The chief 
 indications for their employment are the nature and the advanced 
 period of the fever, the absence of signs of active determination to the 
 head, the want of vigour in the heart as to its impulse and the intensity 
 of its sounds, and, lastly, the age and previous history of your patient. 
 16 
 
242 LECTURES ON FEVEK. 
 
 With regard to this last point, you will remember what I have said 
 in a former lecture as to the sanative influence of stimulauts so often 
 observed in patients of previously temperate habits. 
 
 The question of the exhibition of sedatives in delirium may fitly 
 be considered in connection with the treatment of insomnia, or sleep- 
 lessness, to which I would now bespeak your attention. The symp- 
 tom is frequently one of the most serious, troublesome, and unmanage- 
 able of the evidences of nervous derangement in fever. It is sometimes 
 combated successfully by such measures as have been already 
 considered — namely, moderate leeching, the cold affusion, and the 
 application of ice. In cases where the bowels are confined with more 
 or less tympany, Dr. Hudson states that the best effects were produced 
 by the administration of a full dose of turpentine. I have myself ob- 
 served a like result follow the relief of some local distress in a distant 
 part of the body. A man in advanced fever, who had been sleepless 
 and very delirious, was found to labour under a distended bladder. 
 The catheter was at once passed, and an immense quantity of urine 
 drawn off. Very shortly the delirium ceased and the patient fell 
 asleep. 
 
 It remains for us to speak of sedatives in fever. 
 
 In seeking for a guide as to the exhibition of opium you will find 
 assistance in observing the state of the eye, for the contracted or " pin- 
 hole" pupil seems to be more closely related to active hyperaemia of 
 the brain than the natural or dilated one. Still, the condition of the 
 pupil is not an absolutely certain guide, and cases are recorded in 
 which an opiate acted well notwithstanding its contraction. This sign 
 also may be present in one eye and absent in the other. Speaking 
 generally, it is far safer in fever to give opium in small and repeated 
 doses than to venture upon a large single dose. It may be advanta- 
 geously combined with antimony, as advocated by Dr. Graves, not so 
 much as an antiphlogistic or eliminative agent, but as a direct means 
 of increasing the hypnotic influence of opium. This appears to be 
 one of those therapeutic results, the explanation of which, like that 
 of many others relating to the action of medicine, is so far involved 
 in obscurity. Dr. Graves used to prescribe a mixture containing 
 four grains of tartar emetic and a drachm of tincture of opium in 
 eight ounces of camphor water. A tablespoonful of this was given 
 every second hour until the desired effect was produced. The efficacy 
 of the remedy in his hands was most remarkable ; and in the number 
 of the Dublin Quarterly Journal for August, 1849, Dr. Robert Law 
 bears his testimony to the value of this treatment. 1 
 
 1 Second Series, vol. viii. p. 63. 
 
SEDATIVES IN FEVER. 243 
 
 Tartar emetic and opium are in general indicated in those cases of 
 even high delirium, with sleeplessness, where the head is cool and 
 the action of the heart is not vigorous. 
 
 Other sedatives which you will find of use in fever are the tincture 
 of hyoscyamus, bromide of potassium, and chloral. With respect to 
 the last-named remedy, I would caution you against giving too large 
 a dose at once. In fever ten or fifteen grains of the hydrate of chloral 
 are generally sufficient to produce the wished- for effect, and if this 
 dose fails it can be repeated after a lapse of one or two hours. The 
 remedy is of especial value in the management of many cases of 
 simple delirium tremens. In this disease it may be employed in 
 moderate and repeated doses if necessary. 
 
 You will occasionally find that wine has a well-marked calming 
 and sedative effect in fever. A patient who has been restless, sleep- 
 less, and delirious will sometimes become quiet and fall asleep after 
 the administration of a little wine. This occurs where the nervous 
 symptoms are probably clue to an anaemic or spansemic condition of 
 the brain associated with a weak heart and a flagging circulation. 
 
 Convulsions in fever are among the most formidable complications 
 of the disease, more particularly so when they occur in its advanced 
 stages. Under the term "convulsions" may be included a group of 
 phenomena varying from slight subsullus iendinum and floccitatio, or 
 picking at the bed clothes, to the most violent and general pertur- 
 bation of the muscular system. These symptoms in a more advanced 
 stage of the fever are often attributed to urasmic poisoning, and there 
 can be no doubt that there is frequently disturbance referable to the 
 urinary organs. You will see in Dr. Hudson's work 1 a quotation 
 from Sir Dominic Oorrigan in reference to the importance of atten- 
 tion to the relieving of the bladder. Sir Dominic shows that daily 
 attention to the state of the bladder is imperatively necessary, and 
 that the catheter should be employed in retention of urine with or 
 without dribbling. In truth, you must not trust to any report from 
 the nurse as to the existence or absence of retention, for often, 
 although a large quantity of water may have been passed, the bladder 
 will be found greatly distended. This state may have been preceded 
 by suppression, and it sometimes happens that the return of the 
 secretion is attended by an enormous flow, especially when this 
 occurs at a critical time of the fever. In such a case it will be right 
 for you to revisit the patient within an hour or two after catheterism, 
 when you may be surprised to find the bladder again over-distended. 
 
 1 Lectures ou the Study of Fever, second edition, p. 183. 
 
244 LECTURES ON FEVER. 
 
 The amount of distension is sometimes extraordinary. " I saw not 
 long since, in private practice," says Sir Dominick Corrigan,in speak- 
 ing of the necessity of attending to the bladder in fever, " another 
 case illustrating the same point. In this case the patient was a lady 
 under the care of a homoeopath. You know a homoeopath would 
 not use a catheter. It was on the fifteenth or sixteenth day of fever. 
 I found her in epileptic convulsions, which had continued for some 
 hours, foaming at the mouth, insensible, unable to swallow, and, to all 
 appearance, dying. On examining the abdomen, I felt the bladder 
 extending up as high as the umbilicus. On introducing the catheter, 
 it was scarcely possible to bear the intolerable ammoniacal smell of 
 the urine, which must have been shut up for several days. It con- 
 tinued to flow until some large basinfuls were drawn off. This patient 
 recovered, but she suffered much from the neglect. Subacute and 
 then chronic cystitis followed, under which she continued to suffer for 
 more than a year afterwards." 
 
 In connection with the presence of uraemia in fever we have 
 observed the urine in such cases to effervesce briskly on adding a 
 dilute acid, and I have already mentioned a case of extreme subsultus 
 in which the cerebral sinuses and the veins of the pia mater contained 
 air in considerable quantity. 
 
 The most long-continued and violent attack of convulsions I ever 
 witnessed was in the case of a student of this hospital, who had gone 
 on to the thirteenth day of fever. The distended bladder could be 
 felt; but such was the violence of the convulsions, attended with 
 extraordinary priapism, that all attempts at catheterism were futile. 
 It was also impossible to get the patient to swallow anything, or to 
 use an enema, and under these desperate circumstances we determined 
 to employ chloroform inhalation. The greatest difficulties attended 
 the administration, but at last the effect was produced. The convul- 
 sions ceased like magic, and suddenly a jet of urine sprang upwards 
 to a great height from the still erect penis; the stream continuing to 
 flow until the bladder was empty, when the priapism disappeared. 
 
 We see, therefore, that, where the uraemic condition and its accom- 
 panying convulsions depend on mere retention of urine, we have a 
 ready and efficacious remedy in careful and judicious evacuation of the 
 bladder by the catheter. 
 
 But in suppression of urine our treatment must be different. Dry- 
 cupping freely employed over the kidneys, the diligent application 
 of poultices and sinapisms in the same region, the use of diluents, and 
 the exhibition of a combination of nitre with the spirit of nitrous 
 ether, are the measures in which you are to place most confidence. 
 
PHLEGMASIA ALBA DOLENS. 245 
 
 It is also necessary to keep the bowels open by turpentine enemata, 
 and the action of the skin may be stimulated by sponging with tepid 
 vinegar and water and subsequent rubbing with a dry towel. 
 
 LECTURE XXXI II. 
 
 Phlegmasia Alba Dolens— The swelling is not always painful, or white in appear- 
 ance — Symmetry of the affected limb not lost — Professor Trousseau's views as to 
 the etiology of the affection — Phlegmasia (1) of puerperal women, (2) in scrofu- 
 lous and (3) cancerous cachexia — Pulmonary embolism caused by phlegmasia — 
 Case of phlegmasia after typhus fever— Treatment of the affection — General Con- 
 clusion. 
 
 Gentlemen, you may remember my mentioning to you that a 
 continued rapidity of pulse after the other constitutional symptoms 
 of fever had subsided was to be taken, not — as suggested by Laennec 
 — as a sign that the heart had been weakened, but rather as showing 
 the existence of some acute organic change attended with irritation. 
 I mentioned as examples of these changes two pathological condi- 
 tions — one, the acute and sometimes general development of tubercle; 
 and the other, that form of disease to which the name of phlegmasia 
 dolens, or phlegmasia alba dolens, has been given. 
 
 We shall by-and-by examine how far the term " phlegmasia" is 
 properly applied; and, although the disease is commonly more or 
 less painful, it may occur so free from local suffering that its discovery 
 is accidental; and so, as I have already shown, the adjective "dolens" 
 is not always applicable. Again, in place of the swelling being 
 colourless, the entire limb may be covered with deep purplish-blue 
 arborescent stainings, so that the remaining portion of the term is 
 not always appropriate. This, however, is less often met with than 
 the absence of pain. The pain, too, may be singularly localized; 
 thus, in a case which was under the care of an eminent physician, the 
 pain was confined to the sciatic notch. The disease was held to be 
 merely sciatica, and the actual cautery ordered to be applied over the 
 nerve. In preparing to effect this the assistant accidentally exposed 
 the opposite extremity, when he was struck by its comparative ema- 
 ciation, and the real nature of the case was at once revealed. 
 
 This illustrates an interesting circumstance, which we have often 
 observed — namely, that, though the swelling of the limb may be 
 general, it has little if any effect on the symmetry of the part. The 
 limb is simply larger and fuller than the opposite extremity, so that 
 
246 LECTURES ON FEVER. 
 
 it is often only by comparison that the morbid enlargement is recog- 
 nized. I detailed to you a case in which symptoms of intermittent 
 fever, which, however, was then epidemic, were present and exaspe- 
 rated by the use of quinine. Here the discovery of the nature of the 
 disease was due solely to an accidental comparison of the lower ex- 
 tremities. The patient was not conscious of the existence of any 
 enlargement or pain in the limb. 
 
 It is probable that this remarkable appearance of symmetry of the 
 affected limb occurs more frequently when the disease is a sequela of 
 fever than in other cases. Thus Professor Trousseau, 1 in speaking 
 of its occurrence in tubercular and cancerous cachexias, refers to the 
 irregular form assumed by the painful oedema in these affections. 
 
 In his lectures the same great clinical teacher dwells on phlegmasia 
 alba dolens as a result of puerperal fever, and also mentions its occur- 
 rence in typhus and in typhoid fevers. 
 
 He inclines to the opinion that it results rather from a condition 
 of the blood predisposing to coagulation in the veins, and their con- 
 sequent obstruction, than to primary phlebitis. The result is what 
 he denominates "painful oedema," which disappears either by the 
 establishment of a collateral circulation or by the resolution of the 
 clot. He gives some important facts showing that the existence of a 
 phlegmasia abla dolens may have an important influence in the diag- 
 nosis of visceral cancer. 
 
 You may now ask how far the term " phlegmasia" is applicable to 
 this disease, or whether the coagulation of blood in the veins is not 
 the first step of the local malady, while the inflammatory condition is 
 secondary and reactive. Certain it is that when a cordy and painful 
 state of the veins, such as the femoral or saphena, exists, the moderate 
 use of leeches over the vessel is advisable. This is true at least in 
 the case where the disease occurs as a sequela of fever, and it is on 
 this that our observations are based. 
 
 Now, whether phlegmasia occurring in puerperal woman is or is 
 not due to the presence of uterine phlebitis and the extension of in- 
 flammatory action along the veins, producing obstruction of them, 
 may be a question ; but that actual primary or traumatic phlebitis is 
 capable of obstructing a vein so as to cause painful oedema— in other 
 words, phlegmasia dolens — appears from a case which occurred some 
 years ago in our wards. It was of a patient labouring under an acute 
 attack of visceral inflammation who was bled from the arm. The 
 operator used a rusty and blunt lancet. The arm became painful and 
 
 1 Clinical Medicine, vol. v. lect. xcv. New Syd. Soc. Translation. 
 
THE BLOOD IN PHLEGMASIA. 247 
 
 tender along the course of the median basilic vein above and below 
 the bend of the elbow. There was no swelling, but the type of fever 
 changed to an asthenic form, attended by sweating and anxiety, so 
 that the state of pyaemia was apprehended. This having continued 
 for a few days, the arm suddenly swelled from above the elbow down- 
 wards, and presented all the characters of phlegmasia alba dolens. 
 The constitutional symptoms subsided, and the patient gradually 
 recovered. 
 
 Now, you know that ordinary phlegmasia dolens is seldom a fatal 
 disease, a fact which may be accounted for by assuming that, as in 
 the cachexias, the coagulation of the blood is the principal morbid 
 condition, or that it acts in preventing the blood-poisoning by the 
 localization of phlebitis. Be this as it may, it seems certain that the 
 danger is inversely as the amount of swelling. I believe that in the 
 case I have just now detailed suppurative inflammation of the vein 
 was about to commence when coagulation put an end to further 
 absorption. 
 
 In connection with this point I may notice that in certain forms of 
 visceral irritation the bulk of the affected organ is greatly augmented. 
 And it may be that this is caused by oedema, the result of venous 
 obstruction. Thus in a case of croupous or plastic pneumonia which 
 was brought before the Pathological Society of Dublin by Professor 
 Eobert William Smith the enlargement of the affected lung was so 
 considerable as to simulate empyema ; the side was much dilated and. 
 the liver depressed. Every air-cell seemed to be filled with minute 
 granular fibrinous bodies, of which thousands were obtainable by 
 washing the cut surface of the lung. 
 
 Trousseau has shown that the principal condition in the phlegmasia 
 dolens is coagulation of blood in some venous trunk, and not, as has 
 been held, an affection of the lymphatics. In this hospital we have 
 verified his statement of freedom of the lymphatics and glands in the 
 groin. You will do well to study his 95th lecture, in which, in addi- 
 tion to an exhaustive pathological account of the disease, he shows 
 that, in the cachexias generally, hasmatologists 1 have established that 
 there is a diminution of the red globules and an augmentation of the 
 fibrin and serum of the blood. This condition predisposes to a spon- 
 taneous coagulation, the tendency to which we may well suppose to 
 be still further increased by the presence of any phlebitio irritation. 
 
 I have told you that Trousseau explains the frequency of phleg- 
 
 1 Andral et Gaverr«t, Rucherches Bur lea Modifications des Proportions des quolques 
 Prineipes du Sang daus les Maladies. Paris, 184'J. 
 
248 LECTURES ON FEVER. 
 
 masia in the cancerous and tubercular cachexia? by a reference to this 
 fibrinous and leucaematous condition of the blood, and it is more 
 than probable that its occurrence as a sequela of fever depends on the 
 same cause. In further support of this view I may recall the fact, 
 also noticed by Trousseau, that phlegmasia is more common after 
 enteric than after typhus fever, the longer duration of the former 
 tending to modify the constitution of the blood to a greater degree. 
 There can be little doubt also that the local abdominal irritation so 
 common in the advanced stages of enteric fever, like the uterine 
 irritation in cases of phlegmasia puerperarum, acts as an exciting 
 cause in the presence of such a deteriorated condition of blood. 
 
 Viewing the question again from another point, it may be held 
 that the affection following fever is the result rather of a state of 
 blood predisposing to coagulation than of an original phlebitis. It 
 has been observed that there is often little, if any, increase of local 
 temperature, and the disease appears to differ from the secondary 
 affections of fever in not presenting any well-marked signs of pe- 
 riodic retrocession. Still, as I have said, in cases where at an early 
 period a cordy state of the femoral or saphena veins — accompanied 
 by tenderness — exists, the application of a few leeches along the 
 course of the vessels, fomentations, poultices, and the moderate use 
 of opium are followed by good effects. 
 
 Professor Trousseau also alludes to the occurrence of pulmonary 
 embolism in phlegmasia dolens in the male subject, showing that 
 spontaneous coagulation may be developed in the saphena, crural, or 
 any other vein, and remain limited to a very small extent of the 
 vessel. He observes that generally the migratory clot reaches the 
 lung, causing dyspnoea and rapid death by apnoea; but he believes 
 that in certain exceptional cases the clot may be arrested in the right 
 auricle or ventricle of the heart. He says that, in accordance with 
 the predisposition of the patient and the volume of the clot, the 
 phenomena which belong to syncope will be observed ; the heart, 
 surprised, so to speak, by the arrival of the migratory clot, will at 
 once cease to beat with regularity and power, and ere long contrac- 
 tions will entirely cease. In these cases death will take place by 
 syncope — by " arrest" of the heart — in fact, the prolonged syncope 
 leads to death. 
 
 I have sometimes thought that this form of syncope was induced 
 less by the " surprise" of the heart than by the sudden cutting oft* of 
 the blood supply from the left ventricle. A case was some years ago 
 presented to the Pathological Society of Dublin in which symptoms 
 of heart disease were at last followed by a sudden and fatal syncope. 
 
CASE OF PHLEGMASIA DOLENS. 249 
 
 An indurated coagulum of a spherical form had entered the funnel- 
 shaped sinus described by Mr. Adams, and completely occluded the 
 left auriculo-ventricular opening, thus absolutely and suddenly cutting 
 off the blood supply from the left ventricle. 
 
 Before I conclude this lecture I will read the notes of a very inter- 
 esting case of the affection which has been engaging our attention- 
 The subject of it was a pupil of Dr. Graves and myself at this hospital) 
 who for many years since has enjoyed an extensive practice in the 
 country. The facts of the case are given in the gentleman's own 
 words. He says : — 
 
 For a great part of the years 1827, 1828, and 1829, I acted as clinical 
 clerk to you and our lamented friend Dr. Graves in the Meath Hospital, 
 during the protracted continuance of an epidemic of typhus fever, which we 
 cannot easily forget. My principal business was to ascertain, as far as 
 possible, the critical days of the fever, in the investigation of which you and 
 Dr. Graves were deeply interested at the time. In this occupation it was 
 my duty to spend several hours every day at the bedside of patients in all 
 stages of the fever, and my immunity from contagion for so long a period 
 led me to imagine that I had become absolutely fever-proof; but I was des- 
 tined to be undeceived. 
 
 One morning in June, 1829, Dr. Graves called the attention of the class 
 to a remarkable instance of color mordax in a female patient. Of course 
 there was a rush of the pupils to witness this unusual phenomenon, myself 
 amongst the foremost. I had no sooner laid my hand on the burning skin 
 of the patient's arm than I was conscious, by a sudden thrill or shock through 
 my whole frame, that I was stricken by fever. That day and the next con- 
 stituted the period of incubation. I was not actually ill, but I was languid, 
 uncomfortable, listless — out of sorts in every way. On the third day I had 
 a rigor, followed by an intense pain in the head, with nearly all the usual 
 characteristics of typhus, including a full crop of petechias. (It is worthy 
 of notice, however, that neither in this nor in several subsequent fevers had 
 I ever the slightest delirium.) On the twenty-first day from the rigor I ap- 
 peared to have a crisis, and a terrible crisis it was. I was suddenly seized 
 with violent pain, apparently in the left hip-joint, and gradually extending 
 to the leg and foot. The whole limb became swollen and glazed, presenting 
 all the appearance of a leg affected with pMegmasia dolens, as no doubt it 
 was. The pain was excessive and almost intolerable. For fourteen nights 
 the most powerful opiates which could be safely administered failed to pro- 
 cure sleep, though they served, in some degree, to alleviate pain. 
 
 After about three weeks of acute suffering — six weeks from the commence- 
 ment of the fever — I was enabled to leave my bed. But the swelling of the 
 limb remained, and it was evident that there was permanent hypertrophy of 
 the cellular substance. In all likelihood I was doomed to have a thick leg 
 for life. For many years, too, I continued to have more or less pain in the 
 hip, always increased by exercise. Some short time after my recovery from 
 the fever the veins of the affected leg became varicose, and I had a varicose 
 ulcer which remained open for nearly two years. This, however, was healed 
 under the influence of country air and consequently improved health, and it 
 has never returned. Once — about twenty years ago — a vein burst, and I 
 lost a considerable quantity of blood. Since then 1 have persistently worn 
 a bandage, and the veins have given me little further trouble. No special 
 
250 LECTURES ON FEVER. 
 
 remedies were adopted for the reduction of the swelling of the leg; but on 
 one occasion Dr. Graves hesitatingly suggested a line of treatment to which, 
 as it involved an undesirable contingency, I demurred. 
 
 I now come to a curious and interesting phase of the history of this thick 
 leg. You recollect that the swelling of the leg appeared to be a sequela of 
 one typhus fever. Exactly thirty-one years afterwards — that is to say, in 
 June, 1860 — I had another typhus fever, when you and Dr. Hudson kindly 
 came to the country to visit me. (Bow I came to pick up this well-marked 
 maculated typhus I never could divine. There was no epidemic fever of 
 any description in the neighbourhood, nor had I seen a case of typhus for 
 seven years.) Well, the result of this fever was to restore my thick leg to 
 its original dimensions. There was no marked crisis. After two or three 
 weeks of extreme danger, in which my life hung by a thread, the fever 
 gradually subsided, and disappeared by the twenty-seventh or twenty-eighth 
 day, leaving the affected leg as slim and emaciated as its fellow ; and the 
 hypertrophy has never since reappeared. 
 
 But this is not all. In the spring of the present year (1813) I had a 
 severe attack of influenza, from the effects of which I have not even yet 
 recovered. After two or three months of delicate health, during which my 
 professional engagements prevented my having change of air, a blush of 
 redness appeared over the middle third of the tibia of the varicose leg, 
 accompanied by tingling pain, tenderness to the touch, and slight cedema 
 of the leg. The redness gradually increased from day to day in extent and 
 intensity, and from its upper margin a well-defined dark red line extended 
 to the knee, where it abruptly terminated. Under the use of bark and 
 iodide of potassium the redness and tumefaction subsided, and I then de- 
 tected a hard ridge, apparently bony, and about three-fourths of an inch in 
 length, on the inside surface of the tibia. At first I attributed these symp- 
 toms to periostitis; but when the cedema had almost entirely disappeared, I 
 discovered that the " ridge" which I had believed to be bony was not bone 
 at all, but a portion of obliterated vein like a piece of hard whip-cord and 
 movable under the finger. Was this an attempt at a natural cure ? I 
 sometimes fancy that the varicose veins have diminished in fulness and bulk, 
 though it may be only fancy. 
 
 Before I conclude I may be permitted to refer to a couple of facts which 
 bear upon the vexed question of a change of type in fever and other dis- 
 eases. 
 
 1. I was never strong or robust, and at the commencement of my first 
 typhus fever, at the age of twenty-three, my health had been impaired by 
 arduous study and close attendance on patients in a hospital atmosphere. 
 And yet the treatment — which I maintain was at that time the correct and 
 proper treatment — would not be adopted at the present day. After an 
 unsuccessful attempt by poor Dan Pakenham (the worthy apothecary of the 
 Meath Hospital) to open my temporal artery, a dozen leeches were applied 
 for the relief of the pain of my head; and during the whole progress of this 
 petechial fever I obstinately and successfully refused to swallow wine or any 
 other stimulant whatever. Again, after twenty-one days' reduction of 
 strength by typhus, and when phlebitis set in, I had a hundred leeches, in 
 two relays, applied to the painful hip — without much apparent benefit, I 
 admit, but still without killing me or causing any perceptible injury. What 
 would happen under similar circumstances now? 
 
 2. I was placed under much more favourable circumstances when, at the 
 age of fifty-four, I was attacked by my second typhus fever. I had pre- 
 viously been in good health, and was residing in pure country air. Never- 
 
TREATMENT OF THE AFFECTION. 251 
 
 theless it was only by the continuous and lavish administration of stimulants 
 — alcoholic and diffusive — that my life was saved. I offer no comment; is 
 comment needed? 
 
 In this very remarkable case there are two circumstances of pecu- 
 liar interest. One of these is the undoubted occurrence of a second 
 typhus fever in the same individual after a long lapse of time, the 
 malady setting in, in the absence of any of its presumed exciting 
 causes; the other, the fact that the tumefaction of the limb, which 
 had been of many years' standing, completely subsided during the 
 second fever. It is also worthy of note that last year my friend's 
 health had not been so good, as a result of which a cachectic condition 
 of blood was established, and determined venous coagulation in the 
 leg. At least this would seem to be the probable explanation of the 
 recent attack of irritation and coagulation in the vein of the leg. 
 
 The treatment of this affection is sufficiently simple, and I have 
 given you an outline of it as regards local measures. In the advanced 
 stages the exhibition of iron is often most useful, the preparation on 
 which I would specially place reliance being the " ferrum tartara- 
 turn." 
 
 In conclusion I would caution you against a possible error of diag- 
 nosis. In phlegmasia, when the oedema in lessening loses a certain 
 condition of tension, the local sensation of fluctuation singularly simu- 
 lates that of an abscess, even one near the surface. This is often more 
 or less localized, and the surgeon who neglects the history of the case 
 and the attending phenomena may commit the error of taking a dif- 
 fused cedema for a localized purulent collection. I have known an 
 operation to be performed in two situations in the same extremity ; 
 fortunately no bad result followed. A similar condition more com- 
 monly observed is where parotid swellings form in connection with 
 the eruptive fevers. I have seen deep incisions performed on the 
 same occasion at both sides of the neck in cases where the sense of 
 fluctuation solely was relied on. One patient died of oozing hemor- 
 rhage under these circumstances, the bleeding setting every treatment 
 at defiance. A fact such as this will show you that the caution I give 
 is not unnecessary. 
 
252 LECTURES ON FEVER. 
 
 Gentlemen, — We have now gone over the principal facts con- 
 nected with the great subject of fever and its treatment, and have been 
 much occupied with the local affections referable to one or more of 
 the large cavities ; but I trust that the junior members of the class 
 will not imagine that, as a rule, they are to put all the recommenda- 
 tions given into force in any one case, or that I would encourage any 
 meddlesome or complicated treatment in fever. There are cases in 
 which you will have to change your hand several times in the course 
 of the disease ; but the worst kind of physician is the man who, from 
 his own timidity or want of confidence in himself, is constantly chang- 
 ing his treatment and interfering with his case. You may still meet 
 such practitioners — I regret to say it, too frequently — physicians, who 
 have not learned to look at fever as a whole, who do not recognize 
 the law of its spontaneous subsidence, or the great fact — especially as 
 regards the nervous conditions — that the toxic state is to be looked to 
 more than any supposed organic change. 
 
 I remember a case of bad cerebral typhus attended by a gentleman 
 who every day made a new diagnosis, and who at last gravely assured 
 me that he had come to the conclusion that there existed acute inflam- 
 mation of the hippocampus major ! 
 
 You must engrave on your minds that fever, although often show- 
 ing secondary functional or organic anatomical change, may run its 
 course without such complications. In these simple, or so to speak 
 normal, cases you have to see only that the patient is placed in the 
 best condition as regards ventilation, cleanliness, and fitting nourish- 
 ment ; that stimulants are given when indicated ; and that the state of 
 the bladder and bowels is attended to. Should symptoms of local 
 suffering occur, you are to meet them — at least in the first instance — 
 as signs of functional rather than of organic disease, and seek to relieve 
 them at the least expense to the system. You will remember what 
 has been so often impressed on you here and in the wards — always to 
 consider the epidemic character ; and that in fever danger arises from 
 debility — often an early effect of the poison ; or, on the other hand, 
 from the varied and inconstant forms of the secondary functional and 
 organic conditions. 
 
 To conclude, it would appear that the more fever and its effects are 
 studied — whether at the bedside or in the dead body — the less im- 
 portance will be attached to anatomical change. It is to the varying 
 condition of innervation and of the chemico-vital states of the fluids 
 that the great phenomena of Continued Fever are to be referred. 
 
 In relation to the weighty question of prognosis, you will ever re- 
 
APPENDIS B. 253 
 
 member that the course of a fever will be favourable in direct pro- 
 portion to the absence of anomalous circumstances — even though 
 individually these may indicate freedom from disease. 
 
 APPENDIX B. 
 
 The following observations have been furnished me by my colleague, 
 Dr. A. W. Foot, as bearing upon the subject of the use of the ther- 
 mometer in fever in our medical wards. 
 
 The thermometer has been in daily use in the medical wards of the Meath 
 Hospital for many years. Its value as a reliable clinical aid in the diagnosis 
 and prognosis of acute disease, especially in essential fever, has been estab- 
 lished as fully as it has wherever else this instrument has been habitually 
 employed. 
 
 During the past three years, 1871, 1872, 1873, 9248 observations on the 
 temperature of the sick have been made in the medical wards. The obser- 
 vations are made twice daily, at or about 9 A. M , and 9 P. M., by the clinical 
 assistants, the practising pupils in charge of the cases, or the physician on 
 duty, and are recorded on the clinical charts of temperature published by 
 Harvey and Reynolds of Leeds. 
 
 Of the 9248 observations 3696 were upon cases of typhoid and typhus 
 fever; the remainder were upon cases of simple continued fever, scarlatina, 
 measles, variola (1026 observations), lung diseases, erysipelas, cerebral 
 fever, etc. 
 
 Of the 3696 observations on typhoid and typhus fever, 2649 were upon 
 typhoid and 1047 on typhus fever. It has to be observed that there has 
 been during the three years above mentioned — 1871, 1872, 1873 — much less 
 demand than usual for the admission of " fever" patients — in part perhaps 
 owing to the intercurrence of the smallpox epidemic. 
 
 The 2649 observations in typhoid fever were made upon 70 cases. The 
 highest temperature registered among these was 107.2° Fahr., and the lowest 
 temperature 94° Fahr. 
 
 On 27 occasions temperatures of 105° Fahr. or upwards were registered 
 in typhoid fever in 15 patients, and of the 15 patients in whom the temperature 
 on one or more occasions reached 105° Fahr. or upwards, five died. On 
 four of these cases whose illnesses had been marked by high temperature 
 post-mortem examinations were made. 
 
 (a) A girl aged 16, temperature on 30th morning 107.2° Fahr., died on 
 the 31st evening. Her mean temperature (51 observations) during the 26 
 days she was in hospital was 103.1° Fahr. 
 
 The morning temperature, 107.2°, was coincident with severe rigors, pre- 
 ceded by violent pain in the abdomen, ushering in peritonitis, not due to 
 perforation, but to propagation outwards of the irritation arising from 
 numerous ami extensive ulcerations of the intestinal glands. 
 
 (b) A female, aged 24, who died on the afternoon of the 36th day. Her 
 average temperature was 102.1° Fahr., but did not, exceed 105.2° Fahr. 
 There were 17 patches of ulceration in the last 53 inches of the ileum, pleuro- 
 pneumonia of tin' righl side with exudation of plastic lymph ami sero-tibri- 
 nous fluid in the right pleural cavity. 
 
254: LECTURES OX FEVER. 
 
 (c) A female, aged 20, who died on the 36th day, with most extensive 
 ulceration of both solitary and agminated follicles of the ileum. Her mean 
 temperature (45 observations) during the 28 days she was in hospital was 
 102.3°. 
 
 (rf) A lad, aged 16, who died on the 15th evening of his illness after 
 repeated intestinal hemorrhages. The mean temperature (14 observations) 
 during the seven days he was in hospital was 103.5°. 
 
 (e) A young man, aged 18, who died on the 15th evening. On the 9th 
 evening his temperature reached 105.8°. He was of intemperate habits, and 
 had albumen in the urine. The mean of 16 observations on his temperature 
 during the eight days he was in hospital was 104° Fahr. In this case a 
 post-mortem examination was not obtained. 
 
 Cases have proved fatal in which the mean temperature was not very high, 
 especially under two circumstances — great protraction of the fever, and the 
 collapse consequent upon perforation. Of this latter kind two examples have 
 been verified by post-mortem examination. 
 
 (a) A man, aged 40, brought into hospital \n collapse on the 10th day of 
 illness, and who lived until the morning of the 16th day. The mean of 12 
 observations during the six days he was in hospital was 99.5° Fahr. His 
 temperature on admission was 97° Fahr. ; the highest it reached in hospital 
 was 100.8° Fahr. 
 
 (b) A man, aged 27, brought to hospital on the 8th day of illness, and 
 who died on the 1 lth morning. His mean temperature during the four days, 
 or part of four days, he was under observation was 100.2° Fahr.; the lowest 
 point he reached was 97.7° Fahr. 
 
 In contrast with the two preceding cases is the case of a boy aged 18, who 
 was brought to hospital in a state of collapse from perforation, and who 
 only survived his admission 40 hours; the mean of three observations showed 
 an average temperature of 103.7° Fahr. 
 
 In these three cases the intestinal perforation was discovered after death, 
 and in each case fecal extravasation had taken place. 
 
 The extremely low temperature of 94° Fahr. was observed in a young 
 woman, aged 24, upon the 24th morning of her illness. She was under 
 observation during the whole course of her illness, as she got typhoid fever 
 while under treatment in the medical wards for a different affection. She 
 recovered, but had a long fever. Her chart was discontinued on the 46th 
 day She had during convalescence several abscesses over the sacro-iliac 
 articulation, which were evacuated by aspiration. 
 
 Mistrusting the accuracy of the practising pupils' observation, I repeated 
 it myself at 9^ A. M., and found the temperature of the axilla, with every 
 precaution to secure accuracy, and with a correct instrument, to be 94°. The 
 body felt cold and clammy like that of one taken out of water; cutis anserina 
 was most strongly marked ; she had no new abdominal symptom ; the pulse 
 was 88, regular, and easily felt at the wrist ; the respiration 26. The col- 
 lapse came on early in the morning ; the temperature on the previous evening 
 had been 101.6° Fahr., the pulse 101. She was quite conscious and sensible, 
 felt cold, but had no pain anywhere ; there was a tendency to vomit. She 
 had not been taking any antipyretic medicine. The temperature began to 
 rise from noon, and by 9 P. M. had risen 6.2° Fahr. higher than it had been 
 in the morning. This sudden collapse was never accounted for. The high- 
 est temperature recorded among 70 observations made on her case was 
 105.5° on the 12th evening. 
 
 Among 1047 observations made upon 43 cases of typhus the highest tem- 
 perature recorded was 106° Fahr. On twelve occasions temperatures of 
 
APPENDIX B. 255 
 
 105° Fain*, or upwards were observed in the cases of eight patients, four 
 males and four females. Of these eight cases in which temperatures of 105° 
 Fahr. or upwards were observed, two died: one — that above alluded to — in 
 which the temperature reached 106° on the 16th evening, was a man, aged 
 34, affected with well-marked sclerosis of the posterior columns of the spinal 
 cord (autopsy made) ; the other was a man of bad constitution, and 43 years 
 of age, who succumbed on the 14th day. 
 
 Deaths from typhus of course occurred in cases whose temperature did 
 not reach 105° Fahr., other lethal conditions being in operation. For ex- 
 ample, a boy, aged li, died on the 10th evening of typhus caught during a 
 convalescence from scarlatina, which in its turn had followed closely in the 
 footsteps of typhoid fever. He had been exposed to infection in a fever 
 hospital. He was brought to the Meath Hospital desquamating, but covered 
 with a copious typhus eruption ; he had epistaxis, haamaturia, green vomiting, 
 and died in convulsions. His temperature did not exceed 104° Fahr., and 
 was twice in the six days he was under observation as low as 98° Fahr. 
 
 The employment' of the thermometer has proved of great value in the 
 diagnosis and prognosis of a given case, in distinguishing a factitious from 
 a genuine convalescence, in estimating the severity of a case, in estimating 
 the results of antipyretic treatment, in detecting imposition, as an indicator 
 of complications. The students are soon firmly convinced of the great value 
 and importance of medical thermometry, and the patients have never ex- 
 pressed themselves as in the slightest degree annoyed or fatigued by even 
 the frequent use of the instruments. Its employment is general in the 
 medical wards, and by no means confined merely to cases of acute disease. 
 
INDEX. 
 
 ABDOMEN, affections of the, see Abdomi- 
 nal symptoms. 
 Abdominal symptoms in fever, 56, 62, 135 
 seg., 142 seq., 146 seq. 
 swelling, 139 
 tenderness, 139 
 aorta, Increased action of, 139 
 abscess, 149 
 Abernethy's chylo-poietic theory of disease, 
 
 219 
 Aborted typhus, 91 
 Abscess, hepatic, 111, 157 
 
 internal, in yellow fever of 1826-27, 
 
 111, 149 
 splenic (?), 149 
 
 simulated by the oedema in phlegma- 
 sia, 251 
 Absence of anatomical change in fever, 20 
 
 of symptoms unfavourable, 207 
 Abuses of the antiphlogistic treatment, 9 
 Acetate of lead and opium, 229 
 Acland, Dr., on preventive medicine, 35 
 on therapeutical research, 188 
 Affections, secondary, see Secondary affec- 
 tions. 
 Affusion, cold, 238 
 Age determining propriety of stimulation 
 
 in fever, 197 
 Ague, see Intermittent fever. 
 Alison on change of type in disease, 12 
 
 on coexistence of various species of 
 fever, 52 
 Alteratives, danger of using, 228 
 Anaemic condition of organs in fever, 58 
 
 murmurs, 131, 132, 133 
 Analogy between fevers and toxic diseases, 
 24 seq. 
 and tubercle and syphilis, 32 
 and increased arterial pulsa- 
 tions in various diseases, 
 140 
 from effects of local depletion, 1G3, 
 164, -l-l* 
 Anatomical character, diseases with an, 22 
 chiinge may be absent in fever, 20, 69 
 
 seq. 
 expression for fever, wanting, 50 
 local symptoms in Fever, 68 
 Anatomical school, 182; errors of, 182, 
 
 183 
 Anatomy fails to solve the problem of 
 
 healthy life, 19 
 Andral's description of French fevers, 67 
 
 17 
 
 Annesley, Mr., on adhesive peritonitis, 157 
 Anster's, Dr., translation of Goethe's Faust, 
 
 quoted, 19 
 Anticipative stimulation in fever, 195, 215; 
 rules for, 195 
 in bronchial affection, 223 
 Antiphlogistic treatment not always called 
 for in primary inflammation, 5 
 abuses of the, 9 
 
 contra-indicated in perforative pe- 
 ritonitis, 234 
 Aorta, increased action of abdominal, 139 
 
 pulse in patency of the, 140 
 Aphouia in laryngo-typhus, 106 
 Appendix A, 40: Appendix B, 253 
 Arachnitis, cerebro-spinal, 165 seq., 239 
 Armstrong's theory of fever, 218 
 Arteriotomy in delirium, 240 
 
 in headache, 238 
 Asthenic pneumonia, 93 
 Astringents, 231 
 
 BANKS, Dr., on cerebro-spinal fever, 169 
 Bark, failure of, in intermittent fever, 
 6, 113 
 Beatty, Dr., on frottement of peritonitis, 
 
 158 
 Beaumont's, Dr., experiments on digestion, 
 
 190 
 Bed-sores, 209; treatment of, 212, 213 
 
 subject to law of periodicity, 210 
 Belly, see Abdomen and Abdominal. 
 Black vomit, 147 
 Blane, Sir Gilbert, on mortality in the 
 
 Peninsular War, 3 
 Blisters, 225, 226 
 
 Blood, characters of the, in phlegmasia do- 
 lens, 247 
 Blood-letting, local, 164, 226, 327, 237 
 Blood-waste in fever, 120; urohsematin as 
 
 a sign of, 120 
 Boston, North, New York, outbreak of en- 
 teric fever at. 46 
 Brain, Louis' researches on the, in fever, 
 CO seg., 161 
 inflammation of the, see Cerebritis. 
 Brennan's, Dr., receipt to make a fever, 
 220 
 couplet on turpentine, 225 
 Hrinkley. Bishop, problems on contagion, 
 
 80 
 Bromide of potassium, I7"> 
 Bronchial affection of fever, 68, 72 at q. 
 
258 
 
 INDEX. 
 
 Bronchial affection of fever described, 73 
 not primarily bronchitis. 75 
 subject to law of periodicity, 
 
 77 
 treatment of the, 77. 223 seq. 
 simulating phthisis, 78, 79 
 associated with weak heart, 
 223 
 muscular fibre, paralysis of, 105, 223 
 Bronchitis, see Bronchial affection. 
 Broussais, theory of fever held by, 6, 218 
 error of his school, 21 seq., 102, 137, 
 141, 161, 181, 218, 228 
 Buffed and cupped blood-clot, 16 
 
 nALCULI, bronchial, 83 
 
 \J Camp fever, 45 
 
 Cancerous cachexia, phlegmasia dolens in, 
 
 246 
 Cardiac muscular fibre, weakening of, 105 
 affections in fever, 106 seq. 
 softening, 1 17 
 excitement, 119, 200 
 depression, 121, 200 
 murmurs, 131. See Heart. 
 Catheterism in retention of urine, 243 
 Cause of fever, proximate, undiscovered, 
 
 23 
 Causes of fever, various, 32, 34, 48, 185 
 Cerebritis in fever, 162, 222 
 Cerebro-spinal complications, 159 seq., 165 
 seq., 173 seq. 
 causes of, 164 
 fever, 103, 160, 165 seq. ; symptoms, 
 170 
 an essential disease, 168 
 Change of practice in treatment of fever, 10 
 of type in disease, 10 
 
 Alison's views on, 12 seq. 
 Christison's views on, 12 seq. 
 the author's views on, 14 seq 
 evidence from symptoms, 14 
 seq. 
 from appearance of 
 
 drawn blood, 16 
 from pathological ap- 
 pearances, 16 
 from isolated sthenic 
 
 cases, 17 
 from influence of treat- 
 ment, 18 
 Change, anatomical, see Anatomical change. 
 Changes, local, in fever, nature of the, 64 
 
 seq. 
 Characteristics of fever, 54 
 Chest, effusion into the, 77, 105 
 Cheyne, Dr., on hysteria in fever, 177 
 
 on intestinal ulceration in late 
 stage of fever, 63, 79 
 Chloral in fever, 175. 243 
 Choice of food in fever, 189 
 Cholera, first invasion of, coincident with 
 occurrence of change of type in disease, 
 18 
 Christison, Sir Robert, on change of type 
 in disease, 12 
 
 Classification of diseases, 22 seq. 
 Clutterbuck's theory of fever, 218 
 Cold lotions, 237 
 affusion, 238 
 Colles, Mr. Abraham, on simulative ague, 
 
 113 
 Collins, Dr. E., on epidemic of 1867, 166, 
 
 seq., 239 
 Complications, see Secondary affections. 
 Congestions of the lung in fever, 89 
 Consolidation of lung, treatment of, 226 
 Consolidations of the lung in fever, 89 ; 
 critical, 91 
 ending in sphacelus, 96 
 differential diagnosis of, 97 
 Constipation, treatment of, 229 
 Contagion, 23, 27 seq. 
 
 implies essentiality in disease, 28 
 arguments in favour of, 29 seq. 
 problems on, 30, 31 
 in enteric fever, 46 
 Continued fever, see Fever. 
 Continuity, diagnosis of internal solutions 
 
 of, 154 
 Convalescence, imperfect, 79 
 Convertibility of zymotic diseases, 39 
 Convulsions, 243 ; urremic, 244 
 Correlation of zymotic diseases, 39 
 Corrigan, Sir Dominic, cases of cerebritis 
 in fever, 163 
 on attention to the bladder, 243 
 Crepitus redux absent in resolution of ty- 
 phous consolidation, 102 
 Crisis in fever, 92 
 
 Critical consolidation of lung, 91, 226 
 Croly, Mr., on cerebro-spinal fever, 171 
 Curative contrasted with preventive medi- 
 cine, 34 seq. 
 Cusack, Mr., cases of tubercular fever, 
 
 88 
 Cusack, Dr. Samuel, on wine and opium in 
 puerperal fever, 235 
 
 DANGER, sources of, to patient, 21, 188, 
 137 
 Deglutition, power of, retained, 205, 214 
 Delirium, Louis' investigations on, liO seq., 
 103, 159, 161 
 in fever 239; treatment of, 240 seq. 
 toxic, 240 
 
 asthenic, 241 ; stimulants in, 241 
 Depletion, local, 163, 226, 227, 237 
 Deposit, specific typhous, 64 seq. 
 Description of continued fever, 20, 217 
 Diagnosis iu presence of fever, 56, 59, 98 
 from want of accordance of phenomena, 
 
 82, 134 
 of softening of the heart in fever, 134 
 of intestinal perforation, 140 
 of internal solutions of continuity, 154 
 Diarrhoea, treatment of, 229; diet in, 231 
 Digestion, Dr. Beaumont's experiments on, 
 190 
 in fever, 191, 192; influence of rank 
 on, 192 
 Disease, theories of, 5, 6 
 
INDEX. 
 
 259 
 
 Disease, return to sthenic forms of, 17 
 vital character of, 18 
 sources of danger in, twofold, 21, 188, 
 
 classification of, 22 seq. 
 toxic, 25 
 
 endemic, see Endemic disease, 
 essential, 29; contagious, 33 
 
 acute, two phases in history of, 
 
 33 
 correlation of zymotic, 39 
 convertibility of zymotic, 39 
 Dothinenteritis. 136, 137 
 Dry-cupping, 225, 244 
 Dublin, epidemics in, 37, 42, 44, 165, 172 
 
 }?CCm r MOSES, 168 
 \i Eclectic school, 183, 217 
 Edinburgh, epidemics of fever in, 13 
 Effusion into the chest, 77, 105 
 Embolism, pulmonary, in phlegmasia dolens, 
 
 248 
 Emetics in bronchial affections, 224 
 Empiric, 180 
 Empiricism, 180 
 Endemic disease arises independently of 
 
 contagion, 28 
 Enemata, nutrient, 214 
 aperient, 229 
 of turpentine, 230, 245 
 Enteric fever, 45; contagious, 46 
 and typhus contrasted, 45 
 causes of, 38; Murchinson on, 
 38; Sir W. Jenner on, 38; au- 
 thor's views, 38, 39 
 resemblances between, and typhus, 
 
 50.se?., 135, 208 
 and typhus, species, not genera, of 
 fever, 51, 135 
 Epidemic character, 42, 44, 252 
 Epidemic of 1826-27, 44, 137, 143, 146 
 of 1847, 52 
 
 of 1867, 160, 165, seq. 
 of 1S46, 172 
 Epidemics of fever in Edinburgh, 13 
 
 in Dublin, 37, 42, 44, 165, 172 
 in Stockholm, 130 
 Epidemics within epidemics, 166 
 Eruption of rose-spots, 145 
 Eruptions, 145, 208 
 Essentinl disease, see Disease. 
 
 fever, 55 
 Essentialism in fever proved, 44 
 f'jui poisseux of heart, 107 
 Excitement of heart in fever, 110 
 Expectoration of calculi after fever, 83 
 Eye, condition of the, in fever, 61 
 
 FAMTNE fever, 52 teg. 
 Fatty degeneration of heart, slow pulse 
 in, 129 
 Fear, physical, 3 
 Febris nigra, 166, 173 
 
 Fever, continued, importance of a practical 
 knowledge of, 1 
 
 Fever, principle of treatment of, the same 
 in all its forms, 2, 179 seq 
 mortality of, in the Peninsular War, 3 
 may be the opposite of an inflamma- 
 tion, 5 
 described, but not defined, 20, 217 
 proximate cause of, as yet undis- 
 covered, 23, 184 
 nature of its secondary affections, 26 
 
 seq 
 causes of, are various, 32, 34 seq., 48 
 contagion a cause of. 27 seq. 
 analogy between, and tubercle and 
 
 syphilis, 33 
 varieties of, dependent on epidemic 
 character, 42 
 observed in the same epidemic, 
 43, and in members of the same 
 family, 43 
 resemblances between forms of, 49, 
 
 50 seq. 
 species, not genera, 51, 135 
 characteristics of, 54 
 no anatomical expression for, 56 
 pathological conditions of, 66 seq. 
 treatment of, change of practice in, 10, 
 
 121 
 bronchial affection of, 72 seq. 
 pulmonary affections of. 72 seq. 
 cardiac affections of, 106 seq. ; intes- 
 tinal, 235 seq. 
 cannot be cut short, 186 
 intermittent, see Intermittent fever, 
 temperatures in [Appendix BJ, 253 
 Fever-odour, 197 
 
 Fevers, distinctions between, and neuroses, 
 23 
 analogies between, and toxic diseases, 
 
 24 seq. 
 subject to law of periodicity, 23 
 causing secondary affections, 23 
 transmissible by contagion, 23 
 knowledge of, negative, 122 
 Flint, Dr. Austin, on contagiousness of 
 
 enteric fever, 46 
 Floccitatio, 243 
 
 Foetal heart in fever, 124, 128, 199, 203 
 Food in fever, 188 
 
 Dr. Graves on giving, 188 seq. 
 choice of, 189; rules for giving, 
 190 
 Foot, Dr. A. W., a case of hysteria in fever, 
 174 
 observations on temperature in 
 fever [Appendix 15], 253 
 Fordyce, Dr., definition of fever, 179 
 /''itiiilrni/iiiilr, Mrnini/ilr. 1 * • T 
 
 Frottement of peritonitis, 158 
 Functional or nervous local symptoms in 
 fever, 57, 59, 159, 165, 173 
 
 GANGRENE of bin-. 96, 227 
 in epidemic of 1826-27, 147 
 
 (iiingreiious vesicles. 2<I9 
 
 Qastro-cntnrrhal typhus, 7:; 
 
 Genera of fever do not exist, 51, 135 
 
260 
 
 INDEX. 
 
 Geographical variation in form of fever, 67, 
 
 206 
 Goethe, Quotation from, 19; referred to, 
 
 184 
 Gordon, Dr., on cerehro-spinal fever, 166, 
 1G8, 171 
 and coincident epidemic of 
 measles, 173 
 Graves, Dr., on causes of epidemics of fever, 
 36 
 of typhus, 37 
 on temporary pneumothorax in 
 
 pneumonia. 101 
 on yellow fever of 1826-27, 111, 
 
 150, 172 
 on treatment of fever, 182; on 
 
 food in fever, 188 
 on nutrient enemata, 214 
 on value of turpentine, 225 
 on acetate of lead and opium, 229 
 on opium in intestinal perforation 
 
 and peritonitis, 233 
 opposed to treatment of perfora- 
 tive peritonitis by antiphlogis- 
 tics, 234 
 on tartar emetic and opium, 242 
 Grimshaw. Dr., on defective sanitary state 
 
 of Dublin, 38 
 Gurgling in ileo-ctecal region, 141 
 
 HEMORRHAGE, intestinal, 235; treat- 
 ment of, 236 
 Hemorrhagic smallpox, 173 
 Hardcastle, case of, 206 seq. 
 Harley, Dr. George, on urobtematin as an 
 
 indication of blood-waste, 120 
 Harvey's, Dr., advice, 191 
 Haverty, Mr., on cerebro-spinal fever, 169 
 Hayden, Dr., observation of tympanitic re- 
 sonance of lung, 101 
 Head symptoms in fever, 56, 59 seq., 159 
 seq. 
 treatment of, 237 seq. 
 absence of, an indication for use 
 of stimulants, 215 
 retraction of, 171 
 shaving the, 238 
 Head-ache, 237 ; treatment of, 237 
 Heart, fatty degeneration of, slow pulse in. 
 129 
 chronic failure of the, 196 
 escape of, in fever, 200 
 arrest of the, in phlegmasia dolens, 248 
 in fever, 61, 106 seq., 114 seq., 121 
 seq., 127 seq., 198 seq. 
 not altered except in rate, 115, 
 
 118 
 weakened after a few days, 116, 
 
 199 
 excited, 117, 119, 200 
 softening of, 117 
 depression of, 121, 200; more 
 
 marked in typhus, 122 
 diminution of impulse of, 122 seq., 
 
 199 
 vermicular impulse of, 123 
 
 Heart in fever, diminution of sounds of, 
 125 seq., 199 
 physical signs of, 126, 199 
 murmurs of the, 131 seq. 
 " Heart, foetal," 124, 128, 199, 203 
 Hepatic abscess, 111, 157 
 Hudson, Dr., on tympanitic resonance in 
 typhous consolidation of luug, 
 99 
 cerebri tis in fever, 162, 163 
 arteriotomy in delirium, 240 
 on turpentine in tympanites and 
 sleeplessness, 242 
 Humoral theory of disease, 5 
 Huss, Professor, on epidemic of 1841 at 
 Stockholm, 130 
 on value of turpentine, 225 
 Hypercatharsis, danger of, 229 
 Hysteria in fever, 173 seq. ; Dr. Foot's case 
 of, 174 
 significance of. 173, 176 
 masking diseases, 176 
 outbreak of, in fever-ward, 177 
 
 ICE, 238; mode of applying, 238, 240 
 Idiopathic inflammation, 184 
 pyremia, 110; iritis, 184 
 Ileo-Cfecal tenderness, 139 
 
 gurgling, 141 
 Ileum, ulceration of, 143; latent, 139 
 
 perforation of, 153 
 Impulse of heart, progressive diminution 
 of, 122, 123, 124, 199 
 " vermicular," 123 
 effect of position on, 124 
 Indications for stimulation, 197 
 Inflammation, erroneous views as to the 
 universality of, 4 
 acute febrile diseases may be the oppo- 
 site of, 5 
 primary and antiphlogistic treatment 
 
 of. 5 
 erroneous ideas conveyed by the word, 
 
 8 
 secondary, in fever, 103, 142, 224 
 something the reverse of, 4, 130 
 of brain rare in fever, 159 
 a cause of nervous symptoms, 164 
 "Inflammation, healthy," 110 
 Inflammatory theory of disease, 5, 181 
 
 symptoms in fever, 58 
 Insomnia, 242 
 Intermittent fever, 112 
 
 failure of bark in, 6, 113 ; Mr. Colles 
 
 on, 113 
 mode of origin of, 28 
 
 symptomatic of urinary disease, 
 113 
 Intestines, ulceration of the, indicated by 
 quick pulse, 108 
 perforation of the, 151 seq. 
 Intestinal affections, secondary, 135 seq., 
 142 seq.. 146 seq , 227 seq. 
 treatment of, 227 seq 
 perforation, 151 seq.; latent, 151 
 intussusceptions, 148 
 
INDEX. 
 
 261 
 
 Intestinal hemorrhage, 235 
 Intussusceptions in yellow fever of 1826-27. 
 
 148 
 Involuntary muscular tissue in fever, 117 
 Iritis, specific and idiopathic, 184 
 
 JAIL-FEVER, 45 
 Jaundice in fever of 1826-27, 147 
 Jenner, Sir William, causes of enteric fever. 
 39 
 
 K 
 
 ENNEDY, Dr. Heury, on coexistence of 
 various species of fever, 52 
 on cerebro-spinal fever, 169 
 
 LAENNEC on waste of red blood in fever, 
 120 
 on phenomena of pneumonia, 95 
 on softening of the heart, " Vital pois- 
 
 seuz," 107, 114 
 on muscular softening, 118 
 on error as to quick pulse in conva- 
 lescence, 108, 245 
 Laryngeal muscles, paralysis of, 105 
 Laryngo-typhus of Rokitansky, 104 seq. ; 
 
 aphonia in, 106 
 Larynx, inflammation of, 177 
 Latency of secondary affections, 74, 138 
 
 of intestinal perforation, 151 
 Law of periodicity, 1, 6, 21, 64, 77, 141, 
 187, 188, 210 
 interfered with by local irritation, 
 
 7, 141, 238 
 action restored, 238 
 Law, Dr. Robert, case of softening of spleen, 
 150 
 on tartar emetic and opium, 242 
 Lawrence, Dr., on yellow fever, 148 
 Leeching, see blood-letting, or depletion. 
 Levy on cerebro-spinal fever, 167 
 Liver, see Hepatic. 
 
 Local changes in fever are symptomatic, 
 64 
 are subject to periodicity, 64 
 symptoms in fever, 57 
 
 functional or nervous, 57 
 anatomical, 57 
 
 secondarily inflammatory, 57 
 due to anaemic condition of organs, 
 58 
 change masked by neighbouring irrita- 
 tion, 153 
 Lombard's, Dr., views on British fevers, 08 
 Louis, numerical system of, 29 
 
 investigations on delirium, 60 seq,, 
 mi:;, i.v.i, 162 
 on softening of the heart, 114, 
 117, 122 
 Lyons, Dr., on tympanitic resonance of 
 lung, 100 
 on cerebro-spinal fever, 16!) 
 
 MacDOWEL, Dr. B., affection of the joints, 
 108 
 Mackintosh, Dr., on emetics in bronchial 
 affection, 221 
 
 MacSwiney, Dr., on cerebro-spinal fever, 
 
 169 
 Malaise in enteric fever, 138 
 Malignant fever, 45 
 
 purpuric fever, 166 
 smallpox, 173; measles, 173 
 Mayne, Dr., on cerebro-spinal fever of 1 846, 
 
 172 
 Measles, malignant, 173 
 Medicine and surgery, hurtful effects of 
 separation of, 7 
 preventive, contrasted with curative, 
 34 seq. 
 Membranes, mucous, in fever, 66 
 
 serous, in fever, 66 
 Meningite foudroyante, 167 
 Meningitis, epidemic cerebro-spinal, 166 
 Mental study, unfavourable effect of, 71, 
 
 215 
 Mistura olei et opii, 230 
 " Mixed" or " semi-involuntary" muscular 
 
 fibre in fever, 118 
 Mucous membranes in fever, 66 
 Murchison, Dr., on causes of enteric fever, 
 38 
 on distinctions of fevers, 52 
 on rarity of cerebritis in fever, 
 
 160 
 on tentative stimulation, 216 
 on case of latent peritonitis, 232 
 on treatment of peritonitis, 235 
 Murmurs, cardiac, in fever, 131 seq. 
 
 more frequent in enteric than in 
 typhus, 131 
 Muscular softening in fever, 105 seq., 117 
 seq 
 rigidity of abdomen, 141 
 
 NERVOUS local symptoms in fever, 58, 
 159, seq. 
 causes of, 222 
 Neuroses, 22 
 
 distinctions between, and fevers, 23 
 Nourishment, 188; see "Food." 
 Numerical system of Louis, 29 
 
 fallacies of, 216 
 Nurse-tending, skilled, 214 
 Nutrient enemata, 214 
 Nymphomania, 174, 175 
 
 a?DEMA in phlegmasia, simulating ab- 
 L scess, 245 
 Opisthotonos, 172 
 Opium, 229, '233 seq., 212 
 
 in intestinal perforation, 233 
 mode of action of, 233 
 tolerance of, 234 
 wine and, in puerperal fever, 234 
 
 PAGET, Dr., on problems to establish ex- 
 istence of contagion, 81 
 Paralysis of laryngeal muscles, 106 
 of bronchial muscles, 105, 223 
 
 of cardiac muscles, 106 
 Parenchymatous structures in fever, 66, 94 
 Parr, Mr., on turpentine-punch, 225 
 
262 
 
 INDEX. 
 
 Patency, aortic, " steel-hammer" pulse in, 
 
 140 
 Pathognomonic physical signs do not exist, 
 
 134 
 Pathological conditions in fever, 6G seq. 
 
 of heart in fever, 127 
 Pathological school, 182 
 Perforation with peritouitis simulating 
 
 poisoning, 219 
 Periodicity, law of, 6, 21, G4, 77, 141, 187, 
 
 188, 210 
 Peristaltic action in perforative peritonitis, 
 
 Peritoneum, insusceptibility of, to adhesion. 
 
 157, 231 
 Peritonitis, 151 seq ; limited, 102 
 treatment of, 231 
 from eruption of pus, 155, 156 
 from perforation, 170 
 Phlebitis, question of, 246 
 Phlegmasia dolens, indicated by quick pulse 
 in convalescence, 100, 245 seq. 
 treatment of, 251 
 symmetry of affected limb in, 245 
 etiology of. 246 
 cases of. 112, 248 
 Phthisis, rarity of intestinal perforation in, 
 151 
 simulated by bronchial affection, 78, 79 
 a sequela of fever, 80 
 Physical signs, no pathognomonic, 134 
 
 of heart in fever, 126. 199; a 
 guide in stimulation, 201 
 fear. 3 
 Physiological theory of disease, 5 
 
 difference between pus and white-blood 
 cell, 157 
 Physiological school, 182 
 Physiology, experimental, fallacies attend- 
 ing, 187 
 Pin-hole pupil, 242 
 Pneumonia, typhoid. 89 
 
 croupous, or plastic, 247 
 Pneumonic complication of fever, 89, seq. 
 forms. 89, 22*; 
 treatment, 226 
 rneumo-thorax. 232 
 Pneumo-typhus, 72 
 Points of resemblance between forms of 
 
 continued fever, 49 
 Poison of fever, a cause of nervous symp- 
 toms, 164 
 Poisoning simulated by internal perfora- 
 tion, 219 
 Post-mortem appearances in yellow fever of 
 
 1826-27, 147 
 Poulticing, 225, 227 
 
 Practice, change of, in treatment of fever, 
 
 10 
 Pratt's, Dr., views on the causation of 
 
 fever, 41 
 Preventive medicine, 34 seq. ; object and 
 scope of, 35 
 Dr Acland on, 35 
 Principle of treatment of continued fever, 
 179 seq. ; the same in all its forms, 2 
 
 Prognosis, 252 ; influence of appearance of 
 vesicles on, 211 
 in cardiac affection of fever, 130, 145 
 in cerebro-spinal fever, 159, 222 
 Proximate cause of fever undiscovered, 23 
 Puerperal women liable to simulative ague, 
 113 
 fever, wine and opium in, 235 
 phlegmasia dolens in, 246 
 Pulmonary affections of fever, 70, 72 seq., 
 222 
 treatment, 226 
 embolism in phlegmasia dolens, 248 
 Pulse not always a guide in fever, 106, 198 
 full and bounding, coincideutly with 
 
 weak heart, 107, 198 
 slow in convalescence, 107, 129, 204; 
 
 in fatty degeneration, 129 
 rapid in convalescence, 108 
 weak with excited heart, 119 
 " steel-hammer," 140 
 lessened rate of, sign of agreement of 
 stimulants, 203 
 Pulsation, increased arterial, 139 
 Purpuric fever, 166; smallpox, 173 
 Pus, escape of, into peritoneum, 155, 156 
 
 vital characters of, 157 
 Putrefaction, early, in cerebrospinal fever, 
 
 171 
 Putrid fever, 45 
 
 Pyaemia idiopathic, 110; secondary, 142 
 Pythogeuic fever, 39, 45 
 
 fc*/"\UACK" and " empiric" contrasted, 180 
 lc£ Quick pulse in convalescence, 108, 245 
 its significance, 108 
 with tuberculosis, 108 
 in secondary intestinal inflamma- 
 tion. 108 
 in phlegmasia dolens, 109 
 
 RACE, influence of, 67, 206 
 Rank, influence of, on symptoms. 71, 
 197; on choice of food, 192; on giving 
 of stimulants, 215 
 "Rational school." 182 
 Reactive local inflammation, 142, 164, 224 
 " Receipt to make a fever," 220 
 Receptivity of disease, 26 
 Relapsing fever, 52 seq. 
 of 1847-48, 53 
 Resemblances between forms of continued 
 fever, 49 
 typhus and enteric fevers, 50 seq. 
 Resonance, tympanitic, in typhous consoli- 
 dation of lung, 99 seq. 
 Retention of urine, 178, 243 
 Retraction of head, 171 
 Piheumatism, local increased arterial action 
 in, 140 
 no specific treatment in, 2, 187 
 Rigidity of abdominal muscles, 140 
 
 of neck in cerebro-spinal fever, 171 
 Rokitansky on reactive inflammation, 05 
 on broncho-typhus, 69 
 
INDEX. 
 
 263 
 
 Rokitansky on pneumo-typhu3, 72 
 
 on laryngo-typhus, 104 seq. 
 Rose-spots, 145 
 
 Routine systems of practice, 218 
 Routinism to be deprecated, 216 
 Rules for giving food in fever, 190 
 
 stimulants in fever, 196, 351 
 Rutty, Dr., observation on treatment, 45 
 
 SANITARY science, 34 seq 
 Secondary affections of essential dis- 
 eases, 20, 21, 56 
 of continued fever, 26, 67 seq. 
 treatment of, 222 seq. 
 nature of the, 56 
 geographical variation of, 67 
 seat of, influenced by locality, 70 
 
 by social rank, 71 
 alternating. 78 
 bronchial affection, 72 seq. • treatment 
 
 of, 223 seq. 
 pneumonic affection, 89 seq. ; treat- 
 ment of, 225 seq. 
 its three forms, 95, 96 
 cardiac affection, 106 seq. ; treatment 
 
 of, 192 seq. 
 intestinal affection, 135 seq. ; treat- 
 ment of, 227 seq. 
 cerebral and nervous affections, 159 
 seq. ; treatment of, 63 
 Sedatives, 242, 243 
 
 Sequela of fever, tubercule a, 80, 108 seq. 
 Serous membranes in fever, 66 
 Shaving the head, 238 
 Sibson, Dr., on treatment of rheumatic 
 
 fever, 1 
 Signs, physical, of heart in fever, 126, 199. 
 
 201 
 Sim u In lire ague, 113 
 Sleeplessness, 242 
 
 treatment of, 242 
 Slow pulse in convalescence, 107, 129 
 
 in fatty degeneration of heart, 
 129 
 Smallpox, epidemic of hemorrhagic, 173 
 
 local depletion in, 164 
 Smith, David, on coexistence of various 
 
 species of fever, 52 
 Smith, Professor R. W , case of enlarge- 
 ment of lung in croupous pneumonia, 
 247 
 Social rank, influence of, on symptoms of 
 fever, 71, 197 
 on choice of food, 192 
 Softening of the heart in fever, 107, 114 
 begins in left ventricle, 
 11--,. 122 
 Bolidist theory of disense, 5 
 Sound of heart, diminution of first, 124, 
 199 
 extinction of first, 125, 199 
 relative augmentation of second, 
 125 
 Sounds of heart, diminution of both, 125, 
 199 
 
 Sounds of heart in fevers, phenomena at- 
 tending the, 124 seq. 
 Spasms, 90 
 
 Species, not genera, of fever, 51, 135 
 Specific typhous deposit, 64 seq. 
 
 treatment in disease not attainable, 2, 
 185 
 Sphacelus of lung, 96 ; illustrative cases, 
 
 97, 227 
 Spleen, enlargement of, in 1826-27, 148 ; 
 
 softening of, 150 
 Splenic abscess, 149 
 Sponging of skin, 245 
 Spotted fever, 45, 166 
 "Steel-hammer" pulse, 140 
 Sthenic forms of disease, return to, 17 
 Stille" on nature of cerebro-spinal fever, 
 
 168 
 Stimulants in fever, 116, 130, 188, 193 seq., 
 201 seq., 212 seq. 
 question of nutrient properties of, 194 
 disagreement of, 195,215 
 a?iticipatwe use of, 195, 223 
 
 dependent on age and habits, 
 196, 215 
 heart, 199 seq 
 signs of agreement of, 202, 215 
 necessity for persevering in use of, 
 
 214 
 should not be given by routine, 217 
 in delirium, 241 
 Stockholm, epidemic of 1841 at, 130 
 Stokes, Dr. Whitley, his anecdote of Mr. 
 West at Rosetta, 8 
 researches on contagion, 30, 33, 
 38 
 Subsultus tendinum, 243 
 Suppression of urine, 244 
 Surgery, exclusive study of, to be depre- 
 cated, 2 
 Surgical student advised to study fever, 1 
 Swelling, abdominal, in fever, 139 
 
 treatment of, 229 
 Symptoms, latent, 73, 138, 139, 151, 152 
 of cerebro-spinal fever, 170 
 absence of, an unfavourable feature, 
 207 
 Symptomatic fever, 55, 141 
 Symptomological school, 6, 181 
 
 theory of disease held by, 6, 181 
 Syncope, death by, in phlegmasia dolens, 
 
 248 
 Syphilis, analogy between, and fever, 33 
 System, numerical, of Louis, 29 
 
 TARTAR emetic, dangers of, 224 
 and opium, 242 
 Temperature increased, constant in fever, 
 
 165 
 Temperatures in fever [Appendix B], 253 
 Temporal artery, opening of, 288, 240 
 Tenderness of abdomen, 189 
 Theories of disease. 5, 6, 218 
 Therapeutical research. 187 
 Therm ometrical observations in fever. 258 
 Thirst, 189 
 
264 
 
 INDEX. 
 
 Thoracic symptoms in fever, -56, 62, 72 
 
 seq., 89 seq. 
 Timidity from want of bedside experience 
 
 of fever, 3 
 Todd, Dr., on secondary pyaemia, 142 
 
 on stimulants in fever, 194 
 Tongue, the. in fever, 141 
 Tonics in fever, 130 
 Toxic diseases, 24 
 Transfusion of blood, 120 
 Treatment of fever based on general prin- 
 ciples, 2, 131, 179 seq. 
 antiphlogistic, not exclusively to be 
 
 used in primary inflammation, 5 
 of typhus and enteric fever, essen- 
 tially the same, 48 
 objects to be sought for in, 48 
 of smallpox by local depletion, 164 
 no specific treatment, 186 
 of the local secondary affections, 222 
 
 seq. 
 of bronchial affection, 77. 223 seq. 
 of intestinal affection, 227 seq. 
 of head affection, 237 seq. 
 phlegmasia alba dolens, 251 
 fever, change of practice in, 10 
 
 by food and stimulants, 188 seq. 
 Treatment, <niticipative, 195 
 Trousseau, Professor, on phlegmasia alba 
 
 dolens, 246 seq. 
 Tubercle, analogy between, and fever, 33 
 as a sequela of fever, 80, 108 
 acute coexisting, 80 
 acute consequent, 81 
 consequent softened, 81 
 indicated by quick pulse in convales- 
 cence, 108 
 Tubercular cachexia, phlegmasia dolens in, 
 
 246 
 Tubercular fever, 84 seq., 152; contagious, 
 
 88; an essential disease. 88 
 Tumefaction of belly, 139 
 Turpentine fomentations, 225 
 
 injections, 229, 230 
 "Turpentine-punch," 225 
 Tussis clangosa, 104 
 ferina, 174, 176 
 Tympanites, 139, 146, 230; treatment of, 
 
 229 
 Tympanitic resonance in typhous consolida- 
 tion of lung, 99 
 Dr. Hudson'- view, 99 
 Dr. Lyons' view, 100 
 Dr. Hayden's view, 101 
 author's view, 101 
 Type in disease, change of, 10; see Change 
 of type. 
 Alison on, 12 
 Christison on, 12 seq. 
 the author on, 14 secq. 
 Typhoid fever, see Enteric fever. 
 Typhoid pneumonia, 89 ; its forms, 90 
 not dependent on gastritis, 98 
 Typhous deposit, specific, 64 seq. 
 vital character of, 65 
 
 Typhus, 45 : causes of, Dr. Graves on, 37 
 and enteric contrasted, 45 seq. 
 
 resemblances between, bUscq., 136, 
 
 208 
 species, not genera, of fever, 51, 
 135 
 aborted, 91 
 laryngo-, 104 seq. 
 broncho-, 68; pneumo-, 72 
 Typhus abdominalis, 72 
 gravior, 45 
 malignant, 45 
 
 ULCERATION of the intestines indicated 
 by quick pulse, 108 
 latent, 139 
 
 in epidemic of 1826-27, 143 seq. 
 Uraemia, 244 
 
 a cause of nervous symptoms, 164, 243 
 Urtemic convulsions, 244 
 Urine, retention of, 178, 243 
 
 effervescence of, in uraemia, 244 
 suppression of, 244; its treatment, 244 
 Urohrematin as an indication of blood- waste, 
 120, 121 
 
 VARIETIES of continued fever, 42; see 
 Fever, continued. 
 Veins, cordy and painful state of, 246 
 Venesection in fever, 10, 15 
 Venienti occurrite morbo, 195 
 Venous irritation, 246 
 "Vermicular" impulse of heart, 123 
 Vesicles in fever, 209 
 
 influence on prognosis, 211 
 Vis medicatrix naturae, 218 
 Vital phenomena, study of, the basis of the 
 healing art, 18 
 character of disease, 19, 184 
 
 typhous deposit, 65 
 depression of the heart, 204 
 Voluntary muscular tissue in fever, 117, 
 
 118 
 Vomiting, black, 147 
 
 WANT of accordance of phenomena, di- 
 agnosis from, 82, 134 
 Warm stupes in headache, 237 
 Weakness of the heart, 116, 199 
 West, Mr., and his party, at the Rosetta 
 
 Pest Hospital, o 
 White blood cells and pus corpuscles, 157 
 Whitlow, increased arterial pulsation in, 
 
 139 
 Wine in fever, 213 ; see Stimulants, 
 and opium in puerperal fever, 234 
 sedative effect of, 242 
 Wolff. Mr. A., on the correlation of diseases 
 (foot-note), 39 
 
 " yELLOW fever" of 1826-27, 111, 137, 
 
 I 146 seq.. 166 
 Yellow fever, Dr. Lawrence on, 148 
 
 ZYMOTIC diseases, convertibility of, 40 
 correlation of, 40 
 
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