THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA PRESENTED BY PROF. CHARLES A. KOFOID AND MRS. PRUDENCE W. KOFOID / \ v^' THE INFLUENCE OF TEOPICAL CLIMATES PRODUCING THE ACUTE ENDEMIC DISEASES OF EUROPEANS. " Rerum cognoscere causas, iiiedicis imprimis necessariiim, sine quo, nee morbum curare, nee prsecavere potest." INFLUENCE OF TEOPIOAL CLIMATES IN PRODUCING THE ACUTE ENDEMIC DISEASES OF EUROPEANS: INCLUDING PRACTICAL OBSERVATIONS ON THE NATURE AND TREATMENT OF THEIR CHRONIC SEQUELS, UNDER THE INFLUENCE OF THE CLIMATE OF EUROPE. BY SIR JAMES RANALD MARTIN, C.B., F.R.S., PHTSICIiN TO THE COUNCIL OF INDIA.; SURGEON BENGAL ARMY, RETIRED; LATE PRE3IDENCT-8URGE0N, AND SURGEON TO THE NATIVE HOSPITAL, CALCUTTA; MEMBER OF THE ROYAL ASIATIC SOCIETY OF GREAT BRITAIN AND IRELAND; AND OF THE ASIATIC SOCIETY OF BENGAL, ETC. ETC. ^^toitb €bltion. LONDON : JOHN CHURCHILL, NEW BURLINGTON STREET. MDCCCLXI. LONDON : SAVILL AND EDWARDS, PRINTERS, OHANDOS STREET, COVENT GARDEN. PBEFACE SECOND EDITION. Although but six years liave elapsed since the first Edition of tliis work was published^ the present is not produced as a mere reprint ; on tlie ^contrary, it is hoped that additions and altera- tions have been made which may be regarded as improvements. The work differs also in the arrangement of the materials, the climatic, statistical, and hygienic departments of inquiry pre- ceding those of the nature, causes, and treatment of tropical dis- eases, acute and chronic. Limited to one volume, and to so many pages consequently, I am not permitted to amplify upon certain subjects, such as fever, the great disease of the world, and the most important branch of scientific medicine, to the extent that I could desire ; but I trust that upon no question has any omission of importance occurred. Since the publication of the former edition numberless addi- tional examples of the sequelae to acute tropical diseases have presented themselves to me, so as to test and illustrate the doc- trines and practices set forth in my first work ; and the result has been that I am more and more confirmed in the truths that if, in the Eastern Hemisphere, in treating Europeans in youth. aiid' middle life, we would prevent the destruction of organs essential to life, we must overcome congestive and inflammatory diseases of extreme acuteness and danger with a high hand, whether in the use of depletory and emulgent means for the immediate arrest of dangerous disease, or in the use of antiperiodics for the control of malarious paroxysmal fevers ; while, in the temperate Western Hemisphere, in treating returned Indians of more advanced age, we have to remove passive congestions and organic diseases of the b i&D»*>t> VI PREFACE TO THE SECOND EDITION. abdominal viscera, requiring gently eliminative and tonic means of a diflFerent and milder nature than such as were proper under the previous and opposite conditions of tropical climates. Throughout this work I have held in constant view the fact, that a true pathological induction depends mainly on a careful observation of disordered function during the progress of disease, and not upon mere morbid anatomy : in other words, I have endea- voured always to rest pathological conclusions on a physiological basis. It is now felt, says an admirable writer on fever, Dr. Handfield Jones, generally by our best writers and practitioners that morbid anatomy, and even physical signs, are very unsafe guides to trust to exclusively in the treatment of disease. There are symptoms and external signs in fever, for instance, which are more declarative of the true quality of the disease, than sounds appreciated by the ear or post-tnortem revelations. The adage adopted by Trousseau, that " naturam morhonim remecUa ostendntW is to the clinical observer the most practically important. As in the former edition, so in the present, I am under great obligation to Mr. Athol Johnson for his kindness in revising the work while being printed. J. R. MARTIN. 24, Mount-street, Geosvenor-squaee, October, 1861. PREFACE FIKST EDITION. When, little more than twelve months ago, I was called upon to prepare anew the work composed by the late Dr. James Johnson and myself, in 1841, on the ^'Influence of Tropical Climates on European Constitutions," I felt that a mere reprint could not in justice be proposed as a Seventh Edition. Many years had elapsed since Dr. Johnson's original and admirable work on the subject first appeared. The additions in subsequent re-publications con- sisted chiefly of his able reviews of the labours and researches of other authors on tropical diseases, which appeared in the " Medico- Chirurgical Review.'^ The work thus became in great part a collection of reviews, which, excellent as they were at the time, could not now be made to represent the advancing knowledge of the day. I have therefore ventured to re-cast and re-write the entire work. Even the Introductory Chapter is entirely re-written — so much only of Dr. Johnson's observations being retained as appeared to me proper to the subject, and all beyond is exclu- sively my own composition. I am well aware of the responsibility I have thus reluctantly assumed. Throughout the present Edition I have adhered to, and preserved the medico-topographic and statistical character of my original Official Reports, which were printed and circulated at the public cost in Bengal, by order of the Supreme Government of India, while I was serving under its orders. In doing so, I am actuated by the conviction that, next to the importance of physio- logical investigations, stand those which relate to the discovery of the EXTERNAL CAUSES OF DISEASE. By such a course of inquiry h 2 Vlll PREFACE TO THE FIRST EDITION. we shall, I think, most readily appreciate both the prevention and cure of those formidable diseases to which Europeans are subject in hot climates. I have likewise continued, so far as the scope and intent of the work admits, an examination of the physiological influences of climate, both Asiatic and European, while every suggestion is oflFered which seemed to me likely to enhance the value and importance of preventive medicine. For the discussion of the nature, causes, and treatment of tropical diseases, my opportunities, whether rightly or wrongly applied, have been both varied and extended. I served in various parts of India — in peace and war — amongst natives and Europeans — in hospital and in private practice — for two-and-twenty years, and during this time I did my best to collect materials in the ample field which came under my observation ; I wish much that I could command more leisure for the arrangement and completion of my subjects. A treatise purporting to describe "The Influence of Tropical Climates on European Constitutions,^^ which should not comprise some description of the sequelae to tropical diseases, and of the counter-influences which, under an European climate, afi'ect the health of persons who have resided long in warm regions, would be obviously incomplete. I therefore here reprint from "The Lancet" certain articles published by me during the last six years, on " The Nature, Causes, and Treatment of the Diseases of Europeans on their Return from Tropical Climates.'^ The want of such a supplementary treatise was felt by my friend Dr. James Johnson, who urged me, on my return from India, to this under- taking ; and having now been several years in extensive observa- tion of this class of invalids, I venture on the discharge of the duty which my friend proposed to me. In conclusion, I cannot refrain from ofl*ering a tribute of respect to the memory of the author of the "Influence of Tropical Climates on European Constitutions," originally published in 1813, from materials col- lected and arranged by him when he was not twenty-four years of age. Having served not quite three years in the Indian seas, as surgeon to a ship-of-war, he had at this time returned home with broken health, several abscesses having been discharged from the liver, rendering his life one of extreme sufi'ering for years there- after. By great native elasticity of mind and body, he overcame PREFACE TO THE FIRST EDITION. IX his distresses and difficulties, and ended his career as an esteemed and eminent physician of this metropolis. Referring to the subject of the sixth edition of the work, com- posed jointly by Dr. Johnson and myself, in 18il, he observes, with a just pride, that " Although successive editions have received additions and improvements, yet very few of the Author's original doctrines have been subverted or practices exploded, during a period of more than a quarter of a century." Few men in our profession could say so much ; and I speak but the general sentiment when I say, that fewer still have departed from us lea^dng a higher reputation for kindliness of feeling and high sense of honour than did Dr. James Johnson. To his talented son, Mr. Athol Johnson, I am under much obligation for the aid he has given me in revising the work while being printed. J. R. MARTIN. Grosvenor-strebt, Grosvenor- square, December, 1855. CONTENTS. PAET I. CLII^ATE AND MEDICAL STATISTICS. Sketch of the Physical Climate of Calcutta, with General Remarks on the Causes of Physical Climate in Bengal Action of the Sun upon the Atmosphere Internal Heat ....... Elevation of the Ground ..... General and Local Aspects . . . . • Position of Mountains ...... Effects of the Neighbourhood of the Sea Geological Nature of the Soil .... Influence of the Labour of Man — General Population The Predominant Winds ..... The Rains — Sources of Aqueous Exhalations — Humidity The River The Salt Lake Woods and Marshes of the Soonderbuns Medical Climate and Influence of Seasons Physical Effects of Climate . The Hot Season . The Rainy Season The Cold Season . The Sol-Lunar Influences The Electrical Condition of the Atmosphere The Influence of Atmospheric Pressure 1 5 7 10 11 )i 12 16 25 26 29 32 33 35 40 41 42 52 57 63 71 78 Xll CONTENTS. Statistics of the Influence of Climate and Season in Pro- ducing Sickness and Mortality in Calcutta ... 84 Mortality of the Various Races, European and Native . . 89 Statistics of the Influence of Climate and Season in the Presidency of Madras Ill Mortality of British Soldiers and Seamen during War . .119 Physiological Observations Preliminary to the Considera- tion of the Prevention of Disease in Tropical Climates 13G Capability of Man to bear Changes of Climate . . . „ Perspiration . . . . . . . . .139 Sympathy of the Skin with the Internal Organs ,,. . .142 Influence of Tropical Heat on the Biliary Function . . 144 Lichen Tropicus, or Prickly Heat . . . . .147 PAET II. PREVENTION OF DISEASE. General Observations — Importance of the Subject . . . 150 Circumstances to be investigated in the Art of Preserving Health 154 More Immediate Objects of State Medicine . . . .155 Neglect of this Subject in the United Kingdom , , .157 Tropical Hygiene — Rules to be observed in Hot Climates . 163 Regarding Dress . . . . . . . .164 Food 167 Drink 170 „ Exercise ........ 172 „ Bathing 174 „ Sleep ........ 176 „ the Conduct and Government of the Passions . 178 Military Hygiene — Preservation of the Soldier's Health . 180 CONTENTS. Xlll Memoranda on the Hygiene of Camps and Cantonments in Warm Climates, with a Sketch of Medical Arrangement for Field Service Diet of the Soldier Drink „ Sleep „ Cooking „ Dress „ Accoutrements „ Barrack Tents „ Hutting „ Exercises and Amusements Marching of Troops in Hot Climates Topographical Precautions — Localities to Choose „ „ Localities to Avoid Barrack and Hospital Accommodation Medical Officer of Health for Armies . Sketch of Personal and Material Arrangement for Field Service ....... Postscript ....... Transport of Sick and "Wounded in India Field Hospitals ...... Furlough, Invaliding, and Pay Character and Capabilities of the British Soldier The Army Surgeons his best Friends . Sanitary Precautions necessary in Camps, Barracks, and Hospitals — Camps „ in Barracks and Hospitals Note on the Ventilation of Barracks and Hospitals Habits of the British Soldiery and their Influence on Health Observations on the Barrack Life „ on the Necessity for Exercise . „ on Intemperance „ on the Immoderate Use of Tobacco 197 201 206 208 209 210 213 214 215 216 220 224 225 227 228 238 239 240 241 243 245 246 249 255 257 262 263 266 XIV CONTENTS. PAGE On the Selection and Improvement of Localities for European Troops in our Intertropical Possessions . . . .270 Sacrifices and Sufierings consequent on the Neglect of this Subject 271 . 279 . 280 . 289 . 288 . 295 Benefits of Mountain Climates in India Memoranda on Barracks and Hospitals „ on the Medical Topography of India . Neglect of the Army Medical Officers by the State On the Term of Efficient Service in India On the Mortality and Physical Management of European Children in Bengal 302 PAET III. ACUTE TEOPICAL DISEASES AND THEIE CURE. Remittent Fever of Bengal 306 General Observations — Topographical and Statistical Details . „ Historical Notices . . . . . . . .307 Predisposing Causes 312 Symptoms and Progress 313 Pathology 317 Selection and Application of the Means of Cure . . .321 On the Use of Emetics 323 „ the Warm Bath — Tepid and Cold AflTusions — Cold Drinks 324 „ Blood-letting 326 „ Purgatives . . . . . . .333 „ Diaphoretics ....... 334 „ Mercury 335 „ Bark 337 ,, Arsenic ...... . 341 CONTENTS. XV PAGE On the Use of Wine 343 „ Opium „ „ Colchicum . ...... 344 „ Blisters .......•» „ Diet „ Application of Kemedial Means to tlie Individual Case . .346 Management of Convalescence ...... 352 Gestation in the Open Air ....... 354 Catalogue-raisonne of tlie Treatment of Remittent Fevers by diflferent Authors in different Ages and Countries . . 356 General Observations in conclusion ..... 359 Intermittent Fever — General and Historical Notices . .366 Causes 368 Symptoms and Progress . . . . . • .369 Pathology 370 Treatment 376 Congestive Continued Fever of the Cold Season in Bengal 384 Pathology 385 Treatment .......... 386 Ardent Continued Fever of the Hot Season in Bengal . 388 Pathology „ Treatment 389 Heat Apoplexy — Coup-de-Soleil, or Sun-Fever . . .391 Causes 392 Topography and Statistics ....... 394 Symptoms and Progress . . . . . . .397 Premonitory Symptoms . . . . . . .398 The After Symptoms ,.......„ Pathology 399 Treatment 403 Note on the Fevers of the Natives of India . . .411 General Topographical View of Hindustan . . . .412 Physical Character of the Natives . . . . '414 Military „ 417 XVI CONTENTS. Europeau Medical Officer — liis Position „ Military Officer — his Position and Character Native Army, its Past and Present Strength Fever amongst the Native Soldiery General Sketch of its Treatment . Acute Dysentery of Bengal .... Predisposing Causes ..... Symptoms and Progress .... Complications, Hepatic, Splenic, and Scorbutic Pathology ....... Treatment of Acute Dysentery . „ Hsemorrhagic „ . . . „ Hepatic „ . . . „ Complicated with Fever . „ „ Splenic Disease „ Convalescence from Dysentery Catalogue-raisonn^ of the Treatment of Dysentery Ages and Countries .... General Observations in conclusion Chronic Dysentery ..... Note on the Dysentery of the Natives of India On the Diseases of the Liver Increased Secretion of Bile .... Treatment ..... . . Congestion of the Liver .... Treatment ....... The Acute Hepatitis of Bengal . Symptoms and Progress .... Causes Pathology . in different Treatment . Hepatic Abscess Treatmeut . Jaundice CONTENTS. XVll PAGE Causes ......... . 489 Pathology ........ . 490 Treatment . 491 Chronic Enlargement and Induration of the Liver . 493 On the Endemic Congestion of the Spleen . . 499 Symptoms ......... . 500 Causes ......... . 501 Pathology ......... . 502 Treatment . . . . . . . ' . . 503 Epidemic Cholera . 509 Sketch of its Earlier Indian History . . . , if Geographical Progress . 514 Natural History, Origin, and Local Causes . ; . 515 Symptoms and Progress ..... . 523 Predisposing Causes ...... . 524 The Six Theories as to its Cause and Propagation . 526 Preventive Measures ....... . 528 „ „ in the Army . 534 Morbid Appearances after Death in Collapse . 538 Pathology . 543 Treatment . 547 Notice of Epidemic Cholera in Calcutta . 555 Cholera-Fever of 1834 . 556 The Influence of Season . 558 Predisposing Causes ...... . 560 Precursory Diarrhoea ....... )} Treatment . 563 Yellow, or H^mogastric Fever .... . 571 General and Topographical Observations • » Symptoms and Progress . 577 Sequelae ........ . 580 The Black Yomit • • 5> Diagnosis ........ . 581 Prognosis ........ . 583 XVIU CONTENTS. PAGE Mortality 584 Post-Moi-tem Appearances . . . • • • .586 Predisposing Causes ........ 588 Endemic Causes . ........ 589 Infection .....••••• 593 Prevention . . . . • • • • • .001 Cure 604 P.S. Suggestion for the External and Internal Use of Nitro- niuriatic Acid ........ 609 Delirium Tremens .......... Symptoms and Progress . . . . . . .610 Causes .......... 612 Complications . . . . . . . • .613 Pathology 614 Prevention . . . . . . • ■ .617 Treatment 618 PAET IV. CHKONIC DISEASES OF EUEOPEANS ON THEIR RETURN FROM INDIA, AND THEIR CURE. Introductory Chapter — Genersil Observations . . . 624 Physiological Influences of the Climate of India . . . 629 Physical Qualities which fit Europeans for Service in India 631 }) j> » unnt „ „ „ „ ,j Physiological Influences of the Climate of Europe as affecting the returned Indian . 634 Personal Examples of such Influences . . . . .637 Moral Disadvantages — "the sharp sword of separation" . . 640 Concluding Observations . . . . , . .641 The Anemia of Tropical Invalids 651 Causes and Pathology . . . . . . , .652 CONTENTS. XIX Examples of Excessive Blood-letting by Leeches Symptoms and Progress .... General Treatment — the Benefits of Travel . Union of the Ocean Air with that of the Mountains in Scotland Medical Treatment .... Chronic Diarrhoea. — General Observations Its complicated Nature Associated with Intermittent Fever Injurious Influences of Cold „ „ of the Climate of the Himalayas Personal Examples of the Disease Pathology ...... The Means of Cure .... Chroxic Dysentery ..... General and Statistical Observations . Symptoms and Pathology The Means of Cure .... Treatment of Hsemorrhoidal Affections Congestion of the Liver General and Descriptive Observations . Cases in Illustration .... Torpor of the Liver .... General and Pathological Observations The Measures of Cure — Cases in Examjile Nitro-Muriatic Acid Bath . Chronic Enlargement of the Liver General Observations . Efficacy of Nitro-Muriatic- Acid . „ even after its Discontinuance Remarkable Cases in Proof of its Effects Conclusion. — Use and Abuse of Mercury . PAGE 652 655 656 35 657 672 673 674 675 )} 676 681 684 703 j> 707 708 716 725 j» 727 735 » 738 742 753 » 756 757 }> 776 PAET I. CLIMATE AND MEDICAL STATISTICS. SKETCH OF THE PHYSICAL CLIMATE OF CiVLCUTTA, WITH GENERAL REMARKS ON THE CAUSES OF PHYSICAL CLIMATE IN BENGAL. " L' ensemble de toutes les circonstances naturelles et physiques, au milieu desquelles nous vivons dans cbaque lieu." — Cabanis. "Tlie best observations upon climate often lose half their value for want of an exact description of the surface of the country." — Malte-Bkdn. Whoever considers climate Tvitli reference to its vast import- ance to human welfare^ must feel some degree of disappointment at the meagreness in which the advanced state of knowledge in the nineteenth century has yet left this most interesting branch of inquiry. On this all-important subject it is but too evident that^ in the language of Sir John Herschel, we have not yet determined ''what ought to he observed," and thus it has happened^ for want of '^a right direction/^ that much of the labour of observation and minute investigation has been '' but labour lost.^^ In medical pursuits, we find continually that the apparent cause of sickness, or of death, is not the real cause ; and so it is with the causes of physical climate. "When a thing is accounted for in two ways/' says Fontenelle, " the truth is usually on the side most opposed to appearances." One philosopher^ for instance, will view climate as any space distant from the equator and poles ; another^ as nothing more than a well-arranged table of the winds, of the thermometric, barometric^ and hygrometric degrees ; a third, as having reference solely to elevation above the mean level of the earth's surface ; a fourth, as consisting only of the internal heat of the globe ; while a fifth, supposed to be better informed than all the rest, an authority who 2 SKETCH OF THE PHYSICAL CLIMATE " seemed to have been in nature's cabinet council/' pronounces climate to be influenced only by latitude and local elevation, and allows it to be but slightly afi"ected by any other causes. We may, then, with some show of reason, exclaim with Dr. A. T. Thomson, ^' What is climate ?" That such partial views are unequal to the elucidation of the subject of climate, will at once be apparent by reference to the common geographical fact, of two places in the same elevation and degree of latitude possessing climates the most opposite. We must, then, look for the causes of climate elsewhere ; and however much those may be influenced by elevation and latitude, we shall find other and powerful accessories which greatly influence health, and consequently human happiness. lie must be a bold, if not a presumptuous man, however, who shall pretend to do full justice to a subject so elaborate, and which demands the application of such refined principles in physical science as climate ; yet I can- not help thinking that much that is important may be done by a careful observation and comparison of facts, made at diff'erent times and places ; for it is by such means that a complex science like that of climate can alone be perfected. A most interesting demonstration of the local character of climate is furnished by Mr. Glaisher of the Royal Observatory, Greenwich, in his remarks on the weather during the quarter ending September 30th, 1847. After showing from a most accurate series of observations, conti- nuous and comparative, that the climate of Cornwall and Devon- shire is not only diff'erent from every other part of England, but is far from being the same in diff'erent parts of these counties, this eminent meteorologist concludes : — " In fact, there seem to be several diff'erent climates in these counties, but all of them free from extremes and sudden changes of temperature." If this be true (and who that knows anything of the subject can doubt it?), how vast and various must be the climates over the great continent, the islands, and the extensive lines of coast of the East Indies, and how important must be the careful study of local influences throughout our empire there! Whether we view the subject in a physical or medical sense, we shall do well to carry along with us the maxim of Professor Adam Fergusson, " that all observation is suggested by comparison.'' The value of all scientific facts depends in a great measure on their being comparal)le, and this in an especial manner applies to inquiries relating to medical topography and medical statistics. Speculation can here yield no profit ; it is but throwing words in the air. Milton tells us that — " To know That which before us lies in daily life Is the prime wisdom." I am satisfied that, in a professional sense, it is impossible to take too extended a view of the subject of climate, and that he who OF CALCUTTA IN BENGAL. 6 succeeds best mast follow the indication of Cabanis ; ''L'ensemble de toutes les circonstances naturelles et physiques, au milieu des- qiielles nous vivons dans chaque lieu •/' for this much is certain^ that the fraraers of elaborate tables of the winds and of the degrees of the thermometer^ have as yet done little to inform our minds, or guide our inquiry. " Le climat n^est done point resserre dans les circonstances particulieres des latitudes, on du froid et du chaud ; il embrasse, d'une maniere absolument geuerale, Fensemble des circonstances physiques attachees a chaque local, il est cet en- semble lui-meme ; et tous les traits caracteristiques par lesquels la uature a distingue les diflerents pays entrent dans Pidee que nous devons former du climat." INIedical men, to whom a right understanding of the subject is paramount, whether we consider the good or the evil to be derived from climate, are happily beginning to be a^vare of this fact ; and it is with much satisfaction I find a late writer on medical topo- graphy in England declaring, in furtherance of the just and com- prehensive views above quoted, that the character of a climate is much more faithfully indicated by such a natural test as its influ- ence on vegetable products, ''than by any instrumental or artificial means whatever." Dr. Mason Good asserts, with truth, that it is no exclusive reproach to medicine that meteorology has hitherto been turned to so little practical advantage ; " for, of all the subdivisions of general philosophy, there is none so little entitled to the name of science as meteorology itself. And, till the naturalist has explained the variations of the barometer, the physician need not blush at being incapable of turning to account the supposed influence of the planets, or unfolding the origin, or tracing the capricious courses of epidemics and pestilence." Difficult as is the subject, however, it ought to have its great attractions for the physician; for, assuredly, no other afl'ords so free a scope for original observation and inquiry ; and this applies in an especial manner to tropical climates. Dr. Watson observes justly, that "to ascertain the causes of any disease, and to display them before the public mind, are large steps towards the ultimate removal of such as human endeavours are competent to remove. To know the cause of a disease is sometimes to be able to cure, often to be able to 2^rei'ent it." Medical officers who go to India may therefore rest assured that, in respect of the climates and their di^yeases, they will there acquire a real and practical amount of knowledge in exact proportion to the theoretical knowledge of them which they may take to that country. The mind of the young surgeon must be prepared by a careful previous study, so as rightly to distinguish between what may and what may not be analysed and reasoned upon with advantage. Such a course of preparation would be alike advanta- geous to those whom it will render better qualified to serve the State, and to the State which will be so much the better served. B 2 4 SKETCH OF THE PHYSICAL CLIMATE Malte-Brun's division of Physical Climate shall here be adopted, because it marks the geographical points to which our inquiries may most profitably be directed, inasmuch as a consideration of the details, as given by that admirable writer, brings us at once to the discovery of such errors in the physical condition of any given place as may lead to its improvement, and the consequent pre- vention of disease — the great end of medical topography. When, again, we look back to our native country, and boast of its pure and bracing air, let us not forget the important fact, "that it is man himself who has in a great measure created these salu- brious climates. France, Germany, and England, not more than twenty ages ago, resembled Canada and Chinese Tartary, countries situated, as well as our Europe, at a mean distance between the equator and the pole.^^ "Whenever nature is more powerful than industry, whether for good or for bad, man receives from the climate an invariable and irresistible impulse /^ and so it is in Bengal, ''for had," in conse- quence of the total absence of that "industry" which elsewhere moulds nature to the purposes of man, for his " good." Physical climate, says Malte-Brun, comprehends the degree of heat and cold, the drought, the humidity, and the salubrity which occur in any given region of the earth. The causes of physical climate he states to be nine in num- ber : — 1st. The action of the sun upon the atmosphere. 2nd. The interior temperature of the globe. 3rd. Elevation of the earth above the level of the ocean. 4th. The general inclination of the surface and its local ex- posure. 5th. The position of its mountains relatively to the cardinal points. 6th. The neighbourhood of great seas and their relative situa- tion. 7th. Geological nature of the soil. 8th. Degree of cultivation and of population at which a country has arrived. 9th. The prevalent winds. To these perhaps may be added : — 10th. Position in respect to the equator. 11th. Position in respect to large rivers or lakes. 1 2th. Position in respect to forests. By tracing these causes, and by uniting and arranging under general points of view, the results of particular local observations, we shall, according to Malte-Brun, arrive at an approach to climatology, in some measure corresponding to the present state of the other sciences. OF CALCUTTA IN BENGAL. ACTION OF THE SUN UPON THE ATMOSPHERE. Of all the elements whieli constitute climate the subject of Heat is the most immediately important to the medical inquirer. Sennertus declares that " Physicians do not calculate the seasons by the sun's course, but by the temperature of the atmosphere." " All observation/' says Dr. Richardson, " leads to the inference that the sun, acting by means of caloric, is the source of all physical power. We have evidence of this in measuring the amount of life, animal and vegetable, throiighout the world ; for we find that the proportion of life and of motion, from the poles to the equator, corresponds with the heating power of the central luminary. Further, when we desire to supplement nature, we call caloric into action ; as in the warming of our bodies at the fire ; in the application of heat to the artificial forcing of flowers and fruits ; in the employment of heat in the processes of the chemical laboratory or of the iron-foundry ; and in the production of motion by the alternate expansion of water into steam and con- densation of steam into water." At all places between 20° and 23^° of latitude, the solar rays during two months fall at noon either perpendicularly, or at an angle which deviates from a right angle only by 3^° at most. The degree of temperature is also increased by the greater length of the longest days, which near the tropic are 13|^ hours. The ap- plication of these facts to the geographical position of our Eastern capital, during portions of IMay, June, July, and August, is suffi- ciently obvious, and would not seem to require the lengthened details offered by some writers. The difference between sensible heat and that indicated by in- struments, is nowhere more remarkable than within Calcutta during the hot months; where, from the length of time the houses, walls, and roads are getting heated by the sun, the first houi's of the night are rendcj'ed even more oppressive than the day, from the copious radiation going on for some time after sunset. " The true indication of the force of the solar rays," says Herschel, " would seem to be, not the statical effect upon the thermometer, but their momentary intensity measured by the velocity with which they communicate heat to an absorbent body." Professor Daniel's observations also go to show that the power of solar radiation in the atmosphere increases from the equator to the poles, and from below upwards. Chowringhee and Garden Reach have a perceptible advantage over Calcutta, from their openness and the great extent of evaporation from trees, which tends so much to reduce tem- perature. 6 SKETCH OF THE PHYSICAL CLIMATE This delightful property in trees should always he turned to our advantage ; and where the grounds are kept in proper order, a moderate number of trees will prove grateful and beneficial in every sense, but especially in the hot dry season. The influence of trees, like that of water expanse, is powerful in another way. By a process of nature, as yet unknown, umbrageous trees arrest the extension or neutralize the qualities of malaria. In the rains, the evaporation from trees can add but little to the humidity already existing in the atmosphere. It has been computed, however, that a country covered with trees emits more vapour by one-third than one even covered with water, and it is this property that gives to the shade of vegetables a coolness so much more effectual and agreeable than that of rocks or walls. In the sweeping condemnation by Dr. M^Culloch, of trees, &c. — down to the very flower-pots, he goes a length unwarranted by any known facts. It is surely unphilosophical to view everything in nature as made only for man's destruction. The following table will exhibit the state of the atmospheric tem- perature in Calcutta, its weight and humidity, during the years specified. The thermometer in the open air is found to vary from 40° to 110° in this city. INSTRU- TEAR. MENT. MAXIMUM. MINIMUM. REMARKS. ^ O) "^ ( Therm. ... 90°-4 53°-3 Mean barometer. I S ^ 2 S 1830 Barom. ... 30 -131 29 -512 Wet bulb depression j |2-Bl Hygrom... 16 -9 1 -5 ( Tlierm. .. 95 -8 57 -8 .o-ggg 1831 Barom. ... 30 -122 29 -456 observat; ay, at sur ;nee the nimum a I Hygrom... 14 -5 1 -5 Mean barometer. ( Therm. . . . 96 -9 54 -6 29°-764 1832 Barom. ... 30 -071 29 -467 s'°-°'S ( Hygrom... 15 -2 1 -6 J in cu a ^ ( Therm. ... 97 -2 61 -1 Mean temperature. \ 1 .£ ft « 1833 ( Barom. ... 30 -095 29 -485 78° >^."S3 1 Hygrom... Therm. ... 17 -3 99 -4 2 -3 58 -9 "I'S a 1834 Barom. ... 30 -022 29 -470 sc s a" a ( Hygrom... 13 -8 1 -4 I'l^l In the sun. On the ground. J ft ( Therm. ... 110°-2 42° -0 \ m '*' 1835 Barom. ... 30 -038 29 -480 OJ 1=1 ( Hygrom... 13 -9 3 -2 I Therm. ... May 97°-9 Jan. 53° -5 1836 f Barom. ... Jan. 30 -087 Aug. at 9 h. 50 29°-569 (i! Hygrom... March 14 '8 August 5 '6 / Therm. ... June 98 "2 not observed. Each entry is the 2 > >> . 62 Cumberland coal mines 600 „ >) . . 66 Durham coal mines . . 900 >i . 69 Cairo well 210 ,, >» . . 70 Monkwearmouth mine 1500 ,, l> . . 72 Artesian well, Crenelle 1300 . . 73 Mexican mines . . . 1650 „ >> . . 75 Valenciana mine, Mexico >> >> . . 91 Grenelle well . . . 1794 >> . . 91 The temperature in mines rises on an average 1° for every 49-6 feet_, while that of water in the wells rises 1° for every 54< and 55 feet ; the average ratio of increase, in various parts of England and the continent, being about 1° for 46 feet in depth. In the Artesian well of Grenelle the temperature rises 9° in the last 500 feet. The temperature of the deep sea, on the other hand, varies but little from the equator to the poles, while that on the surface varies considerably, being about 27° in the polar regions, and 88° under the equator. The conclusions arrived at by the authority here referred to, on the important subject under discussion, are : — 1st. That the temperature of the surface of our globe, including that of the air, earth, and sea, depends exclusively upon the quantity of heat transmitted to it from the sun, the heat thus re- ceived being again lost, partly by radiation into space, and partly by conduction downwards through the superficial strata. 2nd. That the chief loss takes place undoubtedly by radiation, and that it is by the amount of this last we learn the temperature of the medium (space) in which our globe is floating. 3rd. That at a certain depth below the surface of the earth, there is a source of heat which progressively affects the thermo- meter as we descend. 4th. That this interior heat cannot be derived from the sun or from local chemical changes. 5th. That it does not directly affect climates or seasons, or perceptibly influence the temperature of the surface of the earth, the depths of the ocean, or the atmosphere floating above them. 10 SKETCH OF THE PHYSICAL CLIMATE 6tli. That tlie vicissitudes of climates, seasons, and cycles of years are due entirely to solar influence. 7th. That this influence, even at a maximum, does not pene- trate to a greater depth than the l-400,00Uth part of the earth's diameter. 8th. That although we have positive evidence of the existence of subterranean heat, we can neither measure its degree, nor, at present, determine its exact ratio of increase downwards into the interior. 9th. That there is not the slightest evidence to show that the earth is gradually cooling from a high temperature, or that, within the last two thousand years, its temperature has undergone any increase or diminution. ELEVATION OF THE GROUND. When we consider the accuracy and extensive knowledge we have arrived at in the position of points of interest on the surface of the globe, with regard to the co-ordinates of latitude and longi- tude, and how little has been done for the third co-ordinate of elevation, we shall have a field before us open to cultivation in many parts of our empire, and of the greatest interest within the Tropics — in the East aud West Indies especially. The importance, in a sanitaiy point of view, of attention to the subject of elevation, is exemplified in the fact that, plague in Egypt, yellow fever in the West, and marsh remittent in the East and West, have never been known to ascend to any considerable height. The limit of yellow fever, in the Island of Jamaica, was long ago observed by Eoljert Jackson, while it is notorious that the plague of Egypt confines itself to the low, damp, and marshy districts — never ascending so far even as Assouan, where the soil and, consequently, the atmosphere are dry. But so virulent is the malarious power in the East and West Indies, that an elevation of from two to three thousand feet is necessary to exemption from fever; while in Italy the same immunity is attained by a rise of about fifteen hundred feet above the marshy plains. With the elevation of the land cold increases in a very rapid progression, being caused by the enlarged capacity which air acquires by rarefaction. While in descending into the earth we obtain an increase of heat of one degree for about every fifty feet, we find that the rate of increase of cold is one degree for every three hundred and fifty feet of mountain altitude ; and this latter beneficent appointment of nature considerably increases the number of habitable countries in the Torrid Zone : — '' In ascending from Bengal to Thibet, we OF CALCUTTA IN BENGAL. 11 imagine ourselves in a few days transported from the equator to the pole/' The site of Calcutta is said to be, on the average, but little, if at all, above the level of the tides at Sagor : in the diplomatic language of Asia, " "What more need I say l!" as to the choice of our position ! GENERAL AND LOCAL ASPECTS. The general aspect should be distinguished from the local aspect. The general declivity of a country, large in itself, does not exclude the most opposite local declivities. It may, however, be admitted as a general principle, that the positive sum of all the local aspects is in the same direction as the general aspect. This principle can only be applied to spaces of great extent ; for example, the entire tract of country through which a river flows. Every one knows of what effect as to temperature is the exposure of a soil relatively to the sun. A hill inclined 45° to the south, when the sun is elevated 45°, receives solar rays perpendicularly, whilst upon a plain the same rays strike the soil under an angle of 45°, that is, with one quarter less of force ; and a hill inclined 45° to the north will be struck by the solar rays in a horizontal direction, which makes them glide along its surface. Malte-Brun, speaking of the northern hemisphere, says that the soutli-south-west and south-west situations are the warmest of all ; whilst, on the contrary, those of the north-east are the coldest. The general aspect of the valley of the Ganges is about east and west, with an inclination of the delta to the south. POSITION OF MOUNTAINS. Mountains act on climates in two ways. They attract the vapours suspended in the air ; these vapours, by their condensa- tion, produce clouds and fogs ; often, also, these assemblages of watery substances, which the winds waft in every direction, are stopped in their devious course by chains of mountains, in the elevated valleys of which they continue to accumulate. These effects are still more sensibly felt, when a chain of mountains is crowned with extensive forests. In hot climates mountains of certain elevations secure two cardinal advantages, namely, purity of air and coolness. The elevated lands in Bengal-Proper hardly merit the name of mountains, and are mostly situated in the districts of Bheerboom, Sylhet, Chittagong, and along the eastern boundaries of Tipperah. They are limited in extent, and exert apparently but little influence on the climate of Calcutta. 12 SKETCH OF THE PHYSICAL CLIMATE EFFECTS OF THE NEIGHBOURHOOD OF THE SEA. The neighbourhood of the sea moderates the excess of tempera- ture, besides contributing, according to Pouillet, through evapo- ration, one of the most important sources of atmospheric elec- tricity. In hot climates the maritime regions are not so warm as the centre of the plains ; — of this we have an annual example in the marine current of the south-west monsoon. " In the trade-wind regions at sea/^ says Lieutenant Maury, ''^ " evaporation is generally in excess of precipitation, while in the extra-tropical regions the reverse is the case ; that is, clouds let down more water than the winds take up again ; and these are the regions in which the Gulf Stream enters the Atlantic. " Along the shores of India, where experiments have been care- fully made, the evaporation amounts to three-fourths of an inch daily. Suppose it in the trade-wind region of the Atlantic to amount only to half an inch, that would give an annual evapora- tion of say fifteen feet. In the process of evaporation from the sea, fresh water only is taken up, the salts are left behind. Now, a layer of sea-water fifteen feet deep, and as broad as the trade- wind belts of the Atlantic, and reaching across the ocean, contains au immense amount of salts. ^^ In some parts of the earth the precipitation is greater than the evaporation ; thus the amount of water borne down by every river that runs into the sea may be considered as the excess of the precipitation over the evaporation that takes place in the valley drained by that river. This excess comes from the sea ; the winds convey it to the interior, and the forces of gravity dash- ing it along in mountain torrents or gentle streams, hurry it back to the sea again. In other parts of the world the evaporation and precipitation are exactly equal, as in those inland basins such as that in which the city of Mexico, Lake Titicaca, the Caspian Sea, &c., are situated ; which basins have no ocean drainage. If it were not so, the Caspian would in the one case overflow the surrounding countries, and in the other it would dry up, leaving plants and animals to perish. In the Desert of Sahara, again, there is neither evaporation nor precipitation, and in it we find neither plants nor animals. In his annual report of the Bombay Geographical Society, from May, 1849, to August, 1850, Dr. Buist states, on the authority of Mr. Laidly, the evaporation of Calcutta to be " about fifteen feet annually ; but between the Cape and Calcutta it averages, in October and November, nearly three-fourths of an inch daily ; between 10° and 20° in the Bay of Bengal, it was found to exceed * " Physical Geography of the Sea." By M. F. Maury, LL.D., Lt. U. S. Navy. OF CALCUTTA IN BENGAL. 13 an inch daily. Supposing this to be double the average through- out the year, we should have eighteen feet of evaporation annually. " On the other hand, we have a rainless region about the Red Sea, because the Red Sea for the most part lies within the north-east trade- wind region, and these winds when they reach that region are dry winds, for they have as yet in their course crossed no wide sheets of water from wliich they could take up a supply of vapour. " Most of New Holland lies within the south-east trade-wind region, so does most of inter- tropical South America. But inter- tropical South America is the land of showers. The largest rivers and most copiously-watered country in the world are to be found there ; whereas, almost the exact reverse is the case in Australia. Whence this difference ? Examine the direction of the winds with regard to the shore line of these two regions, and the explanation will at once be suggested. In Australia, east coast, the shore line is stretched out in the direction of the trades ; in South America, east coast, it is perpendicular to their direction. In Australia, they fringe this shore only with their vapour, and so stint that thirsty land with showers, that the trees cannot afford to spread their leaves out to the sun, for it evaporates all the moisture from them ; their instincts, therefore, teach them to turn their edges to its rays. In America, they blow perpendicu- larly on the shore, penetrating the very heart of the country with their moisture. Here the leaves, as the plantain, &c., turn their broad sides up to the sun, and court its rays." Calcutta is situated about 100 miles from the sea, but so level is the country that the tides ascend in the dry season as far as Sooksagur, being 140 miles from Sagor Point. In the beginning of March, when the south-west monsoon sets in, the currents set up the Bay of Bengal, and gradually raise the sea at its head several feet, raising the river Hooghly with it, and that long before the freshes are felt. This continues till October, when the pouring of the rivers into the bay, during the rains in July, August, and September, and the changes of the monsoon to north-east in the end of October, give the current a set in the contrary direction, and gradually restore the sea and river to their condition in the previous March. The effect of the two monsoons upon the currents, and the height of the sea in the Bay of Bengal, may therefore be considered as that of two long unequal tides during the year — eight months of flood and four of ebb. From the point of lowest low water in the dry season, to that of the highest high water in the freshes is 20 feet 10 inches. The greatest mean rise of the tide from low- to high-water mark in the freshes is ten feet. The smallest mean rise of the tide in the dry season, neap tides, is four feet. The " Bores " in the Hooghly occur only in the highest, or alternate spring tides ; their 14 SKETCH or THE PHYSICAL CLIMATE appearance may with certainty be predicted by tbe season of tbe year and the parallax of the moon. They are greatest under the influence of the south-west monsoon, and are only felt in those portions of the river where the peculiar form of the sands, and the direction and set of the tides in any particular reach, actuate their rise."^ Persons who speak confidently, and enter into minute details on the tides and levels, assert that we are only protected from irruptions of the sea by the counter-currents of the rivers, and the friction of the tides against their banks. They state the tides in the Salt Lake to be but two feet above the mean level at Sagor, and consequently several feet, at flood-tide, below that at SJigor. Of the truth of some of these assertions we had a cala- mitous illustration on the 20t]i and 31st of May, 1833, when the sea, backed by a storm from the east-south-east and south-east overran the low countries along the coast from Balasore, along Hidgelee, and up to Tumlook and Diamond Harbour, making a breach over the Soonderbuns as far north as Calcutta, and extend- ing its devastations as far east as Dacca. There have been many irruptions of the sea within fifty years, but none to equal this last in violence and extent. In some days the barometer stood at 28 inches and 8 decimals, being lower than it had been known for years ; the thermometer averaged 84°. The tide, which ran for seven hours, rose to a height of twelve feet above its ordinary level, destroying embankments and build- ings of every kind, while the storm levelled the trees ; nothing stood within the influence of tide and wind, and the loss of human life and destruction of cattle must have been enormous. SJigor Island was covered seven feet deep ; and out of a popu- lation of 7000 persons few escaped. The rains were nearly a month later than usual in setting in, and the ordinary cultivation was arrested from the saturation of the soil with salt. The starv- ing survivors from these united calamities crowded about the outer suburbs of Calcutta, and were at last reduced to the necessity of supporting the parents' lives by the wretched and unnatural traffic in their children, the most emaciated of whom sold at last /or one rupee. Government did much to relieve the more pressing necessities of these poor people ; but there was much that no power could relieve. Towards the end of August there broke out a severe epidemic fever, which, by the end of September, and during the drying process, ripened into terrible violence — carrying oft", accord- ing to the reports of respectable natives, nearly three-fourths of the remaining population to the south and east of us. Neither did Calcutta escape ; thousands of the natives died, particularly in the suburbs, nearest the land inundated in May ; even the * Tide the interesting paper by Mr. James Kyd, Trans. A. Society. OF CALCUTTA IN BENGAL. 15 Europeans suffered severely, though there Avere not many casual- ties ill proportion to the numbers attacked with the fever. It is an object of interest to ascertain the surface temperature of the sea in different situations. The following is stated by Dr. Mitchell, on the authority of Aime, to be the temperature of the Mediterranean at a distance of 100 to 2000 metres outside tlie port of Algiers, compared with the temperature of the air, from obser- vations made between 1840 and 1S4!5. Averages calculated for the seasons. Sea. Air. Difference. Winter 57-92 . . 54-32 . . +3-60 Spring 5990 . . 61-34 . . -1-44 Summer 71-96 . . 73-40 . . -1-44 Autumn 69 03 . . 68-00 . . +1-08 Annual averages . 64-71 . . 64-26 " In winter and autumn, therefore, the surface temperature of the jNIediterranean off Algiers is higher than the temperature of the atmosphere, but lower in spring and summer. In the waters of the Mediterranean outside the port of Algiers, the diurnal variations cease at a depth of about 60 feet, and the annual varia- tions at a depth of 380 to 440 yards. Observations made in France and Belgium show that the diurnal variations of tempera- ture of the crust of the earth cease at a depth of rather more than 4 feet, and the annual variations at about 80 feet.^' It has been shown by the observations of Drs. Lloyd and Hen- nessy, that the mean temperature of the sea on the west coast of Ireland is foui' degrees higher than the mean temperature of the land. The winter temperature is as high as that of the southern shores of the Euxine, while, on the other hand, the great precipi- tation of vapour gives a summer heat as low as parts of Finland. These results are due to the warm current of water which flows from the Gulf of ]\Iexico towards the British Islands and the north of Europe. This current, heated in the warm regions of its origin, exercises its influence very sensibly on the atmosphere, raising its temperature, and charging it with vapours which are known to give out a certain amount of heat. On the general question, Dr. Lloyd states that, " According to the computation of Bessel, 25,000 cubic miles of water flow in every six hours from one quarter of the earth to another. The store of mechanical force is thus diminished, and the temperature of our globe augmented, by every tide. We do not possess the data which would enable us to calculate the magnitude of these effects. All that we know with certainty is, that the resultant effect of all the thermal agencies to which the earth is exposed has undergone no perceptible change within the historic period. We owe this fine deduction to Arago. In order that the date-palm should ripen its fruit, the mean temperature of the place must exceed 70° Fah. j -and, on the other hand, the vine cannot be 16 SKETCH OF THE PHYSICAL CLIMATE cultivated successfully when the temperature is 72° or upwards. Hence, the mean temperature of any place at which these two plants flourished and bore fruit must lie between these narrow limits, i.e., could not differ from 71° Fah. by more than a single degree. Now, from the Bible we learn that both plants were simultaneously cultivated in the central valleys of Palestine in the time of Moses ; and its then temperature is thus definitively deter- mined. It is the same at the present time ; so that the mean temperature of this portion of the globe has not sensibly altered in the course of thirty-three centuries. ^^ GEOLOGICAL, NATURE OF THE SOIL. Whenever the natives of India speak of climate, they designate it by the terms " air and water." They have, indeed, no other definition of it. The circumstance is here mentioned to show that the popular impression on this important head, throughout Hin- dustan, is at least as well-founded in fact as some others that, in Europe, are entertained by philosophers. The nature of the soil, which must of necessity influence the qualities of both air and water in an essential manner, remains unnoticed in most definitions, European and Asiatic; yet the geological nature of the soil would seem one of the most important of the causes of physical climate. Of this I became satisfied very early in my service in India. " Man," says Boudin, " is in more respects than one the mere expression of the soil in which he lives." Clay lands, while they retain water and moisture of every kind, do not readily admit either heat or air, owing to their compact and adhesive nature. They are proverbially cold, as- are also the chalky soils. Soils containing much carbonaceous or ferruginous matter, on the other hand, acquire a very high temperature under the solar rays, while they likewise cool more rapidly than other soils, especially when dry. Dark soils, too, absorb heat more powerfully, and radiate heat more energetically than light-coloured soils, which reflect a great portion of heat. In short, a very slight attention to the effects of various qualities of soils will be sufficient to show that these last affect very powerfully both the temperature and the humidity of the atmosphere ; and hence the vast importance of this branch of study. The internal nature or composition of the soil must have an in- fluence on climate in a variety of ways. All grounds are not heated equally soon. One soil quickly parts with its acquired heat, while another retains it for a long time. Exhalations, which vary according to the nature of the soil, rise into the atmosphere, and become identified with it. Clayey grounds, and those which OF CALCUTTA IN BENGAL. 17 arc impregnated with salt^ cool tlie atmosphere ; extensive accu- mulations, when they are dry, augment the heat. The general soil of Bengal is clay, with a considerable proportion of silicious sand, fertilized by various salts, and by decayed substances, animal auc" vegetable. Both the upper and sub-soil are generally per- vious to water, but at an average depth of twenty feet is found a tenacious clay ; at this depth, too, brackish water is obtained. In sinking wells in the vicinity of Calcutta no springs of fresh water were reached at a depth of 480 feet. In the old magazines and newspapers printed in Calcutta, I find very frequent mention of earthquakes ; but in none of these does there seem to have been aiiy material injury sustained, Avhich looks as if the causes were remote from us. In April and May, while marching to join the Bamghur batta- lion, over the abrupt mountain ranges which are crossed between Midnapore, in the province of Orissa, and Sumbhulpore, on the Mahanuddy river, province of Gondwana, I observed tliat through- out the entire extent of that country, so noted for the fatal cha- racter of its fevers, the soil Avas invariably ferruginous. During the whole march through this deadly country free electricity wai noticeable in the air to an amount which I never observed any- where else. Crackling noises and distinct flashes of light accom- panied the passage of the comb through the hair. The late Major Markham Kittoe, of the Bengal army — a fellow- sufferer from the destructive fevers of those countries — presented me with the following sketch from memory, when at home on sick leave, in l8i-3. The quality of the soil is given as the result of repeated personal examination : — Calcutta and Fort William, on the Hooghly. Tunalook. The Roopnarrain and Doomooda. Midnapore on the Kossai. High land of Midnapore between the Roopnarrain and Kossai rivers. Iron clay resting on decomposed primitive rock and lithomarge — soil and water strongly impregnated with iron oxide — -cerebral fevers common here. Seersa on the Subanreeka. Shingle and sandy tracts — quartz and hornblende — oxide of iron — ^forests of stunted saul and Assina — fevers prevalent. Granite, sienite, quartzose rocks, steatite, and serpentine hornblende — this is the first range run- ning north and south, varying from 500 to 3500 feet, covered with dense forests of saul and other 18 SKETCH or THE PHYSICAL CLIMATE R ; trees, and the climate deadly — water very scarce, impregnated with vegetable and mineral matter — iron ore in great abundance, the soil red with its oxide. Kennjhiir on the Byturnee. Bonaie on the Brahmini. This country is very deadly ; the soil chiefly red from ii'on oxides. Keunjhur and Mahagirri Hills, sieiiite, gneiss, talcite, hornblende, kidney-iron ore and iron in every shape — it affects the needle — deadly climate except on the heights, which vary from 1700 to 4000 — gneiss — gold found in the rivers. Beaumurra Hills — gneiss, quartzose, iron ore in abundance — some very fine falls of water strongly impregnated with calcareous matter, leaving stalac- tite — considered wholesome — height 1200 feet. Height of this range about 300 feet above Sum- bhulpoor, or 800 feet above the sea. Sumbhulpoor on the Mahanuddi. Gneiss formation, talcite — much iron, though less than in the other i-anges — diamonds and gold worked for — matrix red clay and sand — height supposed to be about 500 feet — climate very un- healthy in the hot season — to strangers deadly. In tlie " Madras Quarterly Medical Journal," for 1841, is pub- lished a very interesting report " On the Hill Fevers of the Southern Peninsula of India/' by Dr. Heyne, of the Madras army. This officer, after describing the hill ranges, " which have rendered themselves known to Europeans for the malignity of the fever/' and likewise those that are " as constantly free of the hill fever," goes on to state that here, the received opinions, as to the vegetable or marshy origin of fever, will not hold, for that the hills in question " are not more woody than in other healthy places ; — some, indeed, where the epidemic of 1808 and 1810, as well as the endemic, were most destructive, are quite naked of trees, as Dindigal, jNIadura, and the rocks west of Seringapatam. Now, if it should be found that the fever exists constantly and invariably among certain description of hills, when others of a different composition are as constantly free from the same, would it not become reasonable to suppose that the nature or composi- tion of the rock itself must furnish the cause of the calamity ? The hills where it is found to prevail appear, at first view, to be quite harmless, as they are granite, which is the most common OF CALCUTTA IN BENGAL. 19 rock-kind on this globe. They contain, however, besides quartz, fehpar, and mica, a great proportion of ferruginous hornblende, which, by its disintegration or separation from the rock, becomes highly magnetic, and /;/ which, I suppose, the cause resides which produces this fever, besides a great train of other diseases. The iron hornblende occurs in such quantity that all the rivulets, public roads, indeed, all hollows along the hills, are filled with its sand ; from which, also, all the iron in this part of the country is manufactured.^^ Dr. McClelland of Bengal, in his excellent "Medical Topo- graphy," draws a distinction which, if fully verified by future observation, may prove of importance in a sanitary point of view, namely, that between hilly districts composed of laterite — hard, rough, and much inclined, having but scanty vegetation — and the flat, low, wet lands, or laterite covered with sandy soil, always clothed with coarse rank grass, there is a difference as to season in manifesting their evil influences — especially in the production of fever, " The character in common which the remittents of these late- rite districts present, and by which they are distinguished from the corresponding type of fever of the Tarai and Soonderbuns is, that while the fevers of the laterite districts prevail during the hot weather as early as March, those of the low districts, composed of light sandy soil, do not set in until after the rainy season has commenced, being above two months later. " Again, the jungles of laterite districts do not become safe until the month of January — that is, three months after the rains have subsided ; while those of the light soils of the flat jolains become safe in November, within a month or six weeks of the breaking up of the rains." In the districts referred to in my personal experience, it did not happen that, of two detachments of troops employed there in two different years, either found any difference in health between tlie hot and the cold season, both having proved equally obnoxious to fever. In pursuance of my early observations, and referring also to those of Dr. Heyne, I obtained through the kindness of my friend Sir Charles Trevelyan, Secretary to the Treasury, a report on the quality of the soils of all the most unhealthy stations on the west coast of Africa, as well as samples of the several earths. Tliese last, including the mud of the rivers, were, without exception, ferrugi- nous. Reports from Hong-Kong speak of " ferruginous-looking clay," and of " pestiferous mineral gas." The soil of this station proves on analysis to be ferruginous. Captain Pemberton says that the ranges of hills stretching south of Chittagong, and forming a great portion of the prover- bially unhealthy country of Aracan, are composed "almost entirely of sandstone, with which a stiff ferruginous clay is frequently c2 so SKETCH or THE PHYSICAL CLIMATE commingled." Here the army of General Morrison was destroyed by malignant fever chiefly, in 1825, Europeans and natives of Hindustan suffering alike. In the " Excursions " of Mr. Eeatherstonhaugh into the Slave States of the American Union, we find "malaria" mentioned in continual connexion with the " ferruginous " soil of those coun- tries, with the " red sandstone rock," and '' the red mud of the Arkansas." In the " Medical Topography of the West Coast of Africa," by Mr. Ritchie, surgeon R.N., it is stated that the rugged surface of the country around Freetown, Sierra Leone, is composed of a " scanty and red earth." Speaking of Bathurst, at the mouth of the Gambia, Mr, Ritchie says of the rainy season and its tornadoes, which are most prevalent at the commencement and termination of the rains : — " They always come from the eastward, and produce violent electrical phenomena. This period of the year is the most pregnant with disease." My friend. Dr. M'William, in his admirable " Medical History of the Expedition to the Niger," speaks of " fever of a most malig- nant character" as having broken out in the Albert, within a short distance of the red cliff of Iddah. This cliff is composed of " ferruginous sandstone." Sir William Napier, in his history of Sir Charles Napier's administration of Sindh, states that Dr. Kirke, of the Bengal army, who bestowed great attention upon the subject, attributed the fatal fever of that country, in 184«4', "to exhalations from limestone rocks on which the barracks were built." Others again attributed the fever, so fatal to the 7Sth Highland Regiment, to neglect of the tanks ; but the sickness Avas more generally ascribed to " an unusually high and anomalous inundation, and an equally anoma- lous fall of the Indus, which brought an extraordinarily fertile but premature vegetation. The early and entire subsidence of the waters left this vegetation to be withered up by the sun, which produced, as it always does in Sindh, malaria." Sir William Napier, referring to these several opinions, justly observes, that probably all the causes were here condensed. He adds, that " this and other epidemics which prevail at irregular periods in Sindh, arise from exhalations produced by volcanic action ; for the country, though alluvial, is so subject to sudden and extensive changes from earthquakes, that in 1819 nearly the whole surface of Cutcli was changed." But soils of various colours may be quite as ferruginous as the red soils — the difference being that, when dark, they retain organic matters, while, in the purely red earths, all organic substances have been more or less decomposed or dissipated. May not this decomposition by the iron, together with the magnetic pheno- mena elicited by heat and other agents, be productive of disease, and of fever especially, in certain climates and localities ? OF CALCUTTA IN BENGAL. 31 T am aware of tlie numerous objections that may be urged to tliis, or to any other hypothesis ; but, in the absence of conchisive aids from chemistry and meteorology^ we can do no better than have recourse to rational conjectures. " There is nothing so clear and obvious/' says Biot, " as the discovery of yesterday : nothing so obscure as that of to-morrow. '^ "Whatever may be the cause/' says Hennen, "it is certain that, in many countries, the malaria does not arise until all tlie sui'face- water has totally disappeared, and leaves the whole surface of the country, including the many courses of the winter streams, an arid desert." The difference in the composition of the soil on the sea-coast and in the interior of the United States, is declared by Dr. Forey to cause the vast difference observable in the prevalence of inter- mittent fever. On the coast, with a sandy soil, the rate of inter- mittent fever is but 36 per 1000 annually, while in the interior, where the soil is alluvial, composed of a rich vegetable mould from three to six feet deep, the fever is nearly six times as prevalent. In the suburbs of London it is said that in places drained within the last few years the temperature has been raised, fogs have disappeared, and influenza, marsh fevers, rheumatism and neuralgic, pains have much diminished. The deaths also in the clay districts of the metropolis, compared with the " gravelly districts within a few miles of London, were as three to one." LI. Boudin, surgeon-general to the jNIilitary Hospital at Ver- sailles, speaking of the great importance of the nature of the soil in relation to public health, and how necessary it is that this should be an object of special attention on the part of military surgeons especially, observes : — " It may not be out of place at present to call to mind the connexion which the attentive ob- server remarks between the configuration and the geological cha- racter of the soil. If Ave consider that other connexion Avliich exists Avithin certain limits betAveen the geological nature of the soil and certain pathological conditions of man, we comprehend at once the important part reserved in future, in a medical point of view, for the study of physical geography. Thus the occur- rence of goitre and cretinism in the Alps and Pyrenees caused the existence of the same forms of disease in the Himalayas and Cordilleras to be foreseen a long time, and experience has verified the induction." The same able Avriter says justly, that the kuoAvn effects of the marshes of the Italian rivers enable us to determine with certainty the character of predominant disease in the great deltas of the Blue and YelloAV rivei's in China ; the Zaire, the Orange, and Zambeza, in Africa ; the Amazon, the Orinoko, and the llio del Norte, in America. " Finally," he says, " as under a dissimilar geological constitution, we see the forms of disease difler entirely 22 SKETCH OF THE PHYSICAL CLIMATE at the raoiitli of tlie Po from those of the Arno, so we can predict a similar difference between the eastern and western coasts of America^ and affirm safely the rarity of marsh fevers at the grani- tic embouchures of the Simpson^ the Columbia, the Oregon, and the St. Francis." The same authority remarks, that a reference to the geological map of England exhibits the sites of the largest of our towns on the hard red sandstone ; while the smaller towns, and those of the agricultural districts, are situated on the chalks or oolites. When we reflect on the vital importance of the cerebral and organic functions, and on the readiness and power with which these functions are influenced by the electric and malarious states of the atmosphere, we shall at once comprehend the vast interests connected with the subjects treated in this article. They form^ indeed, the real and only excuse for its length. It has long been known that animals Avaste and perish when they have been deprived of their positive electricity by being attached to the opposite pole of a galvanic battery. When the human body, on the other hand, has been for some time exposed to an atmosphere of a negative electricity, it is believed by many to become thus incapable of resisting the various causes of disease, as the exhalations from the earth, the force of epidemics, &c. The varyini^ states of the earth's magnetism cannot fail of exercising powerful influences on human health, however little may be the present amount of our knowledge respecting the nature and opera- tions of these influences. In 1815 I obtained, through Sir Charles Trevelyan, samples of three kinds of earth from Sierra Leone ; — viz. that of the Coast, of the Isles de Loss, and of Grand Cape Mount, as also of the rivers Sierra Leone and Pongos. The following replies to questions submitted by me were likewise received from the colony of Sierra Leone : — '^ 1. What is the geological character of the soil in and around the settlement ? " Above high water mark, red earth — specimen sent. Below high water mark, black mud — specimen ' sent from Congo Creek. Flats and valleys, black earth — specimen sent from King Tom's Point. " 2. Does ferruginous or red sandstone prevail, or red earth? " Red earth. Red sandstone in the strata (used for building) underneath — specimen sent from Freetown. Occasionally large blocks and some strata of blue granite (now used in building) — specimen sent from Fort Thornton. " 3. Is the soil of the most unhealthy stations of a ferruginous nature ? " I have never heard any one station in this colony called less healthy than another. OP CALCUTTA IN BENGAL. 23 "4:. Does the soil of the valleys or flats partake of the ferru- ginous character ? "Yes. " 5. Do the lovr lauds emit any offensive gases or smells, and, if so, at what period of the twenty -four hours ? " The mud by the river banks smells when exposed to the sun at ebb tide. " 6. Does magnetic iron exist, and, if so, is the variation of the compass affected by it ? '' Yes — specimen sent from Tower Hill barrack-yard. '^ 7. Has the nature of the soil in general, or of the most un- healthy localities in particular, been chemically analysed ? " Answer by Dr. Fergusson — So far as I know there has not been any minute analysis of the soil of this colony beyond the general one, that the soil is ferruginous ; gravelly in some parts, loamy in others, in others sandy ; but in all ferru- ginous.^' For the following report on the qualities of the specimens of earth from Sierra Leone, I am indebted to Professor Bowman, of King's College, London. The numbers, as given below, do not correspond with those mentioned in the answers to queries ; and one of the specimens reported on by Professor Bowman was from the colony of Hong-Kong : — " I have now completed the estimation of the oxide of iron in the specimens of soil from Sierra Leone, and beg to hand you the following results. They are nearly all remarkable for the large quantity of ferruginous matter which they contain : — "No. 1 contains 8"84 per cent, oxide of iron. 2 „ 26-00 3 ,, 11-48 4 ,, 23-20 5 „ 29-00 6 „ 46-12 8 ,, 6-92 9 „ 11-56 Another, numbered 9, 12-48 ,, ,, This is described as " taken up at the rising of the hill below Mr. Melville's farm, not far from the Regent Farm road, and a fair specimen of the earth of the colony. That in the bottle, with no label, but which is probably No. 7, contains ll'OO per cent, oxide of iron." Mr. Clarke, the colonial surgeon of Sierra Leone, states that " among the causes of unhealthiness of the climate the electric condition of the atmosphere, and the sudden alternations of tem- perature may be mentioned ; but the latent cause of the atmo- spheric impurity has hitherto eluded the investigations of the chemist. Sulphuretted hydrogen, no doubt, plays a distinguished part in this infection of the atmosphere." 24 SKETCH OF THE PHYSICAL CLIMATE The opinion here expressed refers, doubtless, to the report of Mr. Daniel, who was sent by the Admiralty to the west coast of Africa to analyse the sea-water along the coast between latitudes 15° and 16°. In it he found a large quantity of sulphuretted hydrogen, emanating from a soil of volcanic origin, or from the decomposition of sulphates in the sea-water by the carbonaceous matters arising from the decay of the immense masses of vegetable productions which grow down to the water's edge. For a long ' time past it has been observed that the copper sheathing of a ship will be more damaged during a nine months' cruise off this coast, than from a service of three or four years in other climates. By some authorities it is deemed probable that, of all the matters evolved in volcanic eruptions, sulphur is the agent which, by its affinities, adds most to the intensity and virulence of malarious exhalations along the west coast of Africa — a region at all times so fatal to European settlers. " If sulphuretted hydrogen," says Dr. Aitken, " should hereafter be determined to be an element increasing the virulence of the disease [fever], it will be an interesting question whether it acts merely as a depressant, or whether, by combining with the poison, it augments its intensity." In many hot climates the most deadly sites for encampments have been the dried-up beds of rivers, or their immediate vicinities. Humboldt, in the 5th volume of his '' Personal Narrative," in mentioning the fevers in the villages of Atures and IMaypures, around the two great cataracts of the Orinoko, says that the natives believe the pestilent exhalations that arise from the bare rocks of the Raudales to be the cause : — " Among the cataracts, and whenever the Orinoko, between the missions of Corichana and Santa Barbara, periodically av ashes the granite rocks, they become smooth black, and as if coated with blacklead. The colouring matter does not penetrate the stone, which is coarse- grained granite containing a few solitary crystals of hornblende. The same appearance is seen in the primitive rocks of Syene, and was observed by the naturalists of Captain Tuckey's expedition in the ' Yallalas ' that obstructed the Congo." Humboldt asks, " Can it be possible that, under the influence of excessive heat and constant humidity, the black crusts of the granite rocks are capable of acting on the ambient air, and producing miasmata with a triple basis of carbon, azote, and hydrogen ?" OF CALCUTTA IN BENGAL. 2o INFLUENCE OF THE LABOUR OF MAN — GENERAL POPULATION. AVitliout cultivation few climates would be salubrious or agree- able^ aud it is by its means that man exercises so powerful an in- fluence upon the temperature and purity of the air. By cultiva- tion the husbandman eradicates noxious elements from the earth, and thereby warms, dries, and purifies the atmosphere he breathes ; while by his neglect of tillage he renders the soil and air impure and unwholesome. Parisot remarks justly, that animalized vegetable matters in a state of decomposition are condensed and not decomposed by porous bodies, amongst Avhich fine sand may be classed. " In the mild and moist winter putrid decomposition commences. The subtle ferments it produces are condensed in the sandy soil of which Egypt is formed, and in which the dead repose. When the elevation of the temperature makes the ferments evaporate, man receives them by the superficial absorbent vessels, or by those of the lungs in the act of respiration." Let US contemplate a desert country, the rivers, abandoned to themselves, become choked and overflow, and their waters serve only to form pestilential marshes. A labyrinth of thickets and of brambles overspreads the most fertile hills. In the meadows the unsightly wild mushroom and the useless moss choke the nutri- tious herbs ; forests become impenetrable to the rays of the sun ; no wind disperses the putrid exhalations of the trees which have fallen imder the pressure. of age; the soil, excluded from genial and purifying warmth of air, exhales nothing but poison ; and an atmosphere of death gathers over all the country. But what do not industry and perseverance accomplish ? The marshes are drained ; the rivers flow in their disencumbered channels ; the axe and the fire clear away the forests ; the earth furrowed by the plough is opened to the rays of the sun and the influence of the wind ; the air, the soil, and the waters acquire by degrees a character of salubrity ; and vanqinshed nature yields its empire to man, who thus creates a country for himself. " The increased fertility of the soil," says Dr. Southwood Smith, " renders it more healthy by diminishing its moisture and raising its temperature. One cubic foot of water in the process of evapora- tion deprives three millions of cubic feet of air of one degree of temperature. An undrained field growing nxslies has a permanent temperature from four to six degrees lower than an adjoining field drained and growing wheat. By draining and manuring, by throwing down fences, by removing trees, by clearing underwood, and by promoting the free aeration of the soil, the temperature of large tracts of land in the north of England has been permanently 26 SKETCH OF THE PHYSICAL CLIMATE raised three degrees. Thus that very culture of the earth by which it is made to yield the largest amount of food, increases its salubrity as an abode for man, and lessens at their source the main causes of epidemics/^ Agriculture must be much improved in Bengal before the Euro- pean, in the language of Malte-Brun, can be said to have created a country for himself. A Hindu field is described by Mill to be in the highest state of cultivation where only so far changed by the plough as to afford a scanty supply of mould for covering the seed, while the useless and hurtful vegetation is so far from being eradicated, that where burning precedes not, the grasses and steriles which have bid defiance to the plough cover a large por- tion of the sui'face. The same author concludes, that " every- thing which savours of ingenuity, even the most natural results of common observation and good sense, is foreign to the agricul- ture of the Hindus. Their ideas of improvement are very limited ; they scarcely extend beyond the introduction of irrigation into land which was formerly cultivated dry. Each small proprietor is content to follow the customs of his forefathers ; the same rude implements of husbandry, the same inferior race of cattle, and the same practices are still in operation, Avhich have existed unchanged for centuries. As to any new experiments of general manuring, draining, differences in the rotation of crops, introducing new grain or vegetables, or new sorts of those already known, any attention to their breed of cattle, any adoption of a better and more combined system by which a smaller number of people could raise the same or a larger proportion of produce — all these are out of the question." I cannot find that the example of European superiority has had much influence on the state of agriculture around the metropolis of India. It is certain that in the cold season the markets are supplied with excellent vegetables of every kind ; but beyond this I believe matters are much the same as in the days of Job Char- nock, the founder of Calcutta. The general crops are of rice. In the Appendix to the Parliamentary lleports of 1831, I find the population of the 24 Pergunnahs, suburbs, and city, rated at Ij225j000, which I have reason to think is over-estimated. THE PREDOMINANT WINDS. The united influence of all the elements which constitute phy- sical climate is variously modified by the prevailing winds ; and all their variations depend on the equilibrium of the atmosphere, the heat of one climate and the cold of another, exercising a con- tinual influence on each other. Atmospheric currents prevent the accumulation in it of the noxious elements which are constantly emanating from the earth's surface. Winds are justly stated to OF CALCUTTA IN BENGAL. 27 control tlie temperature and humidity, to promote evaporation, and to possess individual unexplained peculiarities which affect both animal and vegetable life. Mr. xVtkinson, referring to the well-known influence of different winds on plants and insects — on the animal and vegetable fibre — observes, that " there is something in the atmosphere which, by change of wind, causes a simultaneous action in all living sub- stances and structures. The pimpernel, ' the poor man^s weather- glass,' and the chickweed," he says, " are both excellent natural barometers, opening their delicate structures on sunny days, and closing them against rain. So also the spiders prognosticate the north and east winds, Avhich ' cause them to leave their webs and shelter themselves in holes.' ■" Mr. Hingeston suggests that the causes of the violence of the winds, if not their directions, are electro-magnetic, and that the partial rarefaction of the air by heat, and its condensation by cold, hitherto employed for explaining the force and current of the winds, are most likely only striking parts of terrestrial electro-magnetism. — Dr. Pickford's llijfjlene. The northern parts of a great continent will sometimes send forth their cold air towards the southern parts ; and sometimes they will receive warm air in return. The monsoon always changes some time after the equinoxes, and constantly blows to- wards that hemisphere in which the sun is found. The action of this luminary on the atmosphere is therefore plainly one of their causes, the cold air from the mountains of Thibet following its course for half the year, and that from the southern seas during the other. The south-west rainy monsoon, the most remarkable of our periodical Avinds, begins on the Malabar coast in May, and reaches Delhi by the end of June, extending to the north-eastern parts of Affghanistan, but greatly modified. It prevails more in the mountains than the fiats of the Punjaub; the hills and valleys of Cashmere have their share of it, and it gradually loses itself west- ward in the valley of Peshawur, v/here it appears only in clouds and showers. On the Coromandel Coast it is retarded, the clouds brought by the south-west winds being detained by the Ghauts. It reaches Bengal by the 15th of June. Owing to the arrest of the south-west monsoon by the moun- tains, and consequent accumulation of vapour, an extraordinary deposition of rain takes place on the Malabar Coast, being not less than 123 — 5 inches in the year in the latitude of 11 j° north. When not influenced by elevated lands, this monsoon generally prevails north of the Equator from April to October, accompanied by tempests, storms, and rain, while a north-east wind blows during the other six months. The periodical winds that prevail in the Bay of Bengal extend their influence over the flat country, until they are diverted by chains of mountains into another direction, nearly correspondent, however, with the course of the 28 SKETCH OF THE PHYSICAL CLIMATE Ganges. When the sun has passed into the southern hemisphere, the monsoon alters its direction; the mass of air which had, been accumulated during the hot season and rains on the central plat- form of Asia, now bestirs itself, and moves towards the regions south of the Equator, where the atmosphere has been dilated and dissipated by the solar heat. Over most parts of the Indian Ocean this monsoon proceeds from the north-east, because the central platform lies to the north-east. On the other hand, as the seas of China, of Borneo, of New Guinea, of Java, have the centre of Asia to the north and north-west, the monsoon comes to them from these points. In the south of Bengal the prevalent winds are north and south ; in Behar east and west, and the same takes place in Assam, following the course of the Brahmaputra. That the monsoons exercise a beneficial influence on health cannot be doubted, but especially the south-west, from its preva- lence during the greatest heats, and from its greater power of thoroughly ventilating the country — " Q/uilis aer, talis spiritus." Stagnation would prove immediately destructive to health in a climate where so many and such abundant sources of noxious effluvia exist, ready to ripen into activity should such a cessation of wind occur as would admit of their accumulation, and that of heat, in any one place, or in such streets, for instance, as those of the native portion of Calcutta. Of the north-east monsoon I must limit my praises solely to its ventilating properties ; for in every other respect it exercises an unfavourable influence on health to a degree not generally known ; indeed, so far from it, that it is common to hear the accession of the cold season hailed by in- valids who are ignorant of the many dangers it carries along. It is the true " Sirocco of the North." The following table gives the direction of the winds at noon during the years specified : — Years. N. NW. W. SW. S. SE. E. NE.Calm Unregistered j„,„. Days Days Days Days Days Days Days Days Days uaj-o. In 1832 the wind was 44 60 26 44 67 49 4 71 1 1 9 |No regist. 1 day. | 1833 „ „ 56 39 14 30 115 24 25 32 29 >> >> 2 ff 1834 „ „ 53 52 12 25 99 22 26 40 36 1835 ,, „ 41 65 31 84 41 45 12 31 7 f> )> " ft 1836 ,, „ 67 58 88 38 46 7 23 20 12 1837 „ „ 83 26 77 43 76 6 21 13 7 >> )> 3 ,, 1838 ,, ,, Total 344 1300 248 264 444 153 111 207 100 No regist. 20 days. The following table,"^ given by Mr. Smeaton ('' Philos. Trans.,") and confirmed by Mr. Hutton (" Mathematical Dictionary,") ex- * A. B. Maddock, M.D., on the "Influence of Air and Weather." OF CALCUTTA IN BENGAL. 29 hibits in pounds avoirdupois the pressure which different winds will exert upon a square foot of surface exposed directly against them. The first column is a rough representation of the second : — Velocity of winds. Force on one square foot in pounds avoirdupois. Character of the wind. Miles per hour. Feet per second. 1 2 3 4 5 10 15 20 25 30 35 40 45 50 55 60 80 100 1-47 2-93 4-40 5-87 7-33 14-67 22-00 29-34 36-67 44-01 51-34 58-68 66-01 73-35 88-02 117-36 146-70 •005 •020^ •044 \ •079 •123$ •492 1-107$ 1-968 3-075 \ 4-429 I 6-027 i 7-873 9-963 j 12-300 17-1715 31-490 49 -200 Hardly perceptible. Just perceptible. Gentle pleasant wind; Pleasant brisk gale. Very brisk. High winds. Very high. Storm or tempest. Great storm. Hurricane. Destructive hurricane. THE RAINS SOURCES OP AQUEOUS EXHALATIONS HUMIDITY. The eudiometric processes having failed of discovering in the atmosphere of places the most opposite^ such as the narrow lanes of Loudon and the summits of lofty mountains^ any difference in the constituent properties of their permanent gases, it becomes a question of the highest interest and importance to ascertain the varying quantity of aqueous vapour in our atmosphere ; for it is the only ascertainable fluctuating ingredient in its composition. To the medical topographer, a minute inquiry of the kind here suggested may lead to a knowledge interesting and important respecting the causes and cure of certain diseases, in so far as these may be connected with climate, and this is no small benefit from the proper application of instruments. "The rain in falling,'^ says Miilder, ''carries with it everything that floats in the atmosphere and which is not essential to its constitution; which brings back to the earth what came from the earth ; and which, while it thus purifies the atmosphere from these hurtful adulterations, restores to the soil these numberless volatile substances, where they have abundant opportunities of forming not only harmless but useful combinations." Mr. Hingeston states that during the fall of rain electricity is positive, and very 30 SKETCH OF THE PHYSICAL CLIMATE often active ; and that in damp weatlier tlie amount of animal electricity is the smallest, and the most easily parted with. Without taking into view the expanse of the Bay, the coup-d'ceil of a good map of Bengal will at once show how bountiful nature has been to that country, by means of her majestic rivers with their innumerable tributaries, in yielding the sources of aqueous exhalations ; and it were gratifying to the medical topographer, could his description be limited to these. There are not any lakes in Bengal resembling those of Scotland or Canada, but there is a profusion of extensive j heels, which may be either denominated shallow lakes or morasses, A large proportion of these in the dry season contain little or no water, but during the rains present immense sheets, over which boats of the greatest magnitude may be navigated, and some are navigable to a certain extent through- out the year. There is reason to believe that nearly all these stagnant sheets of water rest in what were, at a remote period, the channels of large rivers, which have since altered their courses and now flow in other directions. The area of Bengal and Behar is 149,217 square miles, and with Benares not less than 165d,000 square miles. The following proportions of the surface are grounded upon many surveys, after making allowance for large rivers : — Parts, Rivers and lakes (one-eighth) 3 Deemed irreclaimable and barren (one-sixth) ... ... .. ... 4 Sites of towns and villages, highways, tanks, &c., (one twenty- fourth) ... 1 Free land (three twenty-fourths) remaining liable to revenue .. ... 3 In tillage (three- eighths) ... 9 Waste (one sixth)... ... ... ... ... ... .-• ••• 4 Total 24* According to another calculation, Bengal contains 97,244 square miles ; if from this, that portion of Tipperah which is independent, the tract of the Soonderbuns and other wastes, equal to 1 3,244 miles, be deducted, the remaining inhabited country will be equal to 84,00U square miles; but the extent of waste and surface occu- pied by rivers, marshes, &c., seems here greatly underrated. When all this is considered, along with the complete saturation, during five months in the year, of every inch of soil, even that which may not be actually inundated, the extent and sources of aqueous exhalation — the commerce of land and water — may be imagined. It is ascertained that the capacity of the atmosphere for moisture varies with its temperature, so that at 113° it holds a twentieth part of its weight of moisture ; at 80° a fortieth, and so on. To a scientific officer well acquainted with the localities, I put the two following questions : " 1st. Taking the area of the 24 * W. Hamilton. OF CALCUTTA IN BENGAL. 31 pergunnalis to be 882 square miles, what proportion should you say the water surface bears to the land, on the 30th of May and the 10th of October, the first being just before the rains, and the latter just after? 2nd. What proportion does the cultivated land bear to the waste and jungle within the said area?" Answer to \st Quest tun. — '^ I should say that on the 10th of June you might assume l-EOth part as the proportion of the water to the land ; of course, I mean by water, ground from Avhich exhalations could ai'ise. Answer to 2nd Q/cestion. — The cultivated land may be about lJ-20ths ; water, l-20th ; roads and villages, 2-20ths; uncultivated, 3-20ths.'' The subjoined table will show the annual fall of rain during the years specified. The average annual fall is about GO inches. Rain. Inches. 1830 63-28 1831 1832 1833 1834 1835* 1836 1837 1838 57-50 49-26 60-56 68-73 85-50 45-39 43-06 Mean 59-228 The following are the average rates of evaporation for the dry months : January, three inches ; February, five ; March, seven ; April and May, nine. It is during the periods of the year when the drying process is in greatest activity that unhealthiness prevails with greatest severity, namely, the commencement and termination of the rainy season. In the former, or that called by the natives the lesser rain (Chota bursat), common remittent fevers arise, and at the termination, or that from 15th September to the end of October, the severest forms of the same fever prevail, but chiefly amongst the indigent natives, and Europeans newly arrived. The connexion of the rainy season with disease would, in such a climate as this, form a highly interesting subject of inquiry; but the absence of every thing like statistical object in our older hospital reports prevents even an approach to accuracy on this, or indeed on any subject connected with climatorial influence. The following statement is taken from the " Bengal Hurkaru " of September 6th, 1845. ''The Englishman is informed that seventy-four inches of rain fell in Arakan during the last month ; and that fifty inches had fallen during the first twelve days of the present month. The whole fall during the monsoon, to the 15th August, was two hundred inches." * Sixteen inches fell on the 10th of May in less than twelve hours. 32 SKETCH OF THE PHYSICAL CLIMATE The quantity of rain that occasionally falls in a brief space of time within the tropics, and especially near the equator, is enor- mous : — On the lOtli of May, 1835, sixteen inches fell in Calcutta in twelve hours. But owing perhaps to the direction and elevation of the mountain ranges, and to the nearer approach to the equator, it is in the Burmese territories that we find the most surprising examples of great falls of rain. Those who served at Rangoon, and in Upper Ava, as the first European observers, will never forget the rainy seasons of those countries. The " Calcutta E-eview,^' in an article describing the Khasia Hills, says of the station of Chirra-Poonjee : — " Professor Oldham informs us that the fall during the year 1851 amounted to 592 inches, or to eight fathoms and a quarter of water ; for it seems absurd to use a smaller unit in treating of such a quantity." This is the greatest fall of which as yet we have any record. '' The climate of Khasia/' says Dr. Hooker, '' is remarkable for its excessive fall of rain. Attention was first drawn to this fact by Mr. Yule, Avho stated that in the month of August, 1841, 264 inches fell, or twenty-two feet, and that during five successive days, thirty inches fell in every twenty-four hours. Dr. Thomson and I recorded thirty inches in one day and night ; and during the seven months of our stay upwards of 500 inches fell; so that the total annual fall perhaps greatly exceeded 600 inches, or fifty feet, which has been registered in succeeding years. This unparalleled amount is attributed to the abruptness of the mountains which face the Bay of Bengal, from which they are separated by 200 miles of jheels and soonderljuns.^' THE HOOGHLY RIVER THE WESTERN BRANCH OF THE GANGES THE BHAGIRATHI, OR TRUE GANGES OF THE HINDUS. By some persons who have spoken of our climate, a large por- tion of the evils under which we suffer has been ascribed to the river — its supposed overflowings — its sluggish tides and foul waters — its muddy and slimy banks, and the action of a vertical sun upon them, &c., but I shall view the river in a different and more friendly light, as the piirijier of our city. Certain am I that, without this great scavenger, to whose tides we owe more than Captain Hamilton ever dreamt of, we should now be in a worse condition even than when he left us a hundred years ago. The truth is that, under moderate supervision on the part of the police, the river banks are inoffensive ; and along their whole extent, although crowded with buildings for a space of nine miles, disease will be found less prevalent by far than in the interior quarters towards the east ; in short, the causes of fever are to be traced to other and more palpable sources than the river- bank, which is the most elevated of all our ground s^ being from Feet. Inches, 6 9 6 12 6 4 OF CALCUTTA IN BENGAL. 33 three to four feet above the surrounding levels. The causes of unhealthiness in Garden Reach, after the salt-water inundation of lS33j could he readily traced to the state of the back-grounds — no one ever thought of looking for them in the river-bank. The annual rise of the Ganges and its branches^ is in May June July Half of August Total ... ... ... 32 From above 350 observations of temperature made by Mr. G. A. Prinsep, of which the details are given in the "Journal of the Asiatic Society/' it would appear that " the mean temperature of the surface water exceeds 8i° Fah., everywhere between Calcutta and the sea." In the dry season the mean rate of motion is less than three miles per hour; in the rainy season, and while the inundations are draining off, the current runs from six to seven, and even eight miles in particular situations. The river is at its lowest in the beginning of March, and the freshes are at their height in September, when the tides are scarcely visible off Calcutta ; and the river water is " perfectly sweet far beyond Sanger in the open sea.'' The following table exhibits the depths of the river channel at the different seasons : — Dry season. Minimum depth ... ... ... ... ... 8 4 feet. Maximum average depth of eleven of the shallowest places in the Hooghly, spring ebb ... ... ... ... 15^ ,, Maximum average depth over the same places, spring flood 31 ,, Eainy season. Minimum depth ... ... ... ... ... 16 feet. Minimum average depth of eleven of the shallowest places in the Hooghly, spring ebb ... ... ... ... 22 J ,, Maximum average depth over the same places, spring flood 32 j ,, Highest rise, ditto, ditto ... ... ... ... 36 ,, Difference between highest and lowest, 20|. Dry and rain. THE SALT LAKE. The situation and extent of the salt-water lake have already been described ; and it only now remains to state the probable advantages of causing its area to be drained, filled up, and brought under cultivation. Owing to the shallowness of the lake generally, it is easy to drain it for the purposes of native agriculture ; but to deprive the ground so drained of the soiu'ces of noxious exhalation is not so easy. It is not sufficient to convert the ground into a state of soft low meadow land ; for the most dangerous exhalations are those which D 34 SKETCH OF THE PHYSICAL CLIMATE are retained^ and occasionally emitted from under a crust of earth during the drying process, whereby they would appear to acquire unusual concentration, and prove the origin of the worst fevers. It is necessary that the grounds be thorouglily drained, leaving none of the characters of the marsh, otherwise it had better be left as it is ; its present condition being one of far greater safety than such half- drained soil as that obtained from the marsh of Chartreuse, for instance, near Bordeaux, which cavised in the year 1805 alone, 12,000 persons to be affected with fever within the city, of whom 3000 died within five months ! Two modes of effecting the drainage suggest themselves ; the one by letting in the river during the rains, and thereby gaining a succession of deposits of the river silt, so as gradually to fill the lake, and thereby bring it in time to a level with the surrounding land ; this would seem the easiest ; it imitates the simple opera- tions of nature, and would be the cheapest ; but perhaps not the most conducive to health. Another mode is by a deep and well- constructed canal, so as to effect the drainage ; but, as even this must, to a certain degree, prove a receptacle for noxious matter, and offer a considerable surface for evaporation, a close line of umbrageous trees shovild, under the proposed plan, be planted along each side of the canal, as being powerfully attractive of marsh exhalation. This property in trees was practically known to the ancients,"^ and is now beneficially exemplified in Demerara, and other parts of Guiana, '^ where the humid heat constantly cherishes the seeds of disease." The ground cleared from water should be well ploughed and cultivated, the ploughing to be done during the heaviest rain, so as to prevent exhalation ; for it is during a certain stage of the dry- ing process that marsh exhalation is most concentrated, and it has been observed in many countries that the drying up of brackish water is more injurious than that of either salt or fresh alone. A succession of crops purifies and evaporates the soil, and thereby obviates exhalation ; but they should not be of rice, or such crops as require profuse irrigation. The want of attention to some of the precautionary measures above hinted at, has neutralized the advantages that would otherwise have resulted from extensive draining executed in some parts of France and Italy ; and I have only thus long dwelt on that of the Salt-water Lake, because I believe its proper performance to be a matter of great importance to this city, so far as regards the prevention of disease ; and I need not here insist on the superior efficacy oi lyreventlve measures, such as have advanced in our own country apace with our civilization, and altogether banished from us some of the severest calamities that have ever afflicted the human race. * Regaud de L'Isle says of the malaria of Italy, that various obstacles form barrierg which they cannot pass, and against which they deposit themselves. OF CALCUTTA IN BENGAL. 35 THE WOODS AND MARSHES OF THE SOONDERBUNS. The enormous extent of tlie Soonderbuns — covering a superficies of more than :20,000 square miles, and extending 180 miles to the South and East of Calcutta — is composed of marshy land, covered with forest and underwood, together with the numerous embou- chiu'es of the Ganges — a region from whence the solar light, the heat, and the air are excluded by the forest-trees, to the extinc- tion of all minor vegetation. When we consider all these circum- stances, and their common influences on all the conditions of the atmosphere necessary to health, we shall be at no loss to perceive how great must be the deteriorating influences of so vast a region on the climate of Calcutta. That " forest on the borders of the sea" — that "land of flood and forest" — must necessarily exercise a very powerful influence on the temperature, humidity, electricity, and freedom of cii'culation of the atmosphere in and around it, not to speak of the noxious exhalations generated within and dis- seminated without. It is evident that the electric condition of the air must be greatly affected by the combination of oxygen with the materials of living plants over so vast a surface, as also by the enormous extent of evaporation from it ; and these are subjects deserving our most careful consideration. How far the geological nature of the soil — the amount of evapo- ration — the presence of forests — the vicinity of seas, lakes, and rivers ; how far, in fact, all the local circumstances noted in our topographic charts may aff'ect the electrical states of the medium in which " we live, move, and have our being ;" these are questions of the last importance to be observed and noted. Humboldt, in describing the forests of tropical regions, says : — " Under the bushes, deep, green verdure of trees of stupendous height and size, there reigns constantly a kind of half daylight, a sort of obscurity, of which our forests of pines, oaks, and beech- trees aff'ord no example ; forming a carpet of verdure, the dark tint of which augments the splendour of the aerial light. The mould contains the spails of innumerable quantities of reptiles, worms, and insects. Wherever tlie soil is turned up we are struck with a mass of organic substances, which by turns are developed^ transformed, and decomposed. Nature in these climates appears more active, more fruitful, we might say more prodigal of life. " On fixing our eyes on the tops of the trees, we discovered streams of vapour wherever a solar ray penetrated and traversed the dense atmosphere, exhaling, together with the aromatic odour yielded by the flowers, the fruit, and even the wood, that peculiar odour which we perceive in autumn in foggy seasons. It might be said that, notwithstanding the elevated temperature, the air D 2 36 SKETCH OF THE PHYSICAL CLIMATE cannot dissolve tlie quantity of water exhaled from the surface of the soil and of the vegetation." In the Bight of Benin, West Coast of Africa, a tract of forest land, covering a superficies of a hundred thousand square miles, presents an unbroken surface of densely-wooded alluvial soil, intersected by innumerable creeks and rivers. "At the distance of several miles from the coast," says Dr. Daniell, " the peculiar odour arising from swampy exhalations and the decomposition of vegetable matter, is very perceptible, and sometimes even oflFensive. The water also is frequently of a dusky hue, with leaves, branches, and other vegetable debris floating on the surface, brought down from the interior by innumerable narrow channels that empty their turbid streams into the open ocean." Here, as might be anticipated, the atmosphere is truly pesti- lential. " It is under these climatic conditions,^^ says Dr. South- wood Smith, '' that the worst forms of epidemics are engendered ; the most sudden in their attack, the most rapid in their develop- ment, the most general in their prevalence, and the most mortal." Por the most part, adds the same author, these epidemics are strictly endemic, and are confined to the particular regions in which they are engendered. That the clearing of the extensive surface of the Soonderbuns, or of any considerable portion of it, leaving belts and clumps of forest- trees, would tend greatly to improve the local climate in and around Calcutta there can be no doubt. The history of this city, and that of the effects of clearing marshes and forests in the neigh- bourhood of other cities in other countries, offer a demonstration of this fact. Such a measure would open out the city to the more free influence of the sea-breezes, diminish the moisture of its atmosphere, and purify it. These are no speculative results. The Soonderbuns, described by De Barros three hundred and fifty years ago as a well-peopled country, has since become what we have seen it. This desolation is stated by the best authorities, as quoted in the " Calcutta Review," to have resulted from the gradual process of silting at the heads of many of the rivers. Through this circumstance the influence of the tides prevailed a greater dis- tance north; and the water consequently lost its sweetness, and became brackish. " The cause of the desertion by the people was the salt water." The Bengalee, whose system of agriculture is limited by extreme poverty, will squat on the banks, plant his fruit-trees, raise his homestead, and dig his tank so long as the water is meetah, or sweet. It is found, contrary to the vulgar opinion, that in cleared and cultivated tracts the air is rendered drier and warmer in summer, and colder in winter, than in such as, from want of cultivation, remain, like the Soonderbuns, covered with wood and marsh. '^ Earth-clouds" are commonly observed in the early morning to OF CALCUTTA IN BENGAL. 37 the east of Calcutta, over the borders of the Salt-water Lake and the cleared portions of the Soonderbuns. They are caused by the immense radiation of heat in the calm nights, and by the cooling of the earth's surface far below that of the air above — thus forming vast clouds, or mists, close to the earth's surface. If, then, to counterbalance the only disadvantage attendant on clearing — some little increase of temperature — we obtain more purity and dryness of our atmosphere, we shall still be very greatly the gainers; for it is not so much from the high rate of temperature we Europeans sufler, as from the excessive humidity that is conjoined with it for so many mouths in the year, and both which, commingled with the terrestrial exhalations, tend gradually, through their united in- fluence, by inducing what may be termed a Cachexia Loci, to under- mine the best and most robust of constitutions. The clearing and draining immediately around the city, partial and imperfect as these are, have removed only some of the con- centrated evil ; but that emanation which was death within a few yards, cannot be other than insalubrious even at the distance of a few miles, and in a diluted form. The general influences produced by trees on the climate of a country, or, as St. Pierre defines it, "^ the elementary harmonies of plants with the water and the air by means of their leaves and their fruits,'' have been ably summed up by Dr. Balfour of the Madras array as follows : — " 1st. That the extensive clearing of a country diminishes the quantity of running water which flows over the surface. " 2nd. That it is impossible for us to determine at present whether this diminution is owing to a smaller annual fall of rain, or to an increased evaporation of the surface-water, or to those two causes combined. "■ 3rd. That it is, however, shown by various authors that rain oftener falls, and that more dew is deposited in well-wooded countries than where the country is naked ; and, drawing our con- clusions from the meteorological facts collected in equinoctial regions, we may presume that the extensive clearing of a country diminishes the actual quantity of rain which falls upon it. "4th. That mountains, particularly when covered with their native forests, by an electric action on the atmosphere cause clouds to form around them, collect and condense the vapours of the air, and equalize the fall of rain. " 5th. That the forest-trees which grow on mountain summits have a structure peculiarly fitting them to receive the waters of the clouds. ^' 6th. That lands destitute of the shelter of trees allow of more rapid evaporation. " 7th. That, independent of the preservation of surface-water, forests husband and regulate its flow. " 8th. The authors alluded to also show that in all forest-tracts 38 SKETCH OF THE PHYSICAL CLIMATE the temperature of tlie air is more equable throughout the year; that in tropical regions the atmosphere around trees is cooler, and con- tains more moisture than the air on the open glade ; that the atmosphere of a tropical country without trees has an arid dryness in it totally dissimilar to the cool softness of a well-wooded one ; that lands covered with trees are cooler and moister than those which are exposed ; that in hot climates the destruction of forest trees, by inducting aridity, destroys vegetation ; and that forests and trees afford the shelter from violent winds which is absolutely essential to the health of the vegetable creation. " 9th. That springs draw their supplies from sources in their immediate vicinity ; that the presence of trees near these sources seems to prevent the dissipation of the supply of water. " 10th. That in clearings which are purely local, springs may disappear without there being any ground to conclude that the annual quantity of rain has diminished. " 11th. That the tenacious clayey under-soil found in forests is peculiarly adapted for preserving the surface and subsoil waters. '' 12th. That there is a difference in the condensing power of trees, but by means of the vegetable creation a valuable supply of moisture is collected from fogs, and from the atmosphere in the form of dew. '' If the facts detailed warrant these deductions, it may be con- fidently asserted that Southern India would be greatly enriched and its climate ameliorated by the introduction of arboriculture." POSTSCRIPT. Referring to the influences of all the physical and geographical circumstances detailed in the foregoing notes as affecting the elec- tricity of the atmosphere, I would call attention to the conclusions arrived at by Dr. Pallas of the French army in Algeria, offering them here only as subject-matter for examination and test in other hot climates. Dr. Pallas considers : — " 1st. That, just as light and air are the essential agents of vision aixl respiration, so electricity is the functional agent of innervation. " 2nd. That the greater number of diseases, and especially those which belong to the class of neuroses, are occasioned by the ex- aggerated influence of general electricity, of which clouds, storms, and marshy regions are the most fruitful sources. " 3rd. Marshes, in their geographical constitution, and in the effects which they produce upon the economy, present the greatest analogy to the galvanic pile. Thus their action is much the more baneful, as they contain certain proportions of water, and their activity is considerably increased when the water contains organic or saline matters in a state of solution. This explains why salt OF CALCUTTA IN BENGAL. 39 marshes and siicli as are near maritime rivers are the most in- salubrious. The drying up or submersion of marshes produces analogous conditions to those of a galvanic pile deprived of humidit^^Yj or Avhich is under water, and the effects of which are then insignificant. " -Itli. The researches of philosophers and physiologists have shown that the electricity produced by our machines exerts a special action upon the nervous system. Experience and rigorous observation of facts prove that the diseases which are produced by a marshy atmosphere are primarily nervous, and become in- flammatory only by the re-action of the nerves upon the vascular system, inducing consecutive, local, or general irritation. " 5th. The neuroses are occasioned generally by the effects of electricity, and intermittent fevers have a similar origin ; that is to say, they are due to the electrical emanations of the marshy pile, which are very active in hot countries, and not to miasmata, which have never been met with." Professor Schonbein considers, on the other hand, that the physiological importance of electricity has, upon the whole, been much exaggerated, that agent, in comparison to heat and light, acting but an inferior part in the economy of organized beings. " Electricity," he says, "would affect neither the sense of taste nor smell, if atmospheric air did not contain oxygen and nitrogen; and the phenomena of sound and light, perceived during electrical discharges, are due to the vibrations into which the particles of air are thrown by the electrical discharges, electricity having directly nothinar to do with them." 40 MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. "Si I'histoire naturelle a besoin d'une bonne geographie physique, la science de I'homme a besoin d'une bonne geographie m^dicale." — Cabanis. PHYSICAL EFFECTS OF CLIMATE. Under tliis liead I shall offer some cursory observations on what is usually called by physicians "medical climate;" meaning thereby the physiological forces which act perceptibly upon our organs. I desire also to submit some brief notices of the geography of disease, as connected with our Bengal climate and seasons. Temperature and hvimidity being the elements that give activity to terrestrial emanations and all the external causes aft'ecting health, derived from locality, I shall now consider them apart from the subjects above classed; remarking generally that the heat of Hindustan, as compared to that of other regions, is moi*e charac- terized by its duration than by its intensity. On the other hand, where the cold is excessive, the rise of temperature in spring and summer is sudden and intense, while again in those countries where the range is more limited, the seasons glide gradually and imperceptibly into each other. It has been well observed that the most poisonous gases, mephitic emanations, malarious, mias- matic, and paludal exhalations, the products of putrefactive changes o^ organic 2aiA vegetable origin, are extricated by heat, and dissolved and retained in the atmosphere by moisture. In Bengal, throughout the hot season, the rivers become shallow, the tanks dried up, the water impure and scarce, while the air is rendered thick and hazy by the quantity of impalpable matter floating in it. Speaking of the average of men, the terms hot, warm, cool, cold, as applied to the surrounding air, are regulated by the sensations produced ; and if the heat be carried oft' as fast as it is generated, and no faster, no particular sensation is felt — the bodily powers being neither stimulated nor exhausted. Supposing then that no extraordinary exertions are made, the equilibrium is main- tained when the thermometer stands at 6£°, or thereabouts ; and this point in the scale is therefore called temperate. All degrees above that point, up to 70°, are reckoned wwn;? ; all above 70°, hot. Descending again in the scale, we speak of the temperature denoted by any degree between the 60th and the 50th as being cool, and any lower degree of temperature as cold. Changes of tem- perature seem to be as readily felt at one part of the thermometric; MEDICAL CLIMATE AND TOE INFLUENCE OF SEASON. 41 scale as at tlie other, and in wliicliever direction they take place. Captain Parry found that a rise in the thermometer from 13*" below zero to 23° caused discomfort to his men. " I may possibly incur the charge of affectation in stating that this temperature was much too high to be agreeable to us ; but it Avas nevertheless a fact that everybody felt and complained of the change." On the other hand, the fall to from 40° or 50° at night in Bengal, during the cold season, might seem to an European as both agreeable and salutary ; but a very brief experience teaches him the contrary. Much has been said and written on the superior capabilities of adaptation to climate in man over the lower animals ; but if the power and just application of the arts of civilization be deducted, I am disposed to think, with Dr. James Johnson, that the difference would be but small ; for, even with these aids, we find that in this climate " many die suddenly, others droop, and all degenerate," very much as with the lower animals of more temperate regions ; and all we can hope to learn is, how best to conquer by obeying nature. It is thus that man, the weakest of animals, is, in reality, the strongest; and it is under circumstances apparently calculated to overAvhelm and destroy his vigour that he finds the means of developing new faculties and resources, which excite even his own astonishment. Gibbon, after stating that the Roman soldiers, from their " ex- cellent discipline," maintained " health and vigour in all climates," adds, that " man is the only animal which can live and multiply in every country from the equator to the poles. The hog seems to approach the nearest to our species in that privilege." It is true, as stated by the historian, that men do " live" in other than their natural climates, but their existence is very unlike to the health and vigour of the Roman soldier, whose habit and discipline did not allow his manly character and physical energy to be dissolved in indolence. " The truth is," says Dr. Johnson, " the tender frame of man is incapable of sustaining the degree of exposure to the whole range of causes and effects incident to, or arising from, vicissitudes of climate, which so speedily operate a change on the structure, or at least the exterior of unprotected animals. The object of these remarks, which at first sight might seem irrelevant, will now appear. Since it is evident that nature does not operate more powerfully in counteracting the ill effects of climate on man, than any other animal, it follows that we should not implicitly confide, as too many do, in the spontaneous efforts of the constitution, but on the contrary, call in to its aid those artificial means of prevention and amelioration which reason may dictate and experience confirm. In short, that we should stvidy well tlie climate, and mould our obsequious frames to the nature of the skies under which we sojourn." Although the physical effects of climate_, in forming or influ- 42 MEDICAL CLIMATE AND THE INFLUEKCE OF SEASON. encing the differences by wliich the varieties of tribes of the human species are characterized^ are foreign to the present inquiry^ still one cannot help remarking that, if the native of Bengal Proper is to be classed among the Caucasians — the standard of the human race — the effects of climate and locality must indeed be great and remarkable. No climates exist that are uniformly hot and dry, hot and moist, cold and dry, or cold and moist ; yet certain countries have such a preponderance of one or other of these qualities, as to give a very marked character to the physical and moral nature of man ; and physicians would do well to observe these results of climate more closely than has yet been done : — " Si I'histoire naturelle a besoin d'une bonne geographic physique, la science de I'homme a besoin d'une bonne geographic medicale." The moral as well as the physical influences of climate have been considered so powerful by some philosophers, as to make some persons doubt whether a people situated as our Asiatic sub- jects are capable of receiving the impress of European knowledge and institutions. There is in hot climates, it has been well ob- served, a vis inertia which indisposes men to change their customs, or to cope with abuses ; and the indolence which the climate occa- sions conduces to the stability of their barbarous institutions. " The astonishing rapidity of political revolutions in Asia,'^ says Montesquieu, " arises out of one fact which is really dependent on its physical geography. In that part of the world, weak nations are opposed to strong ; people warlike, brave, and active border upon those who are effeminate, idle, and timid; the one must necessarily be conquerors, the others conquered. Here we have the principal reason of the liberty of Europe and the slavery of Asia." Malte-Brun, commenting on the above observations, says : " It is necessary to combine this just remark with another truth proved by physical geography, namely, that Asia has no temperate zone, no intermediate region between very cold and very hot climates. The slaves inhabit the hot, and the conquerors the elevated and cold regions." In European countries, a certain amount of injury is caused to public health by the agitations of ceaseless competition, commer- cial speculation, religious controversy, and party politics ; and though these influences are not apparent in India generally, we cannot altogether overlook them, or the many causes arising from long ages of civil and sacerdotal domination, and other abuses of native government which, with difference of race and of religion, produce so remarkable a distinction between the moral and physical constitution of the Asiatic and European, rendering the latter so much more liable to be affected by tropical climates. The hot and dry season in Bengal extends from the beginning of March to the middle of June, dui'ing which the winds are steady and strong from south and south-west. The temperature MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. 43 rises gradually from 80° to about 90° — 95° in the shade, and reaches to 100° — 120° — 130° and upwards in the open air. Notwith- standing the high temperature, this season is rendered far less oppressive to the feelings than might be supposed, by means of the moisture carried along with the monsoon in its passage over the Bay of Bengal, and likewise by the frequency of refreshing storms, accompanied by rain, lightning, and thunder. Of Calcutta at mid- day, in April, May, and part of June, it may be said, however, with truth, that it is " a city of stone, in a land of iron, with a sky of brass ;" the soil of the surrounding country being '' rent and riven as if baked over a volcano," often emitting noxious vapours. The local newspapers of May, 1851, speak of the heat as more intense than it had been for years. '' The thermometer in the coolest rooms stands at 92° to 94°, and the breeze which should bring refreshment at the close of the sultry day, has been as the breath of a furnace.''^ The intensity of light at different places differs greatly, and it is a matter of regret that there is no ready means of measuring it, as the results would certainly prove interesting. According to Herschel, that of the Cape of Good Hope, compared with that of a bright summer's day in England, is as 44° to 17°. '' There is,'' says Dr. Mitchell, " a health-giving influence in a bright atmosphere and a cloudless sky, which is not fully appre- ciated. Light has a higher power on the functions of the animal economy than we are apt to think ; and proofs are not wanting. Deprive the tadpole of the influence of light, and nourish it as you like, it remains the tadpole still. This agent is essential to its development, and it is arrested when deprived of it. Again, disease among the soldiers who lived on the dark side of an exten- sive barrack at St. Petersburg, was uniformly in the proportion of three to one compared with that on the side exposed to a strong light. " But it is in the vegetable that we have the clearest manifes- tations of its markings. In plants we find the secretions developed ' in greater perfection according to its intensity.' Deprived of it, we find them flowerless, fruitless, and with small and stunted leaves, while on branches of the same plant ' which grow towards the light we have full-sized leaves and perfect flowers and fruit.' Had we no other, we shoidd be authorized in inferring that that which is so potent on vegetable is not inert on animal life. The physiology of the two kingdoms is ever more or less closely related ; and that which stimulates the flower to expand its petals — giving a welcome, as it were, to the vivifying influence — is also, though perhaps more obscurely, a stimulus to man. But the operation of no stimulus must be continued or uninterrupted. And that of light is no exception : hence darkness and light alternate." Well may Boudin declare that light exercises an influence as powerfid as it is varied on entire nature. 44 MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. The most ordinary and simple effects of the Bengal season just described are — determination of the fluids generally to the surface of the body, the blood being- venalized in proportion to the eleva- tion of temperature ; and respiration being less perfectly carried on, owing to the rarefaction of the air, and the consequent dimi- nution of its oxygen in a given bulk, a vicarious decarbonization of the blood is established in the increase of the biliary secre- tion ; while, at the same time, the urine is surcharged with saline impregnation, and much diminished in quantity. Recent experiments render it probable that, as temperature rises, the quantity of oxygen consumed in respiration is less, while the amount of carbonic acid exhaled is less also ; and hence lassitude, diminished muscular power, and diminished change of matter. At this season, too, it is believed that both the relative and abso- lute quantity of carbonic acid exhaled is diminished. There seems at length some reason to hope that the vicarious nature of the relations existing between the depurative functions of the liver, kidneys, mucous surfaces, skin, and lungs may receive demon- stration from chemistry ; meanwhile we know that there is not a function of the body the integrity of which does not depend on that of respiration. " Vierordt has made a very extensive series of observations, with the view of ascertaining the connexion between the tempera- ture and the pulse, the respiratory movements and the volumes of air expired, and of carbonic acid, in one minute. His experi- ments were made at every degree of temperature between 37° and 76° Fah. " From a table of observations, we see that elevation of tempe- rature is accompanied by a diminution of the number and of the depth of the inspirations ; its effect on the excretion of carbonic acid is, to a certain degree, of an indirect nature, since the dimi- nished number and depth of the expirations must have a conside- rable influence ; but inasmuch as the diminution does not merely show itself in the total quantity excreted, but also in the per centage of carbonic acid in the expired air, it seems obvious that the elevation of temperature has a more direct influence on the excretion of carbonic acid than could be accounted for by the modified respiratory action. " The degree of atmospheric moisture, to a certain degree, in- fluences the respiratory functions and the excretion of carbonic acid. Lehmann, some years ago, experimented on this subject with pigeons, greenfinches, and rabbits. The quantity of carbonic acid exhaled in a moist air was much greater than in a drier atmo- sphere. . . The researches of Vierordt on the influence of atmo- spheric pressure, show that this also is by no means an unimportant element. . . Vierordt and Baral agree in the opinion that more carbonic acid is excreted in winter than in the summer. " The excretion of carbonic acid is very considerably diminished MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. 45 during sleep. This is most decisively proved by the experiments of Scharling, who found that a man, during one hour of the night, exhaled only 2:Z'77 grammes, -who, during an hour of the next day, immediately after a meal, exhaled 33'69 grammes; and who, in another case, found that the horary excretions of carbonic acid during the night and during the day were as 31'39 : 40'71<.^^ — Brit, and For. M. C. Bev., July, 185^5. The alternations here mentioned cannot fail of being important in relation to European health within the tropics. It has been observed in all malarious countries, that to night exposure, and to the condition of sleep, is the greatest danger — a lowering of the nerve-power, and a eonse- sequent vascular debility occurring in the night time. These physio- logical alternations may be more or less immediately connected with the circumstance of the hours of 3 and 4 a.m. being the minima of atmospheric electricity, and of atmospheric pressure likewise. THE HOT SEASOX AND ITS EFFECTS. Dry heat causes a very rapid evaporation, a high degree of electric tension, and a generally stimulating effect. These effects, however, vary according to age and individual temperament, whether sanguine or leucophlegmatic. It appears to me that the physiological action of heat is ex- hibited, first, in its temporary stimulation of both the ganglionic and cerebral systems of nerves, and in the increased manifesta- tion of all those functions governed by them ; and secondly, in its sedative and more lasting influence on the same systems of nerves, in the progress of years, and in diminished manifestation, conse- quently, of all those functions governed by them. This last result is strikingly exemplified in the diminished muscular powers of both the heart and uterus. Heat may be regarded for a time, and for a short time only, as the universal chemical quickener of the various functions. Besides its direct efi'ects, heat is in fact the great moving power of all other subordinate sources of disease, whether these last be neglects in public or personal hygiene. Bearing in mind these important and interesting facts, as they appear to me, we shall at once perceive how it is that for a cer- tain time the respiration, circulation, the hepatic function, and that of innervation itself, are unnaturally excited, and how the newly- arrived European is exhilarated in mind, and so prone also to acute inflammatory and congestive abdominal diseases. But, as this state of over-excited or exalted function cannot be main- tained beyond a certain limited term of years without danger to the power and equable functional action of the source — the ganglionic nerves — Ave see how, along with a feeble respiration and circulation, diminished power of generating heat, and torpor of the hepatic function eventually succeed ; — all tending to conges- tion and other dangerous forms of more passive disease. Again, 46 MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. we perceive liow tlie long-continued operation of alternate stimu- lation, and of subsequent depressive and sedative influences on the functions of the organic and animal sj^stems of nerves, produces and confirms that eventual bodily and mental inertness and indis- position to healthy action, which not even the most powerful of Europeans can hope always to resist, beyond certain defined limits as to time. The ansemic states of the system induced by a lengthened exposure to the influences of heat, moisture, and malaria are fre- quently referred to, more or less in detail, in the course of this work ; and all I would say is, that the existence of this morbid con- dition should be constantly held in recollection by the medical officer when called upon to treat Europeans suff'ering from tropical disease, and who may have resided long in hot climates. Old Indians may occasionally prove of plethoric habits ; but the asthenic condition of the system is by far the more general among that class. The hot season swells the exterior and produces that general cliubbiness of appearance which is so remarkable in the torrid zone, even where the weight of the body is sensibly diminished : it in- creases the animal heat, and accelerates the pulse, accompanied by a prodigious increase of tlie pulmonary and cutaneous transvida- tions : it produces nervous excitability varying in degree in most persons — an exaltation of the general sensibility : eruptive diseases, latent during the cold season, become actively developed ; and the cutaneous vessels, even in healthy persons, are excited to the extent of producing the distressing eczema solare, known in the tropics by the name of prickly-heat. In ordinary seasons, we find that here, as in the West Indies, the most healthy months are from February to May inclusive ; while in the seasons of epidemics (cholera in particular) these are the months in which the disease is most fatal and long-continued ; indeed, it seldom vanishes till the setting in of the rains. Under exposure, excessive fatigue, mental depression, or neglect of temperance in diet, results ardent fever, with some serious local determination, and that very frequently to the cerebral organs — occasionally to the liver ; but though this is admitted, under the measures of precaution dictated by common sense and experience, the very hottest are yet the healthiest of our seasons, and of our stations also,"^ which goes far to prove that it is not heat aloiie that does all the mischief, but something else in the climate and in the constitution and habit of the stranger European, not common to the native of the country. From the results of personal observa- tions in active field service both in India and in Ava, I am led to conclude that mere heat, unless long continued, and combined with * At Agra, the hottest of our stations, the per-centage of death has not been two, or one in fifty per annum, out of a garrison of one thousand men ; a more favourable result than shown in any table hitherto prepared in India. — Asiatic Researches. Major Henderson. MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. 47 intemperance, with chills, and other untoward circumstances, is very rarely the direct cause of disease. Edwards states it as a fact that the quantity of cutaneous exha- lation from the human body is sometimes ten times greater in dry than in moist air, and that it is doubled in the mere passing from 32° to 64.° F. I have seen men of the Bengal Pilot ser^dee, persons who lived and laboured in the sun during their youth and manhood, in whom the functions of the skin appeared at length to have been exhausted. They exhibited a permanent dryness, roughness, and scaliness of the whole surface of the body, from which they experienced dis- tress in the cold season of Bengal, and more in the English winter and spring. One old pilot's skin was so furfuraceous that he would often say : " I could write my name with my nail on any part of my body and limbs." With these men the functions of the kidneys were always distui'bed also. The troops from Bengal and Madras were exposed, in the expe- dition to Egypt, to an excessive heat in crossing the Desert from Kosseir to the Nile ; yet they enjoj'cd excellent health, because they were not exposed to extreme fatigue or to excesses, and their minds as well as their bodies were kept in activity. The service, too, was not protracted. The superior power of enduring heat, rmder a sudden effort, or while the mind is heenJij occujiied, possessed by Europeans in India, even beyond the natives, has often been exhibited in other climates. It would seem to arise from the same causes that enabled the natives of the southern countries of Europe, according to Larrey, to bear the cold of the Russian winter, during the French retreat from Moscow, "better than the natives of the Northern and moister climates — such as the Hanoverians, the Dutch, the Prussians, and the other German people : the Russians themselves, from what I learned at Wilna, suffered more from the cold than the French." These last suffered also in Holland, in 1799, much more from cold than the British with whom they co-operated, as observed on the spot by Robert Jackson. The inhabitants of the temperate regions of the globe, it is supposed, having their constitutions matured by genial climates, are able to bear the extremes of both heat and cold, during a short time especially, better than those whose frames have been weak- ened either by the severities of the arctic, or the relaxations of tropical climates. Robert Jackson, speaking of the first American campaigns, says : — " Bad eflects from the greatest exertions in the hottest weather of summer were extremely rare in that country, after the campaign had been continued for a few days." These remarks must be understood to apply only to sudden efforts or brief exposures ; for it is now well known that to the duration of heat more than to its intensity — to the long-continued 48 MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. exposure to an unnatural and uniformly high range of temperature, more than to the temperature itself — must be referred much of the injurious influence of tropical climate on Eui'opean constitu- tions. Dr. Armstrong says of the unnaturally extreme climate of the polar regions, that " Men are less capable of resisting cold in the second year in the climate than they are in the first, and so on for every subsequent year of their sojourn." The equable determination to the surface consequent on the progressive increase of temperature, seems to exercise an agreeable as well as a favourable influence on general health, especially in the old Indian; and even a new comer seems to bear without complaint or apparent injury the great augmentation of the sen- sible perspiration. It is only the opposite condition — the total suppression of it in our cold season — that is felt by all as unnatural as it is unhealthy : — indeed, we then become aware of the effect of long-continued exposure to a high range of tempera- ture, through our extreme predisposition to be injuriously influ- enced by cold. Miscarriages, frequent at all seasons in India, occur yet more frequently in the hot season, and the recovery is more protracted, owing to the increased force and frequency of the circulation, especially in those of plethoric habits. There are two classes of persons to whom our climate seems genial, the weak-chested, as they are called in England, who are of a scrofulous habit, but in whom pulmonary disease has not actually declared itself. These are saved by going to India ; and I have known many persons in the curable stage of consumption — that is, labouring imder the preceding stage, or that of " tubercu- lous cachexy" — enjoy good health in Bengal, and survive their brothers and sisters at home. The greater expansion of the lungs produced by the warmth and rarefaction of the air would appear to aid the other influences already mentioned. The soft and moist air of marsh-districts, also, as long ago remarked by Dr. Harrison of Lincoln, may exercise a beneficial influence. The fate of those, on the other hand, who go to the East with suppurating tubercles, or even in the softening disorganization approaching it, is only precipitated. Persons of phlegmatic habit also, with dyspepsia, languid circulation and cold extremities, seem to have better health there than in Europe. The climate of India tends, in fact, powerfully to the production of disease within the abdominal cavity ; while that of Europe tends as powerfully to the production of disease withiii the thoracic cavity. Tliat catarrh, bi'onchitis, and pneumonia will occasionally arise among British soldiers in India, when exposed to cold and damp while marching and campaigning, and when sleeping on the ground, is well known ; but that such diseases are either generally prevalent, or often fatal, is equally well known as not being the case. MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. 40 As the two lieraisplieres are divided, the eastern from the west- ern, by the meridional line, so the diaphragm separates the two great cavities of the body, in one of which, the thoracic, is mani- fested very generally the morbid results of the Western, while in the other, the abdominal, are generally manifested the morbid results of Eastern climates. Thus, as the globe is divided into two hemispheres and great climates by the meridian, so, to a great extent, the influences of those climates on health are marked and bounded in the cavities on each side by the diaphragm ; the line of demarcation being as determinate in the one instance as in the other : the climate in each instance determines with accor- dance and correspondence of effect the cavity of the human body in which disease shall manifest itself. Again, speaking in reference to particular tissues, we find that in the acute diseases of temperate climates inflammations of the serous membranes occur frequently, while in tropical climates it is the mucous surfaces that are involved in disease. Out of 1000 deaths in England and Wales, mortality occurs from the following causes, and in the following proportions : — From diseases of the cerebral cavity ..... 144 „ ,, ,, thoracic ....... 302 ,, ,, ,, abdominal, including childbirth, &c. . . 87 ,, other diseases ........ 430 ,, violent deaths ........ 37 Males and females at all ages ....... 1000 Out of 1000 deaths (males) in London, mortality occurs from the following causes, and in the following proportions (age 15 to 35 included) : — Diseases of cerebral cavity ....... 80 ,, thoracic ........ 559 ,, abdominal ........ 74 Other diseases ......... 202 Violent deaths ......... 85 1000 The returns from the East Indies include soldiers only, men of the mean age of twenty-six years ; and the British military returns comprehend the same class. But the returns of the civil popula- tion of England and Wales by the Registrar- General include persons of all ages and of both sexes ; and here, under the head of diseases of the abdomen, we have included all diseases of the uterus and urinary organs. Besides the protecting influences already mentioned, an anta- gonism of phthisis and intermittent fever is believed by some observers to exist ; and the fact that tubercular disease is much less frequent in marshy districts than in any others, has been insisted on by certain physicians of France and Italy, supported by statistical details, the results of experience in many of the E 50 MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. marshy quarters of those countries. But, like the influence of heat, the malarial influence must, they say, be sufficiently intense and continued in its action to jDroduce the marshy cachexia, or, in other words, the antagonism to phthisis. In Algeria the French surgeons found phthisis a rare disease. Out of 1480 French soldiers in hospital, M. Haspel found but three cases of pulmonary disease, and only one death was caused by it out of 138 deaths. A general report gives but thirteen phthisical cases out of a total of 8185 patients, and but ten deaths from pialmonary disease out of a total of 871 deaths. But the infrequency of pulmonary consumption in Algeria is not, as sup- posed by M. Boudin, the consequence of malarious fevers and their eflicient causes, so much as from peculiar climatic circum- stances. It may, then, be asserted, on the ground of statistical evidence of the most extended nature, that climates and employments that induce sweat, or that induce a gentle perspiration not subject to check, are unfavourable to the existence of scrofula or consump- tion. It may be inferred also that the curative virtue of marshy countries, as respecting phthisis, resides less in the miasmata themselves than in the uniformity of temperature, the heat of the atmosphere, a moderate degree of moisture, and the absence of dr}^ sharp winds. Even in the favoured Nice — the resort of thou- sands of sufferers from thoracic disease — the Cimios, those unri- valled hills where old Rome sent her convalescents, are still the chosen spots. There is, on the other hand, a malarious cachexy, or cachexia loci, generally observable in Europeans who have resided long in the more unhealthy districts or stations of tropical climates, even when they have escaped actual visceral disease there. But when the contrary holds — when organic disease within the abdomen has resulted — the condition of the blood here referred to forms a serious complication. It renders the cure difficult and tedious, the system being cachectic, the blood dissolved, there being a general anaemia, in short. To give a more concentrated view of the physical circumstances above related, it may be said that in hot climates, the air being expanded, less oxygen is taken in at each inspiration ; and thus the changes effected by respiration on the blood are diminished. The necessity for hydro-carbonaceous food is therefore lessened. Less of the " elements of respiration " ought to be taken in the food than would be taken in colder climates. In consequence of the internal increase of temperature, less internal heat is re- quired — the supply of and demand for animal food depending, in fact, on the external temperature. Exercise increases the heat of the body by increasing the rate of circulation and respiration. In a very hot climate all increase of heat is undesirable. Moreover, the excessive heat renders mus- MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. 51 cular action impossible, because the circulation is chiefly directed, in consequence of tlie activity of the skin, to the surface, in order that fluid may be furnished for evaporation, to keep down the heat of the body, to prevent the parching of the surface, which other- wise must ensue. In consequence of the lessened muscular action, less of the albu- minous constituents of the food are required to suj)ply the waste of the muscles. Hence, in hot climates, less of both kinds of food should be taken, and nature points this out, in the absence of appetite ; to force an appetite stimulants are taken, and then the system is over- loaded with nourishment. The excessive perspiration requires an excess of liquids ; but, instead of water alone, sugar and spirit, the elements of respiration, are taken with the Avater as beer, and the spirit, by its stimulating properties, is doubly injurious. The excessive flow of blood to the surface (the consequence of the high temperature) no doubt prevents for a time the evils re- sulting from an excess of the two kinds of food. The chemical changes and evaporation going on in the skin draw the circulation to the surface of the body, just as the flame of the lamp draws the oil up the wick. Whilst the high temperature lasts, this increased action of a flow to the surface is kept up. It is probable that the action of the heart is thereby made feeble by the excessive suction of the skin, as we see it frequently is, temporarily, by the perspira- tion bath. As soon as the temperature falls, the blood ceases to flow in excess through the skin. According to the degree of cold, it is almost driven from the surface. It accumulates within, and congestions and inflammations are produced. Free action on the inner or outer surface of the body for a time relieves the conges- tions, and enables the circulation to proceed. After such alternations for years, the resident in the hot climate returns to a far colder home. There no heat leads the blood to the surface ; it accumulates in the enlarged capillaries of the in- ternal viscera. The outward appearance is that of anaemia ; whilst in reality an internal plethora frequently exists. The more frequent and severe the temporary congestions of the viscera have been, whilst in the hot climate, the more permanent does the internal congestion become, when the surface is con- stantly exposed to cold. Though the surface and extremities may look void of blood, the capillaries of the liver and spleen will often be full ; and the enlargement of the internal capillaries which Avas the eft'ect of temporary congestion for years, becomes permanent when the coldness of the atmosphere leaves the blood to be circu- lated by the enfeebled heart alone. The consideration of the effects produced by migration, daring a state of disease, from a cold to a warm and moist climate, says Dr. Copland, is of the utmost importance. Keeping in mind it>s influence on the healthy frame, chiefly in exciting the functions of £2 52 MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. the skin and liver, and diminishing those of the lungs, we are led to prescribe it in A^arious diseases. In hsemoptysis this change is obviously beneficial, especially as a warm and moist atmosphere, by this mode of operation, lessens the activity of the pulmonic circulation and the disposition to sanguineous exudation from the surfaces of the bronchi ; bronchitis and tubercular phthisis are also often benefited, and the progress of the latter much delayed by this change of atmosphere, especially when adopted early. Chronic rheumatism is sometimes cured by this measure, seem- ingly owing to its influence in promoting the biliary and cutaneous functions. Dropsies, particularly anasarca and hydrothorax, have been, in a few instances, removed by a change to a warm climate ; but whilst a moist state of the air is most serviceable in pulmonary and haemorrhagic diseases, dry warmth seems more beneficial in drop- sies, dyspeptic aff'ections, and hypochondriasis, evidently from its effects in augmenting the insensible perspiration and the pulmo- nary exhalation, and imparting tone to the capillary circulation. Besides these, he adds, gout in its early stages, clymienorrhma, and scrofula in nearly all its forms, are benefited by a change to a warm or even a mild atmosphere. THE RAINY SEASON. % Although medical authorities have not been able accurately to estimate the effects of moisture, either acting simply or in combi- nation with heat, yet it is certain that this last union is more inju- rious than either applied separately. In warm and moist climates, obesity and laxity of frame are induced — a fact which was very early observed ; thence the proverbial acuteness of the Athenians, and the sluggishness and stupidity of the Boeotians. On the other hand, countries where it seldom rains are generally the healthiest — fevers of the malarious type being almost unknown in them. The effect of situation upon the habit may in some degree de- pend also on the gravity or weight of the atmosphere connected with locality. When the barometer is high, we feel vigorous and cheerful ; when it sinks, languor and low spirits oppress us. Bichat states that, " accumulations of fat are said to take place in some animals in a few hours, in certain states of the atmosphere. During a fog of twenty-four hours' continuance, thrushes, wheat- cars, ortolans, and red-breasts are reported to become so fat that they are unable to fly from the sportsman." In Bengal, as on the West Coast of Africa and other unhealthy climates, the heat and moisture coralnned cause a vast increase of minute vegetable and animal life, while the decomposition of dead animal and vegetable matter is equally rapid, showing the aptitude MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. 53 of all sustaiices to pass from the inorganic to the organic, and vice versa. The oxidation of metals proceeds with immense rapidity also during the rainy season. During the first month of this season, the temperature falls considerably, accompanied by a freshness of the air deligiitful to the senses, after the previous excessive and dry heat. The mon- soon is steady and veers to the south and south-east ; vegetation springs up with all the exuberance of a tropical climate, promoted, as is supposed, 1)y an electric current of increased activity between the atmosphere and the earth ; and the dust, so offensive at all other seasons, subsides and is washed away. In the rainy season, but especially on its subsidence, the rapid growth and rank health of the vegetation may, in neglected, ill-drained and impure locali- ties, be taken as a kind of measure of the sickness and mortality prevalent in them. We find that even in the temperate climate of England, and in a beautiful village in Hertfordshire, scores of its inhabitants have within a few years perished from fever, owing to the want of clearing, draining, and other most obvious measures of sanitary regulation. Let those who may be in charge of sta- tions and cantonments throughout India reflect on these simple facts, and on the evidences of the disastrous consequences of igno- rance and neglect of sanitary precautions, as exhibited in every page of this work. From the 15th July to 15th October, and as the rains advance, we live in an atmosphere having all the properties of a tainted vapour-bath ; and when the wind comes sifting through the Soon- derbuns at south-east, we experience many of the inconveniences ascribed by Ilennen to the sirocco of the Mediterranean, which, '' xolthout affedhig the titer mo meter or liarometer in ain/ remarkable derjree," yet inflicts on the delicately sensitive human frame a feel- ing of indescribable languor and oppression, with an exhausting perspiration, much like what we suffer from in Bengal during the latter portion of the rainy season, and which a West Indian lady, speaking of the sirocco, described as giving " the feel as if she hail lee II bathing in a boiler of si/rup ; while a Bishop of Calcutta said that in the rainy season he felt " lihe a boiled eabbage." This is the moist sirocco of Bengal. The mind, too, seems to partake in the general relaxation, being unfitted for vigorous or sustained effort ; in short, we here perceive the capipleniinu, la,i- giior, et expletio remarked by Petronius amongst the luxurious and dissolute Romans of his time. The muscular system, including the heart, is relaxed and weakened ; so that, and after a time, it becomes irritable and very defective in tone. These circum- stances, together with the influences of malaria on tlie nervous system, appear to me to occasion the intermitting pulse so com- mon to the old Indians. At this season, through the saturation of the atmosphere, the perspiration by evaporation is suppressed, but that by transudation 54 MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. is enormously increased, thus rendering the system susceptible of the least impression from cold or malarious exhalation, with a strong tendency to congestion in the abdominal vessels, while at the same time absorption is increased, and all the excretions diminished. The excessive watery discharge from the skin, during this season, must also, and of necessity, have the effect of rendering the venous blood unnaturally dense, and thus cause the European to be more liable to congestive forms of disease. Dr. J. B.Williams refers the disposition to liver complaints, dysentery, and cholera, to the stimulating properties of the blood, deprived, as we have seen, of more than usual of its water, and less of its hydro-carbon. Such is the rainy season, and such are some of the reasons for its proverbial unhealthiness in all tropical climates. If it be true that an individual in health ought to be in that state of perspira- tion in which it is insensible, what are we to think of the exhaust- ing drain flowing from the pores of an European during this and the preceding season, though differing in their modes of action? When, during the rainy season, the temperature ranges as high as, or higher than, that of the human body, and when, at the same time, the atmosphere is saturated with moisture, we find the accu- mulated animal heat carried off by becoming latent in the then extraordinary transudation which covers the whole surface of the body. Evaporation being noAV at its lowest point, we have here a beautiful illustration of the wonderful power of nature in establish- ing an immediate and effectual compensation, without which life would speedily be endangered. As in the sirocco, we here experience an extreme oppression of the nervous energy, and consequent muscular lassitude, with disinclination to active exertion of mind or body, the body seeming more bulky &nd Jeelh/fj heavier to the individual ; the hair looks dank and greasy, while the scalp is covered with furfuraceous eruption, and exudes an unpleasant acid odour. " The walls of houses, stone-floors, and pavements,'^ says Hcnnen, " invariably become moist when the sirocco blows. I have seen the stone- floors at Corfu absolutely wet without any rain having fallen, and gentlemen who made hygrometrical experiments state to me, that the instrument has frequently fallen from ten to twenty degrees during the prevalence of this wind — wine bottled in a sirocco is greatly injured, and often destroyed. Meat taints astonishingly soon during its prevalence. No prudent housekeeper ever salts meat at this time, for it either taints at once, not taking the salt, or else it keeps very badly. Drains emit more putrid smells in a sirocco than at any other period. No carpenter uses glue in the sirocco, for it does not adhere. No painter willingly works during its prevalence, for his paint will not dry. Bakers diminish the quantity of their leaven during the sirocco, as dough is found to ferment sufficiently without. It is a remarkable fact that wounds and ulcers, and t!ie discharge from mucous surfaces generally, MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. 55 deteriorate during the prevalence of the sirocco, and it is equally certain that if vaccination or smallpox inoculation be performed at this period, they are both extremely liable to fail ; and if they succeed, the progress of the pustule is often suspended, and it is frequently ten or twenty days in reaching the state usually at- tained in six or eight/' When we come to the influence on vege- table life the parallel ceases. Hennen says that, though " the sirocco is so charged with moisture, vegetables, especially that part of them exposed to it for any lengtli of time, appear quite shrivelled and burnt up, and very frequently they are destroyed altogether." The whole of these observations, in so far as they relate to the human frame, were annually verified in the surgical wards of the Native Hospital under my charge ; and we had the same discom- forts in perhaps a severer degree whenever a calm of any duration existed during the rains : in former times, ulcers used to assume a gangrenous condition, but vigorous measures of prevention en- tirely obviated these occurrences in latter times. I know nothing I should dread so much as a long calm at this season in Calcutta. It might not be followed by plague as in London, Nimeguen, and Vienna, in former times ; but in the re- sult, as affecting human life, I think we should not fare better than did those cities. Amongst Europeans the diseases of the rainy season assume a character of diminished vital action ; the ardent fever, with burn- ing skin and racking head, of the hot season, degenerating into the congestive form, with a moist cool skin, indicative of an extreme atony in the sudatory vessels, and an oppressed pulse ; the com- plications are generally abdominal. Dysenteries, as well as fevers, become more frequent, severe, and complicated, as the rainy season advances, the former implicating the whole of the abdominal organs ; but the most severe cases, especially amongst newly- arrived Europeans, are at the commencement and termination of the rains. During the former, or that called by the natives Chota-Bursat, which leaves some days of sunshine between the falls, fevers of a severe and complicated form arise, and during the drying process which terminates the season, they are even more so : occasionally these last are attended with a yellow suf- fusion of the skin ; but I have only once seen anything like black vomit. The greater liability of the human frame to fever, during natural sleep, may be referred to the diminished power of generating heat in the system during the time of repose — a time when the circvila- tion is comparatively languid, tending farther to diminish the power of generating heat, and consequently to increase the morbific power of both cold and malai'ia on the system. But may not this greater susceptibility to disease be also promoted by the known increase of putrefaction in dead animal and vegetable substances 56 MEDICAL CLIMATE AND THE INELUENCE OF SEASON. fliiring the night, resulting from the rapid abstraction of heat from the earth's surface by radiation, and the consequent production of moisture in the form of vapour, dew, or water — all productive within the tropics of vast increase of decomposition? That persons who have undergone fatigue, been exposed to great solar heats, and been subjected to its peculiarly debilitating influences, are greatly more liable to be affected by malaria, and by the cold or poisoned night air, is a fact often observed in various countries. The abortions of the rainy season appear to arise from simple congestion and relaxation, aided and promoted by diminished nervous power — the natural results of an excessive and exhausting humidity joined to a high temperature. Humid air, says Dr. Edwards, at an equal or even superior tem- perature, produces a peculiar sensation of cold which differs, not in its intensity, but in its nature. It is more profoundly felt, and seems to penetrate the whole system, and particularly disposes to paleness and shivering. By these characters I could not mistake a species of refrigeration, which consists in the diminution of the power of producing heat. In dry air, on the contrary, a sensation is experienced which is called a sharp cold, and which designates rather the nature than the degree of sensation ; moreover, it is superficial, and when the reduction of temperature is not too great, an increase of activity is experienced ; the skin reddens, and in extreme cases the limbs have a tendency to stiffen, instead of yielding to the irregular and involuntary motions, which constitute shivering. It may be seen by tliis comparison, and by what we have stated above, that damp cold must tend to produce in individuals whose power of developing heat is rather feeble, the series of actions which con- stitute the accession of an intermittent fever, especially if they are exposed to that action during sleep. The confirmation of this will be found in the study of medical topography. In the greater number of cases these fevers are ascribed to marsh miasmata in fine weather, but others occur in places and at seasons at Avhicli the atmospheric constitution which we have mentioned predomi- nates. ''As a general rule, the merits of a dry atmosphere are su- perior to those of a moist one. It is obvious that man was not intended to live in an atmosphere saturated with vapour, since, if so constituted, it would be unable to carry off" the aqueous exhala- tions for which it is palpably the intended medium. A perfectly dry atmosphere — whetlier cold and dry or hot and dry — would only be less objectionable. We have seen that it is prejudicial to vegetable life. It would be to the skin what a purgative is to the mucous membrane of the intestines, and in its stimulating action would subject it to an increasing and exhausting drain. Nor would this ' simply involve the drinking of a pint or more of extra fluid,' according to Dr. Forbes Watson, since the function of the skin being complex or manifold, it would not be stimulated to MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. 57 liypcraction in one direction and remain unaffeeted in the others. '' — Dr. jNIitchell's Ahjena. A familiar but emphatic illustration of the effects of our climate maj'^ be seen in its influence on the habitations of Calcutta. Con- structed of the finest known materials, whether of wood or mortar, and of such solidity that in England they would endure for cen- turies, and in Upper Egypt for a thousand years, they are here, through the destructive influence and severe alternations of climate alone, rendered in a score of years, or less, fit habitations only for crows j in much less time, indeed, they may be seen reduced to a heap of rubbish covered Avitli vegetation. " A deserted village is overflowed by the forest like the waves of the sea, in course of two wet seasons, and the traces of man are buried by the exuberant productions of nature" — all mark of human labour, industry, and art being obliterated in the East, by the influence of climate, in an incredibly short time. Of all the causes which thus render household and other pro- perty so surprisingly pei'ishable, heat, humidity, and the exuberant vegetation caused by them would seem the most influential. The peepul tree [Ficis In die us) is the gi'eat enemy of buildings in Bengal. " No wonder," says Colonel Sleeman, " that super- stition should have consecrated this tree, delicate and beautiful as it is, to the gods. The palace, the castle, the temple, and the tomb — all those works which man is most proud to raise, to spread, and to perpetuate his name — crumble to dust beneath her wither- ing grasp. She rises triumphant over them all in her lofty beauty, bearing high in air, amidst her lig-ht-green foliage, fragments of the wreck she has made, to show the nothingness of man's efforts.'^ THE COLD SEASON. I believe it was Charles the Eirst who described the best climate as that in which a man could bear exposure during the greatest number of hours at all seasons. On this view our climate of Cal- cutta is assuredly one of the worst, for even during the cold Aveather, from the end of October to the beginning of Eebruary, an European cannot be exposed for any length of time with impunity ; the hot sun and cold parching wind, with its evening and morning rawness, causing the most vmcorafortable feelings of external dry- ness and internal fulness, ludess it be in persons of youth and robust health, and under exercise sufficient to determine moisture to the surface. But, with all its disadvantages, this is the season during which the European soldier should be initiated into the climate of Bengal, and of India generally. This truth is now be- ginning to be understood by the authorities ; and let us hope that we may never again witness the arrival of recruits from England, as of old, in the month of May, the hottest of the year. It was a cruel and destructive custom. 58 MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. The unfavourable influence whicli the north-east monsoon ex- ercises on the general health of persons of a feeble constitution, or who are ailing, may in part be ascribed to its relatively low electric state, or its being in a negative state, thus attracting the positive electricity of the animal frame, as well as that of the soil. If the powerful physical agent of electricity is that which, through the system of organic nerves, influences the various secretions, how much must our climate, and consequently our health, be influenced by those causes, whether general or local, which affect the propor- tions of electricity in our atmosphere, always greater and more uni- form than in European climates. Coming down upon us directly from the frozen platform of Central Asia, the temperature of the monsoon is also relatively reduced so as to absorb much of our ter- restrial heat, while, at the same time, its hygrometric capacity is much increased, parching up the soil along with the animal and vegetable fibre. "The temperature of the blood is about 98°, at which it is sus- tained, with some slight variations, even when the body is immersed in an atmosphere of 29°, or of a still lower temperature. But the heat that is lost by the lungs and the skin is so great, that it is not supplied with sufficient rapidity in the very young and the old ; who, to use a common expression, do not ' stand the cold' so well as men in the prime of early manhood. The above numbers show that the power of cold on life varies according to definite laws ; thus the mortality by cold (35) is twice as great under the age of 20 as the mortality (18) at 20 — 40 ; but after that turning point the power of resisting cold decreases every year, and men of 90 and men of 30 have suffered from the cold that we have experienced in the proportion of 100 to 1 (or of 1749 to 17-5).'' — DwFarr, February 27th, 1855. People, on coming into Lower Bengal from the Upper Pro- vinces during the cold season, perceive an extraordinary change in the condition of the atmosphere on first approaching the Delta of the Ganges ; the bracing elastic cold of Upper India is ex- changed for that of a damp cellar, and thus they invariably de- scribe it. At the commencement of the cold season, in October, the tem- perature and the winds are variable, the drying process is in full activity, and the unhcalthiness is great. In General Sir Alexander Tulloch's " Statistical Report on the West Indies," it is stated that, though the months previous to the cold ones have the most sickness, yet " the principal mortality is during the cold dry weather which generally prevails at Christmas." In Aracan also, during the first Burmese war, it was found that, "in September and October, when the rain began to abate, the fever was equally prevalent, and still more fatal than in the preceding months ; and in IS ovember, when little or no rain fell, the disease appears to have been at its height." MEDICAL CLIMATK AND THE INFLUENCE OF SEASON. 59 From tlie 1st of November to the end of February the weather is settled, and agreeable to persons in health ; but to the delicate and sickly the altered balance of circulation and nervous function occasions much discomfort. The monsoon keeps steadily to north- east, the atmosphere during the day is dry, and a slight rise takes place in the barometer — the thermometer ranging from 45° to 75°; the nights are damp as well as cold during this season, the dewing process being excessively productive ; and tlie fogs which prevail occasionally are of a nature more dense than I have anywhere seen, except in Pegu. On the other hand, during the day, the cold north-east wind absorbs moisture with extraordinary rapidity from every object, animate and inanimate, over which it passes. Furniture, although made of the most seasoned wood, foreign or native, warps and cracks audibly ; plaster newly laid falls from the wall through rapidity of evaporation ; the old Indian becomes goose-skinned and shrivelled, with a sense of dryness in the palms of the hands, so uncomfortable as to give to some persons of irritable habit, and in whom the power of generating heat may be diminished by a long residence in India, a constant sense of nervous uneasiness of the whole sentient surface not to be described. '' I can bear the chill- ing blasts of Caledonia," says a Scotchman, quoted by Ward, " but this — this cold, I know not what to do with it;'^ indeed, it requires a degree of equilibrium of health not commonly enjoyed by persons of long residence in Bengal, to take kindly to the alterna- tion from copious and incessant discharge from the surface, to its total suppression, and consequent abdominal and cerebral engorge- ments. By the older British residents it has long been matter of obser- vation that the fall of heat a few degrees below the mean warmth is more productive of disease than the highest rise above the mean heat even of the hot season. Under direct exposure to such re- duction of temperature the morbid results become at once manifest. " The first night the regiment spent in Sindh," says Dr. Arnott, of the Bombay European Fusiliers, " was upon the open bunder ; most of the men and officers marched about the whole night to keep themselves warm, being without tents, bedding, or shelter of any kind. They felt the cold severely ; and six of the deaths that occurred during the following twelve mouths were traced to the exposure of that night. For some years afterwards it was spoken of in the regiment as having given rise to its subsequent bad health." It is only to the sound of constitution, in fact, who are tem- perate in all ways, and thereby able to bear the cold-bath, or to such as are recently arrived from Europe, that our cold season is either agreeable or healthy. But here I would observe, that the degrees of health and disease are not always to be measured by the thermometer, taken singly — such observations in connexion with 00 MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. health affording little information to the medical inquirer ; and it has been well observed in our own country, that the influence of the weather on the human frame is not to be thus estimated. An east wind, with the thermometer at 56°, will impress the body with a more chilling effect than a south-west wind, when that instrument indicates a temperature 1 U° lower ; and a foggy atmosphere, in like manner, much more injuriously than a clear one of equal cold. In the " Statistical Report on the West Indies,^^ already quoted, it is stated that in Jamaica the lowest mortality throughout a long range of observation was in the three months prior to June, 1827, when twelve deaths only were reported through the Avhole quar- terly returns. The next quarter, remittent fever broke out, and among a diminished force the deaths amounted to 252 in the same period, without the thermometer indicating any further increase of temperature than about 3°, and without any remarkable change in the weather. The diseases more peculiar to the cold season in Bengal are — congestive fever of the continued form ; intermittents, with the sequelae of tumid or indurated liver or spleen ; hepatic insidious sub-acute inflammation, terminating rapidly in abscess, if not promptly and vigorously treated ; dysentery, frequently compli- cated with hepatic congestion — all more or less acute, according to individual habit or length of residence in India. Catarrhs and bronchial affections are not so severe or so prevalent as the con- trasted nature of the season would lead us to suspect. Haemor- rhoids with many persons follow immediately on the drying up of the surface, and consequent fulness of the internal vessels. It re- sults also from the cold season that the blood is more venalized, a larger quantity of oxygen being consumed in the maintenance of the temperature of the body; and this condition of the blood, aided by congestion, would seem to dispose to apoplexy, the most fatal forms of which that have come under my observation in Bengal having occurred at this season ; and paralytic affections are not unfrequent amongst the aged and infirm. Chronic erup- tions, in an active state of development during the previous hot season and rains, now become suddenly repelled, accompanied by headache and vertigo. In old residents, the appetite fails, accompanied by an oppressive sense of abdominal fulness ; and when this state is not met by a suitable change of diet, clothing, and some medicine to act upon the skin and bowels, visceral congestion, cedema of the lower extremities, or some more active disease may ensue. New-born infants suffer materially from, and are sometimes destroyed by, the impression of our cold season on the unguarded and delicate surface. The abortions of the cold months have always appeared to me connected with acute venous congestion ; and the intermit- tiug states of the pulse and epigastric pulsations common to old Indians at this season are increased by this state of the great MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. 61 venous trunks. The kidneys act during the continuance of the cold weather with diabetic violence, the urine being limpid, and they only cease to do so on the return of a warmer season, and consequent equability of circulation, causing moisture of the sur- face. The biliary excretion, in excess during hot and rainy seasons, is here diminished, as indicated by the whitish or clay- coloured state of the alvine discharges, following the reverse order of what takes place in the instance of the kidneys. The function of the liver, indeed, is now depressed and depraved. The reader will not fail to observe that congestion has repeatedly been mentioned as participating in the most dangerous of our diseases. The blood is thrown inwards so as to be retained and accumulated in the abdominal organs, whose vascular structures have been variously affected, and whose functions have been most disturbed during the previous hot and rainy seasons. Congestions of those organs, by intropulsion, is now the consequence of the cold season. That the peculiar climate of Bengal has a principal share in producing this unfavourable state there can be no doubt; but, admitting this, we must consider also that tlie absence of all exhilarating exercise of mind and body, with their animating, varied, and healthful influences on all the functions, predisposes much, when aided by a too full and stimulating diet, to this end. Unhappily, too, the European resident in tropical climates has no sufficient remedy against the evils of this double inaction, except- ing the moderation in diet, which he will not adopt ; for, during the hot and rainy seasons, the amount of exercise necessary to health in temperate regions would here be impossible, and would be hurtful even if possible. Those who would preserve their healths, therefore, must be temperate,"'^ use such bodily exercise as each season will admit of, and relieve their minds from the monotony of routine official duty by the inexhaustible resources of European science and elegant accomplishment. It is only thus that health, happiness, and reputation can be ensured under the disadvantages of our position in India, where too commonly the whole time is given up to business. From the sketch now given of the locality and climate of Cal- cutta, it will be seen that, without taking the specific or malarious influences into account, we are there exposed to atmospheric changes to an extraordinary degree ; — to an extreme of heat and dryness — extremes of heat and moisture — cold and moisture — cold and dryness. The European exile may well join in the " complaint of the Black Knight" of Chaucer : " Nowe hote as fire, nowe colde aa ashes ded ; Nowe hote for colJe, now colde for hete again ; Nowe cold as yse, and now as coles red, For hete I breune." * It has been shown by experiment, that when alcohol has been introduced in large cjuanii ties into the circulation, " the arterial blood retains the venous colour." It is 62 MEDICAL CLIMATE AND THE INFLUENCE OE SEASON. That these various influences of extremely contrasted seasons alternately excite and depress the vital processes must be evident ; and it is to their long-continued application (even where distur- bance of function does not amount to actual disease)^ that \A^e must refer the attenuated condition and general feebleness of the old Indian, "Bengal has received a bad character for insalubrity/' says Malte-Brun, " and certainly it is in an eaiinent degree exposed to a succession of violent extremes and vicissitudes ; at one time to excessive rain, at another to hurricanes ; then to scorching heat, and frequently to thick fogs; yet the English have, by dint of prudent regimen, accommodated themselves to the climate." In the time referred to by Malte-Brun — the time when English youths went to India " to make a fortune or die of fever" — I fear there was not much of that "prudent regimen" to which he ascribes such happy results ; but let us hope that it is now about to be attained — that it may no longer be a reproach to us that, not satisfied with choosing the worst localities, we also adopt habits of life the worst calci;lated for the accommodation of our constitution to them and their climates ; — that it may no longer be said of the Englishman, as in the days of Clive — that he returned from the East with a ta^-ny complexion, a bad liver, and a worse heart. If Bichat could propound with justice the axiom that, in our native climate of Europe, life is but the assemblage of functions which resist death, what are we to think of the health-history of Europeans in the East Indies during the last hundred years ! I confess that to me the exhibitions of their bodily and mental energies, at all times, but as displayed in 1857-1858 especially, under highly unnatural influences of climate, exposure, mental anxieties, and exertions, have shown a wonderful power in the white man to resist death in the climate of the dark races : yet it is a power that ought not to be overtaxed, if we are to hold India with a firm hand becoming the superior race. The Government of British India has never bestowed any attention on the subject of the injurious influences of climate in that country, or on the means of preventing them. It is true, nevertheless, that the Anglo-Celtic race has there made some advance, by its own unaided action, towards moulding itself to the climate, without succumbing to the enslaving civilization of the East. As illustrative of the conservative influence of good habits of life, it is worthy of remark that, of the European officers on the Bengal establishment, there died, on an average of eight years, of the unmarried class, 8"77 per cent, annually ; while of the married class the mortality for the same term was but 2*74. Of the doubtless through the contamination of the blood chiefly, and through the resulting congestions, that the abuse of ardent spirits proves so baneful in hot climates espe- cially. MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. 63 European soldiery, again, there died annually, during the period here referred to, 7 "38 per cent. This wide difference in sickness and mortality is referable almost solely to the ditlerence of habits of life ; for, in the important circumstances of age and constitu- tion, the private soldier, on an average, has the advantage. On entering the service he may be taken generally to be of a stronger frame than the commissioned officer ; and he very rarely serves to so advanced a period of life as the latter. With the exceptions of coarser diet, a habitation inferior to the officer, and harder work on actual service, circumstances which do not generally tell much on the amount of sickness and mortality, the soldier has thus some real advantages over the officer — excepting in the all- important one of habits of life. Referring, lastly, to the influence of habits of life and of climate, in preventing thoracic diseases, I would quote Dr. Atkinson of Wakefield, and others, Avho infer, that by the use of alcoholic liquids, " a state of the blood is produced opposite to that which obtains in tuberculosis, and may thus prevent the development of it.^^ This view is supported by Dr. Atkinson in a numerical statement, showing a mortality from phthisis, amongst the adults of Wakefield, '' of rather less than one in three, and in publicans of one in twelve and a half." Publicans are here placed in con- trast Avith the general community as affording examples of hard- drinking persons ; but a moderate supply of alcoholic liquids, with a generous diet, is what Dr. Atkinson recommends as a prophy- lactic. This gentleman regards phthisis as " characterized by an excess of oxygen circulating in the system, and that when the blood becomes too highly carbonized from various diseases, tubercles are not deposited.'^ If further observation should confirm this \iew of tuberculosis and its causes, we may receive from it some assistance towards elucidating and determining the actual physiological operation of tropical climates in preventing the development of pulmonary con- sumption. It has been seen that, during the hot weather and rains especially, the blood is venalized, and malaria may perhaps be regarded as having a somewhat similar influence ; so that the antagonism alleged by the French military surgeons to exist in Algeria may, after all, have more of foundation than did at first appear. THE SOL-LUNAR IXFLUEXCES. 1. Many of the great medical authorities of antiquity were clearly of opinion that the celestial bodies exercised a marked influence upon the bodily and mental functions ; and Galen, adopting the Hippocratic notion, declared that the exacerbations of particular diseases were connected with the lunar periods. The critical days, or crises, as they were termed, were said to correspond with the 64 MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. interval between tlie moon's principal phases. There seems no reason to doubt, also, that sol-lunar influence is much more power- ful within the tropics than in other parts of the world. Dr. Forbes Winslow records an alleged case of moon-stroke, in the instance of an officer in India who had slept for several hours in the rays of a full moon. The results were headache and gastric irritation, followed by permanent impairment of memory. 2. The subject is one of medical as well as meteorological and philosophical interest, and cannot justly be passed over in an inquiry ixspectiug the causes of climate. The difficulty of explain- ing lunar influence appears to be the great obstacle Avhich, in modern times, has stood in the way of the belief in its existence and general prevalence ; yet twenty-three medical philosophers, British and foreign, are named by Dr. Forbes Winslow as autho- rities on the subject.'^ 3. But, notwithstanding the investigations of the authorities in- dicated, the subject has still to be investigated systematically by persons possessing that preliminary amount of mathematical, astronomical, and meteorological science indispensably necessary in order to arrive at satisfactory results, with leisure also beyond what is enjoyed by medical men in general. Although we would concede much to those eminent men who have patiently inves- tigated this interesting branch of philosophic inquiry ; still, it must be confessed that, in common with medical meteorology, it has not yet assumed that character of exactness and of demonstra- tion for which we may eventually hope. 4. The doctrine of periodicity, as exhibited in the phenomena of life, is not of modeim origin. The ancients, masters in the science of pure observation, have not overlooked the fact. The phenomena of menstruation were the subjects of particular observations in all ages, and the singular and well- mai'ked periodical character of this function was attributed to the operation of causes acting indepen- dently of those organic laws supposed to regulate the special functions of life. 5. The same character of periodicity was observed in a large class of febrile aflFections, particularly in the bilious remittents, in intermittents of warm latitudes, in the diseases termed neuroses, in all sj)asmodic and convulsive diseases, particularly in epilepsy and its allied aSections, in many forms of insanity, and in the diseases classed under the term exanthemata. 6. The author refeiTcd to in the foot-note considers that Dr. Laycock lias made observations of great value on the philosophy, physiology, and pathology of this subject ; not confining himself to the phenomena of periodicity as exhibited in disease, but with the hand of a master tracing the operation of the same law in the * Vide " Contributions to Medical Jurisprudence of Insanity," Lancet, 1855 — admirable Essays, which are here largely quoted. MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. 65 animal and vegetable, as well as in man in his normal and abnormal state. 7. Dr. Radcliffe is also justly praised as having, in a philosophic spirit, suggested to the physiologist and pathologist the important question — whether the phenomena of periodicity, natural and morbid, result from the operation of causes exterior to the body, or should be considered as the effect of certain laws of organic life yet undefined and unexplained by modern physiologists. 8. Dr. Radcliffe agrees with the ancients, and with Mead and many of the moderns, in seeking for the causes of periodicity in sol-lunar influence ; and he sees days, months, and years reflected in the lives of plants and animals ; but he also considers this evidence in a new point of view, and elicits a new conclusion. In his opinion, this evidence shows that sol-lunar influence is necessary to the life of animals as well as of plants, and most necessary in proportion as the vital principle loses that independency which is characteristic of the higher animal, and approximates to the de- pendency of the plant ; and because it shows this, he concludes that all the changes which are found to take place in the sol-lunar influence must be accompanied by corresponding changes in vital manifestations. In other words, there must be signs of periodicity, and these signs must be most marked where the vital principle is least independent — in the plant more than in the animal, in woman more than man. 9. For the same reason, he supposes there must be more marked signs of periodicity in cases where the vital energy is impaired by disease ; and it is in this impairment, and in this only, that he thinks the true explanation of these signs is to be sought for. Such is the lesson which Dr. Radcliffe deduces from the evidence. The question of lunar influence is not indeed specially gone into ; but the whole tenor of the argument is to show that the moon must exercise a great influence on the body. 10. There can be no doubt as to tbe obscurity of the evidences of periodicity, even where that obscurity is the least, as in epilepsy and the affections allied to it ; but there can be no doubt also as to the existence of these evidences. Thus, on looking at a number of cases, it is found that convulsion and spasm occur more frequently at night than in the day, more frequently about the time of new moon than full moon, and more frequently in the winter months than in the summer months. Of these evidences of diurnal, monthly, and annual periodicity the diurnal are the most frequent and the best established; but all are sufficiently frequent and obvious to any one who will take the trouble to seek after them for himself. There is, in fact, much in the recorded observations of Drs. Laycock and Radcliffe, as well as in the valuable treatises of Mead and of Balfour of Bengal, to strengthen the presiimption that the periodicity referred to arises directly or indirectly from sol-lunar infiuenge. F 66 MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. 11. Mead proceeds to demonstrate, as lie conceives^ on the founda- tions of the Newtonian philosophy, by how much more powerfully the moon influences the atmosphere than the sea, and that the tides of the air, from lunar attraction, are much greater than those of the ocean. After considering the effects of certain unnatural states of the atmosphere upon the barometer, and then the con- nexion between certain states of the barometer and special as well as epidemic diseases, he developes his views as to the mechanical influence of certain conditions of the atmosphere on the respiratory organs. " It will not,^' he says, " be difficult to show that these changes in our atniosphere at high water, new and full moon, the equinoxes, &c., must occasion some alterations in all animal bodies^ and that from the following considerations : — " a. All living creatures require air of a determined gravity, to perform respiration easily and with advantage, for it is by its weight chiefly that this fluid insinuates itself into the lungs. Now, the gravity, as we have proved, being lessened by these seasons, a smaller quantity than usual will insinuate itself; and this must be of smaller force to comminute the blood and forward its passage into the left ventricle of the heart ; whence a slower circulation ensues, and the secretion of the nervous fluid is diminished. '' h. This effect will be the more sure in that the elasticity of the atmosphere is likewise diminished. Air proper for respiration m.ust be, not only heavy, but also elastic to a certain degree ; for as this is by its weight forced into the cavity of the thorax in in- spiration, so the muscles of the thorax and abdomen press it into the most minute ramifications of the bronchia in expiration ; where the bending force being somewhat taken off, and springy bodies, when unbended, exerting their power every way in pro- portion to their pressures, the parts of the air push against the sides of the vesiculse and promote the passage of the blood. There- fore the same things which cause any alterations in the property of the air will more or less disturb the animal motions. We have a convincing instance of all this in those who go to the top of high mountains ; for the air is there so pure (as they call it) — that is, thin — and wants so much of its gravity and elasticity, that they cannot take in a sufficient quantity of it to inflate the lungs, and therefore breathe with great difficulty. " Lastly — All the fluids in animals have in them a mixture of elastic aura which, when set at liberty, shows its energy, and causes those intestine motions we observe in the blood and spirits, the excess of which is checked by the external ambient air, while these juices are retained in their proper vessels. Now, when the pressure of the atmosphere upon the surface of our bodies is dimi- nished, the inward air in the vessels must necessarily be enabled to exert its force in proportion to the lessening of the gravity and elasticity of the outward : hereupon the juices begin to ferment. I MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. C7 change the union and cohesion of their parts, and stretch the vessels to such a degree as sometimes to burst the smallest of them. This is very plain in living creatures put into the receiver ex- hausted by the air-pump, which always first pant for breath, and then swell, as the air is more and more drawn out ; their lungs at the same time contracting themselves, and falling so together as to be hardly discernible, especially in the lesser animals/^ 1 3. Making allowance, says Dr. Forbes Winslow, for the absolute terms used by jNIead, as well as for the state of physiological and pathological science of his epoch, the reader will be able to detect, in the language which he adopts to enunciate the theory of lunar influence, the germs of some great truths wdiich have subsequently been confirmed, in all quarters of the globe, by appeals to the great book of nature. ]Mead has undoubtedly laid himself open to the charge of attempting to prove too much ; but arc not all ardent and zealous cultivators of science exposed to the same im- putation ? 13. The well-known " Collection of Treatises on the Effects of Sol-Lunar Influence in Fevers,^' by the late Dr. Balfour of Bengal, is then reviewed by Dr. Winslow. Balfour devoted great attention to the consideration of this subtle and disputed point of science. The first part of his work is a regular logical synthesis, proceeding from facts observed and collected by himself to the dis- covery of certain prevailing tendencies of nature, and thence to axioms or general laws. The second part is an analysis, in which these axioms or laws are emploj^ed to explain some of the most re- markable phenomena of fevers. The third part is an application of the principles of this theory to form general rules for practice. With a view to the satisfactory elucidation of his priucij)les, Balfour placed himself in communication with all his brother officers of note of the three Presidencies of India, and obtained from them the results of their observations on the subject. 14. Balfour maintains that every type of fever prevalent through- out India is, in a remarkable manner, afiiected by the revolutions of the moon. Whatever may be the form of fever, he says that he has invariably observed that its first attack is on one of those days which immediately precede or fall on the full of the moon, or which precede or fall on the change of the moon, so that the connexion which prevailed between the attack of the disease and the moon at or during the time referred to was most remarkable : relapses, in cases of fever, are also said frequently to occur at such times. 15. Balfour had observed in Bengal, during fourteen years, this tendency to relapse at the full and change ; and in particular cases he was able to prognosticate the return of the fever at these periods with almost as much confidence as he could foretel the revolution itself. The putrid, nervous, and rheumatic fevers of India, as he termed them, Avere equally under the influence of the moon. 16. In attempting to explain these phenomena, he says that, along r 2 68 MEDICAL CLIMATE A]SD THE INFLUENCE OE SEASON. with the full and change of the moon, there is constantly recurring some uncommon or adventitious state or quality of the air which increases fever and disposes to an unfavourable termination or crisis; and that along with the intervals there is constantly recurring a state or quality of the air opposite to the former, which does not excite but diminishes fever, and disposes to a favourable crisis. 17. Tn the early part of Balfour's service in the East (1783-4), he had charge of a regiment of sepoys in Cooch Behar. The pre- valent diseases were fevers, or " fluxes attended with fevers." In the first month some four hundred men fell ill, the greater part of whom became convalescent in course of the eight days that intervened between the full and change of the moon ; but diiring the remaining months of his stay in the district, the diseases just mentioned increased to almost double their extent at every full and change of the moon, falling down again to their former standard during the eight days which intervened between these two periods. 18. With regard to smallpox prevalent in India, Balfour satisfied himself that the full and change of the moon interfered with the eruption, and increased the accompanying fever to a dangerous degree. 19. Balfour collected a vast body of valuable evidence in support of his lunar theory, establishing, says Dr. Forbes Winslow, beyond all dispute that in tropical climates the regular diurnal and sep- tenary changes observed in the character of the fevers of India, are coincident and correspondent with periodical sol-lunar con- ditions. Mason Good thinks there can be no question that, '' tinder certain circumstances, and especially in tropical climates, many diseases are influenced by lunation, as we are sure they are, in all climates, by insolation.'^ Dr. Balfour, he adds, is of opinion " that the influence of the sun and moon, when in a state of con- junction, which is named sol-lunar influence, produces paroxysms or exacerbations in continued fever, in all cases in which a paroxysmal diathesis (for such is his expression) exists ; and as this influence declines, in consequence of the gradual separation of these luminaries from each other, and their getting into a state of opposition, a way is left open to the system for a critical and beneficial change, which is sure to take place, provided the critical disposition is at the same time matured. In other words, par- oxysms and exacerbations in fever may be expected to take place, and do in fact take place, at spring-tides, and crises at neap-tides." 20. Balfour, in his Treatise I., offers the following propositions : — " (1.) That in Bengal fevers of every denomination are in a remarkable manner connected with, and afi'ected by, the revolutions of the moon. " (2.) That in Bengal a constant and particular attention to the revolutions of the moon is of the greatest importance in the cure and prevention of fevers. MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. 69 " (3.) That the influence of the moon in fevers prevails in a similar manner in every inhabited part of the globe, and con- sequently, that a similar attention to it is a matter of general im- portance in the practice of medicine. " (4.) That the whole doctrine of the crisis of fevers may be readily explained from the premises established respecting the influence of the moon in these disorders at the full and change." 21. In his Treatise II. he presents the following axioms : — ■ " (1 .) That the force of sol-lunar influence is much greater during the meridional periods than their respective intermeridional inter- vals, and seems to be somewhat greater during the nocturnal than their respective diurno-meridional periods ; and somewhat greater during the evening than the morning intermeridional intervals. " (2.) The force of sol-lunar influence is much greater during the lunar periods, than their respective interlunar intervals ; and during the no\ilunar and plenilunar periods it is very nearly the same ; and also during their respective interlunar intervals, at the beginning and end of which it seems greater than in the middle. " (8.) The force of sol-lunar influence is considerably greater during the equinoctial periods than their respective inter-equinoctial intervals ; aud somewhat greater during the autumno-equinoctial than the verno-equinoctial periods." 22. The fevers of most unhealthy or malarious countries, as of Gondwana, Aracan, Sindh, Guzerat, and of certain districts in Persia, would appear to present the most marked relations to the lunar changes : — in other words, where the terrestrial causes of fever are most concentrated, there the influences of the moon's changes would appear to be most clearly manifested. At the meeting of the British Association for the Advancement of Science, held in Dublin, 1857, Mr. J. P. Harrison announced a law of temperature depending upon lunar influence : — " The author commenced by saying that, although the question of lunar influence on the atmosphere of our planet was very generally considered as set at rest by the investigations of M. Arago, yet he felt very con- fident that he was in a position to prove the law he was now about to announce without fear of contradiction. He had reduced and thrown into the form of tables and of curves 280 lunations, with the corresponding mean temperatures ; and the laws at which he had arrived were, first, between the first and second octant the temperature immediately after the first quarter, both on the average and also, with rare exceptions, in each individual lunation, is higher than the temperature shortly before the first quarter ; secondly, and more particularly the mean temperature of the annual means of the second day after the first quarter (or the tenth day of the moon's age) is always higher than that of the third day before the first quarter (or the fifth day of the lunation) . The tables and curves accompanied the essay, which illustrated these laws at great length." 70 MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. " An undoubted heat effect" was observed in the elevated points of Teneriffe by Professor Piazza Smyth^ although the moon was at the time of observation "in a low declination^ so as to have a meridional altitude of only 42." Balfour regards the influence of the moon^ in malarious fevers, as more clearly manifested between the 13tli and 26th degrees of north latitude. He also regards the vernal and autumnal periods, or those between 20th March and 21st June, and between 23rd September and 22nd December, as those in which periodical fevers are most severe ; while those diseases were, in his experience, less freqiient and less severe in what he termed the equinoctial intervals. The question of the intensity of malarious fevers has been carefully investigated by Mr. Francis Day, of the Madras army, in the records of 423 cases, among the native troops of that Presidency serving in ]\Iysore and in the Deccan. The result proved " that the most severe cases did occur at the two equinoctial periods." This talented officer sums up the results of Dr. Balfour's obser- vations as follows : — " (1.) That the influence of the moon is less apparent in Madras than in Bengal, but may be traced over every portion of our Eastern possessions. '' (2.) That the lunar influence is thus exerted : — the first attack of fever almost invariably commences on one of those days pre- ceding the full or new moon, or on one of those three which im- mediately follow them ; but that the three last are the most violent in their effects. ^' (3.) That the new moon is more injurious than the full. " (4.) That during these times the most severe as well as the greatest number of cases take place, but that when they occur at other periods they are less severe and of shorter duration. *' (5.) That these laws are as applicable to relapses as they are to primary attacks ; so much so, that the author Avas often able ' to prognosticate the return of the fever at these periods, with almost as much certainty as he could foretel the revolution itself.' " Mr. Day sums up the results of carefully prepared statistical observations as follows : — " (1 .) That no decided preponderance in the admissions for mala- rious fever is observed at the time of the new moon. " (2.) That a decided preponderance is observed at the time of the full moon. " (3.) That more admissions occur in the three days preceding the full moon than in the three days subsequent to those changes. " (4.) That a slight increase in the admissions may be present about the first and third lunar quarters. *' (5.) That the cases admitted at the time of the new moon are generally slightly more severe than the average admissions. MEDICAL CLIMATE AND THE INFLUENCE OF SEASON, 71 *' (6.) That the cases admitted at the time of full moon are much more severe than the average admissions. '' (7.) That at times increased severity is also apparent at the first and third lunar quarters. " (8.) That the cases admitted during the three days preceding these changes are more severe than those admitted in the three subsequent ones.^^ From the entire series of cases, Mr. Day arrives at the pro- bability that " there is a sol-lnnar 'nifiience, which is greater in the equinoctial period than in the respective equinoctial intervals ; and considerably more so in the autumn than in the vernal equinoctial period ; that this force is greater at the full and new moon than at the intervals, and much more so at the full than at the new ; that it is greater during the meridional period than at the intermeridional intervals, and much more so at the diurno- meridional than at the nocturno-meridional periods.^' THE ELECTRICAL CONDITION OF THE ATMOSPHERE. If we attentively regard the agencies operating in health, and the disturbances of them which produce disease, we shall, with Dr. Habershon, recognise the fact that in the exercise of its functions the human body presents the manifest action of the same physical forces within itself which are in operation without the body ; that the chemical forces obey the same laws in the living body as in the laboratory ; that gravitation and attraction, the forces of heat, and electrical or galvanic force also, are in constant exercise, and with them is probably associated another correlated in some manner, which has been called nervous. All these are in constant operation in life, and the disturbance of them may be the cause of disease. Some of the ablest of our physiologists, past and present, have come to the conclusion that "some, if not all, the organic actions which take place in the living body are accompanied with the manifestation of electric action. '"""^ " Starting,'^ says Dr. Carpenter, " with the abstract notion of force, as emanating at once from the Divine Will, we might say that this force, operating through inorganic matter, manifests itself in electricity, magnetism, light, heat, chemical affinity, and mechanical motion ; but that, when directed through organized structures, it affects the operations of growth, development, chemico- vital transformations, and the like ; and is further metamorphosed, through the instrumentality of the structures thus generated, into nervous agency and muscular power.'^ Dr. Laycock says that " without light and heat plants do not grow ; without heat chemical affinity ceases, and animals perish. * F. Baxter, on " Organic Polarity." 72 MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. This correlation of physical and vital forces is, in fact, a necessary deduction from the correlations of the physical forces with each other. Hence the forces set free duinng the changes in the blood and tissues upon which the fundamental phenomena of life depend, are convertible not only into motion, but also into heat, electricity, magnetism, and chemical affinity.'^ I here quote from the interesting communications of Dr. Mad- dock on " The Influence of Air and Weather upon the Mind and Body :"-- " Electricity," he says, " like caloric and light, pervades every element around us, varying in quantity according to the condition of the atmosphere ; and although its existence is not perceptible any more than theirs, till the equilibrium of its distribution is destroyed, it has, probably, even in its latent state, a very con- siderable influence on the actions of organized beings. Positive and negative electricity may be said to stand in the same rela- tions to each other as heat and cold — as light and darkness ; that is to say, it is the former alone which has any existence, and in no degree of negative electricity are plants and animals quite with- drawn from the influence of this principle. It is, however, only in its sensible state that this agent can be recognised ; and in this condition there are few or none, except caloric, which can com- pare with it in its universality of action, since every irritable organ appears to be subject to its agency. " Very formidable difficulties attend all explanations of electrical phenomena, for to the question — What is electricity? — no cate- gorical answer can yet be returned. The question, however, may be set aside, as not demanding to be answered before the effects of cer- tain electrical states of the atmosphere are considered. Of the real nature of light and heat, as well as of magnetism, we are, in truth, quite ignorant ; but we do not hesitate to discuss the varied changes which matter undergoes when illuminated, heated, or magnetized, without waiting till our theories relating thereto are perfected; and in like manner can we do the same in regard to electricity, provided we adopt some provisional theory as to its nature, which shall supply us with appropriate terms for describing the pheno- mena, although it may be quite inadequate to account for them. Experience is in most cases our sole, if not suflficient, instriictress, and the constant conjunction of phenomena, as exhibited in her lessons, is the sole ground for affirming the necessary connexion between them. If we go beyond this, and come to inquire the manner hoio, and attempt to discover the mechanism by which these things are effected, we shall find everything around us equally mysterious, equally incomprehensible, — from the stone which falls to the ground to the comet traversing the heavens — from the formation of a mite in cheese, or a maggot in piitrid flesh, to the production of a Newton or a Franklin. ' If," as a modern writer remarks, 'we perceive an useful end, and means MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. 73 adopted to tliat end, we perceive enough for our conclusion. If tliese things be clear, no matter what is obscure, the argument is finished.' This is the language of a man of sound sense and sober uuderstaudiug ; but, unfortunately, there are many persons who found their pretensions to wisdom on their readiness to scout everything that cannot be proved by mathematical demonstration, not considering that the nature of the subject may preclude the possibility of attaining to any stronger evidence than reason and analogy can supply. " The relative intensity of terrestrial electricity of various parts of the earth is a point worthy of the highest consideration, for it doubtless exercises a most marked effect on physical, chemical, and vital phenomena. Although our knowledge of this subject is too confined to admit of any practical application of it in the choice of a climate, it has been iucontestably proved that in dry and cold states of the atmosphere an accumulation of positive electri- city takes place, which brings about an increased activity in all the functions, and that thereljy the nervous and circulating systems acquire an increased energy and tone, the respiration is more complete, and animal heat is more quickly generated to replace that which has been caiuned off" by the surface of the body ; on the contrary, we find intense and humid atmospheres are extremely oppressive, the lungs do not play freely, and the whole system is prostrated by lassitude and languor. It is to relieve this state of the air that the lightning plays, the thunder rolls, when nature at length recovers from her swoon, and again appears relieved, cheer- ful, and gay. A proper play, therefore, of the electric affinities is evidently and intimateh^ connected with a salubrious atmosphere, and, in truth, when it glides freely along the nervous cord its dis- course is health ; but when the atmospherical electricity is im- peded, or imperfect, the equipoise of humidity is prevented, and the elements of disease are disseminated. " Mr. Mather, an intelligent meteorologist, has endeavoui'cd to show, from his own observations as Avell as from the experiments of other scientific men, that the presence of cholera is invariably attended by marked electrical derangements in the atmosphere, and that when electricity is negative, vitality is depressed, and when positive, excited. In corroboration of these views, Mr. Mather states that when the cholera was so prevalent at Paris, in is [9, the deaths rapidly increased till the Stli of June, on which day they numbered Q-Z'6. On that evening a great thunderstorm shook the city nearly to its foundation. Next day the cholera began to decrease ; in ten days there were little more than 100 deaths in a day, and in twenty days no more than 30. ' In the same year,' says Mr. Mather, 'when cholera of a very fatal character was in this district [South Shields] , I made daily ob- servations, sometimes twice a day, with a magnet which, in its normal condition," carried about 2 lbs. 10 oz., varying with the 74 MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. virulence of the disease. My hygrometer indicated at the same time an atmosphere nearly saturated with moisture.' Mr. Mather adds, that ' in the north, in the year 1853, when the cholera was so very prevalent, the old choleraic atmosphere became as marked as it was in 1832 and 1819.' That a thunderstorm must necessarily exercise a considerable influence on the animal economy may be readily imagined, when it is remembered that not only does it tend to promote a more equable diffusion of heat and moisture, and introduce nitrous acid gas to check the evolution of noxious miasmata by effecting their decomposition ; but, froin some experiments made by Siguor Libri, of Florence, on odoriferous bodies by currents of electricity, it may be inferred that the direct and immediate agency of the storm may be the destruction of subtle emanations. The electricity of the atmosphere may be also materially affected, since ammoniacal gas may be expanded into double its former volume by a current of electric sparks passed through it. But I cannot say that Mr. Mather's experi- ments (although deserving serious attention) accord with the results of my own inquiry, which incline me to the belief that the density and temperature of the air operate on choleraic poison only as they affect its power as a carrier, or a sort of interven- tional medium, and there is no actual connexion between cholera and negative electricity. It may be remarked, en passant, that it is a curious fact that in London, diarrhoea and summer cholera sprung, in 1816, into much greater than their former activity, and have con- tinued to produce a much greater mortality ; whence it seems not unreasonable to infer, as Dr. Farr remarks, that there has existed, during the whole of the last nine years, an increased tendency to the disease, which rose into paroxysms in 1819 and 1851. An inquiry into this point might be usefully extended to other places. " The singular circumstance of high mountains in the Northern hemisphere producing reverse effects ixpon the travellers ascending them, to those in the Southern, have been attributed to tlie fact of electricity occupying the upper parts of bodies in the former, and the lower part thereof in the latter. Dr. Cunningham, R.N., who was, I believe, the first to direct attention to this interesting subject, states, that at high elevations in the Northern hemisphere (such as the top of Mont Blanc) there is a sti'ong determination of blood to the head, indicated by swelling and lividity of the face and lips, sleepiness, and bleedings from the mouth, nose, eyes, and ears ; while at similar elevations in the Southern hemisphere there is an equally strong determination of blood in the contrary direc- tion, indicated by paleness and shrinking of the features, sleepless- ness, giddiness, faintness, and vomiting ; apoplectic symptoms thus characterizing the first, and all the usual accompaniments of faint- ing the second. The treatment affording relief in each is also diametrically opposite (with the exception of the horizontal pos- MEDICAL CLIMATE AND THE INFLUENCE OF SEASON.' 75 ture, wliich is useful iu both), the stimulant drinks and the stimu- lant applications to the external parts, such as the mouth, nose, and ears, so beneficial in the southern affection, being hurtful in the northern. The apoplectic symptoms experienced upon Mont Blanc, and other high northern mountains, has'c been hitherto ascribed to the great rarefication of the air, whereby the soft parts of the human body are permitted to be expanded by the reduction of the atmospheric pressure upon them ; hut as no such effects, but, on the contrary, effects of an opposite nature, are produced by similar elevations in the Andes of South America, we must consequently look to some other cause than atmospheric rarefication to account for them. Dr. Cunningham refers these peculiarities of the respective hemispheres to the circumstance of the electric polarities of bodies being the reverse in the southern to what they are in the northern ; a very curious fact, for the observation of which we are indebted to Lieutenant Leeount, R.N., when em- ployed at the Island of Ascension, during tlie period of Bonaparte's detention at St. Helena. Thus electricity being found to occupy the upper portions of bodies in the northern hemisphere, and the lower portions in the soutliern, will consequently tend to propel the blood towards the head in the first, and towards the feet in the secoud; thereby giving rise to an apoplectic tendency in the one, aud a tendency to fainting in the other ; the symptoms in both being necessarily mitigated by the horizontal posture, whereby the electricity is more equally distributed throughout the body, in consequence of its occupying the latter longitudinally instead of transversely. A remai"kable circumstance relating to this subject was noticed by Dr. Cunningham — viz., that travellers in the Andes seldom experience any unpleasant feeling as long as they remain on horseback, when they are in a great measure insulated from the electric influence of the earth, by the non-conducting sheep- skin paddings placed under the saddles in Peru." Sir Henry Holland states that, " though unable to affirm any one disease to be actually produced by electricity, yet, considering the subject in its whole extent, it is impossible not to see the likeli- hood of its influence on the body in many Avays hitherto undis- tinguished, or not understood. If a stroke of lightning can in an instant destroy muscular irritability throughout the system, and prevent the natural coagulation of the blood, either directly or indirectly, by hastening putrefaction, it is clearly to be inferred that lesser degrees of the same action must have definite effects, bearing proportion to the intensity of the electric changes or trans- ference taking place. The conclusions best warranted by the facts we possess would direct us towards the blood and nervous system generally as the parts of the animal economy most liable to be thus affected. The influence of atmospheric electricity on the latter is shown in the various eff'ects already mentioned on sensa- 76 MEDICAL CLIMATE AND THE INFLUENCE OF SEASON, tions and muscular power ; and the proof is greatly strengthened, though indirectly, by the numerous experiments which prove the influence upon these two functions of electric action from dif- ferent sources applied directly to the nerves themselves. ''The quantity or tension of the agent, as affecting the body through the air, may be less, and its application not so direct on the nervous system. The low average intensity of animal elec- tricity, as ascertained experimentally, must also be taken into account. But, with all these allowances, it is impossible that the effect should be wholly absent or different in kind ; and circum- stances may often greatly augment its degree, disordering in the same ratio that balance which is most conducive to the general well-being of life. The same reasoning applies equally to its in- fluence on the blood ; and though this part of the subject is even more obscure, yet is there presumption that here the effects occur which are of greatest importance in the history of disease. All that chemistry has recently done to determine the nature and re- lation of parts in the blood (concurrently with that great fact which has now been established of the identity of electrical and chemical action) justifies the belief that every material change of the balance between the electricity without and that within the body must have effect on the state of the circulating fluid ; transient and wholly inappreciable it may be in the great majority of cases; in others, possibly, of longer duration and more extensive in degree.'' It is, moreover, the opinion of Sir Henry Holland, quoted by Dr. Pallas, that " electricity may be concerned in favouring the generation of malaria, whatever its nature, or it may induce a state of the body more liable to be affected by tliis^ or by other causes of disease in activity at the time. We have no proofs on which even to approach towards assurance, but presumption from several sources that this great agent cannot be Avholly inert as respects either of the conditions in question. '^ " It has been stated," says Dr. Pickford, " on the authority of Mr. Glaisher and of Mr. Hingeston, that epidemic or pestilential diseases are associated with an absence or deficiency, and their presence with an increase in the amount of positive electricity. The latter gentleman believes it ' all but incontestable that what is called negative electricity goes with diseases called asthenic, while the positive belongs to such as are sthenic or inflammatory ;' and that ' the former is coincident with mild and moist weather — the latter with the cold and frosty, or the hot and dry.' The kind of electricity, again, is certainly connected with the amount of daylight. There is less light on those days on which the negative electricity prevails than on the bright, when the electricity is, with few exceptions, positive. The public health is seldom favourable when the sky is grey, the air moist, the temperature low, the daylight diminished, and the electricity negative. On the contrary, it is good when the season is open, the clouds distri- MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. 77 buted in masses, the moisture condensed in sliowers, the electricity positive, and the solar rays abundant/' In an elaborate work, the result of years of careful observation, '' On the Influence of Variations of Electric Tension, as the remote Cause of Epidemic and other Diseases,'^ by Mr. C'raig of Ayr, the author has endeavoured to establish the following propositions : — " \. That nervous power can be substituted by electricity, to produce not merely muscular action, but also the more vital in- ternal operations. " 2. That the nervous system necessarily depends on the ingesta for the material of which it is composed. " 3. That it is shown whence are produced the supply and the source of the power by which nervous action is produced. " 4. That diseased action is produced by an abstraction of nervous power, and consequent derangement of the corporeal operations. " 5. That cholera prevails in all countries, but is most frequent and virulent in countries within the torrid zone. That it arises from a low state of electric tension, produced either by speedy evaporation, or those occult influences which are the results, sometimes of volcanic actions, sometimes of deviations of ter- restrial currents. That this low state of electric tension causes abstraction of nervous power, and produces enervation of the capillary system, and inverted action of the bowels. '^6. That yellow fever is peculiar to those countries which have a high temperature — where there are successively great drought, heavy rains, and speedy evaporation, producing a low electric tension. That the negative state of the soil thus produced abstracts from the human being nervous power both speedily and copiously, and deprives the secreting, excreting, and other vital organs of that which is indispensable to their healthy and efficient action. That this is followed by vitiation of the blood, clogging up and bursting of the capillaries, and breaking up of some of the internal organs. " 7. That plague has its origin from the same instrumentality, operating, however, less powerfully. That the heat is less intense, and the evaporation less copious, in the localities which are visited by this pestilence. That in those countries in which this disease is endemic the variations of electric tension are neither so sudden nor so great as in those countries where yellow fever prevails. That in plague, the slower but more continuous evaporation causes a more slow and gradual abstraction of nervous power from the animal body. That, as in yellow fever, so in plague, the blood becomes vitiated, but less hurriedly, and its altered consistence renders its progress through the capillaries difficult, causing their rupture where weakest, giving rise to internal lesions and external ulcerations. 78 MEDICAL CLIMATE AND THE INFLUENCE OF SEASON- " 8. That intermittent fever is pi'oduced by a still smaller amount of nervous abstraction. That it has the same origin as the previously mentioned disease. That the localities in which this disease is endemic are marshes^ or in circumstances analogous, and maintain a slower and more persisting evaporation, and a propor- tionally slow abstraction of nervous power. ''9. That the views here taken of the pathology of pestilential diseases satisfactorily account for the difficulty of treating them, especially when they are once established. " 10. That the treatment, to be successful, ought to be com- menced at the time of the earliest manifestation. ^'11. That those living in pestilential regions should have their habitations dry and well elevated, and their beds insulated by good non-conductors, and should be as little out of doors as pos- sible during the absence of sunshine, unless the soil be thoroughly dry. " 12. That fever on board ship is caused by continuous evapora- tion, and consequent low state of electric tension. That on this account ships ought to be kept as dry as possible, and with no water in the hold, especially in hot climates. That care ought to be exercised not to take a moist cargo on board. That in an un- healthy locality the seamen ought never to be on shore at night. " 13. That a high situation is favourable, and a low one un- favourable to health, arises from the more elevated one being drier, and having less provision for evaporation. "14. That authors have long considered that electricity had some connexion with the production of disease, but never have given definite ideas of its modus operandi. "15. That in proportion to the amount of ozone found in the air, so is the locality in an electro-positive condition." THE INFLUENCE OF ATMOSPHERIC PRESSURE. The average pressure of the atmosphere is represented by Dr. Maddock* and others to be the same, or very nearly so, at any one place from year to year, notwithstanding the various temporary alterations arising from meteorological causes ; but it is not yet accurately determined in a sufficient number of places to settle the question whether it is the same either at heights or at the level of the sea, throughout the globe or not. It is obvious indeed that it must always be difficult to determine whether there is an observed difference in the mean height of the barometer at two places from difference of level, or from the atmosphere itself. If the temperature of the higher and lower stations were uniform in all localities and in all times, and if the force of gravity were * Yide a series of interesting articles on the Influence of Air and Weather, " Me- dical Circular," from which this and the previous section are principally prepared. MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. 79 precisely the same at all heights, one formula would serve for all times and for difterent plaees, if the heights of the barometer re- mained invariably the same at the same height above the sea. In such a case, one observation made in London a hundred years ago, combined with one made at Quito in the present time, would serve to settle the point ; and, even as it is, the mean height of the barometer at the two places, when known, Avould be sufficient for the purpose. But, when only one or two observations can be made at each place, the difterence of temperature and other influ- ences must be noted and allowed for ; and this necessity renders the numerical operations connected with the solution of the pro- blem more intricate than they otherwise would be. " The fluctuations of atmospheric pressure, as shown by the rise and fall of the barometric column, are extremely complicated, though very minute. In winter it is found that the column attains a maximum height at nine in the morning ; it falls from this hour until three in the afternoon ; it then begins to rise, and attains another maximum at nine in the evening. In summer, the hour of the first maximum is eight in the morning, and that of the minimum four in the afternoon ; that of the second maximum being eleven at night. In spring and autumn this maximum and minimum take place at intermediate hours. The hours are not exactly the same for all countries, and the extent of variation is also difi'erent in different places; but the rise and fall in the twenty -four hours is a universal occurrence, Between the tropics these variations are very slight, not extending to much above a quarter of an inch ; but beyond the tropics they are very great, and the barometer has a range of three inches. It is presumed that the abundant aqueous precipitations which take place on each side of the ti'opics are the cause of these extensive fluctuations. " A great connexion has been remarked between the pressure of the air, or the height of the barometer, and the direction of the wind. The barometer generally falls during east, south-east, and south winds ; passes from falling to rising during south-west ; rises with west, north- west, and north winds ; and has its greatest rise with north-east winds. It is also a general law, between the amount of vapour and the height of the barometer, that they change in opposite directions. In summer, when the quantity of vapour is greatest, the pressure of the air is least ; and in the winter time, the vapour being least, the weight of the air is greatest. Even in the daily fluctuations of these two quantities this opposition is perceivable. The mean pressure of the atmo- sphere at London, as deduced from twenty years' observation by Luke Howard, is 29'8655, or very nearly 29/^ inches.'' Huxham, referring to the eff'ects of the barometric variations on the phenomena of epidemics, and more especially of inter- mittent fevers, expresses his belief that these last are influenced by the varying pressure of the atmosphere upon the veins. The 80 MEDICAL CLIMATE AND THE INFLUENCE OE SEASON. inquiry is replete with interest, and Dr. Maddock entertains no doubt that facts favour the supposition of Huxham^ whose views are recognised, among others, by Sir David Barry, in the following terms : — '' It being now evident that the blood in the veins is placed under the influence of atmospheric pressure, it would be curious to trace the connexion which appears to exist between disease generally — intermittent fever for example — and the daily atmospheric variations/' All persons are sensible of the effects of atmospheric pressure, and more especially invalids, who are generally susceptible to very slight changes in this respect — as, for instance, the hurried respi- ration, quickened circulation, and tendency to bloody expectoration which attend the ascent of high mountains ; the oppression felt in the diving bell ; the diarrhcea incident to those who remove from low to very high situations— these are all familiar examples of the more extreme eflfects of increased and diminished atmosphere.'^ So great indeed is the influence of atmospheric pressure, that if we could dig a shaft down into the earth to a depth of forty-two miles, the air at the bottom of it would be as dense as quicksilver. On the other hand, if we could ascend to the height of 4000 miles, and there let loose a cubic inch of air, it would become so excessively rare, and so widely diffused, as to fill a space equal to Saturn's orbit : this will give us an idea of the lightness and diflfusibility of the air. We cannot be surprised at the great effects produced by atmo- spheric pressure tipon the health, when it is remembered that our bodies bear a weight equal to the cylinder of the air, the base of which corresponds with the superficies of our bodies : every square inch of the superficies sustains a quantity of air equal to 15 lbs. ; so that, if the superficies of a man's body were to contain 2000 square inches, which is very near the truth, he would support, at the level of the sea, a weight of 15 x 2000 or 30,000 lbs., or nearly fourteen tons ! Hence, so far from it being a matter of astonish- ment that we sometimes siiffer in our health by a change in the weather, it is the greatest miracle we do not always do so. When we consider, too, that the variations in density are so considerable that the mercury in the barometer may indicate a pressure of nearly a ton and a half more weight at one time than another, and that these diff'erences are often very sudden, it may seem wonderful that the vessels of our bodies, being so much acted on by an increased pressure, do not stagnate the blood up to the very heart, and altogether stop the circvilation.f Such indeed would be the inevitable consequence, did not the pressure of the atmosphere act eqiiaUy in all directions — not downwards only, or on the upper * The fall of one- tenth is equal to a diminution of 62 lbs. pressure on the surface of a man's body. -|- At Nice, as in tropical climates, the atmospheric pressure varies only slightly during the year, the variation being but one inch and a half. MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. 81 surface of the body, as might at first be imagined, but on every part of the body in contact Avith the air, as explained by Lardner. The fluids which fill the entire vascular system are exposed, as well as the surface of the body, to the pressure of the atmosphere, which enters the lungs and all the cavities and open parts of other organs. These fluids transmit that pressure to all the minor parts of the body, so that the skin and integuments are pressed by them outwards by a force exactly equal to that with which the air presses the external surface of the skin inwards. These outward and in- ward pressures are necessarily always equal, because, in fact, they are one and the same pressure — i. e. that of the air — the pressure on the external surface acting inwards being the immediate action of the air, and the pressure of the internal fluids acting outwards being the same pressure of the air transmitted by those fluids to the inside of the skin and integuments. Dr. ]\Iaddock {ojjhs citat.) considers that a knowledge of the existing barometric condition of the atmosphere cannot fail to prove of service to the practitioner when treating the different dis- orders of his patients, inasmuch as it produces peculiarities of constitution which, under disease, demand remedies, if not opposed to each other, still very importantly varied. It will generally be observed, he says, that diminished atmospheric pressure has the effect of relaxing the fibre and reducing the vigour of the muscular system, and thereby of occasioning great fatigue. This debilitating influence will be more or less felt according to the state of the general health ; those persons who are of a weakly habit will therefore be most susceptible. Lieutenant Wood, in his " Journey to the River Oxus,^^ re- marks that, when at an altitude of 15,000 feet above the level of the sea, he and his comrades suffered so much from muscular weakness, that even conversation could not be maintained without great exhaustion. The influence of diminished pressure on the circulation is still more extensive and important than on the mus- cular system. Lieut. Wood observing : " I felt the pulses of my party whenever I registered the boiling point of water ; for I found the circulation of the blood to be, in fact, a sort of living baro- meter, by which a man acquainted with his own habit of body can, in great altitudes, roughly calculate his height above the level of the sca.^^ The fact of the bloodvessels being thus influenced may probably be attributed to the air contained in the blood expanding under diminished pressure, and thereby rendering the vessels turgid ; the heart and blood-vessels becoming relaxed, they are then more dilatable, and the blood is accordingly circulated with greater rapidity but with less vigour. If this theory be correct, it is but natural to suppose that such an altered condition of the circulation may induce sanguineous effusions, more especially in those persons in whom the vascular system is already disordered. Apoplexy may thus be produced ; 82 MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. but the air-tubes and lungs being the most permeable to the air, are more particularly susceptible of deficient atmospheric pressure, which, by promoting congestion of their blood-vessels, either originates or conduces to the return of bronchial and pulmonary complaints. On the other hand, an increased pressure of the atmosphere is also frequently found troublesome to patients suffering from asth- matic and other affections of the respiratory organs, by over- powering the already diminished resistance of the air-tubes, and thereby augmenting the dyspnoea. The influence of this con- dition of the atmosphere upon the nervous system is also fre- quently evident in depressing the energies, in debilitating the mental powers, and in lowering the spirits ; and hence Dr. Mad- dock has observed that it is almost invariably accompanied by an increase in the number of suicides. These facts, according to Shute, tend to show that afixjctions of the mind are more influenced by the condition of the blood, which is connected with respiration, than is generally imagined. If the nervous and arterial influences be the same things; if they are both to be regarded as certain modifications of the air; if the mind be influenced by the state of the nervous system (a fact which is proved in syncope, inhaling nitrous oxide, &c., &c.), may we not hope to influence the action of the brain through the medium of the respiratory organs, and thus to acquire some power over mental ailments ? May we not, concludes Dr. Maddock, hope to account rationally for the influence of the air upon a variety of diseases? — Medical Circular, October 17, 18.55. " Of the number of cases of apoplexy which occurred in the years 1850-51," says Dr. Moffat, " 50 per cent, took place on days of decreasing readings of the barometer, and 50 per cent, hap- pened on days after such readings: 100 per cent, occurred with fall of temperalure, and they all took place with a direction of the wind from S. E. and S. W. points of the compass ; and of seven sudden deaths, five occurred with wind from N. W., with hail showers.'^ The high state of the barometer during certain epidemics has been observed as a remarkable characteristic by several persons. The late Dr. Prout, speaking of the high barometric range in London, in February, 1832, says: — "There seems to be only one mode of rationally explaining this increased weight of the air of London, wdiich is, by admitting the diflFusion of some gaseous body through the lower regions of the atmosphere of this city con- siderably heavier than the air it displaced. About the 9th of February, the wind, which had previously been west, veered round to the east, and remained chiefly in that quarter to the end of the month. Now, precisely on the change of the wind, the first cases of epidemic cholera were reported in London, and from that time the disease continued to spread. That the epidemic cholera was MEDICAL CLIMATE AND THE INFLUENCE OF SEASON. 83 the effect of the peculiar condition of the atmosphere is more, perhaps, than can be safely maintained; but reasons which have been advanced elsewhere lead the writer to believe that the virulent disease termed cholera was owing to some matter which produced the additional weight of the air. The foreign body diffused through the atmosphere of London in February, 1832, was probably a variety of malaria/^ Mr. Glaisher, speaking of the three visitations of cholera in London, says : — " The three epidemics were attended with a peculiar state of atmosphere, characterized by a prevalent mist, thin in high places, dense in low. During the height of the epidemic, in all cases, the reading of the harometer was remarkalilij high, and the atmosphere thick. In 1849 and 1854 the temperature teas above its average, and a total alisence of rain, and a stillness of air, amounting almost to calm, accompanied the progress of disease on each occasion. In places near the river the night temperatures were high, with small diurnal range, a dense, torpid mist, and air charged with many impurities arising from the exhalations of the river and adjoining marshes, a deficiency of electricity , and, as shown in 1854, a total absence of ozone, most probably destroyed by the decomposition of the organic matter with Avhich the air in these situations is strongly charged. ^^ The stagnation of the atmosphere, which, in a great city, must mean of itself much impurity, had doubtless given here, as in many noted epidemics, great force and activity to the disease ; but Mr. Glaisher, nevertheless, guards the reader against the conclu- sion that cholera was to be referred exclusively to atmospheric influences, however powerful and extensive they may have been. Sir Henry Holland, speaking of the feeling caused by what are termed, in misplaced or even inverted sense, lightness and heavi- ness of atmosphere, says that it is difficult to declare through what organ or function this feeling is chiefly conveyed ; but pro- bably it is a compound effect of the changes in circulation, in which the sensorium, the lungs, and the musciilar system all participate. " On a general view," he says, '^ of the circumstances stated, there is reason to conclude that the influence of different degrees of atmospheric pressure in disturbing the bodily functions and general health is derived from the frequency of fluctuations, rather than from any state long continued, either above or below the average standard ; that of the two conditions suddenly incurred in any extreme degree, the human frame is better capable of withstanding a rarefied than a condensed atmosphere ; and that, in every case, the previous health and proneness to disorder in particular organs, are greatly concerned in determining the results on the body.'^ In proof of the correctness of these opinions, the author quotes the results of Mr. Green's frequent ascents by balloons, in companjif with four hundred persons at different times. In September, 1838, g3 84 STATISTICS OF THE INFLUENCE OF he and Mr. Rusk ascended to tlie height of 27,136 feet, or 5i miles above the level of the sea, yet neither suffered inconvenience, excepting from cold, and from the toil of discharging ballast and gas. During the ascent the barometer fell from 30°'50 to 11°, and the thermometer from 61° to 5°. The first 11^000 feet were passed through in about seven minutes. STATISTICS OF THE INFLUENCE OF CLIMATE AND SEASON IN PRODUCING SICKNESS AND MORTALITY IN CALCUTTA. SICKNESS. It now remains to trace^ in a more special and statistical manner, the influence of season in producing sickness and mortality; for this purpose I have prepared several tables ; and the first, exhibit- ing this influence on the mortality of natives, was got up, at my request, by Dr. Duncan Stewart; the period it comprehends is seven years — viz., from 1831 to 1837 inclusive: — Months. Of 1000 deaths there occurred in different montlis. Of 1000 living- Hindoos there died in different months. Of 1000 living- Mussulmans there died in different months. Total natives. Of 1000 living, there died in different months. 92| 67k 65| 694 63g 544 70i 904 98 1044 1164 1061 9171 191 184 194 174 144 18 26 28 30 341 311 H H 84 I' H 114 104 12| 124 llf 111 224 164 l.'^f 161 151 13 161 214 234 251 28 25| 7 Februarys 7 Mays 7 Junes 7 Julys 7 Septembers 7 Octobers 7 Novembers This table exhibits in a remarkable manner the fatal influence of the months from September to January inclusive, and which would be even more striking if we possessed the means of deduct- ing the deaths by cholera in the montlis of March, April, May, and June, so as to show only the ordinary endemic influence ; as it is, however, the table is instructive and interesting. The following table I have had collated from the records of the vestry; it exhibits burials in the Protestant burial-ground for CLIMATE AND SEASON IN CALCUTTA. twenty years^ from 1S19 to 1S38 inclusive^ and arranged in months : — Months. Under five years of age. Above five years of age. Total. In 20 Januarys 20 Februarys 20 Marches 53 41 70 105 104 99 104 87 74 84 60 53 257 165 260 307 421 298 285 389 379 368 379 349 310 206 330 412 525 397 389 476 453 452 439 402 20 Aprils 20 Mays 20 Junes 20 Julys 20 Augusts 20 Septembers 20 Octobers 20 Novembers 20 Decembers Total 934 3857 4791 Thus it appears that, though the greatest number of deaths oc- curred in the INIays — the worst of the cholera months — the period of greatest general mortality has been from August to January in- clusive ; and if the deaths by cholera during the hot months could be excluded, this result would appear very striking. With a view to exhibit the simple endemic influence in the fair- est manner, I again had recourse to the vestry records, from which the following table of Protestant burials has been framed for the twenty years just previous to the appearance of cholera as an epidemic, namely, from 1796 to 1815 inclusive: — Slonths. In 20 Januarys ... 20 February's ... 20 Marches 20 Aprils 20 Mays 20 Junes 20 Julys 20 Augusts 20 Septembers 20 Octobers ... 20 Novembers 20 Decembers... Total Under five years. 28 26 31 33 25 22 34 44 42 32 32 23 372 Above five years. 216 153 164 178 235 209 219 288 296 293 331 311 2893 Total. 244 179 195 211 260 231 253 332 338 325 363 334 3265 Thus it appears, that in twenty years Novembers were the most fatal months, and that the five months from August to December inclusive Avere more fatal than the whole seven months besides. 86 STATISTICS OF THE INFLUENCE OF But further to ascertain the influence of season on the health and mortality of the European soldiers and seamen, I have pre- pared the following table from a document furnished by the Medical Board : — it exhibits the totals of admissions and deaths in the Presidency General Hospital in each month during twelve years ; the item " other diseases" has some awkwardness in it, but that I cannot help : — Range of Observations in siontiis. Total Admissions. Total Deaths. %i 64 46 38 42 70 63 38 42 69 48 120 87 727 3 2 11 i OS ->! pq-s "3 CO -2 « 3 M 231 266 323 303 418 488 403 427 416 404 423 311 4443 cS O. a> ^ m 24 51 64 66 53 57 68 38 42 33 39 20 555 ? 1 "a M 1^ 'Si 1 '-*3 a a, "3 -t; O C3 f 1 "3 . 249 263 286 318 330 253 314 321 256 250 203 202 3245 539 627 606 708 726 698 586 609 557 541 574 550 7321 1,043 1,207 1,279 1,395 1,527 1,496 1,371 1,395 1,301 1,228 1,239 1,083 15,564 7 1 9 6 8 5 16 18 18 23 19 16 3 2 1 2 2 2 5 4 4 4 1 20 16 16 19 22 18 28 25 30 21 25 16 10 5 10 9 12 13 10 8 10 6 9 10 40 24 36 36 44 38 59 55 62 50 57 43 12 Mays — 12 Junes 12 Julys 12 Augusts 12 Septembers... 12 Octobers 12 Noverabers ... 12 Decembers ... Total 146 30 256 112 544 It thus appears that in the 12 years there were 15,564 admissions by all diseases, and 514 deaths, or one death in every 28f patients treated, being less by two-thirds than the general average afforded by the General Hospital returns for the same period — an emphatic example of the value of that internal discipline and economy in corj)s to which so much preventive and curative result is ascribed by all military and medical authorities. Out of 541 deaths, 256 are by bowel complaints — 146 by fever, and 30 by liver disease, leaving 112 deaths by other diseases. If from the column of deaths we abstract for the hot months those by cholera, the com- parative fatality of the months from September to January in- clusive, will be rendered very remarkable. The pi^oportions of deaths to cases treated are as follows : — By fever, 4443 admissions and 146 deaths, or one in 30 and two-thirds, nearly : by bowel complaints, 3245 admissions and 256 deaths, or one in 12|^, nearly: by hepatitis, the very large pro- portion of 555 admissions and 30 deaths, or one in 18^: by other diseases, 7,321 admissions and 112 deaths, or one in 65 and ^rd, nearly. The winter, all over Europe, is the season of the greatest mor- tality ; and not only is this a proved fact in statistics, but a mild winter is found to be attended by a diminished mortality, compa- ratively. In the first quarter of 1846, the winter was unusually mild throughout England, and " the rate of mortality was lower than in the corresponding quarters of eight previous years." CLIMATE AND SEASON IN CALCUTTA. 89 In the first quarter of lS-17, on tlie other hand, the temperature "V\"as helow the average, the severity of the weather being through- out unusually great. The mortality corresponded, being " GU35 above the corrected average,'^ for the 1 1 7 districts only comprised in the quarterl}^ returns of the Registrar-General. " Winter/' says Dr. Farr, " appears to be the season in which it is most natural to man to die.'' The same authority justly observes, that '' as man progresses in life, the more necessary does warmth become to him ; while the summer lengthens, the winter shortens his days." Dr. Mouat, of the 13th Light Dragoons, states that, while serving in the INIadras Presidency, out of 3394? cases of disease treated in the Regimental Hospital, 1372 soldiers imputed their illness to cold, while only QZ ascribed theirs to exposure in the sun. The influence of atmospheric pressure on sickness and mortality has not been observed in India ; but the subject is one of much interest and importance. Professor Casper of Berlin founds the following position on numerous statistical tables, ranging over seven years' observation in the Prussian capital : " In nearly all the seasons of the year a high atmospheric pressure increases, and a low pressure diminishes the rate of mortality " MORTALITY OF THE VARIOUS RACES EUROPEAN AND NATIVE. "Man is not born, does not live, does not suffer, does not die in the same manner on all points of the earth. Birth, life, disease, and death all change with the climate and soil, all are modified by race and nationality. These varied manifestations of life and death, of health and disease, constitute the special object of medical geo- graphy." — Buudin. In any inquiry as to the duration of life, and into the causes of mortality amongst the natives of Bengal, we mvist consider, not only that general climate exercises a powerful influence on the longe^aty of different races, by accelerating or retarding the deve- lopment of the human system, but that, along with one of the worst of climates, all the institutions and habits of life of the Bengalis tend materially to abbreviate the term of existence — • their premature decay being in perfect accordance with their early and forced development. The law of cori'cspondence of the period of puberty with the whole term of life is subject to few exceptions, and has been well expressed by Bacon, by " Nature's finishing her periods in larger circles." — Ilist, Vita; et Mortis. It is well known that the proportional number of individuals who attain a given age differs in diff'erent climates, and that the warmer the climate, other circumstances being equal, so much the shorter is the average duration of human life. Even within the limits of Europe the difference is vei'y great, being one death in twenty-eight in the Roman States, and one death in forty-six in England annually. According to Moreau de Jonncs, the rate of 90 STATISTICS OF THE INFLUENCE OF mortality in some instances, and inversely the duration of life, differ by nearly one-half from the proportions discovered in other examples. In approaching the Equator we find the mortality increase, and the average duration of life consequently diminished. The same authority observes, that the comparatively low degree of mortality among the men of colour in the West Indies, and the Javanese and Parsees, in countries where those races are either the original inhabitants, or have become naturalized by an abode of some centuries, is remarkable. " It would seem that such persons are exempted, in a great measure, from the influence of morbific causes which destroy prematurely Europeans and other foreigners. That the rate of moi"tality should be lower among them than in the southern parts of Europe, is a fact which, in the present state of our knowledge, is difficult to explain.^^ The following tables and remarks were found by me amongst the records of the Committee for the Improvement of Calcutta, and were handed to the late Mr. James Prinsep, who published them in the eighty- second number of the " Journal of the Asiatic Society." Mortality among all Classes in Calcutta for Tioenty Years ; hut for tie Native Population only Five Years. .2 6 3 1 Tears. Protestant burials. 3 t« o . 6 n Si Natives, 1817 21G 313 169 4 10 3 1818 272 211 169 2 20 3 1819 275 284 158 23 3 1820 281 282 136 17 1 Native deaths for five years. 1821 246 277 172 16 3 1822 324 Scotch 294 140 16 2 Hindus 8,299 1823 270 burying 277 156 10 2 Mussulmans 1,009 1824 278 ground 282 188 21 1 9,308 in 1832 1825 297 began 285 154 1 12 10 Hindus 15,138 1826 275 1826. 309 145 2 19 17 Mussulmans 2,385 1827 254 11 308 174 ... 15 16 4 17,523 in 1833 1828 * 256 19 250 170 2 15 12 3 Hindus 11,167 1829 184 21 209 146 3 12 16 2 Mussulmans 1,900 1830 224 26 236 138 1 14 15 ■ 13,067 in 1834 1831 186 29 236 122 3 IV 19 8 Hindus 6,873 1832 217 25 269 121 1 17 16 1 Mussulmans 1,229 1833 302 30 288 204 2 23 14 5 8,102 in 1836 1834 281 35 257 199 2 16 17 4 Hindus 6,366 1835 233 18 233 115 1 7 16 4 Mussulmans 1,515 1836 197 26 188 104 15 13 3 7,881 in 1836 55,881 5065 240 5288 3070 24 315 199 34 Average 20 10 20 20 12 20 20 9 S 11,178 253 24 264 153 2 15| 10 3^ CLIMA.TE AND SEASON IN CALCUTTA. 91 Sfaleiue.it of the Average Rate of Mortality per Cent, among the different Classes of Inhabitants in Calcutta per Census and Table of Mortality . Denominations. Number of Inhabitants. Total. Average mortality per annum. Average mortality per cent. Proportion. English Eurasians 3138 4746 7884 3341 59,622 157,418 636 49 362 307 40 55 277 417 1607 9558 25 1 34 3iperct. 2| „ 4tV„ 7f „ 1 in 28 lin 8 lin 36 1 in 16 1 in 25 lin 14 Portuguese French 'Western Mahomedans ... Bengal Mahomedans ... Moguls Arabs 3181 160 13,677 45,067 527 351 Western Hindus 17,333 120,318 683 19,084 Bengal Hindus Mugs Low Castes Armenians ... Native Christians Chinese Jews Parsees Madrassees " The great difference in mortality between the Hindus* and Mussuhnans is striking, while the difference to be observed between the Portuguese, as compared with the English and the Eurasians, is equally so. '' Here is much room for speculation, and it cannot be said that as yet we have as good means of getting correct information upon this subject as they possess in Europe ; nevertheless, we may approach as near as we can to the point we wish to ascertain, and we may hope to improve in such statistical records. " The Portuguese, among whom so great a mortality is shown, are a suffering race, very subject to the catalogue of complaints enumerated in these papers ; while the English and Eurasians are far more prosperous in life, and enjoy comforts and happiness in a very high degree, as compared with the former section of society. The mortality of English and Eurasians, 3^ per cent, per annum, while that of the Portuguese being 12^ per cent., is very great. In 1830 I ascertained, and published in the ^Glean- ings of Science,' the burials in Calcutta of Protestant Christians from the year 1820, to show at that time that, although the Euro- * The difference of mortality amongst the Mahomedans and Hindus may be ac- counted for by the circumstance that tlie Hindus of Calcutta, consisting of families, include a much larger proportion of infant life. The same circumstance will explain the great difference i)etween the average mortality amongst the Portuguese and the Europeans of Calcutta. — Ed. Journal Asiatic Society. 93 ' STATISTICS or THE INFLUENCE OF pean population must liave greatly increased^ yet, that the deaths and burials had not increased ; and now that the same population is acknowledged to have increased very materially indeed^, yet we see, upon referring to the first column of one of the tables, giving the Protestant burials for the last twenty years, no increase of deaths. The years 1833-4, the two years following the sea inun- dations, show the greatest mortality of late years ; while among the native population those two years show an extraordinary mortality. The two last years show in both European and native population that healthiness is restored. The mortality among the other columns of society, the Catholic, Greek, Arme- nian, Hindu, and native Christian, are for the last twenty years, and I believe them to be nearly correct. The Chinese and Jews keep no account of their burials ; I of course could not include them, and they form a minute portion of the popu- lation of this city." '' The native soldiers of Bengal," says Colonel Henderson, '' are very healthy nnder ordinary circumstances. It has been found, on inquiry, that only one man died per annum out of 131 of the actual strength of the army. So injurious, however, is Bengal Proper to this class of natives, as compared with the Upper Pro- vinces, that though only one-fourth of the troops exhibited are stationed in Bengal, the deaths of that fourth are more than a moiety of the whole mortality reported." That the climate of the country of the great waters, the Delta of the Ganges, was not less fatal to our Mahomedan predecessors, is evident from Gladwin's translation from a Persian document : — '' In former reigns, Bengal, on account of the inclemency of the air and water, was deemed inimical to the constitution of Moguls and other foreigners, and only those officers who laboured under the royal displeasure were stationed there ; and this fertile soil, which enjoys a perpetual spring, was considered a strong prison, as the land of spectres, the seat of disease, and the mansion of death." " The Mussulman invaders," says a native writer, '^ of the west of Hindustan, who afterwards established themselves on the throne of Delhi, considered this country, Bengal, to be Dojakh, or an infernal region ; and whenever any of the Ameers or courtiers were found guilty of capital crimes, and the rank of the individuals did not permit their being beheaded, while policy, at the same time, rendered their removal necessary, they were banished to Bengal. The air and water of Bengal were considered so bad as to lead to the certain death of the criminal." In the " Journal of the Asiatic Society of Bengal," vol. vii. Sept. 1838, there is an interesting paper, drawn up with much care by Mr. H. T. Prinsep, on the Mortality of the Indo-British children in the Lower Orphan School of Calcutta. From a com- parison of the mortality at each year of life from 10 to 20 Avith CLIMATE AND SEASON IN CALCUTTA. 93 what occurs in London at tlie same ages, lie dra-vrs the following deductions : — " The decrement in India is, as might be expected from the climate, greater from birth than in London, but the favourable years are the same — viz., fi'om 9 to 14< ; and it will be observed, with dvie allowance for insalubrity, and for not perhaps the most favourable rearing in a large school like our Orphan Asylum, that there is a general correspondence in the results up to the age of six/' By a statement forwarded by the INIedical Board to the Com- mittee for the Improvement of Calcutta, it would appear that, during the thirty yeai's from 1st January, 180S, to 31st December, 1837, there were, of admissions and deaths, amongst the European patients of the Presidency General Hospital, as follows : — Total admissions 35,119 Total deaths 3,607 This, for thirty years, gives a mean ratio of lOy^^ deaths per cent, of the admissions. The quinquennial ratios are as follow : — Years. Admissions. Deaths. Ratio of deaths per cent. From 1808 to 1812 1813 1817 1818 1822 2713 4360 6425 9560 6315 5746 299 450 657 1039 585 577 11 1823 1827 1828 1832 1833 1837 Mean 58531 684| lOAV That is all that the Medical Board could furnish ; for it was not till 1808 that any records were used, even of admissions and deaths. The following table exhibits both the sickness and mortality of the British troops in garrison at the Presidency, together with the proportion of deaths to cases treated, of the three principal ende- mic diseases of Bengal; viz., fever, dysentery, and hepatitis: — 94 STATISTICS OF THE INFLUENCE OF Talle oj Admission into Hospital and Deaths, dimtig 17 Years, of the European Troops in Garrison of Fort William. Years. Strength. Admissions. Deaths. Katio per 1000 of strength. Admitted. Died. 1822 1823 1824 1825 1826 1827 1828 1829 1830 1831 1832 1833 1834 1835 1836 1837 1838 Total Average ... 866 828 736 902 863 893 913 885 808 831 771 687 608 743 734 709 633 1,303 1,687 2,268 2,542 1,826 1,336 1,776 1,995 1,722 1,061 1,024 1,387 1,166 1,211 1,245 899 694 75 51 103 110 96 56 42 58 59 57 59 64 57 33 25 26 22 1,594-62 2,037-24 3,082-32 2,818-18 2,115-87 1,496-08 1,945-23 2,253-07 2,131-78 1,276-77 1,728-14 2,018-92 1,917-76 1,629-87 l,696-]8 1,267-98 1,096-36 86-60 61-59 139-94 121-95 131-23 62-71 45-00 62-14 73-02 68-59 76-52 93-15 93-15 44-41 34-06 36-07 34-75 13,410 25,142 497 788if l,478if 29xV 1,833-33 73-26 The ratio of deaths to cases treated was, during ten years, as follows : — In fever one in 28i^ dysenteiy _ „ 12^f hepatitis, acute and clu-onic ,, 84 The mortality by all diseases in every hundred deaths of Euro- peans serving in the Presidency of Bombay, between 1830 and 1846, was as follows : — Dysentery 28-527 Fevers 23054 Cholera 10-320 Hepatic diseases 9-597 Diarrhoea 3-914 Pulmonary diseases 5-807 Other diseases 18-697 Lost in calculation "084 Total 100-000 CLIMATE AND SEASON IN CALCUTTA. 95 Tdlle of Admission i?ito Hospital and Deaths, daring 12 Years, of the European Troops at Chinsarah [Depot], 18 Miles distant from Calcutta. Years. Strength. Admissions. Deaths. Ratio per 1000 of strength. Admitted. 1 Died. 1826 1827 1828 1829 1830 1083 814 200 132 366 927 737 577 784 832 743 765 818 1,3-29 542 571 822 1,412 1,182 1,155 1,308 872 1,428 1,322 86 80 20 24 24 51 41 54 32 17 39 32 755-31 1,632-67 2,710-00 4,325-75 2,245-95 1,523-19 1,603-79 2,001-73 1,668-36 1,048-07 1,921-93 1,728-10 79-40 98-28 100-00 181-81 65-57 56-01 55-63 93-58 40-81 20-43 52-35 41-83 1831 1832 1833 1834 1835 1836 1837 Total Average ... 7960 12,761 500 6631 l,063yV 41f 1,930-40 73-72 The ratio of deaths to cases treated was^ during tliree years^ as follows : — In fever one in 25| dysentery „ 7|4 hepatitis, acute and chronic .... ,, 8^ The above must be taken as the mortality on the spot only^ and does not include the invalids, who died on their passage to England, or shortly after their arrival there, amounting to 3i annually. If, as is well known also, the medical returns be taken at the highest strength in the course of the year or quarter, or a tenth part higher than it ought to be, instead of the mean monthly strength, the ratio of mortality will be greatly increased. It is believed that a correction of all errors would bring the annual mortality to more than eighty per thousand. That in India, as elsewhere, age materially influences the ratio of mortality will be seen from the following tables for the oflBcers of the Bengal army, and those of the Civil Service. Out of 11 SI* deaths among officers, the proportion occurring annually in each rank, and at each age, has been as follows : — • Tcrcentage of deaths. SI 60 %\ O oj US > OS Lieutenant- Colonels, average age 51. o O oi ^^ > 50 .5 '^ '5 " C be C8 C3 CJ ^ ^ o >■ CO 0) ■*-' bo . s ™» g too g ^ « 3 « Cornets and Ensigns, average age 18 to 33. General average at all ages. Died annually per \ thousand of each > class ) 59-4 48-4 41-0 34-5 27-5 23-4 31-2 96 STATISTICS OF THE INFLUENCE OF The mortality among the civil servants,, for a period of forty-six years, from 1790 to 1^-36, exhibits almost precisely the same re- sults; viz. — ■a a 6 IQ CD 'S o o g 12 O "-1 m O ? C3 2 gH2 U5 4) (M a o a> 4) OO rH bo io bo t-. <) < ^ 48-6 36-4 35-4 23-4 16-6 20-8 19-9 Between ten and fifteen years' service is the period when leave of absence is allowed to those who choose to return to Europe for three years, which of course must have a material tendency in reducing the mortality of that class. With this exception, the results are uniform for both civil and military servants, and they are no less so when extended to the officers of the other Presi- dencies. The official results in regard to the mortality at each age among the military officers and civil servants of the Bengal Presidency, aftbrd a convincing proof that in the East Indies no advantage has hitherto been derived from length of residence. As those indivi- duals are never employed out of India, and generally arrive there about the age of eighteen or twenty, their respective ages and ranks may be assumed as a criterion for estimating their length of residence in the country. On that principle, then, we find, taking equal numbers of each rank, that the mortality among the ensigns, for the most part youths but recently arrived, is only twenty-three ; while that of the lieutenants, who must have been at least three years longer resident to have attained that rank, is twenty-seven ; and that of the captains, who must have been about twelve or thirteen years longer, is thirty-four per thousand, and so on in a corresponding proportion with the higher grades. In case it should be objected that this does not exhibit the precise operation of mor- tality during the first year or two of residence in the country, when the influence of acclimation is supposed to be most strongly manifested, the following information in regard to the civil ser- vants in the Bengal Presidency will supply that defect : — Years of residence. Numbers alive. Deaths in first year. Ratio of deaths per thousand of living. 19-5 23-5 20-0 22-0 975 933 906 874 19 22 18 19 2nd ,, ,, Ath . .. CLIMATE AND SEASON IN CALCUTTA. 97 Here, then, we have traced the same individuals through four successive years of residence, Avith the liability to mortality con- stantly augmenting ; and unless we are to suppose that a different law regulates the mortality among Europeans in the tropical climates of the eastern and western hemisphere, we are inevitably led to the same conclusions which we have already demonstrated from the previous numerical results. — Stat'idical Reports. The result of all inquiry goes to establish the truth of the declaration of Boudin, " that man possesses faculties of acclimation essentially limited, though varying notably according to race. The theory of acclimation, as aptly described by Lord Herbert, would persuade us that a man who suffers from illness in his first year of residence in an unnatural climate recovers his health by remaining there, and that he thus becomes a strong, hale man. The meaning of such a theory is that, if a thing is unwholesome to the constitution, we have but to go on with it." In point of fact, diseases oi'iginating in ill habits of life, or in exposure, may often be speedily cured on the spot ; but the physical degradation result- ing- from long residence in a hot and pestilential country, such as the plains of India, cannot be cured, excepting by a protracted removal to the cool climate of the mountain regions there, or to Europe. The following table exhibits the annual rate of mortality, and tlie influence of length of residence in tropical countries, on Euro- pean troops, from January 1st, 1830^ to 31st March, 1837 : — Siations. 18 to 25. 25 to 33. 33 to 40. 40 to 50. Jamaica 70-0 20-8 24-0 18-2 23-8 107-0 37-5 55-0 34-6 50-3 131-0 52-7 86-4 46-8 50-6 128-0 86-6 126-6 71-1 83-3 Mauritius Ceylon Bombay Bengal The subject of statistics is one that has been altogether neg- lected by the medical a^ithorities of the Bengal Presidency; and though the example of the hospitals of her Majesty's army, from which very complete reports are made, has now been many years before them, this important branch — the very central point of medical science — can scarcely be said, until very re- cently, to have been approached. It is the deficiency here com- plained of that has caused the omission in this work of all men- tion of the hospitals of Calcutta, and of the General Hospital in particular ; — an institution that has existed for more than seventy years, and in which tens of thousands of European soldiers have been treated under three or four different medical systems, yet no one fact, out of the numerous and important observations made during that long time is known to any one of us. Its surgeons, and those of the oth-er public institutions — many of them able and ex- H 98 STATISTICS or THE INFLUENCE OF perienced officers — liave^ through the neglect of the controllhig medical authorities, been rendered, in respect to us and to science, no more than a set of dumb actors in the circle of a routine duty. Dr. John Macpherson forms a very honourable exception, his statistical investigations prepared at the General Hospital of Cal- cutta being works of standard value. All this official neglect and want of discipline has been repeatedly complained of by me in what I tliought the right quarter, and in the most emphatic manner ; but though my proposition met with no very flattering reception, I have yet the satisfaction to know that I produced some action with the civil authorities, tardy perhaps, yet such as will lead to some ultimate improvement. We are in India continually kept in mind of that law of our nature by which old men are disinclined from undertaking anything, however excellent, of which they cannot be expected to see the end. Through the operation of climate also, we have too often to lament the premature display of the con- tracting influences of age on the moral and physical constitution of man, to the prejudice no less of public welfare than of private happiness. From the circumstance that no general mode of registering and recording has existed till lately, on statistical principles, which all should adopt, the great majority of experience in India has hitherto perislied Avith individuals, and the valuable ma- terials of a long and active life have been thus for ever lost to the public service. The labour of analyzing observations which have been irregu- larly kept is immense — to some men impossible ; while by order a habit of observation is fostered and kept alive through the in- creasing facility in the process, and the interest excited by the sii1)ject. Such are the opinions of some of the ablest writers in England ; but they have as yet found no echo in our Bengal Medical Board, where we have still to regret the leaden influences of an exclusive seniority principle of promotion. To ensure precision and uniformity in reports, the nomenclature of hospitals is systematic and strictly ordered in the royal army, and this is one of the many advantages its plan of arrangement possesses over ours. As to the constantly recurring questions, do we not live under an improved climate, and is not the mortality of Europeans greatly diminished of late years ? it is not very easy to speak satisfactorily, owing to the absence of older statistical record. That the climate of the actual site of Calcutta is improved to a certain extent, there can be no doubt ; and that European general mortality is likewise diminished, amongst the better classes especially, I believe to be true ; but the cliief cause will be found in the improved habits of the latter class ; for, with the troops in garrison, notwithstanding the improved discipline and interior economy of modern times, CLIMATE AND SEASON IN CALCUTTA. 90 it would not appear tliat mortality is much diminished, and the same may be said of the nearest military station of former times — Berhampore.''^ The decrease in the proportional mortality of British troops in om* various colonies is stated by Robert Jackson to be only of recent date ; and he adds, that it would not be safe to pronounce positively whether it is owing to improvement in medical manage- ment, with improvement in military economy, or to contingent and temporary change in the nature of morbid causes, producing a less aggravated form of disease than belonged to other times. The soldiers did not die in greater numbers in Germany and Holland in the war of 1793, 94, and 95, than they did in the war of 1803. Further, he says, that the mortality was not greater, cmteris paribus, in North America in the Avar of 1750, than in the revolutionary wars of 1775 — or in the late war of 1813. It is in the navy, he might have added, that a great and progressive re- duction in mortality has been effected by the measures of preven- tive medicine instituted in 1779. Mortality has been nearly equal at all times in the West Indies, viz.j in the war of 1756, in the war of 1778, the war of 1793, and the war of 1803. Of the earlier health history of the European troops in Bengal we have little or no information. I had a table prepared with a view to exhibit the mortality of European troops in gai'rison at Fort William from 1790 to 1810, both inclusive. It aftbrded an average of deaths of 76'40 per 1000 per annum. A similar table for Berhampore, Bengal, from 1788 to 1810, gave an average of deaths at that station of 90 '69 per 1000 per annum. Comparing these figures, which represent the deaths on the spot only, with the most recent retvirns, as prepared by Sir Alexander Tulloch, a great improvement must have taken place, if not in the climate of Bengal, at least in the sanitary condition of the troops now serving there. The following table has been prepared from the admirable " Analysis of the later JSIedical Returns of the European Troops serving in the Bengal Presidency," by Hugh M. Macpherson Esq. :— * Making the corrections stated at p. 87, the table for Fort William will give S8*40, and that for Berhampore 102'69, as the ratio of deaths per 1000. All the tables of the military liave been framed from four official sources — viz., the Adjutant and Auditor-General's Office, that of the Inspector-General and the Medical Board ; and where they differed I took the estimates of the Audit Office. More deaths were recorded in tlie Adjutant-General's returns than in any of the others. Slight errors have been made by the writer in calculating some of the tables, but they in no manner affect the general accuracy of the whole. H 2 100 STATISTICS OF THE INFLUENCE OP Table slioio'mg the Ratio of Sickness and Mortality per 1000 of the Strength of Officers, Soldiers, Women, and Children of the European Troops in the Bengal Presidency. Periods of observation Aggregate strength Diseases. Fevers Eruptive fevers Diseases of organs of re- spiration „ „ heart and blood- vessels „ „ brain & nervous system „ „ alimentary canal Cholera Dropsies Diseases of urinary organs ... Venereal affections Rheumatic „ Abscesses and ulcers Diseases of bones, joints, &c... ,, nutrition ,, the eyes „ the skin „ theear Punishment Ebrietas Anomalous diseases Wounds and injuries Complaints peculiar to women „ „ children Total 8 Tears i '^^^"^ ^^^ ^P'"'^' l^*^' 8 years ^^^ g^^^^ March, 1854. 5708 Treated. Died. 4.50-1 5-G 4-4 •3 49-4 1-9 3-0 •2 27-5 3-2 321-1 6-0 7-4 1-2 1-2 -2 5-1 128-2 ^ 65 9 107-4 -7 2-1 \-' 14-0 7-0 10-3 3-0 7-9 116-8 1-9 1322-5 21 2 156,139 Treated. 814-1 2-4 70-4 6-6 40-0 413 17 2 3 220 93 92 2 9 87 9 7 3 40 24 81 Died. 11-2 •6 •4 5-2 23-4 7-1 •6 CHILDBEN. . (-From 1st April, 1850, 4year3^^^3^g^jj^jpjj_j854. 7941 Treatd. 638-0 27 Died. 11-0 •6 15-5 5-0 925S Treatd, 322-8 62-5 30-6 •3 27-1 169-1 12-0 -6 •3 -8 •5 14-6 ■1 131 75 5 2-8 1-5 •1 6-7 11-0 36-1 Died. 17-8 5-4 4-2 -1 15-9 20-7 4-8 For the following important and interesting General Abstract pf Admissions and Deaths by the principal Diseases among the European troops in Calcutta, Chinsurah, and Berhampore, in Bengal Proper, I am indebted to my friend Sir Alexander Tul- loch — CLIMATE AND SEASON IN CALCUTTA. 101 Diseases. Calcutta for 10 years, viz. from 1827 to 1836 each inclusive. Chinsurah for 8 years, viz. from June,"l826, to June, 1827, and from 1830 to 1836 Inclusive. Berhampore for 10 years, viz. for 1823, and from 1826 to 1834 each inclusive. Aggi-egato strength, 7823. Aggregate strength, 6531. Aggregate strength, 11,077. S -^ cu .a \st March, 1837. Stations. Household cavalry .. ) ^^ ■. ^ n 1 fii r ( United Cavalry oi the Ime ... ]■ t^. , u 4 1 I Kingdom Jboot guards ) ° Gribialtar ) Malta > Mediterranean. Ionian Islands ) Mediterranean stations generally. Bermudas ) isr tli Nova Scotia, &c. } . n J \ America. Canada ) Windward and Leeward command. Jamaica Cape of Good Hope Mauritius Ceylon Bombay Madras Bengal P 8'4 4-4 6-1 10-0 160 6-6 100 ...t 9-0 ...t 4-0 57-0 14-0 11-0 23-3 ...t ...t ...t 14-7 13-9 22-3 18-7 13-0 12-2 155 16-0 14-0 19-7 50-0 700 90 20-8 24-0 18-2 26-0 23-8 11-4 14-0 22-5 23-6 23-3 20-1 22-2 42-0 22-5 27-8 74-0 107-0 20-6 37-5 55-0 34-6 59-3 50-3 16-3 22 17-3 26- 17-7 27- 29-5 34- 34 56- 24-4 24- 28-1 33- 42-0 76- 30-8 41- 37-8 35- 97-0 123- 131-0 12H- 29-7 32 52 7 86- 86-4 126- 46-8 71- 70-7 86- 50-6 83- 14-5 15-3 21-6 22-3 22-3 19-3 21-0 28-9 20-3 25-7 67-0 91-0 17-6 34-6 49-0 33-1 52-2 44-5 * No correct deductions can be drawn from the ratios under 18, as the numbers are so few, and the results consequently irregular. t Not given. CLIMATE AND SEASON IN CALCUTTA. 103 Return shoioing similar Results for the Ten Years from \st April , ISS''' to '6\st Marc/i^ 184?7, at the under-mentioned Periods of Life, and at fhefoUotving Stations. Stations. o U a) •a n P 20 to 24. o o c^ CO o o CO d o « 3 o fe ■s 2 «* < '^ 11-1 13-5 20-4 17-8 16-4 17-0 59-0 : Household v cavalry Cavalry of the line United j ■ Kingdom. 7-5 8-1 11-1 13-0 14-8 37-0 11-7 n-8 21-6 17-8 16-3 131 60-0 10-3 14-3 21-1 19-8 15-1 17-7 50-0 13-3 14-6 19-5 19-8 16-4 19-2 73-0 8-4 15-3 22-4 21-0 25-4 20-3 83-0 13-4 18-3 26-2 23-4 34-4 35-6 97-0 Foot guards ... Infantry of the Mediterranean s Canada and Nov Jamaica a Scotia The same result applies to officers as well as men, civil as well as military, as will be seen from the following calculations. " Out of 118J^ deaths among officers in the Bengal Presidency, the proportion occurring annually in each rank and at each age has been as under : — 8) S a S) tH a bo o bo a bo ? ?" S , o •a v c5 3 > o cs -*' O c« |S ft |2 CD 60 •- bo i Cornets an ' signs, av [ age 18 to General av at all age Died annually per 1000 of each ! rank 59-4 48-4 41-0 34-5 27-5 23-4 31-2 " This extends also to the civil servants, the mortality axnong whom, for a period of forty-six years, from 1790 to 1836, exhibits a modification of the same results^ viz. : — Katio. Above 50 years of age and 30 of service. io- 2 ^ Age 40 to 45, ser- vice 20 to 25. § o o >o CO 2 be > 0) no is 2 ■= Age 25 to 30, ser- vice 5 to 10. Age 20 to 2 5, ser- vice 1 to 5. ,Died annually per 1000 of each rank 48-6 36-4 35-4 9S-4 16-6 20-8 19-9 " Thus there can be no question that the longer any one stayvS in India the more likely is his health to be deteriorated. 101 STATISTICS OF THE INFLUENCE OF " It follows as a natural consequence of these results, that if regiments of the line serving in India are relieved at proper in- tervals, say every ten years, their loss while serving there must generally be less than that of any European corps permanently resident, because they will, as a body, be younger men — hence a strong reason for the employment of the former force in preference to the latter. " Those who contend for a local European army in preference to troops of the line, probably do so on the supposition that it would materially reduce the expense of reliefs, forgetting the im- portant change which has been broiight about by the Limited Enlistment Act now coming into operation in the Indian army. " If the men thus enlisted wish to come home they must be dis- charged at the end of ten years, being the same period I propose for the relief of regiments of the line. If they do not wish to come home, they would be just as likely to continue in the service by the facility of volunteering into a newly arrived regiment of the line, to complete their second period of service, as if they had originally enlisted into a local European force. Besides, it appears very questionable whether, during the excitement of a war in Europe, young men would be disposed to enlist to the required extent in any local corps for remote service, and still more ques- tionable whether it would, be good policy on the part of the Government at such a time to encourage their doing so ; but if the whole European force in India were composed of corps of the line, second battalions could be raised without reference to their ultimate destination ; some of these might then be sent to India to replace the first l^attalions, which could be brought to the theatre of war, with all the experience acquired by their previous service, while the newly raised men would do just as well in India, where the ' Avhite face^ is all that is wanted. " By this arrangement, in the event of war, India would add to our military strength, whereas any local European army woiild tend seriously to reduce it, by keeping back so large a proportion of our trained soldiers, whose services could not be made available elsewhere without a new engagement. " It forms another weighty consideration, militating against the employment of any such force distinct from our troops of the line, that soldiers not returning home periodically, and serving under dif- ferent conditions from the rest of the army, must always, to a certain extent, have local interests, and be subject to local infai- ence. Some question of pay, allowances, or coveted advantages, granted to one branch of the service but denied to another, may with such a force some day create another mutiny. On such questions both officers and men of the Indian army have before now been nearly, if not altogether, in that state ; but were any such feeling ever to arise among regiments of the line, the very first suspicion of its existence would lead to immediate removal to some other foreign station — a remedy which would be impracticable CLIMATE AND SEASON IN CALCUTTA. 105 with any localized force. This danger becomes, of course, the j^rcater the larger the army, as it must necessarily give confidence to the disaffected to know that they make their own terms from the utter impossibility of sending any adequate force against them. Table sJiow'nig the MortalUi/ in each of the Presidencies for a Period of 39 Years, as extracted from the War Office Betnrns. Tear. Bengai. Madras. Bombay. strength . Deaths. Strength. Deaths. Strength. Deaths. 1817 7,284 622 9,092 548 2,607 143 i 1818 6,203 384 9,306 903 3,645 352 1819 6,219 483 7,656 637 3,417 270 1820 6,156 439 7,043 411 3,076 404 1821 5,732 399 6,989 896 2,907 262 1822 5,899 365 6,949 491 3,164 318 1823 6,584 496 6,838 386 3,082 224 1824 6,894 937 7,388 1,068 2,562 147 1825 6,669 1,086 6,919 1,187 3,178 357 1826 7,877 1,312 6,405 1,081 2,936 344 1827 8,035 583 7,061 656 3,063 171 1828 8,284 633 7,602 434 3,222 209 1829 8,5.55 618 7,680 290 ^ 3,978 117 1830 8,325 406 7,408 219 3,914 160 1831 8,347 431 6,976 268 3,845 94 1832 8,031 346 6,773 418 3,723 79 1833 7,569 403 6,241 571 3,583 129 1834 7,340 394 6,086 444 3,426 134 1835 7,655 272 5,881 215 3,415 102 1836 7,541 369 6,646 254 3,465 139 1837 6,878 355 6,078 362 3,226 148 1838 5,401 327 5,493 269 3,319 141 1839 7,645 499 5,792 405 3,422 380 1840 8,581 1,268 6,255 265 4,402 296 1841 9,438 1,020 5,411 223 5,418 601 1842 12,593 1,698 6,101 292 6,106 668 1843 11,003 1,028 7,699 427 6,066 468 1844 11,280 984 7,850 276 6,323 824 1845 11,108 2,213 7,535 351 4,710 337 1846 11,007 1,103 5,772 264 7,197 681 1847 12,349 781 6,040 225 5,556 139 1848 11,502 1,190 5,321 125 6,208 179 1849 14.703 1,306 5,014 159 6,619 310 1850 17,307 911 4,838 110 5,872 165 1851 17,070 849 4,162 88 6,774 194 1852 16,659 1,186 4,548 304 6,688 194 1853 16,190 950 4,598 215 6,306 102 1854 17,087 782 4,357 143 4,104 90 1855 14,980 532 3,209 80 4,423 80 1856 Totals. 377,980 ■ 29,970 249,012 15,462 165,947 10,152 106 STATISTICS OF THE INFLUENCE OF Summary of the p-ececling Taile. Per 1000. Bengal . . strength 377,986 . . deaths 29,970 . . ratio 79-2 Madras . , ,, 249,012 . . „ 15,426 . . ,, 62-9 Bombay. , ,, 165,947 . . „ 10,152 . . „ 61-1 Total .... 792,939 55,584 70-0 "These losses include some 200 or 300 men killed or dead of their wounds during the Mahratta, Pindaree, and other campaigns prior to 1824; also 8750 who perished in the first, and about 1000 in the second Burmese war, chiefly from sickness ; also nearly a whole regiment lost at Cabul ; likewise the casualties during the campaigns of Scinde, of the Sutlij and the Punjaub, about 3000 in all; and nearly 1200 who died in the first Chinese war, all from sickness with very few exceptions. The loss arising from the climate of stations noAv usually occupied on the continent of India may therefore be reduced by about 8000 or 0000 men, or to an average of 60 per thousand annually, though the total loss from all causes has been at least 70 per thousand. " In addition to the latter rate, which must of course form our estimate of the number to be replaced, the proportion invalided annually may be taken at about 25 per thousand more, and of time-expired men not* renewing their engagement nearly the same proportion (the last, of course, is altogether conjectural, as the effect of limited enlistment is only coming into operation). These totals would make in all a decrement of 120 per thousand, or 9600 annually ; whereas the average number of recruits raised by all the recruiting districts throughout the United Kingdom, from 1845 to 1849 inclusive, which may be fairly assumed as an average for a period of peace, amounted to rather less than 1 2,000 annually ; so that, unless means can be adopted to reduce the mortality and invaliding, the force in India alone would absorb nearly all the recruits raised under ordinary circumstances for the whole army, of which the requirements are not now likely to be less than 20,000 men a year — probably more. "It has been ascertained by experience that in all tropical climates, whether in the East or West, localities may be found where the mortality to which European troops are exposed docs not very much exceed that Avhich takes place in their native country. Returns extending over a great number of years show that at Bangalore, or in the Neilgheny hills in the INIadras Presidency, and at Poonah, or the Mahableshwar hills in the Bombay Presi- dency, European troops may be located without sustaining a greater loss than about 3 per cent, annually, a considerable portion of which arises from disease contracted at other stations more unfavourable to health. There can be little doubt that in the Upper Provinces of the Bengal Presidency, at elevations of from 3U00 to 4000 feet, situations of equal salubrity might be found adapted for large bodies CLIMATE AND SEASON IN CALCUTTA. 107 of troops ; but, judging from the results given in the following abstracts and summary, which extend over a period of many years, the selection of stations there does not appear to have as yet been fortunate, probably because strategic may have hitherto overcome sanitarv considerations." Abstract showing the Sickness and Mortality of the Troops of the Line at the tmder-mentioneil Stations of the Indian Preside^icies, as nearly as can he ascertained from the Returns forioarded to the Medical Board from 1817 to 1836 inclusive. Stations. Bengal. Fort William Chinsurah Dinapore Ghazeepore Cawnpore Agra Berhampore Meerut Kurnaul Hazareebaugh Boglipore Madras. Fort St. George Cannanore Trichinopoly Secunderabad Bangalore Quilon Wallajahbad Bellary Arnee Bombay. Colabah and Bombay. Poonah Belgaum Deesa Kiikee Kairab. Yrs. 17 7 9 14 19 4 14 19 6 2 4 18 18 19 18 21 6 5 10 5 16 16 10 4 10 12,855 4,155 6,845 10,936 25,701 2,701 13,342 27,328 5,314 1,368 2,564 13,606 12,809 15,317 13,939 21,870 4,846 2,398 7,504 3,136 11,907 19,974 6,332 2,682 6,207 4,059 23,967 6,930 14,251 16,888 46,471 3,671 26,494 35,949 5,252 2,308 4,338 26,009 18.402 27,394 35, 555 34,538 6,576 4,480 14,911 4,518 22,195 36.140 10,814 2,879 9,447 10,108 Ratio per 1000 of a .2 1 73 < 5 Is o 885 1863 68-82 224 1667 53-91 484 2081 70-70 449 1554 41-05 1495 1808 58-16 49 1359 18-14 853 1985 63-93 862 1315 31-54 137 988 25-78 78 1687 57-01 224 1691 87-36 671 1911 41-96 420 1436 32-80 681 1783 44-46 854 2555 61-26 672 1579 30-73 146 1357 30-1 242 1868 100-9 355 1987 47-3 • 140 1440 44-3 763 1864 64-03 495 1819 24-73 175 1707 27-63 144 1073 53-69 162 1521 26 09 500 2490 123-18 108 STATISTICS OF THE INFLUENCE OF Abstract showing the Sichiess and Mortality of the Troops of the Line at the under -mentioned Stations of the Indian Presidencies, as nearly as can he ascertained from the Annual Sanitary Heports forwarded to the War O^ce from 1838 to 1856 inclusive. Stations. Bengal. Fort William Chinsurah Dinapore Ghazeepore Cawnpore Agra Meerut Kurnaul Hazareebaugh Allahabad Loodian'ih Umballah Kussowlie ., Ferozepore JuUuudur Lahore Rawul Pindee Peshawur Wuzeerabad Dugshai Subatho Madras. Fort St. George Cannanore Trichinopoly Secunderabad Bangalore Karuptee Tennasserim Provinces Bellary Bombay. Colabah and Bombay... Poonah Belgaum Deesa Kirkee Kurraohee Ahmednugger Hyc'erabad Aden Yrs. 7 2 13 5 10 8 14 5 2 2 2 10 7 5 5 7 4 5 4 3 3 16 17 11 8 17 7 9 7 7 13 10 7 14 12 3 4 4,683 859 10,915 3,002 8,985 5,847 14,512 3,434 1,054 938 1,251 13,773 5,040 4,445 4,273 5,232 3,359 8,182 6,889 2,618 935 11,858 15,416 7,628 7,133 17,133 6,014 9,165 5,290 3,606 13,663 7,244 7,473 9,131 12,410 1,154 1,744 3,983 7,735 2,235 20,158 5,638 20,473 13,833 24,522 8,051 1,710 2,325 2,826 20,627 6,160 7,817 7,380 14,901 6,276 26,384 11,436 3,726 1,524 20,804 24,832 14,599 12,243 24,016 12,440 16,218 10,259 7,806 28,541 11,909 12,262 17,218 23,662 2,765 4,352 4,934 ft Ratio pe i 'i s ■a < 272 1652 60 2601 903 1847 276 1878 799 2278 355 2365 639 1690 268 2344 36 1622 108 2479 159 2259 850 1497 247 1222 245 1759 160 1727 473 2848 146 1868 588 3225 408 1660 69 1423 29 1630 343 1754 488 1611 237 1913 405 1716 418 1402 287 2068 302 1770 257 1939 219 2165 451 2089 299 1644 250 1641 234 1886 585 1907 66 2396 74 2495 138 1239 58 69 82 91 88 60 44 78 34 115 127 61 49 55 37 90 43 71 59 26 31 28-93 31-65 31-07 56-78 24-39 47-72 33-00 48-60 •73 ■01 -27 -45 -63 -14 •19 -43 •64 CLIMATE AND SEASON IN CALCUTTA. 109 Summary of the two preceding Periods. Stations. ■ol It o Strength. a .2 'i < .£3 a o l§ 1 = <- 2 It « 68-82 58-08 Bengal. Fort William:— First Period Yrs. 17 7 12,855 4,683 23,967 7,735 885 272 1863 1652 Second Period Total Chinsurah : — First Period 24 17,538 31,702 1157 1807 65-92 7 2 4,155 859 6,930 2,235 224 60 1667 2601 53-91 69-96 Second Period Total Dinapore : — First Period 9 5,014 9,165 14,251 20,158 284 1827 56-64 9 13 6,845 10,915 484 903 2081 1847 70-70 82-73 Second Period Total Ghazeepore .- — First Period 22 17,760 34,409 1387 1937 78-09 14 5 10,936 3,002 16,888 5,638 449 276 1554 1878 41-05 91-94 Second Period Total Cawnpore : — First Period 19 13,938 22,526 725 1616 52-01 19 10 29 25,701 8,985 34,686 46,471 20,473 66,944 1495 799 1808 2278 58-16 88-90 Second Period Total Agra .- — First Period 2294 1930 66-13 18-14 60-71 4 8 2,701 5,847 3,671 13,833 49 355 1359 2365 Second Period Total Meerut : — First Period 12 8,548 17,504 404 2048 47-26 19 14 27,328 14,512 41,840 85,949 24,522 862 639 1315 1690 31-54 44-03 Second Period Total Kurnaul: — First Period 33 60,471 5,252 8,051 1501 1445 35-87 6 5 5,314 3,434 137 268 988 2344 25-78 78-04 Second Period Total 11 8,748 13,303 405 1521 46-30 110 STATISTICS or THE INFLUENCE OP Summary — continued. Stations. ■si o to 1 a _o S P .2 .2 o ,5 <=> ^ '-' ■^ L. .a cS . -c o V, o o '-' .2 ^ Bengal — continued. Hazareehaugh : — First Period Second Period Total Madeas. Fort St. George : — First Period Trs. 2 2 4 18 16 34 1,368 1,054 2,308 1,710 78 36 1687 1622 57-01 34-15 47-07 41-96 28-93 2,422 13,606 11,858 4,018 26,009 20,804 114 671 343 1659 1911 1754 Second Period Total Cannanore : — First Period 25,464 46,813 1014 1838 39-82 18 17 12,809 15,416 18,402 24,832 420 488 1436 1611 32-80 31-65 Second Period Total Trichinopoly :— First Period 35 28,225 43,234 908 1531 32-17 19 11 15,317 7,623 27,394 14,599 681 237 1788 1913 44-4o 31-07 Second Period Total Secundcrahad : — First Period 30 22,945 41,993 918 1829 40-00 18 8 13,939 7,133 35,555 12,243 854 405 2555 1716 61-26 56 78 Second Period Total Bangalore : — First Period Second Period Total Bellary : — First Period ... 26 21,072 47,798 1259 2268 59-74 21 17 21,870 17,133 34,538 24,016 672 418 1579 1402 30-73 24-39 38 39,003 58,554 1090 1501 27-94 10 7 7,504 5,290 14,911 10,259 355 257 1987 1939 47-30 48-60 Second Period Total BOMBAT. Colahah and Bombay: — First Period Second Period Total 17 16 7 12,794 11,907 3,606 25,170 22,195 7,806 612 763 219 1959 1864 2165 47-80 64-08 69-73 23 15,513 30-001 982 1933 63-30 CLIMATE AND SEASON IN CALCUTTA. Summa ry — co nthi n ed. Ill Stations. •si O Strength. Admissions. a .2 ii 73 o a '-' Ratio of deaths per 1000. Bombay — continued. Poonah : — First Period Yrs. 16 13 19,974 13,663 36,140 28,541 495 451 946 1819 2089 1923 24-78 33 01 Second Period Total Behjaum : — First Period 29 33,637 64,681 28-12 10 10 6,332 7,244 10,814 11,909 175 299 1707 1644 27-63 41-27 Second Period Total Deesa : — First Period 20 13,576 22,723 474 1674 34-91 4 7 2,682 7,473 2,879 12,262 144 250 1073 1641 53-69 33-45 Second Period Total Kirhee : — First Pei-iod 11 10,155 15,141 394 1491 38-80 10 14 6,207 9,131 9,447 17,218 162 234 1521 1886 2609 25-63 Second Period Total 24 15,338 26,665 396 1738 25-82 " These results do not exhibit the loss at all the Indian stations during the 39 years included in the first Table, but at those only where regiments have been stationed for the Avhole or the greater part of a year ; they are also exclusive of the loss on long marches, which is often very heavy ; but it has been considered more ad- visable thus to found the results on incomplete data, than to incur the risk of adopting what might prove to be incorrect/' STATISTICS OF THE INFLUENCE OF CLIMATE SEASON IN THE PRESIDENCY OF MADEAS. Madras Presidency. — In an admirable " Report on the Sick- ness and Mortality among the Troops serving in the INIadras Presidency," pi'epared from a " General Topographical and Sta- tistical Account of each of the Military Divisions of the Presi- 112 STATISTICS OF THE INFLUENCE OF CLIMATE dency/' printed by order of the Madras Government, Dr. (Jraham Balfour, of the Grenadier Guards, classifies the stations occupied by the troops, European and native, as follows :* — ■ 1 . Those situated on, or immediately adjacent to, the sea-coast. 2. Those on the plains between the coast and the mountain ranges. 3. Stations on the table lands. 4. Stations peculiar from position, and from being depots for recruits or for pensioners, but which are not included among the first three, with a view to avoid erroneous conchisions. First Class, or Stations adjacent to the Sea Coast, — " On examining the relative proportion of admissions and deaths of Europeans by each class of diseases, it will be seen that fevers and diseases of the bowels furnish a third of the admissions, and that the latter and inflammation of the liver are the cause of half the deaths. To the prevention of these three classes, therefore, the atten- tion of ynedical ojficers in India should be particularly directed. Fevers, although from their prevalence a source of considerable inefficiency, are by no means very fatal, the proportion of deaths not greatly exceeding that among troops in this country, and being even a fraction under that of sepoys at the same stations. '' In this respect there is a striking contrast between the East and the West Indies ; fevers in the latter occupying the most prominent position, both as regards admissions and deaths. In- flammation of the liver, however, is comparatively a rare disease, and productive of little loss in the West Indies, while in the East it* gives rise to a large proportion of sickness and mortality. The troops appear, on the other hand, to enjoy a remarkable exemp- tion from diseases of the lungs, compared with any of the places of which the statistics have been investigated, a subject to which we shall hereafter more fully advert. " To enable us to compare the amount of disease and its efi'ects upon the native soldiers in India with other troops serving in their native country, we have annexed the ratios of sickness and mor- tality among the cavalry in the United Kingdom and the Cape native mounted rifle corps, being the only available information on the subject. The results show a most extraordinary uniformity in the mortality, which amounts to — 15 per thousand for sepoys, 14 per thousand for cavalry in England, and 11*9 per thousand for the Cape corps; or, deducting epidemic cholera, to — 12" 8 per thousand in England, * The records here referred to were prepared throughout Madras, in furtherance of the general plan proposed and carried out by me, in 1835, when in Bengal, for requiring from the medical departments "Topographical, Statistical, and Sanitary Reports on Districts, Stations, and Cantonments throughout the three Presidencies of India, and tlie Dependencies to the Eastward." The manner in which this call was answered ia INIadras reflects great credit on the medical department of that Presidency. AND SEASON IN THE PRESIDENCY OF MADKAS. 113 ]2*2 per thousand in Madras, and 10*9 per thousand at tlie Cape of Good Hope. The class of diseases which has been most prevalent and most fatal amon<;st the sepoys has been feversj for which, on the aggregate of the stations on the coast, 2Z2 were admitted, and 3'1 died per 1000 of the strength. But this has been materially affected by the stations of Masulii^atam and Chieacole. Omitting these two stations, the admissions by fevers would amount only to 129, and the deaths to 2 per 1000 of the strength ; which, however, are higher ratios than in the United Kingdom, or among the native troops at the Cape. " The next class of diseases in point of importance has been those of the bowels, which have caused 45 admissions and 2" 6 deaths per 1000 among the native troops. The ratio appears remarkably low in a coimtry where, among Europeans, this class of diseases occupies so prominent a place; but the constitution of the Indian and the nature of his diet no doubt tend to his exemption. " Cholera has proved a source of considerable mortality, and has displayed, as usual, great irregularity in its prevalence at different stations, the deaths varying from 0-.3 at Mangalore to 16*3 per 1000 at Ramnad. It has, however, fully maintained its fatal character, 217 out of 429 cases having died. " The exemption from diseases of the lungs, which we remarked in the case of Europeans, has been enjoyed to a still greater extent by the native troops ; among whom, also, diseases of the li\er, which were a source of considerable sickness and mortality among the former, are of very rare occurrence. '^ Beriberi, included in the class of dropsies, deserves especial notice, as having been almost entirely confined to Masulipatam, Yizagapatam, and Chieacole. The admissions at the first of these stations were 130, and the deaths 22; at the second 21, of whom 6 died; and at the last 243, and 16 deaths. Bex'iberi is chiefly confined to situations near the coast, being rarely seen on the high lands, and is supposed to be of malarious origin, which derives corroboration from its great prevalence at Masulipatam and Chi- eacole, whei'c the troops were more exposed to that cause of disease than at any of the other stations. It is seldom met with in Europeans. ^^ Second Class, or those on the Plains between the Coast and > THE Mountains. — From a table of sickness and mortality in the sta- tions on the plains between the sea-coast and the mountain ranges. Dr. Balfour, speaking firstly of Europeans, says : — If we deduct the deaths l)y cholera, which, from the irregularity of its visitations, and in the amount of mortality to Avhich it gives rise on different occasions, may fairly be omitted in estimating the influeuce of the climate, we find a remarkable similarity in the ratios, being re- spectively 32*4 "and 33-3 per thovisand. 1 114 STATISTICS or THE INFLUENCE OF CLIMATE The classes of diseases, however^ by whicli the admissions and deaths have been produced are somewhat differently distributed, fevers having been more prevalent and fatal at Trichinoijoly than at the coast stations, probably owing to the extent to whicli irriga- tion is carried on around it, and the consequent artificial produc- tion of marsh ; Avhile it has enjoyed a considerable exemption from diseases of the bowels; and also, though not to so great an extent, from inflammation of the liver. The comparative immunity from diseases of the lungs, which we formerly noticed, is enjoyed to quite as great an extent at this station, being only a very small fraction above that from pneumonia and catarrh alone among the cavah'y in the United Kingdom, and less than a third of that from the Avholc of the diseases of this class. Third Class, Stations on thk Table Lands. — By a well- arranged table the sickness among European troops is shown to have ranged between 1G73 at Bangalore, and 2438 at Kamptce, and the mortality between 22'7 at Bangalore, and 82"1 at Secun- derabad and Jaulnah, the average of all the stations on the table lands being 2082 admissions and 41 deaths per 1000 of mean strength. The mortality at Secunderabad, however, has been more than double that of any other station ; omitting it from the calculation, the average amounts only to 29'2, being very little higher than that of the Mauritius or the Bermudas. The excess at Secunderabad has been caused chiefly by dysentery, which, during the period under review, gave rise to a higher rate of mortality than that Irom all causes at the other stations on the table lands. This disease has been a source of great sickness and mortality among the Europeans ever since Secunderabad was first occupied in 1804, and committees have at different times been appointed to investigate into the causes of it, but without any satisfactory result. The unhealthy character of the station has been attributed by some medical officers to " an endemial malarious condition of the atmosphere, occurring at a season when the vicissitudes of climate and the diurnal ranges of temperature ai'e very great. ^' It is worthy of remark, however, that the great excess of dysentery has occurred among Her Majesty ^s regiments, while the European artillery have been comparatively exempt from it. Thus, out of an aggregate strength of 7561 of the former, during ten years, 2100 cases of this disease were admitted and 306 died, being at the ratio of 278 and 40 5 respectively ; while among the Hon. Company's artillery, out of a strength of 1382, only 2(t2 admissions and 21 deaths took place, or 190 of the former and 15' 2 of the latter per 1000 of mean strength. Other observers attributed the sickness of the troops to the situation and faulty condition of the barracks. Considerable alterations were, in consequence, made in them, and the drainage was improved, apparently with some benefit at first; but in 1843, AND SEASON IN THE PRESIDENCY OF MADRAS. 115 Her Majesty's 4th "Regiment suffered to as great an extent as any that prr^cedcd it. The position of the barracks, nearly surrounded by high kind, Avhich intercepts the free current of air, and on the border of a low, swampy i)lain interspersed with tanks, stagnant pools, and rice-fields, all fertile sources of malaria, seems the most l)robable cause of the unhealthiness of the troops. This opinion is much strengthened by the fact that the cavalry quartered at Bowen, fully two miles north of the cantonment, have gene- rally been very healthy ; but we have no specific returns on the subject. The troops at Kamptee have suffered considerably from fever, which prevailed to a considerable extent in 1831. There is nothing in the position of the cantonment to which this can be attributed. The source to which it is generally referred is the dense and ex- tensive tracts of jungle by which the station is surrounded, although at a distance of upwards of ten miles. The results of the stations on the table lands generally are satisfactory, as showing that posts may be selected where European troops shall be exposed to a rate of mortality in a tropical climate not greatly exceeding that to which they are subject at home. Even Kamptee, although less favouraljle than others, illustrates the advantage of a judicious selection of a site. When the subsi- diary force was first sent into this country, they were quartered close to the capital ; but the situation proving very unhealthy, tliey Avere moved to Kamptee, and have suffered less from sickness than at their first station. The native troops suffered to a greater extent at Secunderabad than at any of the other stations, and, as with Europeans, Kamptee has stood the next in point of mortality. They have enjoyed the same marked exemption from hepatic inflammation, which has already been shown to exist on the coast and plains, and which, with dysentery, forms the most striking point of contrast with the ]']uropeans. The immunity from pulmonary disease, which is one of the most remarkable features in the sanitary condition of the troops in India, exists even in a more marked degree than at the stations already examined. The general results show the same favourable condition of the native army, the mortality from all causes amounting only to 14" £, or within a fraction the same as among troops in the United Kingdom, aiul, exclusive of cholera, only 11*4 per thousand of mean strength. Omitting the consideration of four " stations peculiar from position, and from being depots for recruits and pensioners," we come to the aggregate summary of Dr. Balfour on the more pre- valent diseases of Europeans at all the various stations above severally noticed. FKVtus. — From an elaborate table, it appears that among both European and native troops fevers have been more prevalent and I 2 110 STATISTICS or THE INFLUENCE OF CLIMATE fatal at stations on the table lands than at those on the coast, or on the plains — a circumstance which shows that in India a certain moderate elevation above the level of the sea is not of itself sufficient to secure exemption from this class of diseases. On the coast stations, and among British soldiers, ephemeral and continued fevers predominated in the proportion of three-fourths, and at stations on the plains, of five-sixths of the admissions by this class of diseases ; while on the table lands two-fifths of the cases have been paroxysmal fevers. Of the stations on the table lands Bangalore is comparatively exempt from fevers ; while the proportion is very high at Bellary, Secunderabad, and Kamptee. There is, however, this marked difference between the latter, that at Bellary one-third only of the cases are of a paroxysmal type, but at Secunderabad three-fourths, and at Kamptee five-sixths are of that character. This difference would appear to be explained by reference to the description of tliese stations ; the ground around Bellary being free from marshy ground, with the exception of the tank to the south-east of the fort ; while Secunderabad has been shown to abound in all the alleged causes of fever. The cause of paroxysmal fever at Kamptee is not so obvious, unless it arise from miasm generated in the numerous ravines and running waters by which the country is intersected. A review of these stations will show why, at Secunderabad, no improvement in health has resulted from barrack and hospital amendments ; for such improvement can only be effected by removal to a healthy locality. At Bellary, on the other hand, mere structural arrangements may be expected to be followed by diminution of fever and mortality. The excess of fevers among Europeans, compared with the natives, is not so great as to lead to the supposition that it is a disease peculiarly affecting immigrants — persons not indigenous to the country. There is, however, a very mai'kcd diftei'ence in the prevalent type in the two races. At the stations on the sea-coast two-thirds of the cases among the natives have been paroxysmal fevers, while among the Eui'opeans they have scarcely amounted to one-fourth : on the plains the proportion has been three-fourths among natives, and about one-sixth among the Europeans ; and on the table lands the relative proportions have been three-fourths and three-fifths respectively. Thus the prevailing form appears to be paroxysmal among the natives, and, with the exception of the table lands, continued among the Europeans. It is interesting to observe that the relative amount of paroxysmal fevers among the natives is very nearly the same in all the three classes of stations, and that the intensity of these diseases also very closely approximates — the proportion of deaths to admissions by fevers of all types ranging from one in seventy-two and one in seventy-six. Dr. Balfour concludes the subject of fever by stating that the above results tend to disprove the theory Avhich would refer the AND SEASON IN THE PRESIDENCY OF MADRAS. 117 fevers of the AYest Indies to excessive licat and moisture ; for tliat, were these alleged causes adequate, we should have the worst fevers in the East, the heat and moisture being greatest there, and many of the ^Madras stations being remote from the refreshing influence of sea-breezes. During five years the admissions of Europeans on account of eruptive fevers was only 1 per 1000 of the strength. Diseases of the Lungs. — The ratio both of admissions and deaths among European troops from this class of diseases is lower than when serving in their native country. The mortality has been lowest on the table lands, and highest on the coast stations, especially at Madras, where it has been dovible that of the other stations. This, however, has been caused by the numbers of invalid soldiers assembled there, awaiting embarkation for England. Omitting Madras, the mortality at the coast stations amounts to 2 3 per 1000, or almost the same as on the plain. There is no British colony which appears so suitable or so likely to prove bene- ficial to the class of consumptive men as the East Indies. Diseases of the Liver.— In this class of diseases a remarkable diversity is shown, both in the prevalence and mortality of inflam- mation of the liver among the Europeans as compared with the native troops. Among the latter this disease is of such trifling prevalence as scarcely to require notice, while it is more prevalent and fatal among the Europeans than in any other of our colonies. The same fact holds in respect to our troops in the West Indies, where the negroes enjoy a considerable exemption compared with Europeans. These results may be influenced to some extent by the mode of living and by the habits of the two classes of troops, especially as regards the use of intoxicating liquors ; but this is by no means adequate to explain the difference. The proportion of cases among the Europeans has been very nearly the same on the table lands as on the sea-coast, and the deaths have been even higher. Among the native troops the exemption has been enjoyed alike in all the divisions. Diseases of the Bowels. — This class of disease, though less prevalent than fevers amongst Europeans, is more fatal, causing more than two-fifths of the mortality. The great majority of cases consist of dysentery and diarrhoea, and it will be observed that these have proved most fatal at the stations on the table- lands — a result attributal)le to the great prevalence and fatal cha- racter of dysentery at Secunderabad. During the five years 1S31.-.38, the admissions at that station by dysentery alone amounted to 1591, and the deaths to 235, being in the ratio of 327 and 48-3 per 1000 of mean strength. If the deadly station of Secunderabad be omitted in the calculation, the admissions at the other stations on the table lands by dysentery and diarrhoea amount only to 186, and the deaths to 8-0 per 1000 of the strength. Among the coast stations dysentery is nearly twice as fatal at 118 STATISTICS OF THE INFLUENCE OF CLIMATE Cannaiiore as at any of tlie others^ and lias of late years been on the increase. The concluding observations of Dr. Balfour are eminently de- serving of notice, as bearing out certain of the objects which I had in view in advancing the original plan of medical reports. The facts contained in the preceding paper, he says, point out the necessity for a carefid attention to the selection of the site for a cantonment. It has been shown that there are stations in India where the mortality among European soldiers is but little higher than in their native country, and that even where this is not the case, different localities within a short distance of each other possess very different degrees of salubrity. It is true that military and political reasons do on rare occasions exist, which render the occu- pation of an insalubrious spot necessary ; but where this is not the case, competent medical officers should be directed to inves- tigate and report upon the sanitary condition of any place which is intended to be occupied as a military station. The utility of a system of periodical reports from rll medical officers must be obvious, as affording information to the authorities on the state of the health of the army, and bringing under their notice any extraordinary amount of sickness and mortality that may occur in it. An opportunity is thus afforded, also, of direct- ing inquiry into the origin and progress of the particular disease by which it is produced^ and, if practicable, of removing or miti- gating its causes. The attention of medical officers would thus likewise be more constantly directed to the sanitary state of the troops, and tUc system of reporting would further be attended with a progressive improvement in their professional acquirements ; but to render such reports of practical avail, they must be brought to the notice of responsible authority in a condensed form, and without any delay. Humanity and economy alike require such management of an important subject; for a little just calculation will prove that the expense of preserving the soldier in health and efficiency is much less than that of replacing him, and that in this, as in most other cases, prevention is better than cure. The documents from which the present report has been pre- pared were printed by order of the Madras Government, but not published. Dr. Balfour's object has been to make the results of the investigation generally known, in the hope of directing a larger degree of attention to the important subject of the soldier's welfare — the first step towards which is, the ascertaining with accuracy what diseases he is most liable to, and to what extent, in the different districts, stations, and cantonments in which he may be called on to serve. It is highly desirable, also, that all such information should be gratuitously placed at the disposal of the officers of the army, for their information and benefit. The public sliould likewise have free access to it. AND SEASON IN THE PRESIDENCY OF MADRAS. 110 All these suggestions of Dr. Balfour's are contained in my original plan ; and I am happy in being able here to adduce so able a witness to its desirableness. In conclusion, I quote from Dr. Balfour the tables on pp. 1"20, 1^1, exhibiting the sanitary condition of both European and native troops. CAirSES OF SICKNESS AND MORTALITY OF BRITISH SOLDIERS AND SEAMEN IN DIFFERENT CLIMATES, ON FOREIGN EX- PEDITIONS, AND IN CONFLICTS WITH VARIOUS ENEMIES. M. Meyne, surgeon in the Belgian army, says that, leaving out the influence of epidemics and battles, an army of 100,000 men may, by the sole act of having entered on a campaign, have 10,000 men in hospital. "At the end of some months, if some engagements have taken place, and the numbers of patients have increased, as is usual, vre must count upon a third being placed out of service by disease. During the first fifteen years of the occupation of Algeria by the French, one-eleventh part of the forces was annually carried ofl' by disease, and a two hundred and sixty-fifth part only by the casualties of war — i.e., twenty-three times as many.'' The same author adds, that the losses of the French army in the Crimea were 16,000 deaths by the accidents of Avar, and 53,0i'0 by disease — i.e.^ IG to 53 ; and the proportions were much the same for the Sardinian and the English. Of 25,000 French who marched from Bayonneto Lisbon, in 1808, an enormous but unascertained number perished on the road from fatigue and the scorching sun, no enemy having yet been encountered. In land battles, the ordinary proportion is said to be one killed to every five casualties. Of the wounded, owino; to the greater amount of attention and comforts which the officers, by their jiosition, are enabled to secure, the proportion of deaths from wounds amongst them is found generally to be one-twelfth, while that amongst the rank and file is one-eighth. The following summary deductions are made by M. Budin, in his admirable " Statistics of the Sanitary Condition and JMortality of Forces by Land and Sea, as influenced by Season, Localities, Age, llace, and National Characters." These subjects are of such vast interest and importance, to naval and military surgeons especially, that I hope to stand excused for here republishing the conclusions of our worthy fellow-labourer of the French army : — " 1. The losses of armies from disease greatly exceed those in time of war from the sword and fire of the enemy. In the Wal- chercn expedition, in 1809, the mortality of the English army amounted to 16-7 deaths by wounds, and 332 by diseases per lOOU of the strength. " 2. The most trifling losses are experienced in general by troops 1-20 STATISTICS OF THE INFLUENCE OF CLIMATE 3 ^ ^i pi; =^ 3^05 f^ ?5 '^ ^ a "5. . a i4 5 CO OIi^oOCDOOSoOOSOOCM OO Ol i> 00 OI 05 l'-- -* (» Kl otiOi'^cocooooico^co OS CO 1 01 Oi o 00 oq J:~i— looioosiooooir-oi -*01i00i— I'^^i^cOOO Ol O lO CO t^ Ol O Ol OS CO of of of of of co" co" of i-T rn" Ol r-f of OS a a a 3 o w s (MCT>COa>(MI^O>r5OIOIC0-*OI OO Ol T^t-0SC00SO>0 01l0O -^OCOOlCOoOi-Ht^Oi— 1 r-IOlOlOlCOCOOlCO^^CO CO r-4 CO a 01r-|i:OM0 •£■ CO CO OS CO lO osoiccoocoi^caasooo o oi :::::::::: o OS o bo a s ll^OJVflOOOlOIi— l-*OI-*l IOCO-<1IOI05-*CO->^COCO 1^- co ooo^<^o^^o^cooso:)^pl-l -*cO'Osos.— it^os"OOST-i COOlOli-HCDOlrHOIrtOl o CO oq 13 <1 CC lO Ol lO O O '-0 05 01 I— 1 '*l-*03WCD':0t--OC0'^ -* 00 T— 1 OO lO '^ 'X> CO Ol 01 of r-T of I-T co" CO of of of of Ol ^* Ol 'rtl l^ -^ O OS t^ Ol 00 r-H Ol osoococxoco^oiiot^o ^ TO -^ Ol CO Ol t^ CO 00 'SH rn" I-T I-T r^ of of r-T i-T r-n" i-T OO CO I-T si coocoiocoo^oooco C000C0«DO-*lOC0Oli— 1 COCOlO-^lOlOlOt^tOCO r-li-li-Hi-lT-li-li-li-lr-lr-l o OS • a o a 3 '6 s r-HtOCat^i— I^O5(M^00 COOIOItO^OICOOl^OI 1—1 CO C0>0,— l--tl01i— IT-HOSCOCO 4J^^-(^^dooo6sTHl^3lr50 eooicot~'HOi^oi'*0-*CO cot^^cocoojiocoi— it^ t^OJOIOl-^^COlOtOCO I-l OSOl'^CO^COOt-^Ol OS lO Ol ^ OO 1— 1 OS 'j3 t^ >* OSCOtJJ'^COOOOCOCDCM OS CO lo '^ U-; lo o lo lo rH ^ 00 OS ^^ 1~ lO lO Ol GO 01 0ico4n.i3 Ol OI CO 'i* -* "O '^ Ol OO 03 OS Ol 'a O1-*lOO100i-llO-*>Or— CO Ol 1.^ rH Ot -* 1— 1 OO 0> '^l «DOS t^t^OkOt^OOSt^ of CO* CO' of Co' of r-T of r-T 1-T o co" O) lOCOOlcOOi— ICO'JIOOS r-lT— ICO'^COOS.-hOSIOO CO CO OO 1— _^0 ^ Os^i-H I-H CO r-T r-T r-T r-T oT of t-T of of of CO I-T CI 03 oqco«DOD<3>o-*oco^ OCOO>0 1^01C5Sl/500'0 o-^o^o^oooosoot^ of of of rn" i-h" t-^ 05 co" g » a"? s S 13 S COCOCO»OOOSlr~«Di-icO -*i-ICOOIOI'*<'-101^CO o o CO i-Hlftl^-r-Ht^lOeOi-Ht-OI ojcocboicbos4fOt— (COiDCOOIOOl COOS-^'^lOOSr-IOSrHOO >r5O3(Xl0O00C0^*i'*'OOl 00 of t^OSOl^COCD0001t~i-H coco-no'^ost-it-coio lOOOSrHi— ICOOOOIOS I-T i-f r-T I-T rt" of of or r-T >-l CO cooosoooscoookot^ OS «0 Oi l^ ^ 01 O Ol 1^ lO OiOSOOt~t~COt^-t-.CO'« OS OS O5Ci-lOlCO-*llO«Ot-0O 1^' oicocococoooeocococo lis OOOOCCOOOOOOOOOOOOOO -fJ *— (i-Hr— 0C0t~00 ._ Ol CO CO OO CO CO OO CO CO CO ■t^oocooooooooooooooooo 3 AND SEASON IN THE PRESIDENCY OF MADRAS. 1:21 O M < » oi a S CS )4 5 t--coeoe«siMOOoOi-iOlO 0-1 CD OQ (M!0'0OOC0'*C00i05 00C005O«0— ICO,— (l^ 5O-*o0t^CO^CO-*ri OCO -OCO»0-*COC<1C CO »C C3 -rf (M "O O lO »0 iO^^_^ CO O l^ (N lO t^ Ci (M 1-^ i-T r-T i-T r-T cn-iOiOiO t^Ot^^MCOO'OCOiOCO t^0300(MlOOCOt~,-lCO -*'" ^ co" co" co" co" co~ (m" co" co~ OS lo- co d S v u g 5 1— l-*OCOl^COOi-l05lO OOlO^CO'Hr-HOiJ^t^OO I— 1 r-l i-l rH r-l OS OS -j*l(MCDCOOSO>(?^COr-lOO rH00(Mt-OSQO7-lO3i-«C-l 7-1 (Mr-Hr-iT-li-l T-li-l 4h 'S "I -* 50 OS O t^ t^ (M CO «0 o co' -j^ o' -*" •*" OS co" COI--CO1— liOOOSoOI^t^ l0C0 1^'*Oi-l'*l000SC^ -^COCOCOl^Ot^CDCOt^ CO 1 0'r5(M^(N050COOtO ?o o" :::::::::: < 8 < CO 13 (MCO-*CO(M»0'*C007^07^ r-l i-i rH CM (M p 1—1 1—1 M^ t-^ -*" CO co~ so" co" CM 1 Ml o" CO ■a 4) 5 l:~u:il^->i<'*O-*IMC0O I-- o cs-^^ooosiposcpoAio'0 l-l r-l,-l,-lr-i,-l,-IC*0 1:-^t<005 CT Co' <>f C-l" r-n" "M' r-T i-T C0~ C-f OO CO CO c-f ooscoosioootocoo coMt-coot^ioooioo •-*liO-*-*»OCOCOlOoOI^ »o a Eh Or-icoaicooocof cf co" co" CO os" CO a CT>Or-l'^«OI--CO (MCT'COcooocococococo acooccoocoooooooocco o gOSOr-llMCO'^lOCOl^OO .s'Mcocococococooococo +^00000000000000000000 rtrtr-lT-l.-lr-li-li-lrHr-l.-l i 1.32 STATISTICS or THE INFLUENCE OF CLIMATE serving in their native country ; and tliey augment in European remies in a direct ratio as these approach the equator. The inverse takes phice with negro troops, among whom mortality increases obviously in the direct ratio of their removal from tlie tropics. *^ 3. Even during a residence in their native country, European armies are subject to a mortality exceeding, in a sensible manner, that of the civil population at a corresponding age. In certain tropical countries, Sierra Leone for example, the mortality of the soldier (483 deaths per 1000) surpasses the proportion of deaths which occurs in England among the male population at the age of 100 and upwards (454 per 1000). "4. In localities bordering closely upon each other, the mor- tality often diHers in a very marked degree. This ought to be seriously considered in the selection of military stations and places for garrisons, as well as in the choice of sites for barracks and hospitals. " 5. In tropical regions the annual number of deaths ranges within \crj wide limits from one year to another, so that the mortality of a single year cannot serve as a basis for estimating the mean mortality of these countries. " 6. In the most unhealthy tropical climates the judicious choice of good positions on elevated grounds will often secure to armies, composed of men of the Caucasian race, a perfectly healthy con- dition, worthy of tbe most favoured regions of temperate climes.. The degree of elevation required varies in a marked manner with the geographical latitude and longitude of the place. Residence on the high grounds is fatal to negro troops. " 7. The geological nature of the soil exerts a decided influence, not only on the sanitary condition and mortality of armies, but also on the presence or absence of certain defects which render a man unfit for military service. " 8. The increase of the mortality of armies, especially in warm climates, is determined in a great measure by the marshy character of the localities occupied. " 9. The mortality of the army in the different quarters of the world considerably exceeds that of the navy. "10. In the temperate regie n of Europe, the density of the population in garrison towns temis to affect the sanitary condition, and augment the mortality of the troops. The relative density of the population of the different quarters and streets of a large toAvn should be seriously considered in selecting sites for barracks and hospitals. "11. Numerous facts militate against the hypothesis of a pro- gressive amelioration in the sanitary condition of European troops in warm climates in general, and particularly in tropical regions, as an effect of length of residence. "13. In a military point of view, the knowledge of the patho- AND SEASON IN THE PRESIDENCY OF MADRAS. 123 gouie march of the seasons iu different parts of the globe, and of t'lie relation of the sanitary condition of armies with the different meteorological influences, is of immense interest, and has not yet received the attention it deserves. " 13. The pathogenic influence of the seasons is in a strict de- pendence upon the quality of the soil, the latitude, longitude, and elevation of the places, their position in the northern and southern hemispheres, and the nationality and race of the soldier. " li. In all countries Avhere the influence of age has been studied, the lowest mortality has been found to be that of soldiers from eighteen to twenty years of age. '^15. Nationality and race favour or neutralize the pathogenic action of climate, so that, under precisely similar circumstances, troops of different races and nations may suffer and die in different proportions and of different diseases. ^^ To the above we may add, of our own experience : — 16. That, in the first expedition to Rangoon, the mortality of British soldiers, in the fii'st year of service, 1821-25, amounted to 35 deatlis from wounds, and 150 by disease, per 1000 of strength ; while in the second year, 1825-26, the losses in action and by disease were about one- half of what occurred in the first, making a total mortality by wounds and by disease of 727^ per 1000 of strength in the two years. An expedition to Rangoon havingbeen determined on in January, lS2t, cattle were marched to Calcutta from distant stations, and slaughtered in the month of February, under a degree of heat so high that, before the process of salting could be established, some degree of decomposition must have commenced in the meat in- tended for the use of the soldiers. War was declared on the 5th of March, 182 k '^ From the middle of June,'^ says Sir A. TuUoch, " the troops had nothing to subsist on but salt beef and biscuit of very inferior quality, and were without vegetables of any kind to counteract the effects of such a diet.^^ 17. The other British expedition employed against Burmah, in 1825-26, and employed in the province of Aracan, under Ge- neral Morrison, became speedily ineffective from the malignant fever of the country. Five thousand five hundred soldiers, Euro- pean and native, were soon struck down with the disease, without reckoning the sick of the public establishmeuts, and of tlie camp followers : — soon, indeed, " every one who was not dead was in hospital.^' " The Bengal infantry sepoy suffered the most ; in fact, they disappeared altogether.^' Of the original European force three- fourths perished, and the miserable survivors were ruined in con- stitution — none living long thereafter. 18. It has been seen tliat in the first expedition to Rangoon, l82i-25, owing to the neglect of every sanitary precaution, "the deaths nearly equalled the number of British soldiers originally 124 STATISTICS OF THE INFLUENCE OF CLIMATE employed on this service^ and tliat but for the seasonable reinforce- mentswhich arrived, the whole must speedily have been annihilated." To show, however, that governments, like individuals, are sIoav to derive lessons from experience, we have cattle again marched to Calcutta, and slaughtered in the same heats of February, as stated by Colonel Hough, with the same consequences to the European troops employed in China, in 184U-42. It was the horrors of Rangoon over again. " The attempt to improve the Calcutta salted meat by fresh brine at Singhapore did not answer; and thus, in the island of Chusati, between the 5th of July and the 22nd of October, 1840,'' " out of three thousand six hundred and fifty troops, only two thousand and thirty-six were fit for duty" — the 2Gtli Cameronians and the 49th Regiment being the chief sufferers. These fine regiments, says Colonel Hough, were reduced " to a perfect skeleton;" and, in the short space of three months, the former corps was reduced from upwards of nine hundred strong to two hundred and ninety-one. There was here, in addition to the neglects of the Government, neglect and grievous ignorance in the officer placed in command on the island of Cliusan. " The sickness was comparatively mild amongst the officers, who had means of living on more generous diet." This, it must be confessed, reads very badly of the officer in command, who seems to have lived well^ while he neglected the comfort and welfare of the soldiers. As a contrast to our former arrangements in Burmah, in 1825-26, and in China, in 1840-42, may be cited the following: — "The Marquis Wellesley began early in the cold season of 1800 to pre- pare for the expedition to Egypt, which sailed in April from Cal- cutta." The circumstance here recorded ought to be remembered to the honour of our great Indian statesman, as should also the admirable arrangements of the INIarquis Dalhousie for the conduct of the last Burmese war. Referring to the comparative circumstances of military service in various countries and in different climates, it may not prove un- interesting here to quote the results of some battles, sieges, and campaigns in the East Indies, as compared to similar results in Europe. In Marlborough's battles the losses were as follow : — ■ 1704. Blenheim 1 in 5 \ 1706. Ramillies, about 1 ,, 16 / .,,. , • • i i i TTAQ r> J 1 1 oi? > Allied armies included. 1/08. Oudenarde 1 ,, 36 ( 1709. Malplaquet* 1 „ 5] At Waterloo,f the Duke of Wellington lost in the proportion of . 1 in 6 * In this desperate battle "the total loss of the Allies was not less than 20,000 men, or nearly a fifth of the number engaged. " The proportion of the Allied loss in officers to their total loss was, at Ramillies, one in ten, which is the same proportion as that of the British army at the battle of the Alma." — Colonel Macdougall's Tluory of War, 1856. t In the battle of Waterloo, out of a British force of 36,273, there were killed 1117, AND SEASON IN THE PRESIDENCY OF MADRAS, 125 The Indian returns sliow the following ratios : — 1803. Assaye 1 in 3 1804. Dieg 1 „ 44 1817. Mehetlpore 1 „ 6 1817. Sitabukly 1 „ 4A 1818. Korygaum 1 ,, 3^ 1845. Maliarajpore 1 ,, 6 1846. Battles of the Siitlej 1 „ 5 1848. Chilianwallah 1 ,, 7 "Here/' says the Ed'nihargh Review, No. 197, "is no proof of eowardice on the part of the defeated, whose loss in every affair, except perhaps the last, greatly exceeded our own.'' During the siege of Seringapatain, in 1799, it was stormed and captured " by 1^370 men, in two columns." The loss in the assault was as follows : — Killed. Wounded. Missing. European officers 22 . . . 45 . . . — ,, N.C.O. and soldiers . . 181 . . . 122 . . . 22 Native soldiers 119 ... 420 ... 100 Making a total, killed, wounded, and missing, of 1031 men. Of the above officers, . twenty-five were killed and wounded in the assault. Lord Lake, with an original force of 9000 men, augmented after the second storm by the force from Bombay, according to Colonel Hough, appeared before Bhurtpore in January, 1805. During four successive assaults, each increasing in desperation, Lord Lake was repulsed with the losses on each occasion, and, in the aggre- gate, as follows : — First assault 456 men killed and wounded. Second ditto 573 ,, ,, Third ditto 894 „ ,, Fourth ditto 987 „ ,, Total 2910 „ „ There were of officers killed, 15, and 95 Avounded, making a total of officers killed and wounded, 110. " Major Thorn gives the loss in all the operations at 3100 men and 10.2 officers, killed and Avounded." During the expedition to Walcheren, in 1809, 1"67 per cent, of the entire force was killed in action, and 32*2 per cent, perished by disease, making a grand total of 34'69 per cent, in that fatal and ill-directed attempt. Of our losses in the earlier campaigns of the French revolu- tionary war, we receive but the following general statements : — In 1794^, says Dr. William Fergusson, the French army in Flanders, composed principally of mere boys, many of them of making about 3'9 per cent. ; but, including 362 men killed of the King's German Legion, the ratio rises to 4 '9 per cent. The total force, British and Allied, under the Duke of Wellington,, amounted to 69,686, out of which tiiere was a total killed of 2947, or a grand total killed of 4 '2 per cent., British and Allied. 126 STATISTICS OF THE lATLUENCE OF CLIMATE five feet three or four inclies iu height, " kiclvcd us before them like a foot-ball through Flanders and Holland into Germany, destroying in their course full three-fourths of our army." The same authority, speaking of the same campaign, says that " by disease, by famine, by the rigour of the season, and by the sword, out of a host of fully 30,000 men, Avhen the retreat from Flanders first began, scarcely 8000 remained to witness its completion." Figured statements more in detail would be desirable in respect of so important an operation as that described by Dr. Fergusson, but they are not now procurable ; and in respect of the Continental >vars of 174-5 and of 175(3, as well as of the first iVmerican war, it were in vain to expect any accurate record. The hospital arrangement of the British army, in 1794, was very defective, and the experienced regimental surgeons were set aside by order of '' an old, broken-down court physician of Lon- don — an apothecary from Weymouth, chosen by George III. to direct and administer the complicated and difficult medical and sanitary affairs of immense armies, constantly engaged in active Avarfare, in various countries. He purposely superseded men like Robert Jackson, and placed over them " graduates of the English Universities." The consequences were such as might have been foreseen. . . . Disorderly hospitals," says Dr. Fergusson, " will destroy an army faster than it can be recruited." We may infer, also, that in those days the sanitary general arrangements were on a par with the hospital management ; and w here both these are deficient together, there can be no hope for the safety of any army. In the Peninsular army, again, under the Duke of Wellington, taking forty-one months during which the war was can-ied on with tlie utmost vigour, an annual mortality of about 4 per cent, occurred in battle and from wounds, and 12 per cent. Avas fiom disease, " being nearly 16 per cent, of those employed;" whereas, in the first year of the first Burmese war, 3^ per cent, of the Britisli troops were killed in action, and 45 per cent, perished by disease, " making a total loss of 48^ per cent., consequently each person employed throughout that year encountered more risk of life than in three Peninsular campaigns." In the second year of the Burmese war, as already stated, the losses in action and by disease were about one-lialf of what occui-red in the first, making a total for two years of b^ per cent, killed in action, and 07 5 by disease, or a grand total for the two years of 7£| of the European force employed under Sir Archibald Camp- bell. The official records exhibit a loss of Gi officers of Her Ma- jesty's army alone, killed, wounded, and died of disease — "a very heavy loss, indeed," says Sir A. Tulloeh, "considering that the average number of officers present did not probably exceed 150."* * War Office Statistical Report. Presented to both Houses of Parliament by com- mand of Her Majesty. AND SEASON IN THE PRESIDENCY OF MADRAS. 127 The expedition to Rangoon, during the first Burmese war, was therefore the most fatal of which ^\e have, as yet, any record. This result of a war with a savage race is the most remarkable circumstance of all, and it is well w^orthy of notice. The Burmese are held in light estimation as soldiers by the Europeans, but Avithout reason. Warring in their natural fashion, in well cou- structcd stockades, they inflicted on British troops almost the same proportionate amount of loss as did the legions of Napo- leon commanded by the marshals of France. Speaking of the destruction of the European force on this occasion, Sir A. Tul- loch makes the followi'ig just observations : — " It seems essen- tial to bring such facts as these prominently to notice, because there is no mode of estimating the severity of military service ex- cept by comparison, and it is of importance that tlie authorities with whom rests the ultimate reward of the soldier should have some means of knowiug the risk of life and peril of constitution by which his peni^iou has been earned." A national mode of warfare always makes itself felt. It does not imitate what, from foreigners, is so easy to copy — the only thing that is always imitated — that which is bad. National modes of warfare are not, therefore, subject to the moral inferiority, the weaknesses, inabilities, and incapacities resulting from tlie sys- tematic imitative routine of organized bodies, so cramping to the pliysical and moral energies of men. When the princes of India set aside their hordes of bO,000 to 100,000 horsemen, and imitated Europeans in forming brigades of disciplined infantry, and in stand-up fights, it was easy to foresee the speedy destruction of their armies, and the fall of their empires. The Highlanders, in 1715, were sneered at by British officers, and especially by those of the cavalry, who, as usual, made the least respectable figure in that remarlcable contest. The Bri- tish army was then, as now, officered by gentlemen, and disciplined on the Prussian system. The formation of general lines and move- ments in lines, combining freedom of action with rapidity of move- ment, were then, as now, its characteristics ; yet, in conliict with peasants led by country gentlemen, it was first quickly routed, and then destroyed. Even at Culloden, wdiere the mountain peasant was led in the usual manner, the result was the same. " The Scottish Highlanders,'" says Robert Jackson, '' were badly provided with arms ; they, notAvithstanding, defeated the regular and experienced troops of the Crown, both at Prestonpans and at Falkirk ; and there are grounds to believe, from the de- cided experiment that was made upon Barrel's regiment at Culloden, that tliey Avould liave defeated them a third time, had there beeiv union in council and accord in action." These various circumstances of service and statistical records are Avorthy the careful consideration of the military surgeon ; as, for the conduct of his difficult and toilsome duties, it is not enough 128 STATISTICS OF THE INFLUEXCE OF CLIMATE that he should have some foreknowledge of the probable amount of his sick, but he should also prepare some estimate of the pro- bable amount of his wounded men. He should know with what results men have fought in the hot climates of the East, as in the temperate regions of tlie West. " It is necessary that a medical chief calculate/' says Robert Jackson ; " and he cannot calculate justly without experience of things.^' This kind of general and special tact in calculation forms, indeed, one of the requirements of an effective administrative medical officer ; and records of the kind here presented prove not only of present value, but they con- stitute useful means of comparison for other times and other oc- casions. An accurate knowledge of what ]ia>i happened goes far to forewarn of what may happen again, under like circumstances. Nor are the results of statistical investigations confined to military operations. On the contrary, they may be rendered sub- servient to, and suggestive of vast improvements in civil commu- nities, as remarked by Sir A. TuUoch in the following important observations : — " To ascertain the races of men best fitted to inhabit and develope the resources of different colonies is a most important inquiry, and one which has hitherto attracted too little attention, both in this and other countries. Had the Government of France, for instance, adverted to the absolute impossibility of any population increasing or keeping up its numbers under an annual mortality of seven per cent, (being that to which their settlers are exposed at Algiers), it would never have entered on the wild speculation of cultivating the soil of Africa by Europeans, nor have wasted a hundred millions sterling with no other result than the loss of 1 00,000 men, who have fallen victims to the climate of that country. In such questions, military returns, properly organized and pro- perly digested, afford one of the most useful guides to direct the policy of the Colonial legislator ; they point out the limits intended by nature for particular races, and within which alone they can thrive and increase ; they serve to indicate to the restless wanderers of our race the boundaries which neither the pursuit of wealth nor the dreams of ambition should induce them to pass ; and proclaim, in forcible language, that man, like the elements, is controlled by a Power which hath said^ ' Hither shalt thou come, but no further!'" The worst enemy to the soldier has everywhere, and at all times, been disease. Out of 1000 deaths in the hospitals at Scutari, for instance, 575 were caused by dysentery and diarrhoea, 173 by fever, and 55 by wounds ; but the last nvunbers do not represent those who died within a fortnight of being struck. " Civilians, however, think that shot kills most soldiers j but Colonel Queach, a Peninsular officer of some experience, and an authority upon the subject, having served throughout the Penin- sular campaigns with the old 95th Hifles^ says, that 40,000 men AND SEASON IN THE PRESIDENCY OF MADRAS. 129 were liilled in action or died of wounds — 120,000 died of disease, a great deal of which was rendered fatal by the want of proper medical attendance ; whilst 1^0,000 raore were, by disease, ren- dered unfit for service." It is a principle in modern war, well understood by the great Marlborough, that the more rapid its course the more humane the result ; and Frederick of Prussia held that " all wars shovdd be short and rapid ; because a long war insensibly relaxes discipline, depopiilates the state, and exhausts its resources.'^ During the protracted operations of previous wars, the destruction of men " by famine and the ague" was horrible beyoiid description. The losses in the great battles of Marlborough do not appear so heavy when we consider the unusual nature of the obstacles to be overcome, the numbers opposed to him, and the obstinate nature of the defence. This first of British commanders was careful, in an especial manner, of the health and comfort of his men. It was the restless energy, the genius, the daring, and the impetuous .spirit of Napoleon, which allowed no repose to his own troops or to those of his enemies, that completed the establishment of a system which set all tardy rules and practice at defiance. He brought his men to make forced marches and to bivouac under every extremity of season — his principle being that " legs win more battles than arms." Judging by the mortality records of our several wars, down to that of the Crimea, no perceptible increase of mortality would appear to have resulted from the improvements in the construction of fire-arms, and the relative efficiency of difi'erent weapons — subjects to which hardly sufficient attention has been directed. From a return furnished by the surgeon of the Scots Fusilier Guards, it appears that of that regiment 120 men were hurt at Inkermann, of which 7 were bayonet and 79 were gun-shot wounds. This conflict, in which the regiments of guards had a loss of 594 out of 2382 casualties suffered by 26 battalions, or parts of battalions, has been held as specially won by the bayonet, and the Russians have termed it an embittered bnyonet contest; yet only 7 in 120, or about 58 in 1000, were hurt by the bayonet. Again, in the cavalry encounter at Balaclava, where the British heavy brigade was opposed to cavalry, of lUG casualties by sword and lance only nine were fatal; whereas, of 281 among the light brigade, who suffered from cannon and musketry, as well as from hand-to-hand contest, 160 were fatal, or more than half, the ordinai'y proportion lieing one death to five casualties. The proportion killed of private soldiers was much the same in the wars of 1793-1815, and in the Crimean war of 1851-55, being in the ratio of 193 to 1000 wounded in the former, to 190 to 1000 wounded in the latter. The ratios of deaths among the wounded officers appear to have been nearly the same in 1793-1815 and in the Crimean Campaign; but the proportions returned as killed K 130 STATISTICS OF THE INFLUENCE OF CLIMATE 2 tUD ,_, rH rH »o t- t~ -* 3 "''S CD ,-1 «0 «0 (M -*i (MO-* C!i -* t~ 00 CO a u ^^^ (M «o_ '^ 10 oi 00 10 CO CJ CO lO lO =OT i^ 00 e3 H— 3 ■»" rn" r-T rH~ to" ■*■ ■* ccT cfcT-*" co" co" co" co' ccT ja 1: CO 00 00 m ^ Ji S13 0000000 000 'ce t£ ^ ^ s c> 000 c j^ »0 tl »0 i-H ■* >0 00 M (Nr-ii-lT-ltO «Oi— ilO(N.0> en t^ CO t^i^CO00C0C0rHO^^l-^rH OS t^ rH 05 rH -^ T-^ 1^ CO rH<^^^o«^05u;50o«o^-oo CO t~ -* I- 10 r-i CO 00 r-i : l-H CO rH rH . t~ n3 •*^COlOOOOt^cCOOO lO 1^ rH rH 00 (M »o CO 00 OS CO 1 ) -<*( (M CO -* >^ > ft f £ f^ 1^1 I a|^ « 3^ a c cc 2 - - i I Is it/ o3 .i: m ,i: o 03 ; -w 1 V>» ten »C" i-^o ..»» a.»» P5 CO •»• »H CO • t^ ^ «^» «3l •>» c 00 « o => ■» -t H a « » 1 c^ * * * «; o oo-s-oooo oo o o o o o o 1 o oo:ot--ooo ,oo o o o o o t^ ; 1 5; a08^«?>*»aQ0l^t^CCOXC> "(Mt* .&> •<» t/jn •05 ;2 r* uacoi-<-*t-H (>» eoc^ CO ' in ' IPs t-s •'2 O'*»C0rtiO>O0C0CO-^t»t~5C O i-( o 1 f^sSg' t^OOOWt-.r.^r-OOOCD^:DOCO cs •* C^ •O^ oo^ « OOQ «<» b^ «^ 1 o<>9 1 r-OOCOOOQO— "t' -- t- CO to ■* ca OS U5 1- t- -H r-l r-1 — 1 r-l CO ^ r-l t-1 60 CiOcoo-^tctO'^r^O'^oirsc OO ^ Oi o c O O c: t- CO 1 <=^- u i-H^50c;'j>com(Mt-cocot-'*c o 9 o 3 COCO^tOrOOQOt^rHCOOt''*l> .^ ■* o ^ _H ,_l CI i^tONtO^QOOOi^COOSCS-^r — * r^ to CO C-l 00 i :OC5-q^^t^-Ht^MC«CSOOCOt^ O rt '^ Tji ^ lO oooooooooooooc o o o o o o <=■ o o o 1 ° oooooooooooooc o o o h- O O O O O C: p ^OOOOt)Ot~tOOOOOiOtOOP- C-1 o ut d ^ O o ^ ir 7^ o eo«-ioto-a'COrtr-!I.2C'°-°'^ — •2C'°-Z ^ C3 rt 3 ^ ^ bo to ■a; pitu !)itu ken •id III pitu ken ken ken pitu ken B 2 3 3 a ~ = Sc«cs--'-«--^acsacsj2«o3'> ;^wH'^i;^HHHO^^H^ '< OOO H '^ w 3.2 . rHO*0(M^-H— ^r^rHOC^"*^*f- '^-^ wh. 2§^ ■-itO T-li-Hr1ir< r-ceOi-H CO -t "5 IN I*! IM < o 3 ~3--7:3cj5cjcss rrT: s ct 3-^K3\.^H^i— <*— <"^^3^ta- 2 >-5 oc-icoirseo^cotoot-csr^^QC o ca o X 1-M ^1 OS — Ir-liM 1-1 rtrH — rtrtlM CO 71 f-^ CS nd) ... (Forts) ca (Forts) iian(lst) (•Jnd) n-Zoom . : : d ■3 'E SI tS Louisbou Havana. Monte V Buenos J Flusliing Badajoz Ciudad Hadajoz Almaraz Salaman Burgos . St. Sebas Berffen-o o o Ciudad Badajoz. Tarrayoi Tarifa . Antwern CO 61 CO 13 ja s .2 1 b < < or burnt ) 3 6 32 6,663 13,621 72,102 1,636 27,440 Estimated to have died from ) disease or ordinary acci- V dents on board ) 1 Total 41 92,386 29,076 " With reference to every description of armed force, it is of the greatest importance to ascertain what is the average proportion of men unable to attend to their duty from sickness. We have no information of this kind as to the navy. (See Table, p. 136.) " To facilitate the comparison between the periods of war and peace, the following table has been deduced from the reports on the health of the navy, printed by order of the House of Commons. It contains the results of all the reports yet published, with the exception of those for the East Indian station from 1840 to 1843 : they are omitted on account of the Chinese war, which commenced in 1840. AND SEASON IN THE PRESIDENCY OF MADRAS. 135 f^ 'fe. -^ 00 § QO •5 » I 5^ 1^ %^t o »p o -tS "?* TJ T to > C4 IK IK 03 0) o I— 1 C un o CT> d -* g c CO OD cS i>- 0 -* CD OJ ^ 5 I-l I-l P3 I-l M P^ I-l ^ I— 1 »o to 00 OQ S| c to iH (N CO 00 l> 00 O — M «- 'S 2 03 OS 1-1 lo b- M c 00 0) '"' '^ (N r-t rH 1-1 > "y D JS to ^- t^ CO »p rH M 00 00 *3 ■s g t- OO OJ Ol 10 oc ^ a -§ 5 I-H (M 1-1 1-1 rH ^ "s 05 CO i ■^ S « CO O o 3 S t- rt C oq o CO ^- cq ip 0- 3 := ^ S '"' ""^ irH C5 « )-H -* IM t- CO ^ CO OJ m 00 CO sl (M CO J^- rH 1—1 1 -< From a comparison of the moi'tality of the army and navy during war, it appears that the man who entered the army, from 1793 to 1815, ran between two and three times, if a private, and between three and fonr times, if an officer, the risk of injury in battle that was encountered by one who entered the navy, and that tlie general chance of death in action to the one was double that of the other. 136 PHYSIOLOGICAL OBSERVATIONS. The folloiomg Tahle shoics the Mortality in the Navy on the East Indian Station for Fourteen Years ending with 1843. Years. Mean strength. Annual ratio to 1000 mean strength of the deaths arising from Diseases. Wounds and injui-ies. All causes. ( 1830 to 1836 1849 1883 5156 15-10 14-34 36-78 17-30 21-77 50-23 2-20 Peace ...\ (1837, 1838, 1839... War 1840, 1841, 1842... 2-48 3-49 4-42 4-01 0-53 5-95 PHYSIOLOGICAL OBSERVATIONS, PRELIMINAEY TO A CON- SIDERATION OF THE PREVENTION OE DISEASE IN TROPICAL CLIMATES. It is a general opinion among philosophers that the constitu- tion of man is better adapted to bear those changes of tempera- ture, and other circumstances, experienced in migrating from a northern to a tropical region, and vice versa, than that of any other animal. They proudly observe, that this power of accommo- dating itself to all climates is a distinctive characteristic of the human species, since no other species of animal can endure trans- plantation with equal impunity. But it would not be difficult to show that, for this boasted prerogative, man is more indebted to the ingenuity of his mind than to the pliability of his body. It would appear, in fact, that he and other animals start on very imequal terms in their emigrations. Man, by the exertion of his mental faculties, can raise up a thousand barriers around him, to obviate the deleterious effects of climate on his constitution ; while the lower animal, tied down by instinct to a few simple modes of life, is quite defenceless. Nature must do all for the latter ; and, in fact, this indulgent mother does compensate in some degree for the want of reason by proditcing such corporeal changes as are necessary for the animaPs subsistence under a foreign sky, in a shorter space of time than is necessary for effecting correspondent changes in man. The tender sheep, for instance, when trans- ported from the inclemency of the north^ to pant under a vertical PHYSIOLOGICAL OBSERVATIONS. 137 sun on the eqiiator^ will, in a few generations, exchange its warm fleece of wool for a much more suitable coat of hair. " Can the Ethiopian change his hue'' in the same period, by shifting from the interior of Africa to the shores of the Baltic? or will it be said that the fair complexion of the European may, in two or three generations, acquire the sable aspect of the inter-tropical natives, by exchanging situations ? Assuredly not. Where then is the superior pliancy of the human constitution ? The truth is that the tender frame of man is incapable of sustaining that degree of ex- posure to the whole range of causes and effects incident to, or arising from the vicissitudes of climate, which so speedily operates a change in the structure, or at least the exterior, of unprotected animals. But it is observed that, of ^those animals translated from a tem- perate to a torrid zone, " some die suddenly, others droop, and all degenerate." This is not to be wondered at, considering the dis- advantages under which they labour. Man would not fare better, if placed in similar circimistances. Even as it is, the parallel is not far from applying ; for, of those Europeans who arrive on the banks of the Ganges, many fall early victims to the climate, as will be shown hereafter. That others droop, and are forced, ere many years, to seek their native air, is also well known. That the suc- cessors of all would gradually and assuredly degenerate, if they remained in the country, cannot be questioned ; for already we know that the third generation of unmixed European is nowhere to be found in Bengal. " It has been noted that all the races of mankind have their limits of health defined by a rigorous law of climate ; and the most extended experience proves that the white races attain their highest physical and intellectual development, and the most perfect health, with the greatest average duration of life, above 4-0° in the western, and 45° in the eastern hemisphere. Whenever they emigrate many degrees below these lines, a series of profound physiological changes in the organism commences, and the changes proceed onwards in the ratio of length of residence, and under the conjoined influences of the heat and malaria common to warm climates, and of the altered habits of life incident to emigration to foreign latitudes." On the other hand, if we look at intertropical natives approach- ing our own latitudes, the picture is not more cheering. The African children, brought over l)y the Sierra Leone Company for educa- tion, seldom siu'vived the third year in this country. " They bear tlie first winter," says Dr. Pearson, '' tolera])ly well, but droop during the second, and the third generally proves fatal to them." The object of these remarks, which at first sight might seem irrelevant, will noAV appear. Since it is evident that nature does not operate more powerfully in counteracting the ill effects of climate on man than on other animals, it follows that we should 138 PHYSIOLOGICAL OBSERVATIONS. not implicitly confide^ as too many do^ in the spontaneous efforts of the constitution, but, on the contrary, call to its aid all those artificial means of prevention and amelioration which reason may dictate, and experience confirm. In short, we should study well the climate, and mould our obsequious frames to the nature of the skies under which we sojourn. The British youth leaves his native shores with vigorous health and buoyant spirits, for a foreign land of promise, where he is to meet with adventures, acquire fame, and realize a fortune. All the happy events, real or ideal, of his future journey through life, are painted by his ardent imagination in prominent characters, on the foreground of the scene ; while reverses, sickness, disappointments, death itself, are all thrown into the shade, or, if suffered to in- trude, only serve as incentives to the j)ursuit which has been com- menced. During the short space of existence to which man is doomed on earth, it is a merciful dispensation that youth anticipates no misfortune, and that when the evil day arrives in after life, Hope comes on glittering wing, and gilds the scene even till the last ray of our setting sun is extinguished. That, so circumstanced, salutary precautions in matters affecting health are too often despised or neglected, need be no matter of surprise ; and a quotation from the writings of a gentleman who resided more tlian twenty years in India, and whose talent for ob- servation is peculiar, will place the fact beyond a doubt. "^ Nothing,^' says Captain Williamson, " can be more preposterous than the sig- nificant sneers of gentlemen on their first arrival in India ; mean- ing thereby to ridicule, or to despise, what they consider effemi- nacy or luxury. Thus several may be seen walking about without chattahs" (umlDrellas) " during the greatest heats. They affect to be ashamed of requiring aid, and endeavour to uphold, by such a display of indifference, the great reliance placed ow strength of con - stitidion. This unhappy infatuation rarely exceeds a few days ; at the end of that time, we are too often called upon to attend the funeral of the self-deluded victim." Before proceeding to the individual disorders which prevail in hot climates, it may be well to allude briefly to some of those gradual and progressive changes in the constitution, and deviations from previous health and habits which, though predisposing and varying towards, yet fall short of actual disease. These are consequences Avhich, on leaving their native soil, all must expect to feel more or less, and in Avhich all are naturally and directly interested. For although a few individuals may occasionally return from even a long residence in hot climates, without having suffered any violent illness, or much deterioration of consti- tution, yet the great mass of Europeans will certainly expe- rience the eflects sketched out under this head, and many other PnrSIOLOGICAL OBSERVATIONS. 139 consequences also Avhich will be noticed in different parts of this Avork. It is, however, by the most scrupulous attention to these incipieiif dev'iafious from health, by early arresting their growth, or at least retarding their progress, that we can at all expect to evade those dangerous diseases to which they inevitably, though often imperceptibly, tend. PERSPIRATION. The transition from a climate, the medium temperature of which is 52°, to one where the temperature is from 80° to 100°, or higher, might be supposed, a priori, to occasion the most serious conse- quences. The benevolent Author of our existence has, however, endowed man, as well as other animals, with the power not only of generating heat, and of preserving their warmth in the coldest re- gions of the earth ;* but has also provided an apparatus for carrying off any superabundance of it that might accumulate where the temperature of the atmosphere approaches to or exceeds that of the body. " We have seen,^^ says Mr. Erasmus Wilson, " that the tempe- rature of man varies very little in the whole extent of range between the tropics and the pole ; that he can support the intense heat of the former without much elevation of his inward heat ; that he can. live where the mercury is a solid mass, like lead, with the most trifling depression of his vital warmth. But it must not be sup- posed that the constitution of the man is the same in these two opposite conditions ; it is, indeed, widely diflFerent ; in the one, he enjoys what may be termed a summer constitution : in the other, a 'Winter constitution : and we all, without knowing it, have a summer constitution, to harmonize with the warmth of summer, and a winter constitution, to enable us to resist effectually the in- clemency of that season. " The regulation of the temperature of the body is only one of the purposes fulfilled by the perspiration ; another, and an impor- tant one, is the removal from the system of a number of com- pounds noxious to animal life. It was estimated by Lavoisier and Seguin, that eight grains of perspiration were exhaled from the skin in the course of a minute, a quantity which is equivalent to thirty-three ounces in twenty-four hours. Of this quantity, a large proportion is, naturally, water ; but nearly one per cent., according to Anselniino, consists of solid substances, of the latter, one hun- dred parts contain about twenty-three parts of salts, the remainder being organic matter. An analysis of one hundred parts of the solid matter of perspiration, according to Anselmino, gave the following results : — * la the polar voyages the thermometer was noted as low as 70° below zero, while throughout Hindostau it riaej^ to 120° Fahreulieit, and upwards. 140 PHYSIOLOGICAL OBSERVATIONS. Osraazome,* combined with common salt .... 48 parts. Lactic acid salts, with osmazome 29 ,, Animal matter, with vitriolic salts 21 ,, Calcareous salts 2 ,, 100 " To wliich may be added carbonic acid gas, ammonia, and iron, and, in rare instances, copper. The peculiar odour of perspiration is due to organic matters, and its acid qualities and occasional acid smell to the lactic acid, an organic substance not far removed in composition from distilled vinegar." The talented author above quoted, adds that, " to obtain an estimate of the length of tube of the perspiratory system of the whole surface of the body, 2800 may be taken as a fair average of the number of pores in the square inch, and 700, consequently, of the number of inches in length. Now, the number of square INCHES of surface IN A MAN OF ORDINARY HEIGHT AND BULK IS 2500 ; THE NUMBER OF PORES THEREFORE 7,000,000, AND THE NUMBER OF INCHES OF PERSPIRATORY TUBE 1,750,000, THAT IS 145,833 FEET, or 48,600 yards, or nearly twenty-eight miles.^' Well may the author exclaim, "What, if this drainage were obstructed V This again brings us to the practical conclusion of Moseley, that "■ cold is the cause of almost all the diseases of hot climates to which climate alone is accessory." Even in Europe, the summer night affects us with a chill, while the same tempera- ture, a few months later in the winter season, would feel oppressive from its heat. It is during sleep that alternations of heat and cold most seriously affect us. We are no sooner beneath a vertical sun than we naturally begin to experience the disagreeable sensation of unaccustomed warmth ; and as the temperature of the atmosphere, in the shade, now ad- vances to within ten or twelve degrees of that of the blood, and in the sun actually exceeds it, the heat constantly generated in the body cannot be so rapidly abstracted as hitherto by the surrounding air, and would thus soon accumulate so as to destroy the very func- tions of life, did not nature immediately open the sluices of the skin, and by a flow of perspiration reduce the temperature of the body to its original standard. When we contemplate the admirable provision of Nature, against what might appear to us an unforeseen event ; when we survey the resources and expedients which she can command on all emergencies, her power of supplying every waste, and of re- straining every aberration of the constitution, we would be almost tempted to conclude that man was calculated for immortality ! But alas ! "Nascentes morimur, finisque ab origine pendet." * The peculiar animal principle which gives flavour to meats and part of the odour of perspiration. — A Practical Treatise on the iskin, 1815. PHYSIOLOGICAL OBSERVATIONS. 141 Till at length this wonderful machine, exhausted hy its own efforts at preservation, and deserted by its immaterial tenant, sinks, and is resolved into its constituent elements ! But, reverting to the function of the skin ; we must not conclude that this refrigerating process, adapted by nature to prevent more serious mischief, is in itself unproductive of any detriment to the constitution, when carried to excess. Far otherwise is the fact ; and we may conclude for certain that those Europeans who avoid direct solar exposure, and who are temperate in all ways, but especially in the use of wine, beer, and spirits, will be in enjoyment of health and vigour, and capable to undergo the greatest fatigues, mental and bodily, Avithout injury. One familiar example will illustrate this subject. We will suppose two gentlemen to be sitting in a room, in the East or West Indies, just before the setting-in of the sea-breeze, both complaining of thirst, their skin hot, and the temperature of their bodies 100°, or two degrees above the natural standard. One of them, pursuant to the instructions of Dr. Currie, who never was in a tropical climate, applies to the negus, beer, or brandy-and- water cup, and, after a draught or two, brings out a copious per- spiration, which soon reduces the temperature to 98°. It will not stop here, however, nor will the gentleman, according to the plan proposed ; for, instead of putting the bulb of the thermometer under his tongue, to see if the mercury is low enough, feeling his thirst increased by the perspiration, he very naturally prefers a glass or two more of the same stimulating draught " to support the discharge,^' still, however, " stopping short of intoxication.'^ Now, by these means the temperature is reduced to 97° or 96^°, in which state even the slight and otherwise refreshing chill of the sea- breeze checks more or less the cuticular discharge, and paves the way for future maladies. Let us now return to the other gentleman, who pursues a dif- ferent line of conduct. Instead of the more palatable and stimu- lating drinks, he takes a draught of plain cold water. This is hardly swallowed before the temperature of the body loses, by ab- straction alone, one degree at least of its heat. But the external surface of the body, immediately sympathizing with the internal surface of the stomach, relaxes, and a mild perspiration breaks out, which reduces the temperature to its natural standard of 98°. Farther, this simultaneous relaxation of the two surfaces com- pletely removes the disagreeable sensation of thirst ; and as the simple " antediluvian beverage" does not possess many Circean charms for modern palates, there will not be the slightest danger of its being abused in quantity, or of the perspiratory process being carried beyond its salutary limits. Nor need we apprehend its being neglected ; since from the moment that the skin begins to be constricted, or morbid heat to accumulate, the sympathizing 142 PHYSIOLOGICAL OBSERVATIONS. . stomach and fauces will not fail again to warn us^ by craving the proper remedy. Taken, therefore, as a general rule, the advantages of the latter plan are numerous — the objections few. It possesses all the re- qiiisites of the former in ^Yocuvm^ a just and equable reduction of temperature, without any danger of bringing it below the proper level, or of wasting the strength by the profuseness of the dis- charge. During, or subsequent to violent exertion, under a powerful sun, or in any other situation in a tropical climate, when profuse per- spiration is rapidly carrying off the animal heat, and especially when fatigue or exhaustion has taken place, or is impending, then cold drink might prove dangerous, on the same principle as would cold externally applied. In persons who have been for some time in the climate, and whose digestive organs are enfeebled, some weak wine and water may not be objectionable; but such in- dulgence is by no means necessary in the young and vigorous, and it should be reserved for ulterior residence and more advanced periods of life. I may here mention that, during the first Burmese war, while serving as surgeon to the Governor GeneraPs body guard of cavalry, I found warm tea, after the most severe marches in the sun, by far the most refreshing beverage. The habit of Napoleon under great fatigues was as just physio- logically, as it evinced the sagacity of that Avonderful man. Find- ing that excessive fatigue constricted the skin, and produced a sen- sation of cold, he went into a warm bath, and on getting out he took a cup of strong coffee — a sensorial stimulant. He thus be- came in a few minutes fit for renewed exertions, both mental and physical. It is hoped that these details may not appear prolix, or un- necessarily minute, to the medical reader; but, considering that this is generally the first erroneous step Avhich Europeans take on entering the tropics, and that the function of the skin, here under consideration, is more intimately connected with other very im- portant ones than is commonly supposed, it has been thought pro- per to set them right in limine. The probability oi future suffering will rarely deter the European from indulging in present gratifica- tion; but when stimulating liquids are represented, from high authority, as not only innocent but salutary, it will require some strength of fact, and of argument, to persuade young men to relin- quish their use, or to check the wide- spreading evil. SYMPATHY OF THE SKIN V^^ITH INTERNAL ORGANS. In attempting to delineate the influence of tropical climates on the European constitution, although we may endeavour " to chain the events in regular array," yet it must be confessed that nature spurns all such artificial arrangements. PHYSIOLOGICAL OBSERVATIONS. 143 As matter of fact, however, there does exist between different parts of the body a certain connexion or relation, so that when one is affected by special impressions, the other spmpathizes, as it were, and takes on an analogous action. Of the sympathies here referred to, none is more universally remarked than that which subsists between the external surface of the body and the internal surface of the alimentary canal. This, indeed, seems more easily comprehended than many others, since the latter appears to be a continuation of the former, Avith the exception of the cuticle. I have remarked that, when we first arrive between the tropics, the perspiration and biliary secretion are both increased ; and that, as we become habituated to the climate, they both decrease, pari passu. In the first section an instance was given of the skin sympa- thizing with the stomach, where the cold drink was applied to the latter organ. Had the water been applied to the exterior of the body, on the other hand, the stomach would have sympathized, and the thirst would have been assuaged. ^Ir. Erasmus Wilson justly observes, that the sensibility of the skin conveys to the mind a knowledge of the temperature of the body, thus constituting a " thermometer of vital heat, the degrees upon the scale being computed by the expressions agreealde and disagreeable, in place of the terms of the common thermometer. The value of these expressions to health is not, however, suffi- ciently estimated ; but it is, nevertheless, certain, that a disagree- able impression of temperature in the skin is a warning note of something mischievous to health, acting either within or Avithout the economy." The same author states the rule of health to be, hij food, by raiment, by exercise, and by ablution, to maintain and preserve an agreeable loarmth of the skin. Everything above this is suspicious; everything below noxious and dangerous. For good or for evil, as it may be, the function of the skin is highly important. It will be found, on experience, that the loss of tone in the ex- treme vessels of the surface, consequent on excessive or long-con- tinued perspiration, is accompanied, or soon succeeded, by a consentaneous loss of tone in the stomach, and will fairly account for that anorexia, or diminished appetite, which we seldom fail to perceive soon after entering the tropics, or, indeed, during hot weather in England. Now this, though but a link in the chain of effects, seems a most wise precaution of nature to lower and adapt the irritable, plethoric Eui'opean constitution to a burning climate, by effectually guarding against the dangerous conse- quences of repletion. This A'iew of the actual subject will set in a clear light the pernicious effects of stimulating liquids, operating on an organ already debilitated, probably for salutary purposes, and goading it thereby to exertions beyond its natural power, pro- ducing a temporary plethora and excitement, with a great increase of subsequent atony 144 PHYSIOLOGICAL OBSERVATIONS. '' An important medical law/' says Mr. Wilson, '' is founded on the continuity and similarity of structure of the investing and lining membrane of the body. This law resolves itself into three expressions — namely, that disease affecting a part of a memhrane is liable to spread to the tvhole ; secondly, that disease of the mucous 7nemhrane may spread to the skin, and vice versa ; and thirdly, that disease of a part of a mucous memhrane may become translated to a part of the skin, and vice versa." A remark which every person of ob- servation must have made, even in this country, during the summer, but particularly in equatorial regions, will further elucidate this subject. If by walking, for instance, or other bodily exercise in the heat of the sun, during the forenoon, or near the dinner hour, the perspiration be much increased, and the extreme vessels re- laxed, we find, on sitting down to table, our appetites almost entirely gone, until we take a glass of wine, or other stimulating- fluid, to excite the energy of the stomach. Observation and per- sonal feeling have taught that in hot climates, perhaps during hot weather in all climates, an hour's cool repose before dinner is highly salutary ; and if, on commencing our repast, we find we cannot eat without drinlmig, we may be assured that it is nature's caveat to beware of eating at all. This will be deemed hard doc- trine by some, and visionary by others ; but it is neither the one nor the other, and those who neglect or despise it may feel the bad consequences when it is too late to repair the error. There are several other causes also which operate in conjunction with the above, to impair the appetite ; one of which is, the ab- sence of rest at night. After a disturbed and unrefreshing sleep, but too common in tropical climates, the whole frame languishes next day, and the stomach participates in the general relaxation. The means of obviating and managing these efi"ects will be pointed out in the prophylactic part of this work. INFLUENCE OF TROPICAL HEAT ON THE BILIARY FUNCTION. The effect of a tropical climate on the function of the liver is universally allowed to be an increase of the biliary secretion. This is so evident in our own country, where the summer and autumn are distinguished by diseases arising from superabundant secretion of bile, that it would be waste of time to adduce any arguments in proof. Were this a question of mere curiosity, or theoretical specula- tion, I should pass it by unnoticed ; but from long and attentive observation, as well as from reflection, I believe that I have dis- covered a connexion between two important functions of the animal economy, which will let in some light on this subject, and lead to practical inferences of much importance. The arguments and facts adduced in support of this connexion will be found under the heads Hepatitis and Dysentery, and in other parts of this PHYSIOLOGICAL OBSERVATIONS. 145 work ; and, in the meantime, I shall merely state in a fcAv words the result of my observation, leaving the reader to give credit to it, or not, as he may feel inclined. There exists, then, between the extreme vessels of the vena 2iorf(e in the liver, and the extreme vessels on the surface of the body — in other words, between the b'd'iarij secretion, and jjers^Jira- tion — one of the strongest sympathies in the human frame, although entirely unnoticed hitherto, so far as I am acquainted. That these two functions are regularly, and to all appearances equally increased, or at least influenced by one particular agent, atmospheric heat, from the cradle to the grave, from the pole to the equator, will be readily granted by every observer; and that this sijnchronous action alone, independent of any other original connexion, should soon grow up into a powerful sympathy, manifesting itself when either of these functions came under the influence of other agents, is a legitimate conclusion in theory, and what I hope to prove by a fair appeal to facts. This last consideration is the great practical one j for it is of little consequence whether this sympatliy was originally implanted by the hand of nature at our first formation, or sprung up gradually in the manner alluded to, provided we know that it actually exists, and that by directing our operations towards either one of the functions in question, we can decisively influence the other. That is what I maintain, and what in a future part of the work I hope to prove by facts and cogent arguments. I shall here offer one practical remark, resulting from this view of the subject, and which will be found deserving of every Euro- pean's attention on his emigration to southern regions ; namely, that as the state of the perspiratory process is a visible and pretty fair index to that of the biliary, so every precautionary means which keeps in check, or moderates, the profusion of the former discharge, will invariable have the same effect on the latter, and thus tend to obviate the inconvenience, not to say disorders, aris- ing from redundancy of the hepatic secretion. To this rule I do not know a single exception, consequently its universal application can never lead astray in any instance. It is well known that if any organ be stimulated to inordinate action, one of two things must in general ensue. If the cause applied be constant, and sufficient to keep up this inordinate action for any length of time, serious injury is likely to accrue to the organ itself, even to the extent of structural ^MqxqXaow. But if the cause be only temporary, or the force not in any great degree, then an occasional torpor or exhaustion of the organ takes place, during which period \i% function falls short of the natural range. To give a familiar example, of which too many of us are quite competent to judge : — thus, if the stomach be goaded to immoderate exertion to-day, by a provocative variety of savoury dishes and stimulating liquors, we all know the atony' which will succeed to-morrow, and L 146 PHYSIOLOGICAL OBSERVATIONS. liow incapable it then will be of performing its accustomed office. It is the same with respect to the liver. After great excitement by excessive heat, violent exercise in the sun, &c., a torpor succeeds, which will be more or less according to the degree of previous excitement, and the length of time during which the stimulating causes have been applied. When Europeans first arrive in tropical climates, the degree of torpor bears so small a proportion to that of preceding excitement in the liver, that it is scarcely noticed ; particularly as the debi- litated vessels of this organ continue, like the perspiratory vessels on the surface, to secrete an imperfect fluid for some time after the exciting cause has ceased ; hence the increase of the biliary secretion occupies our principal attention. But these periods of torpor, however short at first, gradually and progressively increase, till at length they greatly exceed the periods of excitement ; and then a deficiency of the biliary secretion becomes evident. This is not only consonant to experience, but to analogy. Thus, when a man first betakes himself to inebriety, the excitement occasioned by wine or spirits on the stomach and nervous system far exceeds the subsequent atony, and we are astonished to see him go on for some time, apparently without sufi'ering much detriment to his constitution. But the stage of excitement is gradually curtailed, while that of atony increases, Avhich forces him not only to aug- ment the dose, but to repeat it oftener, till the organ and life are destroyed ! It is remarkable that this alternation of redundancy and defi- ciency, or irregular secretion in the biliary organ, should pass unnoticed by writers on hot climates. They, one and all, repre- sent the liver as a colossal apparatus, of the most herculean power, that goes on for years performing prodigies in the secreting way, without ever being exhausted for a moment, or falling helotv the range of ordinary action, till structural derangement, such as scirrhosity or tuberculation, incapacitates it for its duty ! A very attentive observation of what passed in my own frame, and those of others, has led me to form a very difi'erent conclusion ; and the foregoing statement will, I think, be found a true and a natural representation of the case. Here, then, we have two very opposite states of the liver and its functions ; — first, inordinate action, with increased secretion — the periods gradually shortening ; and, secondly, torpor of the vessels of the liver, with deficient secretion — the periods progressively lengthening. In both cases the bile itself is vitiated. We can readily conceive hoAV this last comes to pass, by comparison with what takes place in the stomach during and subsequent to a debauch. In both instances the chyme passes through the pylorus into the duodenum, in a state less fit for chylification than during a season of temperance and regularity ; so, during the increased secretion^ and subsequent inactivity in the liver^ the bile passes PHYSIOLOGICAL OBSERVATIONS. 147 out Into tlie intestines deteriorated in quality, as well as super- abundant, or deficient, in quantity. In what this vitiation consists it is certainly not easy to say. In high degrees of it with hurried secretion, both the colour and taste are surprisingly altered, since it occasions all the shades between a deep bottle-green and jet black; possessing at one time an acidity that sets the teeth on edge ; at other times, and more frequently, an acrimony that seems absolutely to corrode the stomach and fauces, as it passes off by A'omiting, and, when directed downwards, can be compared to nothing more appropriate than the sensation which one would expect from boiling lead flowing- through the intestines. Many a time have I experienced this, and many a time have my patients expressed themselves in similar language. The slightly disordered state of the hepatic functions, which we are now considering as primary effects of climate, and within the range of health, may be known by the following symptoms : — Irregularity in the bowels, with motions of various colours, and foetid or insipid odour ; general languor of body and mind, slight nausea, especially in the mornings, when we attempt to brush our teeth ; a yellowish fur about the back part of the tongue ; unpleasant taste in the mouth on getting out of bed ; a tinge in the eyes and complexion from absorption of bile ; the urine high-coloured, and a slight irritation in passing it ; the appetite impaired, and easily turned against fat or oily victuals ; irritability of temper ; dejection of mind ; loss of flesh ; disturbed sleep. These are the first effects of increased and irregular secretion of bile, and may appear in all degrees, according as we are less or more cautious in avoiding the numerous causes that give additional force to the influence of climate. If, for example, I use more than ordinaiy exercise, expose my- self to the heat of the sun, or drink stimulating liquids to-day, an increased and vitiated flow of bile takes place, and to-morrow produces cither nausea or sickness of stoiuach, or a diarrhoea, with gripings and twitchings in the bowels. But a slight degree of inaction or torpor succeeding, both in the liver and intestines, there will probably be no alvine evacuation at all the ensuing day, till a fresh floAV of bile sets all in motion once more. These irre- gularities, although they may continue a long time without pro- ducing much inconvenience, especially if they be not aggravated by excesses, yet they should never be despised, since they ine- vitably, though insensibly, pave the way for serious derangement in the biliary and digestive organs, especially in hot climates, unless counteracted by rigid temperance, and proper prophylactic measures. LICHEN TROPICUS, OR PRICKLY HEAT. Few Europeans escape from this the most primary effect of a hot climate, for it can hardly be called a disease. La 148 PHYSIOLOGICAL OBSERVATIONS. From mosquitoes^ cockroaclieSj ants^ and the numerous other tribes of depredators on our personal property, we have some defence by night, and in general a respite by day ; but this un- welcome guest assails us at all, and particularly the most unsea- sonable, hours. The sensations arising from prickly heat are perfectly inde- scribable, being compounded of pricking, itching, tingling, and many other feelings for which there is no appropriate appellation. It is usually, but not invariably, accompanied by an eruption of vivid red pimples, not larger in general than a pin's head, which spread over the breast, arms, thighs, neck, and occasionally along tlie forehead, close to the hair. The eruption often disappears to a certain degree when we are sitting quiet, and the skin is cool ; but no sooner do we use any exercise that brings out perspiration, or swallow any warm or stimulating liquid, such as tea, soup, or wine, than the pimples become elevated, so as to be distinctly seen, and but too sensibly felt ! Prickly heat being rather a symptom than a cause of good health, its disappearance has been erroneously accused of pro- ducing much mischief; hence some of the early writers on tropical diseases, harping too much on the humoral pathology, speak very seriously of the danger of repelling, and of the advantage of " en- couraging" the eruption, by taking warm liquors — as tea, coffee, wine, whey, broth, and nourishing meats. Even Dr. Moseley retails the puerile and exaggerated dangers of his predecessor Hillary, " There is great danger," he says, ^' in repelling prickly heat j therefore cold bathing and washing the body with cold water, at the time it is out, are always to be avoided." Every naval or military surgeon, however, who has been a few months in a hot climate, must have seen hundreds, if not thousands of seamen and soldiers plmiging into the water for days and weeks in suc- cession, covered with prickly heat, yet without bad consequences ensuing. The eruption is seldom repelled by the cold bath, which rather seems to aggravate it and the disagreeable sensations belonging to it, especially during the glow which succeeds the immersion. It certainly disappears suddenly sometimes on the accession of other diseases, but there is no reason to suppose that its disappearance occasioned them. At the same time, cold bathing and repellents are not to be recommended in this eruption, even in persons of robust constitutions, recently arrived in the country, and who are in the enjoyment of good health. Where any organ happens to be weak, on the other hand, or any tendency to disease exists, the repulsion of an eruption is by all means to be avoided, and the more so if the sufferer have been long resident in the climate. Hair-poAvder, lime-juice, and a vaiiety of external applications have been used for the removal of prickly heat, but witli little or IIO benefit. The truth is^ that the only means productive of good PHYSIOLOGICAL OBSERVATIONS. 149 eifect in mitigating its \dolence till tlie constitution becomes assi- milated to the climate are — light clothing, temperance in eating and drinking, avoidance of all exercise in the heat of the day, open bowels; and, lastly, the nse of the pnnkah, or large fan, during the night, as is now the ordinary practice in Bengal. The punkah is always safe; and, unlike the thorough- draught or ex- ternal breeze, it removes the heated air surrounding the body, without exposing it to the dangers arising from sudden night changes in the temperature and humidity of the atmosphere. NoTA Bene. — In the foregoing sections, as well as in those which follow, from page 165 to page 180, containing special rules respecting dress, food, &c., I have folloAved Dr. James Johnson, offering occasional additions and illustrations. I have endea- voui'ed to place before the reader a fair abstract of the physio- logical doctrine — the cutaneo-hepatic sijmpathij of this distinguished author, together with his excellent hygienic rules. His physio- logical doctrine was propounded by Dr. Johnson in early life, in the East Indies, with a limited range of observation in years, and in the subjects for observation — namely, the crew of a ship of war. But with all these disadvantages, it will, I think, be admitted that, practically considered, in relation to the nature, causes, preven- tion, and cure of disease, there is much in the theory to " lead to practical inferences of considerable importance ;" for it is to the restoring of the lost balance of circulation, of the nervous func- tions, and of secretion that our main efforts have been, and always must be directed, in the treatment of tropical disease, whether it be fever, dysentery, hepatitis, or cholera. For all the other articles contained in this work I am indi- Yidually and exclusively responsible. — J. R. M. PART II. THE PEEVENTION OF DISEASE. If it were possible to make men healtliy in various ways, it would be best to choose that which is least troublesome, for this is more honest and more scientific, unless one aims at vulgar imposition. — Hippocrates. In the prevention of disease, as in its cure, we take the same point of departure — namely, etiology ; for in the study of causes we shall find in reality the only route to a true prophylaxis. Descartes must liave had in view tlie science of Prevention op DiSEASE_, or of State Medicine, when he declared : — " S'il est possible de perfectionner Pespece humaine, c'est dans la medecine qu'il faut en chercher les moyens." This philosopher felt that whatever tended to improve the physical constitution of man, must promote general happiness and virtue, and thus prevent crime and disease. Health and freedom are two blessings which it is said no man thoroughly appreciates till he has lost them. Nor did Bacon hold this greatest department of medicine in less estimation ; for he exhorts the profession in his time to " exert themselves for the general good, and raise their minds above the sordid considerations of cure; not deriving their honours from the necessities of mankind, but becoming ministers of the Divine power and goodness both in prolonging and restoring the life of man.^^ It would accord with the views of these great men that adequate public provision and arrangement should be made to enable the medical profession to render the services desired; but, in this country, it has, until very recently, been employed by the State individually, and chiefly in its curative or therapeutic capacity only ; while it might be emploj^ed collectively, in a higher and nobler — namely, in its preventive or prophylactic office. It is surprising that in so civilized a state of society as ours, we should still be so far behind some of the ancient peoples. Moses imposed sanitary laws upon the Jews ; the Greeks and Romans held their officers of health in high consideration. " In the Cyro- psedia of Xenophon,^^ says Dr. Farr, '' the preservation of health is declared a noble art worthy of Cyrus himself/^ while in modern England the ruling powers do not yet apprehend the trutli, that without the physical care of the people their moral and intellectual THE PREVENTION OF DISEASE. 151 improvement is impossible. "Wisely said Carew, that ''where our prevention ends danger begins.^' " In 92 days of the summer quarter, that ended on 30th Sep- tember, 1857^^' says Dr. Farr, '' 17,653 persons perished untimely in England. What was the cause of this great destruction of life? EWdently the violation of the plain natural laws of life. And the strict observance of these laws must be of the utmost importance to the Avelfare of the human race, otherwise their violation would not be so terribly punished by the Almighty. Indeed, if the English race could lose strength, beauty, health, and life in the impurities of its dwelling-places with impunity, the imagination of SA\'ift alone could conceive — his pencil depict — the depth of de- gradation to which the nation might fall. " The intelligent classes of this country will, however, never acquiesce in the continuance of its present imperfect sanitary con- dition, and of the resulting diseases which it brings down upon the heads of the population ; who often, when they 'violate the laws of nature, know not what they do.^^ Let us hope that this humane expectation may be speedily fulfilled. " England," says Dr. Parr again, " is a great country, and has done great deeds. It has encountered in succession, and at times in combination, all the great powers of Europe ; has founded vast colonies in America ; and has conquered an empire in Asia, Yet greater victories have to be achieved at home. Within the shores of these islands the twenty-eight millions of people dwell, who have not only supplied her armies, and set her fleets in motion, but have manufactured innumerable products, and are employed in the investigation of scientific truths, and the creation of works of inestimable value to the human race. These people do not live out half their days; a hundred and forty thoiisand of them die every year u.nnatural deaths; tioo hundred and eighty thousand are constantly suffering from actual diseases which do not prevail in healthy places ; their strength is impaired in a thousand ways : their affections and intellects are disturbed, deranged, and dimi- nished by the same agencies. Who will deliver the nation from these terrible enemies ? Vf[\o will confer on the inhabitants of the United Kingdom the blessings of health and long life? Who will give scope to the improvement of the English race, so that all its fine qualities may be developed to their full extent under fa- voru'able circumstances ? His conquests would be wrought neither by wrong nor human slaughter ; but by the application of the powers of nature to the improvement of mankind." In the army and navy of England the medical officers have for ages past occupied themselves, spontaneously, and without pro- spect of rcAvard, in establishing important principles in this great branch of medical science — the prevention of disease ; — and the sister science of INIedical Statistics may be said to be founded, in 152 THE PREVENTION OF DISEASE. this country at least, on the labours of such men as Prlngle, Lind, Blanc^ Robert Jackson, Trotter, Hennen, and Henry- Marshall.^ Dr. Alison, in his '' History of Medicine'^ in the present century, observes that, "Next to the additions which have been made since the end of last century to our knowledge of physiology, we may place the numerous important observations by which our information as to the external causes of disease has been rendered more extensive and more precise. " These observations and the inferences from them demand the more attention from physicians, that they necessarily involve a kind of evidence essentially diiferent from that on which we pro- ceed in other medical inquiries ; and if we durst hope that the progress of human wisdom and virtue would bear any proportion to that of human knowledge, we might expect that the lessons to be drawn from these inquiries would prove of even greater im- portance to tlie future happiness of mankind than any which we can gather from the history and treatment of disease. " These inquiries have in some instances been prosecuted by in- * I take leave here to state that, while serving in the East Indies, in March, 1835, I submitted to the then Governor-General of India, Sir Charles, afterwards, Lord Metcalfe, a systenaatic and detailed plan for requiring from all competent medical ofHcers throughout our Eastern possessions, reports on Medical Topography and Sanitary Statistics of the districts, stations, or cantonments, whether fixed or temporary, with the localities of which each officer may in the course of service be best acquainted. In the following year, 1837, I placed before the Government of Bengal a detailed " Report on the Medical Topography, Climate, and Diseases of Calcutta," with sug- gestions for removing the defects, local and structural, which there injuriously affected the health of its inhabitants, European and Native. This report also contained sug- gestions for the removal of the European troops from the plains to the mountain ranges throughout India. The first measure here mentioned, though it received little or no support from the medical authorities of Bengal, was ordered by a direct act of the Governor- General, Sir Charles Metcalfe, to be a standing regulation throughout the three Presidencies of India, and it has stood so ever since. The second proposal for the sanitary improvement of the British Indian capital has for several years been prac- tically carried out under legislative enactments ; — the works are still in progress, under an official board, and will continue to their completion. A fever hospital, for the reception and treatment of natives suffering froiu fever and other acute diseases endemic in Calcutta, formed a supj:)lementary of this my latter plan. This institution is now attached to the Medical College: it was completed in 1853 in all its establishments, and is arranged to accommodate five hundred patients ; it is one of the most useful and ornamental buildings in Calcutta, and was erected at the cost of 20,000Z. Dr. Farr, of the Registrar- General's Office, speaking of the measures above mentioned, says — " We look upon the well-conducted sanitary inquiry, commenced in Bengal, as one of the most important undertakings of the age in India — useful to science, to England, and creditable alike to Mr. Martin, with whom it originated, and to the Government." Lord Hardinge, referring to the same subject, says — "I am happy to bear testimony to the services you rendered to our Indian empire in originating those valuable mea- sures of sanitary improvement which have so materially contributed to the comfort and prosperity of an immense population. The importance of these benefits will be ever felt ; and I am aware, from the interest that, as Governor-General, I took in this subject, that their inestimable results are honourably associated with the active part you took in their first introduction." Thus, although my endeavours were but coldly received by the superannuated members of the Bengal Medical Board, they are ap- proved by persons the most competent to judge of their value, whether scientific or practical.— J. K. M. THE PREVENTION OF DISEASE. 153 dlviduals in civil life; but the opportunities of making decisive observations on some of the causes of disease wliich occur in the experience of medical officers of fleets and armies^ who are per- fectly informed of the whole circumstances of the organized bodies of men under their observation, and often see these circumstances suddenly altered, or have even the power of altering them at plea- sure, are much superior to those which other practitioners enjoy ; and the peculiar value of such observations has never been so well understood as during the last war/' The unobtrusive but important services of our brethren in the army and navy, alluded to by Dr. Alison, are not Avritten in the rolls of fame, but they will be remembered and appreciated by the philanthropist and the statesman, for ages after other and more brilliant services are forgotten. But in public rewards or emolu- ments our brethren must not as yet expect to share ; for " in medicine alone," according to Marshall Hall, "improvement is ■without recompence :" — L'art mddicale est la plus noble des pro- fessions et le plus triste des metiers. Referring to " the progress of Imman wisdom and virtue," it may reasonably be supposed that by rendering men more healthy they may become more happy, and that thus the bonds of our com- mon humanity may be drawn the closer, so that the uncertainties, which are the same to us all, may eventually be regarded as the true and natural bond of union amongst men. From what has been stated, it must be obvious that, for the ad- vancement and perfectioning of the science of Prevention of Disease, we must command the co-operation of the medical pro fession generally, and, in particular, that of the medical officers of the army, the navy, the police, hospitals, dispensaries, lunatic asylums, parochial unions and workhouses, vaccination establish- ments, prisons, factories, mines, provident societies, and other institutions, and public works. The medical profession has so invariably spurned all selfish considerations in originating and promoting objects of great sani- tary utility, that I would here allude only to the obvious advan- tages Avliich will result to medicine, and the increased estimation in which its professors and practitioners will be held, both by the Government and the country at large, from the realization of the projects here contemplated. " One of the first steps," says Heberden, "towards preserving the health of our fellow- creatures, is to point out the soui'ces from which diseases are appre- hended." It has been well observed, says a great popular writer, that if a science can be established by its fruits. Sanitary Science may now take its rank with any of the sciences known to mankind. It no longer pertains to the class of theories, or inquiries, or specula- tions. Its laws have been tested by experiment, and are proved by facts. The object of the new doctrines is an exceedingly simple 154 THE PREVENTION OF DISEASE. one — tlie improvement of public health, or the prolongation of human life. We know the standard fixed by nature. We can all recollect that the years of man are threescore and ten, and that the age of fourscore is reached only through labour and trouble. So exactly does this estimate fit all generations, that the latest reckoning of our latest calculators produces the very same result. It has also been observed as very remarkable, that, among all the movements of the working classes, political or social, there is no example of agitation for what would be the greatest boon of all — Sanitary Reform. No workmen ever struck, combined, or agitated for the essentials of a healthy and comfortable existence. No '' People^s Charter^' has ever yet been framed for pure air, pure water, pure food, good drainage, and open spaces for exercise. The classes in question are easily induced to lavish their savings in pursuit of chimerical objects, or to expend the resources of organization upon impracticable ends, but of their lives and health they take little heed. They, however, are the chief sufferers and the earliest victims ; and they are the people who should be most anxious for reform. The Medical Topographer should investigate all the circum- stances which tend to deteriorate the human race, and to lower its vigour and vitality ; all that relates to the external causes of diseases, their propagation, and their prevention ; all plans for improving the physical, and, through it, the moral condition of the people. He should cultivate more extensively the medical topography of the empire ; the natural features and peculiarities of every locality which may affect materially the life and health of the inhabitants. Any general system of sanitary inquiry should, therefore, embrace information respecting the surface and eleva- tion of the ground, the stratification and composition of the soil, the supply and quality of the water, the extent of marshes and wet ground, the progress of drainage ; the nature and amount of the products of the land ; the condition, increase or decrease, and pre- valent diseases of the animals maintained thereon ; together with periodical reports of the temperature, pressure, humidity, motion, and electricity of the atmosphere. Without a knowledge of these facts it is impossible to draw satisfactory conclusions with respect to the occurrence of epidemic diseases, and variations in the rate of mortality and reproduction. The result of such inquiries Avoiild also, doubtless, show that agriculture is CA'crywhere the most powerful improver of climate, and that its advancement ministers not only to the support of man in the production of his food, but in a greater degree to his health and vigour, by purifying the air he breathes. The practical connexion, therefore, of agriculture with the nutri- tion and growth, the sickness and health, the birth and death, of man and of the lower animals, is inseparable from a comprehensive consideration of the public health. THE PREVENTION OF DISEASE. 155 The science of localizing; tlie population, and of constructing towns, cantonments, barracks, and hospitals, is ranch neglected in this country, and throughout its various intertropical possessions. It is proved over and over again, in the records of the Registrar- General, that, owing to defects in the sites of towns, in the erec- tion of buildings, in the selection of healthy soils and levels, in the supply of pure air and water, in the drainage and cleansing of streets and houses, a mortality of from a fifth to a third part greater occurs in large towns than in small communities and rural districts. The amount of sickness occurring in cities, towns, and villages, and in thinly populated districts, requires a much more careful and extended investigation than it has ever yet received. Evidence should be obtained, on an extended scale, of the moral and phy- sical deterioration of mankind when aggregated in low and crowded towns. " The causes,^^ says the Registrar-General, " that destroy the lives of so many people, degrade the lives of more, and may ultimately, it is feared, have a very unfavourable effect on the energies of a large proportion of the English race. Here is a wide field for salutary and beneficial reform.'^ Amongst those whose habits and pursuits in life qualify them to be consulted in the objects of State Medicine, the following may be enumerated : — The clergy, the statesmen, colonial authorities, philanthropists, naval and military commanders, the legal profes- sion, the medical profession, quarantine authorities, the landed proprietary and the agricultural body, magistrates, poor-law guardians, actuaries, engineers and architects, shipowners, manu- facturers of all classes, the several trades. Professors of State Medicine in foreign countries should be solicited to forward, by their information and experience, the objects in view ; and the various methods which the government of those countries have adopted to investigate and preserve the health of the people, should be ascertained and carefully considered. It will thus appear that among the more immediate objects of State Medicine, may be enumerated the following : — 1. To direct public attention to the increased security of life and property, which must result from a sustained and organized investigation, by competent persons, of all those agencies and cir- cumstances, moral and physical, which deteriorate, through local or general influences, the public health. 2. To disseminate knowledge amongst all classes of the com- munity, on the most obvious and well-ascertained causes of injury to public health, and as to the most eftective and economical raeasui'es of sanitary improvement, both in town and country. It is believed that the union of the medical, clerical, and lay bodies, for the collection of scientific and practical information, for the consideration of sanitary measures within the United Kingdom and its foreign dependencies, and for establishing fixed and deter- minate principles in sanitary affairs, could not fail to enlarge the 156 THE PREVENTION OF DISEASE. sphere of usefulness of the medical profession^ for the most ex- tended and beneficent pursuits, and to promote the moral as well as the physical improvement of the population. '' In the science of health/' says Dr. Farr, " there are more exact demonstrable truths than in the science of disease ; and the advantages of ' prevention' over ' cure' require no proof." I need^ therefore, proceed no further to explain why I here give the priority and the preference to the subject of The Prevention of Disease. 1. The subjects concerning which the State should direct investi- gation, with a view to establishing settled relations between the science of medicine and the executive, are stated by Mr. llumsey to be : — '^ A. Statistical. B. Topographical. C. Jurisprudential. " 2. In relation to Practical Arrangements for the personal safety and health of the people, requiring for their enforcement either direct legislature enactment, or local institutions or regula- tions," the same authority divides them into : — " A. Preventive, and B. Palliative measures. " 3. In relation to the establishment by law of an Organized Machinery for carrying into effect the aforesaid inquiries, for deliberation and advice on special arrangements and emergencies, and for administration of existing laws, there would be required : — " A. The education of medical men, and the qualification of other technical, scientific, and administrative agents. B. The institution of official authorities — board and officers — for central and local superintendence and action." Meanwhile, and pending the ordering of some established regulations for the better care of the health of the national forces by sea and land, there can be no doubt that the first duty of the naval and military surgeon is to preserve the health of the men committed to his charge — a service far higher and more useful than the cure of disease and wounds, however necessary this last function. " Hygiene," says Cabanis, " teaches the means of preserving health, and forms an important branch of moral as well as of me- dical science. Ethics, being in fact but the science of life, how is it possible for this science to be complete, without a knowledge .of the changes which the subject to which it is applied may expe- rience, and without a knowledge of the means by which these changes are effected. Hygiene, therefore, and, consequently, some concise notions of anatomy and physiology, should form part of every system of education." The study of nature^ he says, is^ THE PREVENTION OF DISEASE. 157 in general, a study of facts, and not of causes, a knowledge of these last not being necessary. " For studying the healthy and diseased states, for tracing the progress and development of any particular disease, we have no occasion to know the essence of life, or that of tlie morbific cause. Observation, experience, and reasoning are sufficient for our purposes — we require nothing more.^^ That the subject of public health has not as yet been taught in our schools is matter of mvicli and general regret, and those of the medical profession who have devoted their time and attention to this branch of medicine, have always done so, in the army and navy at least, gratuitously, and under great disadvantages and difficulties. I can say with truth, that I first became aware of the power of external causes in the production of disease, under circumstances of general and personal suffering of the most pain- ful character, in the marshes of Orissa and Gondwana, and after- w^ards in those of Rangoon. Our men were dying a miserable, a dismal, a nameless death, by thousands. We lost more men in- gloriously than would have made the most bloody campaigns. I have gone through so many storms of febrile suffering, on so many occasions, that I often wonder how I came to survive them. I was young, and inexperienced in the " art of preserving health ;" but I laboured hard, and, like others in the public service, I may be supposed to have acquired some knowledge essential to the welfare of the soldiers under my charge.^ But suffering, general and per- sonal, was always the school in Avhich I received my instruction. It was but the other day that the Legislature and Government of this country ordained that a Board for the management of the health-concerns of England should be constituted without any person of the medical profession having a seat in its deliberations. That for this unhappy state of things the medical profession is itself principally to blame is, I think, manifest ; for had " the art of preserving health" been taught in our schools of medicine, and been thus placed on its proper footing in the public estimation, no Government, in these days of free discussion, could have re- sisted the just claims of science. As matters stand at present, there is no remedy ; — but the remedy will eventually be found, when medical science shall be represented in the councils of the nation. I think it necessary here to state my views on this great question, as they have been both misunderstood and misrepresented. Sani- tary measures for the good of the army ought, I apprehend, to be explained, advanced, and practised as a part, and the greatest part, of that science which it is the duty of the military surgeon to per- * " The art of preserving health," says Dr. Farr, " is taught in no regular course of lectures in any of the great schools of medicine in the United Kingdom. Yet the classical sanitary works of Pringle, Lind, Blanc, Robert Jackson, Johnson, and Martin have been framed from observation in the British navy and army." — Rc^iort on the Mortality of CRolera. London, 1852. 158 THE PREVENTION OP DISEASE. form ; and all this should be done by liinij not througb subserviency, apology, or solicitation, biit as a duty of necessity — as bis first duty, in fact. Even Napoleon did not pretend to discover and arrange the sanitary measures necessary to his armies ; these duties he left to those who understood such questions as their proper business, and their recommendations he always carried into effect. The greatest physician who ever served in the British army invariably treated this subject as a science of the utmost need to the soldier; and he declared emphatically, over and over again, that to the ignorance of our commanders, and their indisposition to accept and learn from their medical officers what they could not know of themselves, or from any other source, our armies had always been sacrificed. A man of the most rare courage and virtue, and personally of a republican simplicity, he contended that, inas- much as the medical department of the army shared in the fatigues and dangers of war, so also was it, in right reason, entitled to share in the advantages. In thus acting and writing, Robert Jackson proved himself not only the best friend of the soldier, but, rightly understood, of the officer also. It is true that this good and great man was in his time assailed and misrepresented by some very unworthy members of his pro- fession, and persecuted by a host of the most vile and corrupt of the army contractors; but he had for his unswerving friends and supporters the Duke of York, Abercromby, Moore, the Adjutant- General, Calvert, and all the best officers of his day, who had known him through fifty years of eminent and honest service. That Jackson was in advance of his time is true, but he was not in advance of our time, and we would do well to follow his useful example. Had his injunctions, the suggestions of his thoughtful experience, been put in practice, would England have had to lament the dis- asters and humiliations of Walcheren and of the Crimea ? Let the army surgeon then look well to the science of The Pkevention OF Disease, as now happily taught at Chatham, and he will serve his country to the best purpose and do much honour to himself. I have all my life urged this on my brother officers of the Indian army, and I venture now to do the same to medical officers of all the services at home. I have served long enough to know the value of a good military officer ; and I have seen, on more than one occasion of active service, how great is the amount of ruin which may be con- summated by a bad commander. To honoiir and obey the first is both natural and necessary ; to conciliate, deprecate, supplicate, and wait upon the pleasure of the latter, in his neglects and wrong-do- ings, is certainly not the part of an honest or efficient medical officer. It is true that " the sanitary function has yet to be defined and adjusted'^ to the wants of the soldier. Let the surgeon, then, advocate its immediate introduction into the army as a measure of absolute necessity — let the State Medicjne or the Army be mo- THE PREVENTION OF DISEASE. 159 destly but firmly and perscveringly urged^ until it shall be regulated and established, '' By Order/' like the other rules of discipline. It must no longer be said of the army-surgeon that " it depends on his relations with the officers in command whether any sugges- tions he makes will be listened to ;" in other words, whether the suggestions of science and of experience are to be listened to in order to save the array, or whether the suggestions of the mess- room or the club house are, without a proved necessity, to be the rule. If " officers in command" do not look to it with more Avisdom than heretofore, the House of Commons will some day, not very distant, determine the question in its own way. Referring to the preservation of the Indian army, it has been said by a great woman, and that woman Florence Nightingale, that " the observance of sanitary laws should be as much part of the future regime of India as the holding of military positions or as civil government itself. It would be a noble beginning of the new order of things to use hygiene as the handmaid of civiliza- tion." As regards the medical department, it has shed tears of humanity by order to no purpose long enough. It must now stand on its ground of scientific and practical usefulness alone. Military hygiene now ranks with the State and the public as an accepted science, and we must see well that its results are displayed not only in the economy of military life, but in the expansion of the national resources. For an exposition of the sanitary necessities of the British army, as now ruled, and of the importance of a well-understood military hygiene, I have bu.t to refer to the health history of the Crimean army as given by Miss Nightingale. Public opinion is indeed beginning to perceive, in civil life, that the system of calling in the doctor only on the appearance of sick- ness is radically unsound in itself, quite apart from the question of remuneration. The correct plan, according to the SfanJard, would be to employ the physician's ability and skill for the general and regular superintendence and care of our health and the prevention of disease, and not for applying a remedy to a malady w^hen rendered perceptible, troublesome, or dangerous. " Suppose it were the usage for every family man to set aside a certain sum annually for the regular and confidential attendance of the medical adviser, and let the practice be to prescribe, but never to supply the remedies, we should soon find a change in the entire system of therapeutics and a marvellous diminution of disease." Hitherto, in place of regarding it as their duty to consult the medical officers of the army, our commanders have proceeded at once, and without any knowledge, to issue their orders in matters affecting the soldiers' health. The results have always been, and ever must be, disastrous. In fact, something like a revolution will be necessary in our armies to gain for military hygiene the atten- tion it deserves. ICO THE PREVENTION OF DISEASE. That men wlio know nothing of science, general or particular, of war or of administration — men whose knowledge is confined to the very pipeclay of a section, a company, or a battalion, should, as in Chusan in 1810, yet have the power to judge or to order in matters of sanitary science, affecting the very existence of our soldiers, is surely an abuse which cannot much longer be permitted to disgrace our armies. It is not so much owing to the defects of our ancient sanitary laws, great as these defects confessedly were, as to the utter neglect of their provisions, that matters relating to the public health in this country have been allowed to fall so immeasurably behind the wants, the science and spirit of the age ; and it is feared that popular ignorance, national indiiference, prejudices, and parsimony will continue yet a while, as of old, to neutralize better measures of sanitary regulation than even now exist ! Englishmen, even of classes above the labourer, will agitate and combine for political privileges of no value when secured. They will cry for cheap bread, for holidays, for shorter time of labour, and for higher wages ; but they will neither reflect upon, nor combine for, any matters affect- ing their sanitary improvement. Here, in our cities, as in Paris, the thing must be done for them by an authority which they may not question. The truth I believe to be that, in respect to measures of prevention of disease, medical men have always been ready and capable to direct to good purpose ; but society was not, and is not yet, anywhere possessed of sufficient knowledge to co-operate with them. I happen to possess some official as well as professional knowledge on this head; for I was appointed in 1843 member of the Royal Commission ordered by her Majesty " for inquiring into the present State of Large Towns and Populous Districts in England and Wales, with Reference to the Cause of Disease amongst the Inhabitants.^^ As one of the said Commissioners, I examined and reported on the sanitary condition of six of the manufacturing towns of England, and two thousand copies of my reports were printed by order of the Government. The Commission was com- posed of thirteen gentlemen, including two Cabinet ministers, and its deliberations and inquiries extended over two years. The final " Recommendations" contained in the Report of the Commission to her Majesty, formed the groundwork of the clauses of a Bill, subsequently passed by Parliament, for regulating the health con- cerns of England and Wales. The Recommendations were, with a very few exceptions, of a permissive character. To this principle I ventured on sundry occasions to object, urging that, on the score of experience, whatever was allowed to be permissive was sure to be neglected ; whereas, whatever had been made imperative, like party- walls to prevent the spreading of fire, had surely been obeyed. I urged that Englishmen yield a ready obedience to Acts of Parliament, however stringent, but that to the requisitions of a Sanitary Board they would render neither respect nor obedience. THE PREVENTION OF DISEASE. 161 I think that my anticipations have been amply verified in the ■workings of the first unhappy " Board of Health/^ and that its shortcomings have arisen fully as much from defective legislation as from the intrinsic defects of that ill-sorted board. I feel con- vinced, and 1 have publicly reported my reasons for this conviction, as member of " The Health of Towns' Commission/' that legisla- tion in sanitary affairs, to be effective, must be imperative, and based on the principle that no man can be allowed a right to use liis property so as to cause injury to the health of his neighbour. In the Builder newspaper 1 find, at the moment of writing, the following common- sense view of this question as regards one out of our many nuisances : — " The total abolition of cesspools must be made compulsory ; landlords will not make the necessary outlay unless compelled to do so, and the sooner it is done the better." The State does interfere, and has always interfered, in all sorts of Avays, in the prevention of crime and on many kindred subjects. Centralization may be carried too far, but so also may respect for local government. " System is not always method, much less progress." Again, and in respect of sanitary matters, it must be confessed that the English people have had full liberty of indiscre- tion. What heads of families should be made to understand is this — that the general population cannot be making real progress, moral or physical, so long as individual existence on a large scale remains one entire course of sanitary neglect ; that in the sum of individual and personal hygiene we shall find the true and general advancement of public health. The first principles of justice, and the first sentiments of hu- manity, would seem to be common to all mankind ; but who would trust the framing and the administering of a criminal code to local or municipal management? Self-preservation requires that we should stop an evil where we can, if we must stop it somewhere. AVe cannot give up the right and duty of society to stop crime in the bud ; nor should we hesitate to assert the same right in respect of disease. The simple circumstance that amongst tlie destitute poor we must do the cure, and that the cure is very costly and difficult, imposes on \is also the duty of prevention. The polite or permissive system of legislating for the public health may do when danger is believed to be s\\ppositious or remote, but in the presence of actual danger it will never answer any good purpose in this or in any other country. The right to use one's property is one thing, and the right to abuse the privilege is another thing. It is of this last that I com- plain. The facts and circumstances here detailed will not be consi- dered irrelevant when the important principle involved in them is taken into account. The establishment of sound principles in sanitary affairs "must precede the arrangement of details — a fact 162 THE PREVENTION OF DISEASE. not always present to the minds of tliose wlio frame sanitary regu- lations.^ If it be the business of Government to prevent and to punish crime — to secure the public peace— to enforce industry instead of rapine^ and the settlement of disputes by appeal to reason instead of by fraud and violence ; if the well-being of the subject be, in short, the main object of legislation, then would it appear the special duty of the ruling power to secure the health and the life of those who, of all others, stand most in need of its protection against the invasions of individual or corporate caprice, ignorance, or stolid avarice. Here we perceive a moral and political duty of necessity. On this subject it should ever be borne in mind that where there is disease there also will be found the seat of poverty and crime. Disease, poverty, and crime, in their worst forms, are constantly and everywhere found together. The truth then is, that misery and crime produce disease, and disease produces misery and crime, in a circle which revolves, in the same calamitous monotony, from year to year, of the brief existence of the masses crowded in the worst quarters of our manufacturing cities. Whilst men are in the lowest state of physical destitution, sur- rounded by filth, vermin, privation, and squalor of every conceiv- able kind — familiar with sickness and death — and strangers to every comfort — with the mind continually on the rack, or absorbed in striving against physical necessity — or with the animal spirits broken down by its pressure ; how is it to be expected that obe- dience to the laws, that morals, education, or religion should find a place ? How can a man whose mind is ruined even more effectually than his body — the man by whom moral degradation and physical suff'ering have done their worst — how can such a man be expected to give a passing thought even to such matters ? The thing is impossible. But, not to speak of those higher considera- tions, I should say that the benefits of the surrounding civilization even are not for the occupants of the lanes, courts, and alleys, through which I have of late passed. f Even amongst what are called the better classes of society we find that, in the false pride of a (^/^/aiv'-science, or of civilization, we continually neglect measures of precaution known to the rudest people, as if we thought ourselves not subject to the laws of organization which regulate the func- tions of the inferior animals. The nature of brute animals, indeed, * The Medical Officer of Health, now appointed by the Legislature, is declared by the " British and Foreign Medical and Surgical Review" to be " a great step in modern civilization." The establishment of this sanitary office was exclusively the result of my persistent advocacy as member of the "Health of Towns' Commission." + These two last paragraphs are transcribed from my Official Report of 1842, on the Sanitary Condition of the Labouring Population in our Manufacturing Towns, as Member of the Health of Towns' Commission. Tlie observations are believed to be generally applicable to all persons and places similarly circumstanced ; and they are here presented in order to show what were then my sentiments on this most imjiortant subject. The principle I believe to be the same in respect to sanitary regulations for civil and military communities ; they should be compulsory for both. THE PREVENTION OF DISEASE. 163 we study attentively^ and adapt our conduct to tlieir constitution, whilst of our own we continue ignorant and neglectful. " If one- tentli of the persevering attention and labour bestowed to no pur- pose in rubbing down and currying the skins of horses/^ says Dr. A. Combe, " Avere bestowed by the human race in keeping themselves in good condition, and a little attention more paid to diet and clothing, colds, nervous diseases, and stomach complaints would cease to form so large an item in the catalogue of human miseries ;" while another Avriter declares, with equal truth — " If as much care were bestowed on the breeding of men as upon the breeding of cattle, we should not have books written on the dege- neration of the human race.^^ As regards epidemics, ]\Ir. Cox classifies and enumerates the local causes producing and influencing them. The following table exhibits his views in this respect, being ranged in the order of their presiuned importance. 1, Endemic Atmosphere. Produced by — a. Human effluA^a from lungs and skin ; from over-crowding. h. Ditto, from defective ventilation. c. Defective house and land drainage. d. Personal uncleanliness. 2. Bad Water Supply. Consisting of — a. Insufficient supply. b. Foul percolation through soil charged with organic matter, &c. 3. Social Habits. a. Drunkenness. b. Dirt in and around dwellings. c. Privation of wholesome food. d. Nature of employment. e. Neglect of infantile life. 4. Privation of Solar Light. TROPICAL. HYGIENE. Hints for the Preservation of Health i)i all Hot Climates. Certain popular means of prevention of disease present them- selves to the common sense of most nations to a certain degree, if they would but choose to reflect on their importance and act upon them. But it is with communities as with indi\aduals ; hygienic rules are better known than regarded. They are like the M 2 1 64 THE PREVENTION OF DISEASE. vital points in religion and morals ; — all men agree in tliem, yet liow easily are tliey forgotten ! In order to think seriously on matters relating to health, most men require to suffer from disease, the lessons derived from such experience being longest remem- bered. But there is one circumstance which ought to be impressed everywhere on individuals and communities ; and that is, that however useful medicine may be in moderate and judiciously ad- ministered doses_, under occasional circumstances of change of climate or season, or during the prevalence of certain epidemics, it is yet more on the proper selection of localities, the avoidance of day and night exposure, care in diet, clothing, exercise, &c. ; in short, on the adoption of all those well-known measures of avoid- ance, whether affecting individual habit of life or those more general predisposing causes of disease now so well understood, that the prevention of disease depends, and not on a system of self- quackery with calomel and other mercurial preparations, such as many persons pursue in England, and in India too, to their great injury, for the removal of what they call "biliousness." Many is the robust habit I have seen destroyed by this sense- less custom ; and I have known several lives lost and others put in jeopardy by the use of saline purgatives during seasons of cholera. In respect of the use of medicines in health, we should hold with the French proverb, that better is the worst enemy of well. It is here that a well-understood personal hygiene will prove of the greatest preservative effect ; and it is in seasons of epidemics that its neglect proves most signally destructive. Another source of great injury to health I must here mention, as it has come frequently under my notice both in India and in England ; — I mean the long-continued use of aperient medicines containing the mercurial preparations. Patients frequently obtain from their physicians aperient pills, for instance, containino- some blue pill or calomel. They may have been given with a particular view or for a special occasion only, but it often happens that the patient continues for months, or even for years, tliat which was intended to be used for days or weeks : the results are very lament- able. I have seen persons in a state of nervous irritability border- ing on insanity from this cause, with sub-acute inflammation of the mucous digestive membrane and chronic ptyalism — all result- ing from long-continued and unconscious use of mercury. A field- oflicer used blue pill and colocynth for two years and a half, and an American gentleman took the saiue preparations with ipe- cacuanha dui'ing a voyage from Madras to America, and back to Calcutta. It is quite needless to detail how utterly ruined was the health of both. '' Ingenuity,^' says Dr. Copland, " cannot possibly devise a more successful method of converting a healthy person into a confirmed invalid^ of destroying many of the comforts of existence, and of THE PREVENTION OF DISEASE. 1G5 occasioning hypochondriasis and melancholy^ than the practice of prcscril)iiig large doses of calomel on every trifling occasion, or when the bowels require gentle assistance ; or because the patient erroneously supposes himself to be hUlom, or is told so by those who should know better/^ The same distinguished writer as- cribes the lapse of occasional indigestion into confirmed stricture of the rectum, and of hemorrhoidal affections into fistulfe, to the frequent and injudicious use of calomel for the removal of mere occasional derangements of health. The unfortunate word '' bilious," as applied to slight disorders, is the scapegoat of the ignorant. Dr. Paris assures us, that '' if the truth were told, a large por- tion of dyspeptics seek the advice of a physician, not so much for the better adjustment and regulation of their diet as for the means by which they may counteract the ill effects of their indvilgences — hence the popularity of those '^ antlbilions remedies, which promise to take the sting out of their excesses, and enable the unhappy dupes to fondle and play with vice as with a charmed serpent." There is, in truth, says James Johnson, and referring to tropical hygiene, no situation where the stranger European may not obviate, in a great measure, the first and most dangerous effects of a tropical climate, by a strict observance of two fvmda- mental rules, tempekance and coolness. The latter indeed in- cludes the former ; and, simple as it may appear^ it is, in reality, the grand principle of intertropical hygiene, so well understood and practised by all classes and descriptions of natives of the East, and which must ever be kept in view, and regulate our measures for the preservation of health. Common sense, independently of all observation and reasoning on the subject, might, a priori, come to this conclusion. From Jieat spring all those effects which originally predispose to the reception or operation of other morbific causes ; and how can we obviate those effects of heat, but by calling in the aid of its anta- gonist — cold? ^o \\\Q sudden application of the latter, after the former has effected its baneful influence on the human frame, I have traced most of those diseases attributable to climate : nothing, therefore, can be more reasonable than that our great object should be to moderate by all possible means this heat, and to habituate our- selves, fi-om the beginning, to the impressions of cold ; so that we may thus bid defiance to the alternations or vicissitudes of both those powerful agents. This is, in truth, the grand secret of counteracting the influence of tropical climates on European constitutions ; and its practical application to the common purposes of life, as well as to particu-. lar exigencies, shall now be rendered easy and intelligible. 1G6 THE PREVENTION OF DISEASE. DRESS. When Europeans enter the tropics they must bid adieu to the luxury of linen — if what is uncomfortable^ and indeed unsafe in these climates, can be styled a luxury. The natives of the country, from the lowliest to the highest, wear none but cotton clothes, and those of theui who can afford luxuries wear them in the largest quantities. The waterman of Bengal may be taken as an example of a man who works very hard, on wages of from twopence to fourpence per day. His clothing, like his diet, is scanty and precarious in the extreme ; the former amounting only to a narrow piece of cloth passed be- tween the thighs, and fastened before and behind to a piece of stout packthread that encircles the waist. Thus unprotected, he exposes his skin to the action of an intense tropical sun — to a deluge of rain, to the dews of the night, and to a cold piercing- north-east monsoon — with equal indifference ; and with perspira- tion issuing at every pore, he darts overboard when necessary, and wades through puddles and marshes — this moment under Avater, and the next in the open air, with rapid evaporation from the whole body. It is true that he, in some degree, supplies the defect of clothing by the assiduous and regular use of oil friction to the entire surface of the body ; but, independently of all and every habit, nature has, by race and from birth, done much to secure the hard-working boatman, by forming both the colour and the texture of his skin in such a manner that the extreme vessels of the sur- face are neither violently stimulated by the heat, nor easily struck torpid by sudden transitions to cold. Certain it is also, that the action of the perspiratory vessels is different from those of Euro- peans, the fluid exuded in the native being more oily and tenacious than the sweat of the former. The dress of the shepherds, again, throughout Bengal, who are much exposed to all weathers, consists of a blanket gathered in at one end, so as to rest on the head, the rest hanging all round like a cloak. This answers the triple purpose of protection from the hottest sun — of a tent in the rainy season to throw off the wet — ■ and of a coat in the cold season to defend the body from the pierc- ing cold. Thus our ridicule of the Portuguese and Spaniards for wearing their long black cloaks in summer, to Iceejj them cool, and in winter, to keep them vmrm, is founded on prejudice rather than on correct observation. But if we look beyond the hardy labouring classes of natives of Hindustan, we observe both Hindu and Mahomedan guarding most cautiously against solar heat as well as cold. The ample turban and khummerbund meet our eye at every step ; the former to defend the head from the direct rays of a powerful sun — the latter for the purpose of preserving the important viscera of the abdomen from the deleterious impressions of cold. The khum- THE PREVENTION OF DISEASE. 167 merbimd is certainly a most valuable part of tlie dress, and one that is extensively imitated throughout India, by Europeans, in the form of a cotton or flannel waistband, worn generally next the skin. The cotton dress, from its slowness of conducting heat, is admi- rably adapted for the tropics. It must be recollected that the tem- perature of the atmosphere, sub dio, in the hot seasons, exceeds that of the blood by many degrees^ and even in the shade it too often equals, or rises above the heat of the body's surface, which is always, during health, some degrees below 97°. Here then we have a covering which is cooler than linen, inas- much as it conducts more slowly the excess of external heat to our bodies ; but this, though a great advantage, is not the only one. When a vicissitude takes place, and the atmospheric temperature sinks suddenly far below that of the body, the cotton covering, faithful to its trust, abstracts more slowly the heat from it, and thus preserves to the wearer a more and more steady equilibrium. To all these advantages must be added the facility with which the cotton absorbs perspiration. While linen so circumstanced would feel wet and cold under a breeze, and even occasion a shiver, the cotton dress, as stated, would maintain an equable warmth. That woollen and cotton dresses should be xcarmer than linen, in low temperatures, will be readily granted ; but that they should be cooler in high temperatures, will, perhaps, be doubted. But let two beds be placed in the same room during the day, when the thermometer stands at 90°; and let one be covered with a pair of blankets, the other with a pair of linen sheets. On removing both coverings in the evening, the bed on which were placed the blankets will be found cool, the other warm : the linen transmitted the heat of the surrounding air to all the parts beneath it, while the woollen covering, as a non-conductor, prevented and obstructed the trans- mission of heat from without. From this view of the subject fiannel might be supposed supe- rior to cotton, and indeed at certain seasons, or in particular places where the mercury often takes a wide range in a very short time, the former is a safer covering than the latter, and is adopted by many experienced and seasoned Europeans. But, in general, flannel is inconvenient for three reasons. First, it is too heavy — an insuperable objection ; — secondly, Avhere the temperature of the air ranges pretty steadily a little below that of the skin, the flannel is much too slow a conductor of ^xQ-aXfrom the body. Thirdly, the spiculse of the flannel prove too irritating, and increase the action of the perspiratory vessels on the surface of the body, where our great object is to moderate the process. From the second and third objections, indeed, even cotton or calico is not quite free, unless of a fine fabric, when its good qualities far counterbalance any inconvenience in the above respects. The great object of tropical prophylactics being to moderate, 168 THE PREVENTION OF DISEASE. WITHOUT CHECKING THE CUTICULAE, DISCHARGE, I WOulcl llCrC entei* a caution against a too frequent changing of the body linen, a habit confined to newly arrived Europeans principally. To change morning and evening is enough for all and every purpose, even in the hot and rainy seasons ; and to change oftener is simply injurious. The property which frequent change of linen has, of exciting the cuticular secretion, and the effects resulting from tlie 'Sympathy of the skin with the stomach, liver, and lungs, may account, in a great measure, for the superior health which accom- panies cleanliness in our own climate ; and, on the contrary, for many of the diseases of the indigent and slovenly, which are so frequently connected with, or dependent on, irregularity or sup- pression of the cuticular discharge. But though this is true, by the injudicious, nay, injurious habit of too frequent change of linen in a tropical climate, the fluids on the surface of the body, already in excess, are thus powerfully solicited, and the action of the perspiratory vessels, with all their associations, morbidly in- creased instead of being restrained. The necessity which tyrant custom, or perhaps routine, has hitherto imposed on us, of continuing to appear in European dress, particularly in uniforms, on almost all public occasions, and in all formal parties, under a burning sky, is not one of the least miseries of a tropical life ! It is true that this ceremony is waived in the more social circles that gather round the dinner-table, where the light, cool vestures of the East supersede the cumbrous garb of northern climates. But it is laughable, or rather pitiable enough, to behold a set of griffinish sticklers for decorum, for some time after each fresh im- portation from Europe, whom no persuasions can induce to cast off their exiivm, even in the most affable company, pinioned in their stiff habiliments, while the streams of perspiration that issue from every pore, and ooze through various angles of their dress, might almost induce us to fear that they were on the point of realizing Hamlet's wish ; and that, in good earnest, their * ' Solid flesh would melt — Thaw, and resolve itself into a dew," To the above observations on dress may be added, that no Euro- pean should voluntarily expose himself, at any season, to the direct rays of the sun. If forced to be out of doors, the chatta should never be neglected, if he wish to guard against coup-de-solcil, or some other dangerous consequence of imprudent exposure. FOOD. All must agree with Celsus, that sanis omnia saiia — and with a late eminent physician, that an attention to quantity/ is of infinitely more consequence than the qaalitij of our repasts ; and THE TREVENTION OF DISEASE. 169 also tliat au over-fastidious regard to either will render us unfit for society, and not more healthy after all ; yet, when we change our native climate for the torrid zone, many of us may find, when it is too late, that we can hardly attend too strictly to the quantity and quality of our food during the period of heing accommodated to the new climate ; and that a due regulation of this important matter will turn out a powerful engine in the j)!"©- servation of health. It is now well known, from dire experience, that, instead of a disposition to deh'dlti/ ax'^A jjntresceuc^, a congestive, and sometimes an inflammatory diathesis, with tendency to general or local ple- thora, characterizes the European and his diseases, for some years at least after his arrival between the tropics ; and, hence, provi- dent nature endeavours to guard against the evil by diminishing our relish for food. But, alas ! how prone are we to spur the jaded appetite, not only " by dishes tortured from their native taste," but by more dangerous stimulants of wine and other liquors, as well as by condiments and spices, which should be reserved for that general relaxation and debility which unavoidably supervene dui'ing a jji-otracted residence in sultry climates. Here is an in- stance where we cannot sqfeli/ imitate the seasoned European ; for there are no points of hygiene to which the attention of a new- comer should be more particularly directed, than to the qaanflti/ and simjjllcitij of his viands. They are practical points, entirely within his own command, and a due regulation of them is not at all calculated to draw on him the observation of others — a very great advantage. That vegetable food is, generally speaking, better adapted to a tropical climate than animal will be admitted, especially in the instance of the unseasoned European ; not that it is quicker or easier of digestion, for it is slower, but it excites less commotion in the system, during that process, and is not apt to indvice plethora afterwards. These are the considerations which should give pre- ference to vegetable over animal substances in the diet of the un- seasoned European, and which should induce him to be at least sparing in the use of the latter. Every valetudinarian, and particularly the hectic, knows full well i\\Q febrile movement which follows a full meal ; and the same takes place, more or less, in every individual, whatever may be the state of health at the time. How cautious should we be then of exasperating those natural paroxysms, when placed in situations where various other febrific causes are constantly impending over, or even assailing us ! The febrile stricture which obtains on the surface of our bodies, and in the secerning vessels of the liver, during the gastric digestion of our food, as evinced by diminution of the cutaneous and hepatic secretions, will be proportioned to the duration and difficulty of that process in the stomach, and to the quantity of ingesta^ and as a corresponding increase 170 THE PREVENTION OF DISEASE. of the two secretions succeeds, when the chyme passes mto the intestines, we perceive the propriety of moderating them by abste- miousness, since they are already in excess from the heat of the climate alone, and this excess is one of the first links in the chain of causes and effects that leads ultimately to various derangements of function and of structure in important organs, as exemplified in the fevers and dysenteries, in the hepatitis and cholera of tropical regions. The newly- arrived European should content himself with a plain breakfast of bread-and-butter, with tea or coffee, and avoid in- dulging in meat, fish, eggs, or buttered toast. The latter alone often disagrees, and occasions rancidity, with nausea at stomach, while it increases the secretion of bile, already in excess. A glance indeed at the BmvnrcJ/ee, buttering our toast with the greasy wing of a fowl, or an old dirty piece of rag, will have more effect in re- straining the consumption of the article than any didactic precept which can be laid down ; and a picturesque sight of this kind may be procured any morning by taking a stroll into the purlieus of the kitchen. In regard to dinner, were the Eui'opean master of both time and circumstance, the early part of the afternoon should be that of his principal meal ; but the great majority of men of business, whether official or mercantile, are unable to disengage themselves during the day, and thus from seven to eight o'clock becomes the settled hour. It is true that military men, excepting such as hold staff offices, may choose their hour of dinner, but fashion and routine rule this and other habits ; and the mess hour is too late. The naval cap- tain who exclaimed — " Not eat that ! I will make my stomach submit to anything," represents more persons in every society, and in every country, than careless observers dream of. Naval and military men are, beyond all others, devoted to system, and to a certain extent justly so. But system, like everything in this world, may be abused so as to degenerate into something even worse than mere routine. As matter of fact, regiments in general have luncheon ('^^ tiffin") on table at one o'clock, with wine and ale, and a heavy dinner at seven with more wine and ale. Thus any officer who is so disposed may become the subject of a daily feverishness, soon to be followed by disease ; and even such as are temperately disposed commit excesses in eating and drinking, often without being aware of it. An old staff officer in Fort William used to say that he had known more duels, courts martial, nnd dismissals to result from the " tiffin " alone than from any other cause ; but what were the other results, in the olden times, of the tiffin and the dinner, from year's end to year's end, tliere is no man alive now-a-days to tell ! Although a great deal that was objectionable in the double meal has given way to modern improvement in the general habit of THE PREVENTION OF DISEASE. 171 society throughout India, still too much of both tiffin and dinner remains. Both meals are greatly too much after the European fashion ; Avliile strong wine and ale are too liberally circulated, at least for health. Claret — " the cup that cheers and not inebriates" — is always to be preferred. He then who consults his health in the East will beware of late and heavy dinners, particularly during the period of probation, but will rather be satisfied with a light and early repast as the 2m)icipal meal, when tea or coffee at six or seven o'clock will be found a grateful refreshment. After this his rest will be as natural and refreshing as can be expected in such a climate, and he will rise next morning with infinitely more vigour than if he had crowned a sumptuous dinner with a bottle of wine the previous evening. Let but a trial of one week put these directions to the test, and they will be found to have a more substantial foundation than theory. A limited indulgence in fruits, during the first year, is prudent ; and there is little reason to believe that, when ripe and used in the forenoon, they dispose to irritation of the bowels. Particular kinds of fruits have peculiar effects on certain constitutions ; thus, mangoes have sometimes a stimulating and heating effect, Avhich not seldom brings out a plentiful crop of pustules, or even boils, on the unseasoned European. The pine-apple, though very delicious, is not the safest fruit to make too free with at any time. The orange is always grateful and wholesome, and good ripe shaddocks are so likewise, owing to their cooling subacid qualities. The banana is wholesome and nutritious, whether undressed or frittered. The use of spice or condiment, as already stated, should be reserved for those ulterior periods of our residence in hot climates when the tone of the constitution is lowered, and the stomach participates in the general relaxation. They are then safe and salutary, especially during the rainy season. DRINK. In a vast empire such as that of India, held by the frail tenure of opinion, and where the current of all the various religious opinions of the natives runs strong against intoxication, it was early found necessary, from motives of policy rather than of health, to discourage the acquisition of habits at once dangerous and dis- graceful. Hence the inebriate has always been justly considered as not merely culpable in destroying his individual health, but as deteriorating the European character in the eyes of the natives, whom it is on all accounts desirable to impress with a just sense of our superiority. It is thus that our power may acquire material substance froui the gradually improving convictions of the natives 172 THE PREVENTION OF DISEASE. themselves. Happily, what has been promotive of our own inte- rests has been also preservative of our healthy as well as conducive to our happiness ; and the general temperance which now charac- terizes the European circles of society in the East Indies is most gratifying. We shall no longer hear from medical or lay writers of " gently stimulating liquids/' used during the forenoon " for supporting j)erspiration, and for keeping up the tone of the digestive organs/' for all experience has proved such habits to be actually pernicious. The European who should now take to such unworthy indulgences would soon find himself excluded from good society. It has already been observed that the great physiological rule for preserving health in hot climates is — to keep the body cool. The strong sympathy that subsists between the skin and the several internal organs, as the stomach, liver, and intestinal canal, has also been emphatically referred to. The common sense of man- kind would seem indeed to point out the propriety of avoiding heating drinks, for the same reason that we endeavour instinctively to guard against a high external temperature. But the truth is that, until men begin to feel the corporeal ill effects of intemperance, a deaf ear is turned to the most impressive lectures against the most deplorable of propensities, that which Napoleon declared to be the least compatible with greatness. With the feeble and irresolute the magic bowl, which this moment can raise its votaries into heroes and demigods, will, in a few hours, sink them beneath the level of the brute creation. ^loralists and philosophers have long descanted on this theme, but with little success, as few will attempt to prove that water is the simple and salutary beverage designed by nature for man ; seeing that every nation, even the most refined, has practically repudiated the doctrine. Let the medical profession, however, do its duty in portraying truthfully the ill effects of the abuse of drink, in tropical climates especially. The truth is that, as drunkenness leads, in a moral point of view, to every crime, so, in a physical point of view, it promotes the invasion, and retards the cure, of every tropical or other disease. It may be received as a truth that, during the first tAvo years of residence at least, the nearer we approach to a perfectly aqueous regimen in drink, so much the better chance have we of avoiding sickness ; and the more slowly and gradually we deviate from this afterwards, so much the more retentive shall we be of that in- valuable blessing — health. In speaking of the means of preserving health, which depends so much on the tone of the digestive organs, we must not omit the recent luxury — American ice — which has now become an article of necessity in the East. It would be out of place here to speak of its uses in the treatment of various diseases, and of fevers especially, as those of a cerebral and gastric nature. " Nothing," says Doloraieu^ " is more salutary during the sirocco than iced THE PREVENTION OF DISEASE. 173 beverages ; they revive the spirits^ strengthen the bodj'^ and assist the digestion.'^ Those who have now, during several years past, made use of this real luxury in the East Indies, need no arguments in favour of promoting so remarkable an instance of American enterprise. I would caution the newly arrived European against a very common and very dangerous mistake, namely, the acting in matters of diet and exercise on the supposition that he may with impunity do as the elder residents ; for it is consonant with experience, as with theory, that the latter class may indulge in the luxuries of the table with infinitely less risk than the former. To think and act otherwise is to confound all discrimination between very different habits of body which the seasoned and unseasoned possess. One other circumstance should always be held in recollection, to wit, that when a course of temperance is fully entered on, and the pleasiu'es of temperance fully enjoyed, no consideration should induce us to commit an occasional debauch, especially during our seasoning, for we are at those times in infinitely greater danger of both endemic and epidemic attacks than the habitual bacchanal. In the last article it has been stated that the subacid fruits are both grateful and wholesome, and so will it be found with mode- rately acid drinks, such as sherbet. ISIature seems to point out the vegetable acids in hot climates, as grateful in allaying drought and diffusing a coolness from the stomach all over the body. To the temperate and the healthy they will generally prove salutary, and I have never seen or heard of any ill effects from their use. We hear much amongst vulgar habitual topers of the supposed prophylactic influence of spirits and cigars against night exposure, malaria, and contagion ; but no medical obsei'ver, in any of our numerous colonies, has ever seen reason to believe in any such delusive doctrine, nor is there in reality the smallest foundation for it. All excitement is followed by a corresponding depression of the vital functions, and it is then that the toper is doubly liable to suffer. I cannot quit the subject of diet without referring to an after- luncheon habit to be met with in India, and one not infrequently imported home by persons in the position of gentlemen ; I mean tlie habit of beer-soaking. This habit may by insensible degrees degenerate into wine and spirit drinking ; and then it is unneces- sary to mention the very sad consequences. Surgeons, whether civil or military, can well understand the beneficial actions of wine or of bitter ale, moderately used, in the other sex, after severe confinements, and during protracted wet- nursing, in an exhausting climate. But, unhajjpily, one some- times sees lamentable circumstances connected with such indul- gences, Avhen they have become habitual ; and all I would here insist on is this — that medical officers may never permit themselves, directly or indirectly, to become parties to the initiation or intro- 174 THE PREVENTION OE DISEASE. (luction of such abominations into families. To see an English gentlewoman '^ much bemused with beer/^ is surely a spectacle the most humiliating. EXERCISE. This is one of the luxuries of a northern climate to which we mustj in a great measure, bid adieu between the tropics. The principal object and effect of exercise in the former situation appear to consist in keeping up a just balance in the circulation, iu supporting and maintaining the functions of the skin, and pro- moting the various secretions. But the perspiration, biliary, and other secretions being already in excess in equatorial regions, a perseverance in our customary European exercises would prove highly injurious, and it often does so, by promoting and aggra- vating the ill effects of an unnatural climate. As such excess very soon leads to debility, and to dimimshing action in the functions alluded to, and to a corresponding hieqmlibrium of the blood, so it is necessary to counteract these by such active or passive exer- cise as the climate will admit at partictdar periods of the day or year ; a discrimination imperiously demanded if we mean to pre- serve health. When the sun is near the meridian for several hours of the day on the plains of India, not a leaf is seen to move, every animated beingretreats under cover, and even the "adjutant,^' or gigantic crane of Bengal, soars out of reach of the earth's reflected heat, and either perches on the highest pinnacles of lofty buildings, or hovers in the upper regions of the air, a scarcely dis- cernible speck. At this time the native retires instinctively to the innermost apartment of his humble shed, where both light and heat are excluded. There he sits quietly in the midst of his family, re- galing himself with cold water or sherbet, while a gentle perspi- ration flows from the skin, and contributes naturally and power- fully to his refrigeration. Mr. Twining justl}^ observes that the natives, both Hindoo and Mahomedan, seem to suffer much from the hot season in Bengal. During the latter part of this season those natives whose circumstances enable them to act as they wish, avoid any exertion as much as possible, reducing the quan- tity of their food, and eating certain fruits which they consider cooling. In the afternoons they drink the fluid contained in the unripe cocoa-nut, or a very simple sherbet, or some sugar and water, deeming the latter especially cooling ; and in the mornings they take an infusion of Nalta Fat, or leaf of the Corchorus Ol'itorius, which they say has a cooling effect, at the same time that it acts as a mild tonic, promoting digestion, and preventing lassitude. He adds that the natives, though adapted by nature to bear the climate, take more care to moderate the effects of heat than Europeans, especially in their light clothing, abstemious food, and tranquil habits. THE PREVENTION OF DISEASE. 175 After tliis cxam})lc of the salutary habits of all classes of natives of Iiidiaj it is hardly necessary to urge the iujuriousness of every kiud of active exercises to Europeans under tropical heats, and especially during the heats of the day; yet hundreds perished annually from this very cause, particularly in the West Indies, upon each influx of European troops during the late war. Happily it may now be said that, owing to the removal of the European troops from the plains to tlie mountains, the horrors resulting from the climate of Jamaica liave been exchanged for health and comfort. This beneficent act is due to the generous and noble nature of the late Lord JNIetcalfe, when governor of that island. Who would expect to find tlaaclno a prominent amusement in a tropical climate? The natives of the West Indies are exceed- ingly fond of this exercise j but those of the East are wise men still, for, instead of dancing themselves, they employ Natch girls to dance for them. Gestation of every kind, whether in palankeens or spring carriages, is a species of passive exercise exceedingly well adapted to a tropical climate. The languid state of the circulation of the blood, in those who have resided long there, is pointedly exhibited in the disposition which they evince to raise the lower extremities on a line with the body when at rest ; and this object is completely attained in the palankeen, which indeed renders it a peculiarly agreeable vehicle. On the same principle we may explain the feeling of satisfaction and the utility of sliamjioo'uig, where the gentle pressure and fric- tion of the soft Asiatic hand over the surface of the body, but particularly over the limbs, invigorate the circulation after fatigue, as well as after long inaction, and thus excite the insensible cuticular secretion. The keesa, or hair-glove of India, is an ad- mirable means of giving additional effect to the practice of sham- pooing, a practice which, to the indolent wealthy natives, proves a real and effective substitute for exercise. The swing might perhaps be rendered useful in the hot and rainy season in the East Indies. In chronic disorders of the viscera it could hardly fail to be grateful and salutary, by its tendency to determine to the sm'face and relax the subcutaneous vessels, which are generally torpid in those diseases. It might be practised in the early mornings and evenings within doors, when- ever the weather or other circumstances do not admit of gestation in the open air. BATHING. ;Moscley's caution to the European residents of his day in the West Indies, may be recorded for the benefit of all who think that, in hot climates, they may do what they please with cold water: — " I dare not recommend cold bathing; it is death with intemperance, aiid dangerous where there is any fault in the 176 THE PREVENTION OF DISEASE. viscera. It is a luxury denied to almost all, except the sober and abstemious females, who well know the delight and advantage of it.^^ The cold bath is death, not (hiring intemperance, but in the collapse ^Nh.\c\\ foUoios a debauch, or indeed any other great fatigue of mind or body. It is also dangerous under every form of visceral disease, but the healthy and temperate of habit may as safely partake of the " delight and advantage" of tlie cold bath as Dr. Moseley's " sober and abstemious females." The truth is, that the cold bath is a prize due to, and gained by, the temperate. To all else it is eminently unsafe, as any naval and military sur- geon of tropical experience can testify. To the European resident in tropical climates whose constitution is sound, and whose habits are temperate, no more efficient means exists of obviating the most unpleasant effects even of the cold season ; for he who reacts v.ell under the cold bath will not be troubled with dry skin, and sense of internal fulness. To persons of ordinary health, but who are not robust, the cold bath will be found tonic and agreeable from the beginning of March, in India generally, to the end of Sep- tember. The temperature ranges high in these months, and the determination to the surface is such as to ensure a sufficient reac- tion. It is a common error to think that, before using the cold bath, we must be cooled first, while the very opposite rule is the correct one. To the delicate, indeed, immersion in a wann bath for a few minutes is an excellent preliminary, followed at once by affusion of some three or four vessels of cold water. A glow over the whole surface of the body will immediately follow. This is a safe and excellent mode of bathing to all who shrink from or who feel doubtful of salutary reaction from the use of cold water. We hear warm and cold bathing recommended without refer- ence to the state of health, to the season, or to regularity of habit, although these circumstances sliould form essential preliminaries to the choice. It may be concluded for certain that, to persons who have suffered from tropical disease, or who are affected Avith visceral congestions, or with visceral enlargements especially, the results of fevers or dysenteries, the warm bath is the only safe one at all seasons. The same rule applies to the dissipated, and to such as are in the habit of keeping late hours. In such persons the balance of circulation is already disturbed, and the effect of cold water is to throw the blood with force on organs already irritated by irregular courses of life, the abdominal viscera especially. Under such unfavourable circiim stances it is not to be expected that the " conservative energies " should be capable of being " roused to successful resistance /' Avith the whole external surface parched, and with the digestive mucous surfaces in a state of irri- tation, how can it be otherwise ? As many persons have but an imperfect knowledge of the rela- tive temperatures of the several baths in ordinary use, the follow- ing scale is here presented : — THE PREVENTION OF DISEASE. 177 Cold bath, fi-om 60° to 75° Tepid bath, from 85° to 92° Waiui bath, from 92° to 98° Hot bath, from 98° to 112° By tbe healthy and temperate European, the use of the cold bath sliould be regularly and daily persevered in, from the moment of his entrance within the tropics ; and when, from long residence there, the functions above referred to begin to be irregular or defective, he may prudently veer round by degrees to the use of the tepul bath, whicli will then be found a most valuable part of tropical hygiene. The use of the cold bath being a passive operation, unattended by any exercise, it may be used at any period of the day, although the mornings and evenings are generally selected by Europeans in the East ; immediately after leaving their couch, and before dinner. On both occasions the bath is very refreshing, and it powerfully obviates that train of nervous symptoms so generally complained of by our countrymen in hot climates. Before dinner it seems to exert its salutary influence on the surface of the body, and by sympathy, on the stomach, removing the disagreeable sensation of thirst which might otherwise induce a too free use of potation during the repast. It is always imprudent to bathe while the process of digestion in the stomach is going on, as it disturbs that important operation. SLEEP. When we bid adieu to the temperate climate of Europe, with its "long nights of revelry,^^ and enter the tropics, we may count on a great falling off in this '^ solace of our woes.^^ The disturbed repose which we almost always experience there, has a greater eventual influence on our constitutions than is generally supposed, notwithstanding the silence of authors on this subject. Whatever we subtract from the requisite jieriod of oui' natural sleep will surely be deducted, in the end, from the natural range of our exis- tence, independently of the predisposition to disease which is thus constantly generated. This is a melancholy but a true reflection, and it should induce us to exert oui" rational faculties in obviatina; 80 great an evil. The great object of the European is to sleep cool, and obtain complete protection from mosquitoes."^ Happily both advantages * Sydney Smith's description of the insects in tropical climates is at least character- istic of the author : — "Insects are the curse of tropical climates. The bete rouge lays the foundation of a tremendous ulcer. In a moment you are covered with ticks. Chigoes bury themselves in your flesh, and hatch a large colony of young chigoes in a few hours. They will not live together ; but every chigo sets up a separate ulcer, and has its own private portion of pus. Flies get entry into your mouth, into your eyes, into your nose ; you eat flies, drink flies, and breathe flies. Lizards, cockroaches, and snakes get into the bed ; ants eat up the books ; scorpions sting you in tho feet. Eveiything bites, stings, or bruises ; every second of your existence you are wounded N ITS THE PREVENTION OF DISEASE. may be secured to tlie temperate by the large mosquito frame and curtain with punkab suspended from the ridge, as now prevalent throughout Bengal. This is not only luxurious but safe, the gentle agitation of the punkah removing the heated air surrounding the body without exposing the person to the dangers arising from sudden night changes in the temperature or humidity of the atmosphere. The European is thus enabled to procure more and sounder rest than he could possibly do otherwise ; and by giving his frame a more thorough and complete respite from the great stimulus of heat, he imparts to it tone and vigour, so necessary to meet the exhaustion of the ensuing day, as well as to repair that of the pre- ceding. Early hours are here indispensable ; for the fashionable nocturnal dissipations of Europe would soon cut the thread of our existence within the tropics. The order of nature is never inverted with impunity, even in the most temperate climates ; beneath the torrid zone it is certain destruction. The hour of retirement to repose should never be protracted beyond ten o'clock; and at daylight we should start from our couch to enjoy the cool, the fragrant, and salubrious breath of morn. Without some artificial aid, such as that above mentioned, a great waste of strength — indeed of life — may arise from our inabi- lity to obtain cool repose at night. The cold and rainy seasons, heavy dews, or exhalations from contiguous jungles or marshes, often render it impossible with safety to sleep in the oj}e/i air ; a practice, during the //of sect son, fraught with refreshing benefit, where the obstacles mentioned do not prevent its execution. In Bengal Proper, in the plains of Upper India, and on the Coromandel coast, except during the hot land-winds there, or at the change of the monsoons, Europeans may generally indulge, during the hot and dry season, in the luxury of sleej)ing in the open verandaJts, not only with safety, but with infinite advantage. It is an old habit throughout most parts of India, especially of the military classes; and the judicious Captain Williamson says justly that, while it is attended with the greatest refreshment, by some piece of animal life that nobody has ever seen before, except Swammerdana and Meriam. "An insect with eleven legs is swunming in your teacup, a nondescript with nine wings is struggling in the small-beer, or a caterpillar with several dozen eyes in his belly is hastening over the bread-and-butter! All nature is alive, and seems to be gathering all her entomological hosts to eat you up as you are standing, out of your coat, waistcoat, and breeches. Such are the tropics. All this reconciles us to our dews, fogs, vapours, and drizzle — to our apothecaries rushing about with gargles and tinc- tures — to our old, British, constitutional coughs, sore-throats, and swelled faces." After this we may not denounce as extravagant Dr. Clarke's account of the climate of the Crimea : — "If you drink water after eating fruit," he says, " a fever follows. If you eat milk, eggs, or butter, a fever. If, during the scorching heat of the day, you indulge in the most trivial neglect of clothing, a fever. If you venture out to enjoy the delightful breezes of the evening, a fever. In short, such is the dangerous nature of the climate to strangers, that Russia must consider the country a cemetery for the troops which are sent to maintain its possession." THE PREVENTION OF DISEASE. 179 enabling tliem to rise early, divested of that most distressing lassi- tude attendant upon sleeping in a close oppressive apartment, coramuuieating a febrile sensation, very few instances could be adduced of any serious indisposition attending it. Healthy and temperate persons, and who are habituated to the use of the cold bath, need be under no apprehensions, excepting at the places and seasons alluded to, as to transitions from the scorching heat of the day to the serenity of night, for indeed it is gradual and easy. Those ^^'lio habitually exclude themselves from the breath of heaven, whether from inclination or necessity, become languid from the cont'imiecl operation of heat and want of repose : — even the slightest aerial vicissitude, or admission of a partial current of cool air, unhinges the tenor of their health, and deranges the functions of important organs. These are they who require the afternoon siesta, and to whom indeed it is necessary, on account of the abridged refreshment and sleep of the night; while the others are able to go through the avocations of the day without any such substitute — a manifest and great advantage. A few words on the incubus, or niglitmare — a troublesome visitor to the tropical couch — may properly conclude this section. From the results of treatment it would appear that the primary cause has its seat in the digestive organs, in whatever way it may act ; and that the nightmare originates in defective digestion, producing heartburn, flatulence, griping and eructation, with a train of dyspeptic complaints. Of all medicines, the carbonate of soda will be found the most efficacious, taken in scruple doses at bedtime, or night and morning, in some aromatic water, such as the peppermint. This medicine not only neutralizes the acids of the stomach, but it pro- motes the elimination of the bile, and the evacuation of slimy dis- charges from the bowels. There are few people with whom particular kinds of food do not disagree, and, being l^nown, these should be avoided. Thus, ehestniits or sour wine will almost always produce incubus in those predisposed to it, as was observed by Hildanus : — " Qui scire cvpH quid sit inctihis ? Is ante somuum comedat castaneas, et siijjerbihat vinnm faculentiim'^ In this country, cucumbers, nuts, apples, and flatulent kinds of food are the articles most likely to bring on nightmare. THE CONDUCT AND GOVERNMENT OF THE PASSIONS. Most of the precepts that apply to the regulation and govern- ment of the passions in cold climates will be found to apply to them in tropical climates ; but it is necessary to correct at once an erroneous impression that there is something peculiar to the tropics which excites certain passions in a higher degree than in temperate regions. N 2 180 THE PREVENTION OF DISEASE. Dr. Moseley says tliat " there is in the inhabitants of hot climateSj unless present sickness has an absolute control over the body, a promptitude and a lias to pleasure, and an alienation from serious thought and deep reflection. The brilliancy of the skies and the beauty of the atmosphere conspire to influence the nerves against philosophy and her rigid tenets, and forbid their practice among the children of the sun.^^ However true this description may be in respect of " the children of the sun/' it does not accurately exhibit the condition of the stranger European, in whom such a course of relaxation would be very immoral ; for such a view would furnish the dissolute libertine with a pltus'ical excuse for his debaucheries, when the real source might be traced to laxity of religious and moral principle. We would ask Dr. Moseley if the ^^promptitude and bias to pleasure'' be increased in hot climates, why the ahUitij to pursue or practise it should be lessened ? a fact well known to every debauchee. It has been asked, says Hennen, what has the medical topo- grapher to do with the morals of the natives of a country? and it has been asserted that their immoralities cannot aflect the health of troops quartered amongst them, if proper discipline be observed. Such opinions are founded upon a very superficial view of the subject ; for the soil and inhabitants, he adds, always react on each other, A sober and industrious race of people will, for example, have a greater desire to improve their country than men of a contrary character, and will also possess greater physical power to carry their desire into execution. Place such a body of men in a district overrun with noxious weeds and timber, and fast degenerating into a morass, and can there exist any rational doubt that they Avill clear it sooner, and preserve it longer in that improved state than men of a difterent disposition ? Place in a similar situation, or even in a district thus improved, a body of men who are idle and intemperate, and the immediate result will be that the soil will deteriorate for want of proper care, the weeds will reappear, the drains will become obstructed, the edible pro- ducts of the earth will lessen in quantity, and diminish in their nutritive quality ; the inhabitants will become unhealthy fi-om the bad state of their grou^nds ; and the diminution of their physical powers thus produced will disable them progressively more and more from remedying the causes of the evil. Many of these efi'ects (vill doubtless first be felt in their own persons, but it is undeni- able that they must ultimately operate on their visitors. On this obvious principle is founded the axiom in medical topography — ^' that a slothful, squalid-looking population invariably characterizes an unhealthy country." Whether the founders of the Hindu faith acted designedly or otherwise, there can be no doubt that, by depressing all the phy- sical energies by a diet purely vegetable, they fastened with a firmer and stronger baud the bonds of Brahminical domination on THE PREVENTION OF DISEASE. 181 the people of India, until a chain, forged only by superstition, became, in progress of fifty centuries, and through the most power- ful of moral and physical agencies, strong as death. " The use of certain kinds of food and drink,'^ says Cabanis, '^may tend to confirm or impair certain moral habits. Sometimes it may operate directly, and by the immediate impressions which it produces ; at other times, by the different states of health or disease which it occasions, or by the changes in the fluids and solids which result from it ; for all these different alterations in the system soon manifest themselves more or less distinctly in the ordinary dispositions of the w^ill and understanding. '^ The same great authority in tlie physiology of climates adds that, " the poor diets prescribed by the legislators of various reli- gious orders, have never had the effect of diminishing the vene- real appetite, but have, on the contrary, inflamed these propensi- ties the more, or disordered the imagination in diminishing the physical forces ; and thus men have been rendered more feeble, more unhappy, and more easy of domination." But let us hope that, in respect of the natives of India, the all- powerful benefits of education, and the example of their European governors, may enable them to conquer the influences of climate, and of the depraving religious and political habits of ages. To expect, however, that such changes can be speedily effected were contrary to reason and experience. The caste is of unknown antiquity. " Neither the proselytizing sword of the Mussulman, nor the mild light of Christianity, has had any influence upon it, and the Hindu still worships before the altars of his gods with the same devotion as when Orpheus charmed the wild beasts by the sounds of his lyre, and Avhen Moses ascended Mount Sinai. Religion, manners, customs, costume, civilization, all have re- mained immovable as the temples hewn out of the granite rocks of Ellora." After what has been here stated, it cannot be questioned that the habits and character of the people amongst whom we live, during many years, must have a powerful influence on our morals. But to return to the condition of the stranger European. The removal of religious and moral restraint, the temptations to vice, the facility of tlie means, and the force of example, are the real causes of this bias to pleasure ; and in respect to the effects of licentious indulgences between the tropics, the reader may be assured that he Avill find, perhaps wdien too late, how much more dangerous and destructive they are than in Europe. The nature of the supposed "propensity" has been explained to him ; and as the principal cause resides neither in the air, nor in the " brilliancy of the skies," but in his own breast, he has no excuse for permitting it to grow into the wild luxuries of un- bridled excess.. The monotony of life and the apathy of mind so conspicuous in 182 THE PREVENTION OF DISEASE. liot climates^ together Avitli the obstacles to matrimony^ in former times led too often to vicious and immoral connexions with native females, which speedily sapped the foundations of principles im- bibed in early youth, and involved a train of consequences not seldom embarrassing, if not embittering every subsequent period of life. It is here that a taste for some of the more refined and elegant species of literature will prove an invaluable acquisition for dispelling emmi — the moth of mind and body. military hygiene, or preserving of the soldier's health. M. Thiers remarks that in ordinary histories of war we see only armies completely formed and ready to enter into action ; but it can scarcely be imagined what efforts it costs to bring the armed man to his post, equipped, fed, trained, and lastly, cured, if he has been sick or wounded. All these difficulties are increased in pro- portion to the change of climate, or the distance to which the army moves from the point of departure. Most generals and govern- ments, he says, neglect this kind of attentions, and their armies melt away visilily. Those only who practise them with perseverance and skill find means to keep their troops numerous and well- disposed. Cormenin says truly, that details govern the world ; and Bal- ly et states as confidently that, in an army, contempt for orga- nization is nothing less than contempt for human life. Both aphorisms have an especial reference to the moral and physical welfare of organized bodies of men, such as fleets and armies. It is different with civil communities, in which the defects of law and of details are to some extent compensated by the moral attitude and conduct of the people. Lord JNlacaulay expresses this fact when he declares that the Scotch would be well governed without any laws, or under the worst laws, while the Irish would be ill governed under the best laws. But it is not so with an army — an organized and artificial body, in which good regulations and " details ^^ are everything. It is a beneficent law, also, that all sanitary measures more than repay their costs, and it applies to all such measures, whether in civil or military life. " It is a mean consideration,'^ says the Examiner, " though a true one, that protection against waste mor- tality arising from neglect of the known laws of nature, leads to a sure saving in money, and that the sanitary physician is the best of recruiting officers.^' Of the efforts and difficulties spoken of by M. Thiers, those of the medical officer are not the least; although nowliere elsc/ifhe were fully trusted, could his services be so effective as in the preserving of the soldier's health. As it is, his disadvantages are endless. He is consultedj perhaps on active service^ through ignorance or THE PREVENTION OF DISEASE. 183 caprice^ often when it is too late, but more generally not at all ; and thus the soldier always suffers. In the British armies, at home and abroad, the rule is to leave everything, even of a sanitary natiu'e, to the proper authorities, as they are ealled; and thus much is on all occasions found to be Avanting. There is nothing so difficult to deal with, whether in public or private life, as the ti'oubles we create for ourselves. We boast of our " strong towers,^' in other words, of our stalwart British soldiers ; but so careless are we of the sanitary welfare of the matrix whence we derive them, that in the capitals of the three kingdoms there were rejected, of military recruits, between the years 1833 and 1837, nearly fifty per cent. At this rate, were we to require an army of 100,000 men, we must expect that 50,000 would be rejected ; for the three capitals are by no means so unhealthy as many of the provincial towns. Hitherto unhealthiness has been the rule in our armies, and it has often proved but another name for national humiliation and disaster, not to speak of enormous pecuniary sacrifices. In our foreign possessions during peace, and in our foreign enterprises during war, the rule of unhealthiness has been without any excep- tion. We have often got into disasters before we have seen the enemy, and our campaigns have frequently presented the saddest pages in our military history. Our armies have, on more than one occasion, been conquered by their own commanders — conquered and destroyed by the very organization and system of the British army. When a commander by sea or land is invested with authority, he always desires it to be understood that he is complete master of the situation — that he knows everything, and will do everything. But when such a man knows little, and does less, as too frequently happens, then the results are sure to be disastrous, whether we look to considerations of health or to the completion of warlike enterprises. The truth is that governments may confer material power on governors, admirals, and generals, but if they do not possess moral power, it is as nothing. Nor are ignorance and neglect of matters affecting the health of the soldier confined, as is supposed in civil life, to blundering and ill-informed lieutenants : far otherwise is the case. When very young, and serving in one of the most pestilential countries known in India, I made a topographic examination of the localities, and reported the result to my commanding officer, suggesting at the same time what I regarded as the most suitable arrangement for encamping the men against the coming rainy season, when it was well known that a great increase of deadly fever would result. The answer was — '' TU be d d if I do.'' Now, here was no blundering lieutenant, but, on the contrary, one of the most able and Avell-informed field-officers I have ever known ; yet, such was his treatment of a grave matter of duty, and the neglect of which, before the year was over, cost him his life. 184 THE PREVENTION OF DISEASE. Again^ on landing at Rangoon^ during tlie first Burmese war, I Avas credibly informed that the superintending surgeon of the Bengal division there had warned the officer commanding that, without fresh animal food and vegetables, the European soldiers must perish from scurvy. The answer was characteristic, and somewhat more civil than that granted to me. It was this : — " Medical opinions are very good, sir — when they are called for.'' Here, also, was no blundering subaltern, but a gray-headed general of reputation, and one who received much honour and profit after his army had perished miserably. How fell is ignorance or weakness when armed with might ! If it be asked how come these things, I answer that it has always been so, and that it always will continue to be so — until it is ordered otherwise. We have hitherto encountered the combined horrors of disease without remedies, and those of climate without protection, and it will so continue with us until persons in com- mand shall be held responsible, in short, for ignorance and neglect of duty. Until this shall be done, it will be in vain to expect that we can in future escape from the administrative collapse of all the departments of the army which so disgraced and ruined us in the Crimea. Mr. J. C. Robertson, late Governor of Agra, remarking on the general question, says — " It may, perhaps, be thought that the duly-qualified subordinate can always supply, by his sugges- tions, the deficiencies of his superior ; but they know little of the military variety of the genus homo who Avould rely upon such sug- gestions being frankly made or kindly received. The spirit is nullified, but not extinct, Avhicli prompted the reply of a general in the war of 1757 to some wise hint of the youthful AVashington. ' Silence, sir ; things have come to a pretty pass indeed, when a British general is to be instructed by a Virginia Buckskin !' " I question much whether the old ignorant grudge is in any degree ''^ nullified" which has at all times caused our admirals and generals to eschew common sense as well as science. But the common sense of the country is being made manifest through an influential press, and it becomes more felt in the army and navy every day. In all our wars, pestilence will everywliere be found to form their most dismal and afi'ecting page ; yet it need not have been so. In none of our most fatal expeditions — in that of Rangoon, for instance — was there any actual necessity for serving decayed rations to our men, or for exposing them through the hot and rainy seasons to excessive fatigue, to the rank air and damp en- campment — there to be destroyed without notice and without remembrance. Governments and communities sympathize readily enough with the soldier's triumphs, but not with his perils and suff'erings. Of sympathy with his suffeiings from hunger and thirst — from long and forced marches under the burning sun and the heavy dew — THE PREVENTION OF DISEASE. 185 from tlie cold bivouac— from tlie long suspense attending field operations ; with these, and with his sufferings from inscrutable pestilence, there is but little sympathy ; yet they are, after all, the most ordinary as Avell as the hardest trials of war. For one soldier who is struck down on the field of battle, ten, sometimes twenty, are lost to their country through the luiappreciated hardships here briefly recounted. England, often engaged in great wars, is, of all nations, the most slow to learn the real nature of war and of its requirements ; and when peace arrives, all the experiences of former wars are forgotten in the pursuits of commerce. When we com- plain of inhumanity, military errors, and disastrous national failures, political adventurers and sophists are always ready to declare that '' we have not suffered more than we have invariably done before on many similar occasions.'^ Such men always have an eye to fair seemings, hollow consistencies, and present conveniences^ rather than to truth or humanity. As a familiar example of the results of mismanagement on the part of governments and commanders, I shall here only notice the hospital arrangements during former wars, and especially the general hospital system. Pringle, writing a hundred years ago, saj^s : ''Among the chief causes of sickness and mortality in an army, the reader will little expect that I should rank the hospitals themselves, though intended for its health and preservation, and that on account of the bad air and other inconveniences attending them.^' Robert Jackson is even more detailed and empliatic in his condemnation of general hospitals, and he quotes the military writer of George the Second's time who characterized this institu- tion as " the destroyer of the army.'^ The truth is that the physical ills they produced, by generating new diseases tending to fatal re- lapses and counteracting recovery, repressing zeal in the regimental surgeons, and causing delay in early treatment, were not sur- passed by their moral ills, which went to destroy the best feel- ings of the man, and by consequence the highest qualities of the soldier. Here, if anywhere, one would have expected some de- ference to medical opinion, but the system continued in all its horrors. The general hospital system, if system it could be called, sprung up afresh for the use of the infantry, and was employed on a large scale in Holland in 1791-95, and the mortality was enormous, ending in " dreadful destruction ;" while the cavalry, which " tra- versed the same fields and lived in the same air," but which carried its own sick and treated them regimentally, had "little or no mortality in the whole course of its service." It was the same with some few corps of infantry that adopted the regimental plan of management. In the parliamentary report of the ]\Iilitary Com- mission of 1808, the general hospital system is described as " attended with the most destructive consequences to the sick soldiers, and that it has produced expenditure and waste of every 186 THE PREVENTION 0¥ DISEASE. kind." Again^ we find " the accumulated horrors of ill-arranged hospitals/^ in other Avords^ the terrible consequences of liosjntal miasm, frequently alluded to during the Peninsular war by the historian Alison. "■ The military hospitals," he says, " charged sometimes with twenty thousand sick at a time, fostered contagion rather than cured disease -j" while the government of England, that lavished its millions on the vain and irregular efforts, prompted by the presumptuous folly of tlie Spaniards, left their general no funds " to pay for hospital necessaries " for the use and comfort of bis sick and wounded soldiers. "The mortality in general hos- pitals," says Dr. Knox, " after battles, is so terrible to behold, that I feel convinced it would be preferable to tend the wounded in the open field." But, in truth, these general hospitals are es- tablishments to which our soldiers have been consigned, not so much on account of the accidents of war, as through diseases caused by the ignorance and improvidence of our commanders, who ha,ve on many occasions proved consummate masters in the art of ruin- ing their own armies. In our military history, how often have the most incompetent commanders proved a fate to the British soldier ! A correspondent wi'iting from the Crimea, in December, 185-1', says, " All the officers here concur in describing the general hos- pital at Balaclava as a perfect pest-house." Thus, from the days of George II., general hospitals have in no way improved on ac- quaintance ; if, indeed, without a previous and complete reforma- tion of our military system, so bad an institution, as formed by us abroad, be capable of improvement.* * " The army, at the census of 1851, consisted of 142, 870 officers and men, of whom 66,424 were stationed in the United Kingdom, 2948 on passage out or home, and 73,498 abi-oad in the colonies and in the East Indies. The annual mortality of men in civil life at home of the coiTesponding ages is at the rate of 9 in 1000, but the mor- tality of the troops at home probably exceeds 15 per 1000, and the mortality of the troops abroad, and chiefly in the tropical climates, is such that the mortality of the whole army is said to be at the rate of 30 in 1000 in time of peace. At these rates, 8290 officers and soldiers die abroad annually, of whom about 2193 belong to England, whose names, whatever their connexion with property may be, never appear on the English registers. In the time of war the deaths in the army abroad are raised in two ways ; by the augmentation of the forces, and the increased rate of mortality from wounds and from the diseases that have hitherto been incidental to warfare in the field. Thus the mean strength of the British force, officers and men, in the Peninsula, was 66,372 ; the deaths during the forty-one months that ended May 25th, 1814, were 35,525, of which only 9948 happened in battle or as the consequences of wounds : 225 per 1000 of the 61,511 men, were, on an average, upon the sick list, and their annual mortality was at the rate of 161 per 1000. "To the ordinary deaths of officers and soldiers abroad in 1854 must be added the excess of deaths in the war, which have been caused partly by the extension of the same epidemic of cholera that has prevailed in England, and partly by diarrhcsa, dysentery, and other diseases that, like cholera, are made fatal by lying on the ground, by the use of impure water, by dirt and damp, by privation, and by the substitution of salt pork, rum, and biscuits, for the fresh meat, vegetables, bread, fruit, ale, stout, or wine, that officers and men, like the rest of the people, live on at home. "Sixty-one thousand of the deaths in England, during the year 1854, are referable to the imperfect operation of the sanitary organization of our towns. And the same THE PRETENTION OF DISEASE. 187 When general hospitals must of military necessity be established at the base of operations, even for a short time, their iimiates should consist only of such sick and wounded men as cannot be removed to better quarters, and croicdhig ought, above all things, to be care- fully avoided ; the position, construction, and arrangement being at the same time of the most approved kind ; the charge and control being conferred on medical officers of rank and experience, in order that the various abuses, moral, medical, and financial, in- herent in the general hospital system, may be guarded against as far as possible. It ought also to be made an understood matter, in the establishment of all field general hospitals, that they should be but temporary, and that they should be abolished at the earliest possible moment. When the scene of war is in Europe, the sick and wounded should invariably be sent home, where well-arranged and well-admi- nistered general hospitals ought to be, and may easily be established in permanence, both for the inorc systematic treatment of the sick, and for the purposes of schools of professional training to all medical officers, previously to entering on the duties of the army. So long as the now-existing system of mixed and confused military government holds in England, I see but little hope of oiir attaining to excellence in general hospital management at or near the scene of field operations abroad. In 1854-55 we were roused by a national clamour, and we effected improvements under violent external pressure. Such pressure is neither safe in itself, nor is it, perhaps, likely to recur. With our command of shipping, this removal of the men from the scene of war may always be done, and there is no just reason for neglecting this duty to the soldier. It is never neglected in the instance of the officer. Our base of ope- ration too, in all our European wars, has been, and must be, the sea. As illustrative of this subject I may mention that, previously to enlarging the accommodations of the Smallpox Hospital in London, erysipelas, typlms, malignant cynanchy, and other formidable diseases were common ; but by spreading the same number of cases over doiible the extent of surface, these terrible consequences of crowding; have been altogether avoided. causes, exaggerated certainly, with the absence of tlie comforts and necessaries that are supplied at home, have led to the deplorable destruction of life in the Crimea. " Tli«3 deaths, in an average year, among 54,000 in the town and country popidation of England at tlie same ages as the men in the army, are 486, or nearly 41 monthly, and about 972 are constantly sick. All the deaths and sickness in excess of these numbers, except the deaths and wounds from battle, are, like the excess of deaths and sickness in our towns, referable to conditions that, in the present state of engineering, chemical and medical science, may be removed to a considerable extent in ordinary climates, even in the field and in the presence of an enemy ; for the art of preserving life has, since the Peninsular campaigns, made as much progress as the manufacture of arms, and if skilfully applied, our army will never again endure the mortality from disease that so much impaired its efficiency once in the Peninsula, and again, after the lapse of more than forty years, in the Cranea." — Dr. William Farr ; Rt'im-ts of the Registvar- General. 1S8 THE PREVENTION OF DISEASE. Respecting the ill-regulated general hospitals for seamen and soldiersj the ill- situated and ill- ventilated hospitals of old in our great eities, one might reasonably have asked with Ponteau, "^ Are hospitals^ then^ more pernicious than useful to society ?" So much for one item only of neglect^ in matters affecting the preservation of the soldier^s health. Those who desire to see further into the health history of the British army will find other numerous sources of disease and death in the land forces^ narrated in the famous speech of Earl Grey^ delivered in the House of Lords on the 8th of April, 1854. This noble address went far to inform and confirm public opinion ; and public opinion in this country need rarely be mistrusted if it is but formed on sound knowledge and pronounced with due care ; but the subject is a difficult one. " The administration of an army/' says Audouin, " is sometimes called a trade, but those who understand the subject know that it is a science, and one of so complicated a character that the study of one of its branches might occupy a long life. To comprehend even the elements of the administration of an army, it is neces- sary to know its origin, progress, and rules ; the various means employed to raise soldiers, organize, arm, equip, pay, and put them in motion ; to subsist them in health and in sickness ; to command them in the field of battle ; to profit by their success ; to remedy their failures ; to reward and to punish them ; and to preserve an account of their fortunate and unfortunate operations.'^ — Hlstoire de r Administration de la Guerre. Referring more especially to the preserving of the soldier's health, I would quote the sensible observations of Hennen, who, speaking of the prophylactic value of medicines, says that he does not question their proper use in the eases of reflecting individuals ; '^ but I don't hesitate to say, first— that they cannot be generally applicable to a whole corps or garrison. Secondly, that although the soldier may submit in passive obedience, he will invariably make himself amends, as he supposes, for the restriction, by subse- quent excess of one kind or other ; and thirdly, although military officers are sufficiently enamoured of any favourite theory origi- nating with themselves, they view the proposals of medical officers but too often with a jealous eye, especially when the advantages to be derived from them are merely prospective. We possess the power, by means of the established medical inspections, to meet the approaching disease as early as possible, but I question the prudence, in a military view, of anticipating it before its arrival by a general administration of medicine throughout the garrison; because nearly thirty years' experience has convinced me that no power on earth will reconcile British soldiers to taking physic e7i masse, when they are not sick, nor will they ever view the man who orders it in any other light than that of a speculative experi- mentalist. " The true preventives to disease are shelter from the heat of the THE PREVENTION OF DISEASE. ISO day, and from the dews and cold of night, avoiding the neighbour- hood of marslics and otlier unhealthy spots in military exercises, mounting guards at such an hour that the least possible number of fatigue-parties may be employed in conveying dinners, &c. ; timing duties in sucli a way that the men may enjoy their natural sleep; regulating the messes so that the soldier shall always have a due proportion of vegetables, and especially a comfortable breakfast before going on morning duties ; furnishing every man with flannel waistcoats and cotton shirts,"^ enforcing personal cleanliness by frequent bathing, and by daily washing the feet, &c. ; but, above all, regulating the canteen, so that access can be had to liquor only in the evening, and then taking every precaution that the bad spirits and sour wine of the country be rigidly withheld. We may refine as much as we choose, and we may modify our plans according to circumstances with critical precision, but these are the basis on which health is founded, so far as the soldier is indi- vidually concerned." Of ail the causes which tend to the premature destruction of the British soldier in our intertropical possessions, none are so power- ful as the neglect in selecting proper localities for camps and can- tonments, together with the neglect of suitable structural arrange- ments in his barracks and hospitals. As compared to these neglects, the other ills, although great, sink into comparative insignificance. The dieting of the soldier is another question which greatly concerns his comfort, health, and efficiency, but which has not yet received fi'om authority all the attention due to it ; and with the exception that breakfast has been allowed him, I understand that in most of our colonies the coai'se sameness of his food, and the same inferior cooking of it, remain as in 1793. This subject de- mands the attentive consideration of competent persons — a com- plete revision and reform — so that the soldier's food should be ordered to suit his wants, and changed so as to be adapted to tlie various climates in which he serves. He should also be instructed to dress his food in a palatable, Avholesome manner ; and these things can be done with little cost or trouble. The same indifference is still, after ages of heavy-priced expe- rience, manifested in the ordering of the soldier's clothing and head-dress throughout our intertropical colonies, no adequate arrangement being as yet made for climate, for peace or war service, for the night and day duties. All the best officers concur in the recommendation of Robert Jackson, to permit the soldier to do for himself whatever he can do without injury to his health and discipline ; and I feel quite assured * During the hot and rainy season in Bengal the shirt should be changed after exer- cise, and friction with a dry cloth used at the time of changing ; indeed, every soldier should be supplied with a complete flannel dress, to be worn after the march, or other fatigue duty, while his clothes are being dried. The bedding should also be daily exposed to the sun. 190 THE PREVENTION OF DISEASE. tliat, as regards his food, as one example out of several, there is much truth in the suggestion. As already stated, I do not believe that there is any one cause so effective to the destruction of the British soldier all over the world, as that of the neglect of fitting positions and other arrangements for the temporary and the permanent encampm-ent of our troops. In Holland, in 1794 ; at Walcheren, in 1809-10 ; on the Gua- diana, in 1810 ; in Varna, in 1854, the same grave errors were committed. To station our soldiers in the plains, at the em- bouchures of rivers and low harbours in our Eastern and Western intertropical possessions, and in the south of Europe, is to place them where they are sure to die without any necessity. There never can, indeed, exist under any circumstances any reasons of military or political necessity for destroying an army ; it is a mere subterfuge and misrepresentation, under which no ignorant or negligent commander should be allowed to shelter himself for a moment. If a disgraceful capitulation is punishable with death, surely some punishment should attach to the wanton sacrifice of an army from causes easy of prevention. Wellington is supposed, by those who know but little of him, to have been considerate towards his men ; but his planting of his army in the plains of the Guadiana was a wanton sacrifice, the insalubrity of the country having long been notorious. Sir Charles Napier confirms this view of his character : — '' Again, why did he stay in the destructive marshes of the Alemtejo until nearly the whole of the army fell from sickness ? It is not easy to comprehend all this, and I have heard no good answer to it." Speaking of Wellington and his generals, he adds — " England has paid dearly in men and money for his education indeed, yet if he has thereby been made a good general, the loss is less. We have very few capable of being made w orth a straw, though all the blood and gold of Europe and India were lavishly expended on them.'' This should seem to be the just estimate of Wellington and his lieutenants : — His hard, narrow intellect and great common sense were slow of being opened and matured : with the others, no amount of sacrifices and experiences could make them '^ worth a straw." The extravagant contemporary laudations of W^ellington are easily explained. He was a Tory and an aristocrat at a time when Toryism and Aristocracy were rampant. "The civil power then snored at ease, While soldiers fired to keep the peace. " Abercrorhby and Moore were only gentlemen, and they bore the sign of the Beast, both of them having been Whigs. Wellington rose far above the sense even of military responsibility, but his great memory will suffer for his neglect of the soldier. Sir William Clinton " considered the Duke of Wellington in most respects an able, but also a very fortunate general — fortunate chiefly in respect THE TREVENTION OF DISEASE. 191 of tlie cliaracter of tlie troops when brought into action^ but he also considered hiui a bad soldier, inasmuch as he neglected the health of his troops and greatly undervalued the medical depart- ment. Sir "William Clinton mentioned, amongst others, Sir John Moore as being in every sense both a good general and a good soldier — the latter meaning a general who promoted the health and comforts of his troops." So far back as 1835 I urged on the supreme government of India^ as part of a measure sanctioned and carried at my sole instance and recommendation by Sir Charles Metcalfe, then Governor-General of India, for " Collecting Sanitary Reports from all Districts, Stations, and Cantonments in the three Presidencies of India," the follo^\'ing preliminary clause, namely, that " The topographical reports, when forwarded to each Presidency by the superintending surgeons, shall then be collated by a com- mittee of three medical officers, nominated by the medical boards, and that such as are approved shall be printed and formed into a memoir, a copy of which shall be furnished to all staff-surgeons and officers of the Quartermaster-General's department." By this clause I intended that information on the all-important question of medical topography should be imparted to the officers of the Quartermaster-General's department ; — information which they could not acquire of themselves. In furtherance of this object, I recommend that a medical topo- grapher, an important officer of health, an officer of trust and of rank, be permanently attached to the Quartermaster- General's department, in the British as well as in the Indian army. In time of peace he should inspect and report on the sites of camps, can- tonments, and stations, and on the condition of barracks, and hos- pitals, and transport ships. In time of wai', in addition to the above duties, he should accompany the Quartermaster- General in the field; and, where military reasons do not control, his opinion should be obtained on the sites of encampment, and upon every matter relating to the prevention of disease ; all the suggestions of matured sanitary ex- perience being put in requisition for the protection of the soldiers' health. This great conservative branch of medicine has not even yet been called into sufficient exercise in our fleets and armies ; yet it is on the perfection of its civil establishments that the safety and efficiency of our sea and land forces entirely depend. Had such an officer existed in 1809, the soldiers employed on the expedition to Walcheren would not have been permitted to encamp in a pestilential site, involving as this did the destruction of the army, and the sacrifice of a million sterling per annum in perpetuity; and if Wellington had had such an adviser, he would not perhaps have decimated his army on the Guadiana. But it is in our intertropical possessions that the chronic waste 192 THE PREVENTION OF DISEASE. and destruction of men and money take place ; and could we count the hundreds of thousands of British soldiers, and the millions sterling, there lost unnecessarily, even the humanity of commanders and of governments would be shocked. "With a little attention to matters very easy of being understood, and quite as easy of being executed, we may obviate, for the future at least, those dark passages which tarnish the histories of our colonial administration, and of all our wars. In unhealthy climates especially, and during the prevalence of epidemics in all climates, the medical inspection of the troops should be regular and frequent. This rule tends greatly to the preservation of health, for it is a standing order of all well-regu- lated troops that every individual soldier be fit for duty in the full sense of the word, or on the sick-list under regimen and medical treatment. It is a remarkable fact, and one often observed, that in malarious countries especially, and where vicissitudes are great, most dis- eases have their origin in nif//it exposure. " During natural sleep,^^ says Dr. W. F. Edwards, "there is a diminution in the power of producing heat, and this explains why a damp cold air, or a dry and piercing air, which is borne without inconvenience while the individual is awake, even Avithout the aid of exercise, may be hurtful during sleep. '^ Speaking of the yellow fever, William Fergusson says, "It is my belief that malaria can only prevail upon the body during the passive state of sleep ; in fact, that to sleep is the danger. ^^ It may be remarked, in addition to what is stated at page 45, that the effect of exposure to cold during sleep must necessarily vary according to the power of pro- ducing heat. As a means of guarding the system against the effects of atmospheric vicissitudes, I know of none so influential as the cold bath, provided always that the subject be healthy and of temperate habits. The unnecessary and vexatious restrictions on the soldier's freedom of action, such as we constantly observe in garrisons and cantonments in India, are irksome to his mind, and injurious to his health. In point of fact, they create a profound feeling of dis- content — the parent of mutiny. He should be allowed to do for himself whatever he can do without prejudice to health or disci- pline ; and this ought to be made matter of standing regulation, not depending, as now, on the mere will or the uncertain notions of individual commanding officers. " It is easy to conceive,'' says Pringle, " that the prevention of disease cannot depend on the use of medicines, nor upon anything which a soldier shall have in his power to neglect, but vipon such orders as he himself shall not think unreasonable, and such as he must obey.'^ The flannel shirt was for long a debatable question with military surgeons ; and William Fergusson considers it necessary only for the bivouac. As an article of military wear, he says, it is "one THE PREVENTION OF DISEASE. 193 of which the healthy, hardy soldier (and there ought to be none others in the army) can never stand in need." This dictum faithfully represents the rough^ hardy school of Abercromby, Moore, and Wellington; but we are now satisfied, on the most varied and extended experiences, in many climates, that flannel is a necessary part of the soldier^s dress everywhere, and under all circumstances of service. It is best used as under-clothing, for the reason that it readily absorbs moisture from the skin, while, unlike other fabrics, it causes no reduction of the animal heat. With two flannel shirts, sufficiently long to cover the entire trunk of the body, the soldier need not be hampered with cholera-belts ; for he will be supplied with enough for warmth and cleanliness. In tropical climates, too, he should have a stout and complete flannel dress to use on coming in from the day's march. Fever, dysentery, and hepatitis follow constantly on remaining for hours in damp or wet clothes. The use of the stout flannel dress gives time also for the drying of the regimental clothing — a most neces- sary operation after the march, or hard duty of every kind. The recommendations of Dr. Fergusson are more worthy of attention on another important point — the night-covering and ac- commodation of the soldier. He urges that, in every part of the British Empire the men should sleep in separate hammocks, which are cool, soft, and elastic, and can be washed like a garment, while they cannot be used without raising the body off the ground, or the hard boards, and they require no aid from flock or straw to make the occupant comfortable, an additional blanket in cold climates being all that is necessary. The hammock-railings have the great advantage of preserving freedom of ventilation, even during the night, and of being altogether out of the way during the day. Wherever a couple of stakes can be driven into the ground , they will serve all the above-mentioned purposes in the bivouac ; and the construction of hammock-railings, consisting of uprights, Math cross-posts and hooks, would be as simple as economical. The preservation of the British soldier's health in our various colonies is a matter of paramount importance as regards our poli- tical condition, little as the subject has hitherto engaged the atten- tion of the great body of our legislators. " No cii'cumstance," says a popular reviewer, " has so checked the progress of English rule as the maladies peculiar to tropical climates. And it is no exaggeration to affirm, that any means by which this intense mortality could be diminished would more eft'ectually secure our dominion than the most brilliant victories we have ever achieved. Not only does the expense involved in conveying troops to fill the vacancies in the decimated legions fall heavily on the parent country, but another result, more lamentable than any peevmiary loss, invariably fol- lows. A prestige of insalubrity hangs like a cloud over our colo- nial possessions. The soldier and the emigrant leave home with o 194 THE PREVENTION OF DISEASE. a melanclioly foreboding at tlie probable speedy termination of tbeir career. Hence the colonies unhappily become too often the resort of the desperate and the reckless. The worst features of English society are there perpetuated, with few of its excellences. This aflects the condition of our army to an immense extent." The rulers of France have not considered this question in its just vieWj or they never could have conceived it possible to colo- nize the Algerian provinces under an annual mortality of seven per cent. The result, years ago, has been the sacrifice of a hundred millions sterling, and the loss of a hundred thousand men. Sir Alexander Tulloch justly observes that military returns, properly organized and properly digested, afford one of the most useful guides to direct the policy of the colonial legislator. Nor is the value of w^ell-ordered numerical returns confined to mili- tary questions. " Whether we wish to appreciate the value of symptoms," says Louis, " to know the progress and duration of diseases, to assign their degree of gravity, their relative frequency, the influence of medical constitutions upon their development^to enlighten ourselves as to the value of therapeutical agents, or the causes of diseases, it is indispensable to count." The Tente-d'abri of the French — the suggestion of necessity in their African campaigns — and used only in provisional encamp- ments, or as a bivouac-cover — is the most useful article yet intro- duced amongst soldiers. It originated with the French soldier, was amended by him piecemeal, in the accidents of Algerian ser- vice, and w^as perfected there by Marshal Bugeaud. It is three feet high, four and a half long, and is composed of three pieces of canvas, attached by buttons and strings. Two sticks placed at each extremity serve to support it, and it is fixed by pins to the earth. Three minutes suffice to set it up, and two to take it down. Each tent accommodates three men ; each of the three carries a portion of the canvas, and they divide the sticks and pins among them, and so they march. On arrival at their ground, they pro- ceed immediately to fix the tent, and to dig a trench to carry off" the water in case of rain. At night they sleep wrapped in blankets, and with their knapsacks for pillows. They are thus preserved from damp and rain. The Tenie-d'uhri thus proves a protection for health and a gua- rantee for discipline ; it preserves an effective force and assures the duration of the army. In camps and fleets the officers in command should by every means promote and encourage all kinds of innocent and salutary games and exercises, music, dancing, &c. The monotony of naval and military life, and the varying and sometimes disappoint- ing circumstances of active service, lead to mental despondency and consequent ill health. The fact has often been exemplified ; THE PREVENTION OF DISEASE. 195 so much so, tliat tlie medicina mentis should ever hold a high place ill naval aud military prophylaxis. James Johnson relates, that '' His Majesty's ship Russell, 74-, sailed from Madras on the 2:2nd of October, 18UG, and arrived at Batavia on the 27th of November; the crew healtliy, and. their minds highly elated with the sanguine expectations of sur- prising the Dutch squadron there. Such, however, was their sudden disappointment, and concomitant mental depression on missing the object of their hopes, that they began immediately to fall ill, ten, twelve, or fourteen per day, till nearly two hun- dred men were laid up with scurvy, scorbutic fluxes, and hepatic complaints ! Of these, upwards of thirty died before they got back to Bombay, and more than fifty were sent to the hospital there. The Albion did not fare better. The Powerful fared worse : so that in these three ships alone, in the short space of a few months, y«/<^ an hundred men died on board, and double that number were sent to hospitals, many of Avhom fell victims to the above mentioned diseases, which had been aggravated, and in a great measure engendered, by mental despondency." AVith equal truth Sir Gilbert Blane, referring to the converse influences of high spirits, says : — " When the mind is interested and agitated by warm and generous aflections, the body forgets its wants and feelings, and is capable of a degree of labour and exertion which it could not undergo in cold blood. The quantity of muscular action expended in fighting a great gun for a single hour, is perhaps greater than what is employed for a whole day in ordinary labour ; and though performed in the midst of heat and smoke, and with little bodily refreshment, yet the powers of nature ai'c not exhausted or overstrained — even the smart of wounds is not felt ! .... It is stated that, when the fleet under Ad- miral Matthews, in the year 1 744, Avas off Toulon, in the daily expectation of engaging the combined fleets of France and Spain, tliere was a general suspension of the progress of sickness, par- ticularly of the scurvy, from the influence of that generous flow of spirits with which the prospect of battle inspires British seamen. But if the mere prospect and ardent expectation of battle, without any happy result, could have such a sensible result, what must be the effect of the elevation of mind created by the exultation of VICTORY — a victory in which the naval glory of our country was revived and retrieved, after a series of misfortunes aiid disgraces, which had well-nigh extinguished the national pride and spirit in every department of the service. The plain aud lionest, though unthinking seaman is not less affected by this than the more en- lightened lover of his country. Even the invalids at the hospital manifested their joy by hoisting shreds of coloured cloth on their crutches." In accounting for the sraallness of the mortality amongst the o 2 196 THE PEEVENTION OE DISEASE. soldiers iu the first montli of service at Walcheren^ Claue says that " an excited tone of mind^ as .well as youth and robust health, had a share in keeping down the mortality at this period /' and so it was with the health of Hill's division when it surprised that of Gerard at Aroyo de Molinos, in Spain. Dr. Lusconibe states that during the week in which this surprise was being executed, the rain was heavy and almost incessant, and the men passed two nights in bivouac without fires ; yet the sick in HilFs division, composed principally of Highlanders, was less during that and the subsequent week than in any equal period during that year. Dr. Luscombe, in almost the very Avords of Blane, assigns as the reason of the immunity of the soldiers from the effects of fatigue and ex- posure to cold and wet, that they were under " exercise and mental excitement.'" As an example of the influence of hope in arresting the extension of disease and in repelling it, I may here mention, on the authority of the Statistical Reports, the remarkable fact, that during the epidemic yellow fever of 1822, at Up-Park, Jamaica, among the soldiers of the 91st Regiment, when the order was issued for their removal to another station, the fever ceased ; and though the corps was unexpectedly detained for three or four days after the order was issued, not one case ivas admitted into hospital in the whole course of th^t period. ^^ Finally, it cannot be too often repeated that on the perfection of the so-called civil establishments — the medical and the com- missariat departments — must depend not only the efficiency, but the very existence of our fleets and armies. I say "■ so called," because, in respect to the medical corps at least, it is a complete misnomer, for neither by sea nor on land can there be any absolute protection for the surgeon, during the hour of battle, from the fire of an enemy. The recent calamitous losses in the Crimea have demonstrated another fact, viz., that so long as the departments above-named are dependent and subordinate, and under the management and control of officers holding but an inferior rank, consideration, and power, so long will they remain insufficient to their great purposes. But let them once be ruled and directed by responsible officers of a rank and station adequate to command an instant attention to their respective wants ; let such officers be largely and immediately responsible — and then, but not till then, will the two most important establishments of our fleets and armies rise so as to be equal to all requirements, whether during peace or in war. TUE PREVENTION OF DISEASE. 197 MEMORANDA ON THE HYGIENE OF CAMPS AND CANTONMENTS IN WARM CLIMATES, WITH A SKETCH OP MEDICAL AR- RANGEMENT FOR FIELD SERVICE. The first qualification of a soldier is fortitude under fatigue and privation. Courage is only the second ; hardship, poverty, and want are the best school of a soldier. — Napoleon. The army is a part of society employed, it is true, in services of a peculiar nature, which require a peculiar organization, but not on that account cut off from the general mass of the community. — Count Rumford. Nothing can be so extravagant as to kill good men, v(?ho have been trained at such an expense. — Lord Herbert. Social science as applied to the army is a very young member of the fraternity of sciences. — Calcutta Review. We have made the discovery that an army may be so constituted as to be in the highest degree efficient against an enemy, and yet obsequious to the civil magistrate. — Lord Macaulay. 1 . The moral and material improvement of tlie British soklier, and the education and training of his officer — two conditions in- separably associated in a true military polity, and whose intimate connexion for good is hardly yet appreciated in this country — are matters with ns of such national importance that they can no longer, as of old, be regarded as topics too technical to be under- stood by the public, or as subjects of indifterence to them. Persons of the most ordinary, unmilitary appearance, who have never been seen in public decked out " in scarlet, gold, and cock's feathers" — the feathers " of the male PuUus Domesti- cus ;" — persons who have never been " covered with lace in the course of the ischiatic nerve,"* will now insist on the rii^ht to inquire into, and judge of, everything which relates to the sol- dier ; of the " condition-of-the-soldier question," in fact, in all its latitude ; " the reason why," and all the rest of it. For the medical officer to be complete master of every circumstance which may tend to secure the welfare, moral and material, of the men committed by the State to his care, is therefore a necessity of his position, if he would maintain it with any credit. 2. Very ordinary-looking, common-place people are now beginning to perceive that, for the conduct of war, the mere gentleman without study and without knowledge, is feeble and inefficient. There must be knowledge, carefully acquired know- ledge, before an officer of any rank can deserve the smallest amount of trust or confidence. " By reading," says Sir Charles Napier, " you will be distinguished ; without it, abilities are of little use." Of the use and value of the gentleman in the ranks * Sydney Smith, who is here quoted, seems, like Robert Jackson, to have held in special aversion the tailoring endeavours of certain of our commanders— the "sarto- rial and plumigerous" propensities — and the "clothes-worship." 198 THE PREVENTION OF DISEASE. of our armies, I am deeply and anxiously sensible ; but the officer ^^'E MUST HAVE AT ANY COST : in other words, if the gentleman will not qualify for a duty making certain demands on his time and attention, he must give place to those who are ready for all duties upon all conditions. 3. There are two circumstances in the very nature of our wars which ought to be present to the mind of the medical philosopher ; namely, first, that with us no war can be long carried on against the will of the people ; and, secondly, that Avar never leaves the country where it found it. Changes are indeed its necessary consequences. This truth has not been sufficiently regarded in our country, 4. The public at large is at length beginning to understand that it is HEALTH, and the attentions necessary to secure health, which impart to the soldier "the fortitude under fatigue and privation^' which constitutes his " first qualification,^^ and which is so im- periously necessaiy to him under all the trying and varying cir- cumstances of colonial and of field service. 5. It is further beginning to be understood that the arts of peace must lend their aid to the art of war — that health means efficiency in our fleets and armies— that class interests must be made to cease to injure the public services — and that there ought to be no distinctions amongst our officers by sea or land, but those of merit. The rusty general who now holds that young officers would fight better on account of their utter ignorance of discipline, tactics, strategy, and all other branches of a regular military education, would have no hearers in any even of our clubs — unless it be the " Senior.'^ 6. " The common sense of the country" — the now alarmed common sense of the country — and the slow teaching of experience, so often invoked, and invoked in vain, in support of the soldier's claims, by Robert Jackson, and the old surgeons of our fleets and armies, have at length forced themselves into this, the soldier's question ; and not too soon, if our forces are to be worthy of our cliaracter, traditions, and power. Formerly, the country was wanting in knowledge ; now, the public has more than enough of that needful qualification. 7. Here, indeed, as in civil life, it will be easy, if we will, to set matters to rights, if only amateurs and monied idlers, of whatever class or degree, be made to take to other pursuits than soldiering. Our ancestors had a wholesome and instinctive dislike of " the fantacied men of warre," and we would do well practically to imitate them in their caution. 8. All this may seem to the superficially informed to be an assuming of a State question ; but what army surgeon does not know it to be vitally a soldier's question ! There is one part of this subject which should never be forgotten, namely, that v^"ith our commanders and statesmen it has never been the disaster or THE PREVENTION OF DISEASE. 199 the loss of an army, but always the accusation of having caused it that has disturbed their serenity. 9. But at length, and under a statesman and war minister, singular in the extent of his knowledge and earnest in his purposes, the soldier's treatment, moral and material, has become a system, and been made the great military question of the day. The maxim of Turenne lias been practically accepted by Lord Herbert : — " Le bien le plus precieux est le sang du soldat." The principles and the actual reforms which he has introduced into the sanitary arrangements of the army, being of the nature of well-founded institutions, will, it is hoped, ever be felt ; for they must go on, under improving knowledge, to more and more improvement. 10. Half a century ago, the people had no information, and in consequence they did not reason on military questions ; they took evei'ything as they found it. All this is altered now. The diflFusion of knowledge was reprobated by our administrators of old as tending to the subversion of discipline ; and ignorance was cultivated on system, as an element of order and of subordination. In no other military power has the influence of the haughty ignorance of routine been so fatally experienced as in this our native country. Seamen and soldiers are presumed to spring from " the vigorous race of undiseased mankind :" we have but to main- tain them in their native strength by using the best preservative means with which we are acquainted. Happily, and owing to the sanitary arrangements now in force, this can be done ; and it will no longer be permitted to incapacity or routine to annihilate our armies abroad, and decimate them at home. After these assuring reflections, let us proceed to the more im- mediate part of our business — the consideration of the comfort, health, contentment, and efficiency of the soldier, and the best means of securing them on active service. Notwithstanding our best eff'orts in this direction, the " fortitude," which is " the first qualification of a soldier," will be severely tested in the long campaign. 11. It is here held as a principle that in all climates, and under all circumstances of service, the soldier should be encouraged, nay, ordered, to do for himself whatever he can do without injury to his health, morals, and discipline ; and further, that he be required to do whatever may be essential to his efficiency and serviceable condition, in the event of failure of the appointed means and ap- pliances. Before the soldier can be held to be completely fitted to undertake his duties to the State, he must be made capable of preparing and ministering everything which may be necessary to his personal care and comfort, in the field and in cantonment. 1 ^. He should be taught certain gymnastic exercises — as running, leaping, wrestling, pitching the bar, the sword exercises, and that of artillery. The swimming bath, where practicable, should be used habitually. 200 THE PREVENTION OF DISEASE, 13. Every soldier^ or^ at all events^ a goodly per-centage^ should^ as a preliminary, be taught to handle the spade or mattock, the axe and saw, the hammer and crowbar — to construct his hut and arrange his tent — to bake his own bread and cook his rations — to mend his clothes and shoes. Instruction of this kind is vitally necessary to our Volunteer Force, if it would act effectively against an invading enemy. Without it our best volunteer battalions ■would melt away or be nearly destroyed. 14. One of the greatest banes of our military system has always been the permitting our soldiers to take the field and to act as if commanders and departments could everywhere, and on tlie most remote scenes of operation, be of universal competence and all- sufficient ; whereas experience proves that on extended and remote scenes, however great the commander and excellent the depart- ments, very much must be left to the individual exertions of the men, directed by their officers. This may be termed the trained personal hygiene and sanitary skilled labour of the soldier. 15. Nor should the beneficial influences of mental exercises, diversions, cheeiful occupations and amusements be neglected. The officers, by habit and example, should encourage all such pursuits, and thus lighten the dreary tedium of colonial barrack life and of garrison towns. 16. As the muscles of the body are best exercised in succession rather than all at once, so mental exercises of different kinds ought to be agreeably alternated ; thus obviating the tendency of monotony and idleness to degrade both mind and body. In fact, nature seems not to have designed sameness or uniformity of mental pursuit any more than of nutriment for the body : in the one case, the faculties of the mind are rendered sluggish and inane, while, in the other, the very blood is contaminated, and all the functions of the body are thereby enfeebled and depraved. It is with soldiers as with other men — a cheerful and contented mind conducing powerfully to health and morals. 17. The soldier generally enlists so young that we may make of him what we please ; and he requires more management to turn him to good account than that of the sergeant and the adjutant. Newly-raised and unpractised corps ought not to be employed on active service, or in the intertropical possessions of the empire ; but when such corps must be so employed of necessity, the interior discipline and sanitary economy cannot be too carefully looked to. 18. It is in the earlier years of service — through the sudden change of accustomed habits, the removal from persons and places cherished by them— aided by the influences of change of climate, rapid marches, &c., that the conscripts of the French army suffer the most. General Pelet gives proof of this in the decreasing mortality per 1000 per annum, during the first seven years of service, of from 7 to 2 comparatively. THE PREVENTION OF DISEASE. 201 19. According to Tardieu, the apparent age of full growth in France is twenty years ; and the more the rule of nature sug- gested by that fact is violated in working the recruit, the more the victims of disease are augmented without increasing the real strength of the array. Early enlistment is necessary for the pur- poses of ti'aining j but the soldier should be two-and-twenty years of age before he is called upon to exert his utmost powers, and the age of five-and-twenty would be still better adapted for the hard campaign. 20. Diet. — "Tell me/' says Brillat-Savarin, "what a man eats, and I'll tell you what he is :" — so, if we know what the soldier dies of, we can, on some occasions, as at Rangoon and China, in the first wars, and in the Crimea, tell how he has lived. When, for instance, we learn that armies have died of scorbutic dysentery, we know at once and for a certainty that our men have been ill and insufficiently fed, clothed, and housed. The Scotch saying — " He looks like his meat," has a physiological signifi- cance in the case of the soldier. In all the Indian examples it Avas hard to say which was of Avorst quality, the salt meat or the biscuit. The use of soft bread is strongly urged upon the Go- vernment for the use of the French soldiers in Algeria, who regard biscuit, even when good, with an unfavourable eye. 21. The diet of the soldier should Aary Avith the climate, and with the amount of labour required from him. In the field he works as hard as a dockyard labourer, involving, besides the labour, exposure and Avatching. Under such circumstances of service, the Commissioners of Inquiry into the Supplies for the British Army in the Crimea recommend the foUoAving daily ration : — Soft bread 24 oz. Fresh vegetables 8 Eice, or barley 2 Fresh meat 16 Ground or roasted coffee 1 Sugar 2 Total 3 lbs. 5 oz. Spirits \ pint. To which it is proposed to add weekly : — ^Mustard ^ oz. Pepper ^ Salt 4 22. "Assuming this to be the standard ration of troops in the field by Avhich the amount of nutriment is determined, certain equivalents may be substituted for some of the articles Avhenever economy of transport becomes important; for example, 16oz. of biscuit for 21rOz. of soft bread ; 2oz. of compressed or preserA'ed 302 THE PREVENTION OF DISEASE. vegetables for Soz. of fresli vegetables; |oz. of tea for loz. of coffee/' — (Report of Crimean Commission.) 23. Dietaries ought never to be estimated by the rough weight of their constituents, without distinct reference to the real nutri- ment in these, as determined by physiological and chemical in- quiry. — (Christison.) An accurate knowledge of equivalents would likewise prove of great value towards securing to our armies a proper system of dieting. Disposed, as our troops are, over every kind of climate from Bengal to Canada, such knowledge is of especial need to us.* 24^. The military surgeon should be well acquainted with the economy of food, and with the natural laws of diet, so as to be able to estimate and regulate the labour-value, and the suitable- ness to the various and contrasted climates of the several dietaries in common use. A scale should be fixed which, as far as can be, may be applicable to all olimates and conditions of service. 25. On first arrival in a tropical climate the quantity of animal * For the following valuable information I am indebted to my friend, Dr. Parkes, Professor of Military Hygiene at Chatham : — PfiESENT RATION OF THE SOLDIER AT CHATHAM, SHOWING WHAT IS ISSUED BY THE COMMISSARIAT, AND WHAT IS BOUGHT BY THE SOLDIER. At Aldershott everything is issued by the commissariat, and the same system is to be introduced at Chatham. The nutritive value lias been calculated by Dr. Parkes by a formula which gives the nitrogen in meat and bread lower than Dr. Christison's formula. The carboniferous aliments are divided into fat and carbo-hydrates (starch, sugar, &c.). If the total amount of c.irboniferous nourishment be required, the fat must be multiplied by 2 '4, and the product added to the amount of the carbo-hydrates. The quantity of salts is assumed. Bail^ QuantUi/, Cost, and Nidritwe Value of the Soldiers Ration at Chatham (1861). Quantity and Cost. Articles. Quantity taken daily in ounces and tenths of ounces. Price. To whom paid. Meat Bread Bread Potatoes Other vegetables Coffee Tea 12 oz. 16 8 16 8 0-33 0-16 0-25 1-33 3-25 j Aid. - 3| J Government. Bought in the market. Salt Sugar Milk Total quantity Total value 65-32 oz. 8d. THE PREVENTION OF DISEASE. 203 food should be reduced, during some months at least, allowing compensation in the way of vegetables and fruits. The lighter Nutritive Value in Ounces and Tenths. Articles. Water. Nitrogenous substances. Fat. Carbo-hydrates ' g^itg (starch, sugar,&c.) Meat* Bread 6-75 9-60 11-84 7- 2-'82 1-44 1-92 0-24 0-05 6-109 0-81 0-36 002 0-02 0-12 12-12 3-9 0-52 1-33 0-169 1 Potatoes Other vegetables ) taken, as cabbage \ Sugar Milk Salts (assumed) Total 33 01 3-759 1-33 18-039 1 Total solid nourishment, exclusive of tea, coffee, &c. and 3 ounces for bone Water in food In addition — Coffee 0-33 Tea 0-16 Peijper Bone 3- 24-128 38 01 62-138 3-49 HOSPITAL DIETS.— Fort Pitt, Feb. 1861, Nutritive Value of the Hospital Diets, calculated by Dr. Christison, and communicated li/ him to Miss Nightingale. 1. Tea. Articles. ' Carboniferous. Nitrogenous. Total. Bread, 8 oz 4-12 3- 0-48 0-84 0-0 0-27 4-96 3- 0-75 Tea, \ oz Sugar, 3 oz Milk, 6 oz 7-60 1-11 8-71 4. Milk. Articles. Carboniferous. Nitrogenous. Total. Bread, 14 oz 7-21 1-60 4-80 0-50 1-44 0-20 2-70 8-68 1-80 7-50 0-50 Rice, 2 oz Milk, 60 oz Sugar, 4oz 1411 4-37 18-48 * One- quarter has been deducted for bone. 204 THE PREVENTION OE DISEASE. Frencli wines^ or tlie more grateful light wholesome ale, might at first also be beneficially substituted for the rum ; aud no re- 5. Low. Articles. Carboniferous. Nitrogenous. Total. 2-81 8-68 1-50 0-75 1-80 1-87 0-50 0-70 18-61 Meat, 8oz., exclusive of bone Bread, 14 oz 1-20 7-21 1-50 0-48 1-60 1-20 0-50 0-30 1-61 1-47 0-27 0-20 0-67 o'io Sua;ar, 1^ oz Milk, 6oz / Rice, 2 oz ■nil- 1 Milk, 15oz ^"'^'^"^S Suga;, l^oz I Eggs 13-99 4-62 7. Half. Articles. Meat, 8 oz., exclusive of bone Bread, 16 oz Potatoes, 8 oz Barley, l|oz Sugar, If oz Milk, 6oz Vegetables, 3 oz Butter, 1 oz Flour, J oz Carboniferous. Nitrogenous. 1604 1-20 1-62 8-24 1-68 1 96 0-20 1-17 0-28 1-75 0-48 0-27 0-06 0-01 1-00 0-18 0-04 4-10 Total. 20-14 10. Entike. Articles. Carboniferous. Nitrogenous. Total. Meat, 12oz 1-80 8-24 3-92 1-77 1-75 0-48 0-08 1-00 0-18 2-43 1-68 0-40 0-37 0-27 0-02 0-04 4-23 9-92 4-32 2-14 1-75 0-75 0-10 1-00 0-22 Barley, 2i oz Milk, 6 oz Butter, 1 oz Flour, 1 oz 19-22 5-21 24-43 6. Fowl. Nearly tbe same as half-diet, with half a fowl or chicken weighing 8 ounces, exclusive of boue, either to be roasted or made into soup, in lieu of the 8 ounces of meat. 8. Fisn. Nearly the same as half-diet, but 8 ounces of white fish in lieu of the 8 ounces of meat. 9. Roast. Nearly the same as half-diet, but 8 ounces of mutton chops or steak in lieu of the 8 ounces of meat. THE PREVENTION OF DISEASE. 205 emit should be allowed to use his spirit-ration during the voyage, or yet after landing, until he shall get out of the drill. In hot countries, also, as in Europe, the food-ration should vary with the amount of labour performed by the soldier. 2(3. A mixed diet will, in all countries, be found the best, and the officers should everywhere see daily to the freshness ami j^nrit^ of the rations, both animal and vegetable. Constant attention should also be paid to the cleanly condition of the cooking utensils, and the vessels used in the conveyance of water. 27. The daily ration of the British soldier in the Bombay Fusiliers is detailed by Dr. Arnott to be uniform throughout the year, and to consist of : — Frenli meat 1 lb. Bread 1 Vegetables 8 oz. Kice 4 Salt 2 Sugar Of Firewood 3 lbs. Spirit ration. The only alterations ordered in the above dietary consisted in an increase of sugar and a reduction of the salt. Rice is almost discontinued — the men receiving some condiment in exchange. In India, where there is difficulty in procuring leavened bread, the common ilour-cake of the country (c/tajjatee), warm and fresh from the iron plate, is wholesome and nutritious. Both rice and dhal are excellent likewise, when well dressed with proper condi- ments. 28. The fusiliers had breakfast at eight, dinner at noon, and a so-called supper at four — a meal which might advantageously be deferred to six o'clock. Breakfast consisted in bread with meat, or with fish, eggs, butter, procured by the men at their own cost, with tea or coffee. Dinner was composed of the meat-ration, Avith vegetables ; while supper consisted of whatever may have remained from the dinner, and of such exiras as the soldier may have been able to command. Cai'e was taken that the quality of the ration was good — beef being served out four times, and mutton three times in the week. 29. When salted meat and fish are substituted for fresh meat, they should be carefully soaked before being cooked, and, when practicable, mixed with a certain amount of vegetables. 30. The quality of the soldier's ration is not even now sufficiently regarded at home or abroad. It is too often of so inferior a natiu'c that, if issued singly, it would prove insufficient for his sustenance in barracks even during peace, and while subject to no labour, 31. Condiments in small quantities are good seasoning; in excess they irritate the stomach, and render thirst more difficult 206 THE PREVENTION OF DISEASE. to bear. Saffron increases tlie digestibility of rice and flour^ and is particularly useful witb maize. 3^. Food should always be taken before the march. 33. In the " Report of Royal Commission of 1857," of which I was a member, and which was ordered to inquire into " The Regulations affecting the Sanitary Condition of the Army/' the Commissioners, in their address to the Queen, express their regret at " the great variety both in the amount and composition of the ration which has been from time to time authorized in the Colonies, the frequent changes in the stoppages, both at home and abroad, at various periods, and the different systems on which the ration has been contracted for and supplied to the troops, 34. '' There is no doubt that the frequency of the changes made in the authorized ration since 1813, and the stoppages by which the soldier paid for its value, and the great diversity in the balance of pay to which he has been entitled, according to the station at which he miglit be quartered, have been sources of suspicion and dissatisfaction to him. 35. " It appears to us, therefore, that all the arguments for a fixed stoppage and full ration in time of war, apply also to a time of peace. In both cases it is the duty and interest of the govern- ment to see that the soldier is provided with such a ration as will keep him in health and efficiency. In both cases it is advantageous to get rid of a cumbrous and costly system of accounts, by which time and labour are unnecessarily consumed in peace, and which has to be abandoned in war, when the expenditure requires the greatest vigilance. 36. " We are of opinion that no ration can be fixed upon which shall be adhered to in peace and war. The conditions of life are so different in the two cases, that whatever is suitable for the one must be either too much or too little for the other But the result of the change which we propose will be, that the soldier will receive, whether at home or abroad, in peace or in war, on board ship or in hospital, a uniform net pay and a luiiform ration, sufficient both in quantity and quality to provide him with three meals, and to keep him in health and efficieucy." 37. Drfnk. — No trouble or expense should be spared in secur- ing to the soldier, whether in camp or cantonment, an abundant supply of pure water for drink, cooking, and bathing. Where the water is of inferior quality, the soldier is sure to compensate him- self, as he will call it, by a liberal admixture of ardent spirits. 38. In standing camps and in cantonments water should be carefully conveyed in iron pipes, from a situation beyond reach of contamination. The French before Sebastopol ai'c stated by Dr. Snow to have laid down iron pipes for conveying water to the army from the hills alone above the camp, whilst the British adopted no such precaution. In hot climates, ten to twelve gallons of water will prove, on the average per man, a sufficient daily supply for THE PREVENTION OF DISEASE. 207 all purposes, including that required for the bai'raclc attendants and followers. In temperate climates, each man requires about two and a half pints of water daily, as a minimum allowance. 39. The supposition that, in India, tanks which are covered with green weeds therefore contain impure water, is an error — the very opposite being the fact ; the weeds, the small fish, and infusoria preserving the water clear and fresh. An English general ordered the " clearing" of one of these tanks ; after which operation, care- fully performed, the water " soon turned putrid •'' but on the return of the duckweed, the water again became drinkable. 40. Water drunk in large quantity is always injurious, even when pure. If, after a fatiguing march, a stream of water is met with, thirst must be sparingly satisfied, and the Avater reserved for sub- sequent use. When only a small quantity is procurable, instead of swallowing it, the mouth should be gargled as long as possible, and the water rejected as it becomes warm. 41. When reduced to the necessity of drinking stagnant or impure Avater, it should, by way of precaution, be strained through cloth, to separate leeches imperceptible from their smallness, and which it is very dangerous to swallow. ^'l. A. mixture of Avine and water, brandy and water, or infusion of coffee and water, is always an excellent di'ink, taken in modera- tion. It should be mixed at the time of use, and not prepared beforehand, as it then becomes changed, and no longer fulfils its purpose. 43. When troops are fed on salted meat, whether on shore or on boai'd ship, lime-juice, as ordered by the regulations, should never be wanting to the men. It should be served out independently of such fruits and vegetables as may be procurable. 44. AVhere the spirit-ration is in use, it ought never to be taken in the morning, or before meals : on the contrary, the established rule should be to use it shortly after dinner and supper, diluted with water, and not in its neat state. 45. I have spoken of the " liver-burning" spirit-ration — the "fire-Avater" of the Avhite man — as being especially injurious to the young soldier on first landing in India ; and assuredly it is not beneficial to the old soldier : if he must have it, it should be diluted. Shakspeare Avas aware of the "liver-burning" action of alcohol; for he says — " Let my liver rather heat with wine." 46. All experience confirms the declaration of Dr. Arnott, of the Bombay Fusiliers, that the advantages which have accrued to the soldier's health and morals from the substitution of sound malt liquor for ardent spirits, are perceptible in the diminution of crime, sickness, and mortality. This excellent and experienced officer suggests the desirableness of prohibiting the issue of the spirit- ration altogether in its undiluted form — porter, ale, wine, and spirits and water affording all the variety that can in reason be desired. 208 THE PREVENTION OF DISEASE. 47. But the spirit-ration — anotlier unquestionable form of "regulation poison" — is still regarded by many old officers by sea and land as one of the naval and military institutions ; and it may require the intelligence of another generation to get rid of it. 48. Wherever established, the regimental canteens should be spacious and well-ventilated ; and whatever else they may contain, they should be abundantly supplied with malt liquors and light wines. 49. When troops are on the march, a cup of warm coffee, or of soup, should be served to every man before quitting the ground ; and if some bread or biscuit be added, so much the better. The morning dram was declared by Robert Jackson to be nothing short of " a pernicious bounty." 50. After the most severe fatigues in Burmah, including direct solar exposure during whole days of April and May, and the dis- tress occasioned by volumes of dust, the European officers of the Bengal bodyguard, at the instance of our commanding officer. Major Sneyd, always drank warm tea ; and I can answer for the great refreshment derived from this excellent suggestion. 51. I am satisfied that the encouragement to prudence offered by the more general institution of savings^ banks, would go far towards promoting the morals and health of the soldier. The arrears of pay due to him, after being long in hospital, constitute another " pernicious bounty." They are notoriously ill-used ; often spent in drink, to the injury of health aiul discipline. In fever, dysentery, and hepatitis, drink is a frequent cause of re- lapse, and of death consequently. 52. Sleep. — Whatever may be the opinions of martinets by sea and land, yet is it certain that the refreshment derived from a cer- tain amount of sleep is as necessary to the mental and bodily vigour of seamen and soldiers, as the refreshment derived from a certain amount of food and drink. To the occasional privations of sleep, and to the limited and irregular enjoyment of it at all times, is referred, perhaps with justice, the aged appearance of seamen as compared to soldiers of like ages. 53. Where and how to sleep, are the great considerations in the camp ; for on the damp and cold soil, or exposed to malaria, disease comes rapidly and fearfully lapon the soldier. 54. Under hard labour, and on the march, the hour of retire- ment should be early, say, an hour after supper, so that the soldier may enjoy eight houi^s of sleep. Before Sebastopol, Mr. Woods states that while the French soldiers were " four nights off duty to one on, ours had about ten hours off to twelve on," — a cir- cumstance which of itself would go far to account for the heavy losses of the British force employed. 55. Sick, wounded, and convalescents should be allowed some additional hours of sleep ; and so should soldiers who have under- gone hard labour and inordinate exertion. THE PREVENTION OF DISEASE. 209 56. From the circumstance that dviring sleep the power of f^cne- rating heat in the system is diminished, much care should be given to the proper covering and clothing of the soldier, as well as to the condition of the soil; for, in tropical climates especially, it is in the night that the danger of contracting malarious disease is greatest. 57. In the West Indian commands, where night duties and niglit exposure are believed to influence the health of the troops, the British soldier takes his tour of guards or pickets every third or fourth night, " and every six hours stands sentry for two hours at a time.'' The fact that the mortality of drummers is greatly under the general average among the rest of the troops, in the command referred to, has been ascribed to their comparative exemption from night duties ; but it is probable that causes as yet unascertained operate in aid of the freedom from night duty, so as in otiier ways to favour this class of soldiers. 58. Ordinarily, and in time of peace, European soldiers in the East Indies are much exempted from night duties ; but when on garrison employments at the head-quarters of the three Presiden- cies, or when employed at Aden, for instance, the night duties be- come occasionally heavy. Diseases of the liver and hands are stated by Dr. Arthur to have been much increased in Burmah, in the Madras European Fusiliers, by the exposure attendant on night duties. He adds that the men were "on guard about every fourth or fifth day throughout the year." 59. Throughout the British colonies generally, the men, on an average, have from four to five nights of consecutive rest. In the East and West Indies, where soldiers who are natives of those countries are employed largely, the European should not be placed on guard and on sentry duties without a necessity, especially at unhealthy stations, and in iinhealthy seasons. 60. Cooking. — That the British soldier, in the field of active sernce, with its labours and fatigues, should for ages have been left altogether without instruction in the vitally essential matter of cooking his coarse ration, is but another instance of the neglect Avith which all that related to his comfort and welfare was formerly treated. Let us hope that some general means may speedily be afforded to remedy so great a defect. Every soldier (or at least a goodly proportion per company) should be instructed in the art of cooking his ration of meat and vegetables in a plain and wholesome manner, in making soup and bouillon, and in baking soft bread. These simple matters, so easy of being taught, are essential to the health and comfort of the soldier. It would be a real economy to have a well-trained cook, or even two, in every regiment ; and in cantonments and permanent camps, the cooking-places should be spacious and well covered in, so as to afford places of instruction for the soldiers. An instruction-kitchen, in which cooks from every regiment are to be instructed, has been recently established p 210 THE PREVENTION OF DISEASE. at Aldershott by order of Lord Herbert^ and a competent in- structor in cookery has been appointed. 61. Dress. — Since the days of the Duke of Cumberland, now more than one hundred years ago, imitation — that most feeble of refined flatteries — has been the afflictive principle of the British army, both in discipline and dress. It has been injured by a foreign and unnatural military code, or it has been made to look ridiculous " by regulation ;" or it has been made to feel cruel dis- comfort, just as the superior officers — the stage-hero-makers, the dress-making commanders — as Robert Jackson termed them, may have been at the time more ignorant or more negligent than usual. 62. It is, I fear, in vain to talk of such matters as of past and gone times; for in authenticated publications of August, 1860, in the Mauritius, Ceylon, and West Indies, our soldiers are spoken of as dressed in a "red tunic of thick broadcloth lined Avith serge, the hard leather stock " — the dog-collar of Colonel Mountain, condemned half a century ago by Larrey — " that intolerable shako, precisely the same as at Aldcrshott.^^ The dress is said to be proper perhaps to our northern climate, but cruel in a tropical region. The writer then asks — " Is discomfort in dress necessary to discipline H" During the first war in China, the Emperor was assured by the mandarins that the English soldiers were buttoned up so tight, that if once down, they could never rise again. 63. In the East Indies a better order of things appears to be initiated ; but the commanders of Robert Jackson's time have a wonderful hold on the memories of a certain class of survivors ; and this must always be the case so long as the soldier's dress and accoutrements are to be regarded as a fashion, and treated from the officer's point of view only. The lesson of the life of a great commander belongs to survivors; but so, unhappily, does that of a small commander ; and this last is sure to be followed in our country, for a time at least^ if he be but a man of a " certain position." 61. Hitherto, and in our cavalry especially, our imitations have always been of what is unsuitable, or absolutely bad. Our clumsy copyings have been but vulgar compromises in dress — half German, half Prussian, half French — the poor man remaining an astonished British soldier all the while. Cromwell, Claverhouse, and Marlborough did not spoil their horsemen by foreign imita- tions. The system of the Northern military nations has always been to make soldiers mere machines. That has never been the system of the British navy, and it ought never to be the system of our army. It required the genius of Cromwell to prove that the best horse-soldier of the world might be trained in an island. He and Marlborough won victories with cavalry. 65. In regard to the equipment of this branch of the service. Sir Charles Napier says that he could hardly alter it for the worse. THE PREVENTION OF DISEASE. 211 Imitation then is but a poor thing after all ; for, with the best men and the best horses in the world, the efficiency of our cavalry is constantly being called in question. The truth of Michael Angclo's apophthegm must here be held in recollection — that he who follows must always be behind. (^6. Were I to relate but a tithe of the miseries, sickness, and death described by old officers in India, as resulting from pow- dered and tallowed heads and queues, polished close helmets, aud heat-absorbing heavy black caps, black leather heat-absorbing stocks, heavy tight woollen coats and trousers, leather breeches and jackboots, all worn formerly by our horse and foot-soldiers, under the sun of Bengal, and in the hot and rainy seasons, I should not be credited. But, happily for the European soldier in India, the significant flatteries of imitation are giving place gradually to the suggestions of " the common sense of the country,^^ which is breaking in upon German routine ; and our soldiers serving there may at length hope to be reasonably dressed and accoutred ; not trussed up and throttled in regulation pillo- ries, as of old. 67. For active field service, the head-dress of the soldier shovdd possess, not the properties of a scalp-lock or ray-trap, but be light, and have small perforations for the escape of the heated and consumed air within. It should, so far as may be, consist of such material as will render it sabre and bulletproof ; and the soldier should be able comfortably to lie down wearing his head-dress. 68. A well-formed, light, aud well-adapted helmet, with a good peak in front and rear, would appear to be the best head-dress for both the horse and foot-soldier. For hot climates, it should be constructed on the plan of my friend Mr. Julius Jeifreys, of the Bengal medical corps, as admirably explained in his able work on " The British Army in India, its Preservation,'' &c. 69. Hitherto the head and body-dress of the British soldier has been the same, whether he served in the humid parts of Guiana or Bengal, or in the winter fogs of Holland ; no attempt having been made, until very recently, to adapt clothing to climate ; Prussian costume taking precedence of Prussian code, Prussian discipline, and Prussian floggiug. 70. But, if Ave must always be imitating, I would suggeso that, in head-dress, we imitate our most unwarlike enemy the Chinese. The helmet repi-esented as worn by the Tartar chiefs appears to unite the best and most graceful exterior quality, with adaptation to all useful purposes. Constructed on Mr. Jeffrey's principle, such a helmet ought to be perfect. 71. Some medical officers, in defect of better means, prefer that in India, the head-dress should consist of a make-shift forage-cap, having a white padded cotton cloth passed round the cap turban- wise, leaving .the end of the cloth to fall Templar-like over the nape of the neck. p 2 212 THE PREVENTION OF DISEASE. 72. The sliirt for Indian service should be of cotton stuff, while the outer dress should consist of the regulation shell-jacket^ blue barrack cotton- cloth trousers, stout cotton stockings, and strong high-lows as shoes ; the only alteration required for the hot and rainy seasons being the substitution of a white cotton shell- jacket and trousers for those above-mentioned. Such simple dresses_, together with a white or coloured cotton stock, are suit- able for all seasons in tropical climates, for peace and for war. 73. For marching in all seasons in India Mr. Jeffreys recom- mends a good flannel dress, as the coolest in itself, and as the best protection against chills ; while a comfortably warm and heavier clothing is necessary in the cold weather. 74. The flannel shirt is here of great protective value ; and the blanket, which should ever form part of the kit in all climates and seasons, will be in constant use. Where change of body-clothes is not at hand, the men, after the march, may well be covered in their blankets, while their dresses are being dried in the sun. 75. Wet clothes, whenever possible, should be immediately changed — the remaining in wet being powerfully conducive to disease. For the cold season, and for night duties in a warm climate, the great-coat and woollen cloth trousers prove all- sufficient. 76. Changes such as these, much as they are dreaded, because innovations on the Peninsular usages, by some of our older officers, will not be followed either by " a mutiny or a dysentery," as Sydney Smith would have it. 77. The ordinary blue barrack-changes, if made with fixed dyes, are well suited to the soldier's Avants, as undress ; and the trousers, of whatever stuff, should be made so as to admit of the utmost freedom of movement. The contract system has hitherto proved a failure and an injury to the soldier, both his clothing and foot- gear being far behind the improvements of the day. Country- ^jl^made boots are best for wear during the hot and cold dry season in India, being soft and light; but the English-made boot is the only one proper to the rainy season. 78. Dr. Cordier, of the Imperial Military School of Medicine and Pharmacy, has carried out some elaborate investigations on the relative values of the various materials for clothing soldiers. The following are the conclusions at which Dr. Cordier has arrived : — (1.) The colour of the clothing has but little apparent influence on the loss of heat. (2.) Every fabric is capable of absorbing, in the latent state, a certain quantity of hygrometric water. This quantity is consider- able in woollen material, less so in hempen fabric, and still less so in cotton. This absorption occurs without immediate loss of heat to the human body. (3.) The colour of the fabrics has a great influence upon the absorption of solar heat ; and it is sufficient, whatever else may be THE PREVENTION OF DISEASE. 213 tlic nature of the clotliiug, to modify convenient!)'- the external surface of the clothing, to obtain the advantage by white mate- rials when exposed to the intense heat of the sun. — Brit, and For. Rev. Ap. 1S58. (4-.) Dr. Cordier's experiments further show that a white cotton cloth placed over a cloth dress lowers the temperature 7° per cent. This is a subject well worthy of a carefid investigation. 79. The scarlet woollen cloth of England — that shirt of fire — should never be seen on the plains of India, unless indeed in the northern provinces, and during the cold season. Under any other circumstances the ordinary effect of such a dress amounts to wanton cruelty. The fact is that the dress of our soldiers has yet to be reformed in all ways, so as to secure ease^ lightness, and proper texture and colour for different climates and seasons ; and, in sliort, a suitableness to the advanced and advancing scientific and military movements of the day. 80. AccouTiiEMEXTs. — '' There are five things,^' says Napoleon, " the soldier should never be without — his firelock, his ammuni- tion, his knapsack, his provisions for at least four days, and his entrenching-tool. His knapsack may be reduced to the smallest possible size, but the soldier should always have it with him." We have here the greatest of all authorities in favour of the soldier's carrying entrenching-tools, such as the axe — an instru- ment in itself alone immeasurably more useful to him than sword or bayonet : it is of use in forming the camp, in constructing the hut, in entrenching the village, on the retreat, and in many other ways besides. 81. Comfort and ease of movement will to some extent result to the British soldier in India from the introduction of the small pouch on the waist-belt, with the sliding frog for the bayonet, in lieu of the exclusive old heavy chest-consti-icting shoulder-belt and heavy pouch. By a recent order a shoulder belt, to contain forty rounds, and a waist-belt to contain twenty rounds of ammunition, have been introduced for use in the army of India. This will be some relief, but perhaps not all that might be given. The old shoulder-belt, by throwing the weight of so much ammunition on one shoulder, is injurious ; and it is thought by many that two pouches, one in front and the other in rear, changeable wdien the first is emptied, and attached to the waist-belt, Avould be better. 82. The knapsack, considered by Napoleon as inseparable from the soldier as his arms and ammunition, is not so in the East Indies, where the heat of the climate precludes the strongest men from carrying so much additional weight. In the East the knapsack is carried for the soldier ; and as it gives cover to the " kit," and keeps the men familiar with an old and useful nppliance, it is well to have it always at hand. It should be of the description invented by Mr. Berington, and recommended by the Boyal Commission of 1857. It "is the best that has yet been made in this country . 214 THE PREVENTION OF DISEASE. The knapsack is really a much more important subject than at first appears. To save the soldier's strength he should^ CA'en in Europe^, he exempted from carrying such a load, when employed on a hard or on a protracted campaign. It must ever be remembered that " force expended is force lost.'' 83. The knapsack was "permitted" by Lord Raglan to be left on board the transports in Kalamita Bay, on the landing of the British army in the Crimea. The consequences were most dis- astrous to the health of troops debilitated by previous disease, the result of malarious influences ; and who were now, during six weeks of hardship and exposure, deprived of a change of dress, and of other necessaries. 84. As one error always leads to another, the " permission" to leave behind the knapsack was by the reckless soldier construed into a sanction to throw away his camp-kettles on the march to Balaclava ; and thus began a series of the most astounding blunders and criminal neglects — of military enormities, the very narration of which will interest and shock the feelings of men for ages to come ; a series of cruel ignorances, more ruinous to the soldier and to the military character of England than could have been believed possible of occurrence in the middle of the nineteenth century. 8.^). Bauuack Tents. — The tents supplied for the use of the European troops in the Presidency of Bombay, are stated by Dr. Arnott to be in number and quality all that could be desired, being commodious and lofty .^ Those supplied for hospital purposes are twenty-four feet by sixteen, having single walls and double flies — • the inner fly meeting and lacing to the top of the wall, so as that the outer fly may considerably overhang the wall, giving thus a free and complete escape to rain, along with protection from the Rim's rays. The tents for the men on duty in India are generally sufficient. 86. The securing warmth diiring the night within tents is of the utmost importance to the health of soldiers ; and this is best done by a good layer of straw and a rug to lie on, with camelines, quilts, and the men's great-coats, according to the degree of cold or damp of the nights. Waterproof floorcloths should also be furnished, as being valuable safeguards against exhalations from the ground. 87. When the weather is not rainy or cold, the walls of the tents should be raised or removed on the lee side during tlic night, and in hot fair weather this should be done on two sides of the tent, so as to secure perfect ventilation. In the daytime the same removal should be made on the shady side of the tent, a gentle removal of the air being thus at all times ensured. The men * The admirable " Notes on Moving Troops," by Dr. Arnott, of the Bombay Euro- ).ean Fusiliers, have often been referred to in this article. They bespeak an officer of isiuch discernment and activity. THE PREVENTION OE DISEASE. 215 siiould be made to sleep with their beads towards tbe eirciimfcrence of the tent^ and not to the centre : they tbus escape from the con- sumed air, and breathe a purer atmosphere. 88.- In the Crimea, owing to want of marquees, tlie sick Liy in circular tents of the worst and most unsuitable description. Even for men in health, and during the English summer and autumn, they were found insufficient in the camp at Chobham ; yet the same tents were sent for the use of our men in the Bulgarian summer and the Crimean winter. They are stated to have been served in the following proportions : — na> i- • /• i ^ e i i Two circular tents to each field officer. Officers of infantry and of cavalry, j ^^^ ^^ ^^ to each other officer. ~ •./-•<>. \ One ,, „ to every fifteen men. lo regiments ot iniantry . • . { -c „„t„„ f„„ „„„,.,ic ° •' ( r our ,, ,, extra tor guards. m • i ,. 1 i One ,, ,, to every twelve men. To regiments of cavalry. ■ • • j po^j. /^ ,, extra for guards. 89. Hospital tents and marquees were sent with the original army in sufficient numbers ; but, like the knapsacks, they were " permitted'^ to be left behind at Varna, and were thus eventually lost to the army, including the sick and wounded, for whose special use they had been furnished. 90. "The circular tent used in the British army, which is esti- mated to contain fifteen men, is altogether unsuited for an hospital in any climate. It affords very insufficient protection against cold, or rain, or heat. When there is much wind in wet weather, the rain beats through the canvas ; and when it blows upon the door, which is being continually opened for ingress and egress, the rain is driven to all parts of the tent. The pole being in two pieces, for the convenience of carriage, is weak at the joint, and in stormy weather is apt to give way. The side wall is too low to admit of the use of any kind of cot, there being more than two or three men in the tent ; the space is too confined to admit of proper attend- ance on the patients, even by the medical officer ; and it is im- possible, with safety, to use a stove, or other means of Avarming it. In short, whatever may be the supposed advantages that have led to its adoption as a barrack-tent, it would be difficult to contrive anything much more unfit for the accommodation of the sick.^' The bell tent, the worst ever contrived, should never again be seen in our camps. 91. Hutting. — The soldier should not only be taught to hut himself, but he should likewise hut his cattle of every descrip- tion. Whenever the systematic or organized means may prove deficient, in short, he should understand that it is his duty so to work for his own benefit, and for that of the army at large. A horse-soldier is worse than useless without his horse ; and on the proper care of the baggage-cattle the safety and efficiency of an army may depend. 92. The huts constructed in England for the use of the Crimean 216 THE PREVENTION OF DISEASE. army, and wliich arrived too late to save either men or horses, '^were framed of the liglitest materials that could with safety be used, the boards being about three-quarters of an inch in thick- ness. They were twenty-eight feet long, sixteen feet wide, and from eleven to twelve feet in height to the ridge-pole, with a gradual slope to about six feet at the side, and calculated to con- tain from twenty to thirty-five persons, though, under ordinary cir- cumstances, they would scarcely have been considered sufficient for half that number. The men were raised from the ground by slop- ing floors on each side, of inch plank, leaving an unfloored space of about three feet wide down the centre, in Avhich there was a stove for the purpose of cooking and diffusing warmth. Tlie total weight of each hut, including the iron-work, was about two and a-half tons.'^ 93. Exercises a'sti Amusements. — Roger Ascham maintained that " to ride comely ; to run fair at the tilt or ring ; to play at all weapons ; to shoot fair in bow or surely in gun ; to vault lustily ; to run ; to leap ; to wrestle ; to sAvim ; to dance comely ; to sing and play instru^ments cunningly ; to hawk ; to play at tennis ; and all jjastiraes generally which be joined with labour, used in open place, and in the daylight, containing either some fit exercise for war or some pleasant pastime for peace, be not only comely and decent, but also very necessary for a courtly gentleman to use.^^ 94. In modern times, to comprehend so noble a system of moral and physical training, required a Napoleon ; and his management of his armies of Boulogne, and of Poland, in his first Russian war, is a wonderful example in proof. In his great arrangements the Romans could hardly have excelled him. 95. The commentator of Roger Ascham, from whose writings the above is quoted, observes justly : — " But ' the pastimes joined with labour — the vaulting, running, leaping, wrestling, and swimming' ■ — were as necessary for the yeomen, the artisans, and the peasants, as for the gentlemen of England. Such training, ' fit exercise for war,^ has won our country's battles, from Agincourt to Alma. Such training, "^ pleasant pastime for peace,' has still done some- thing for brotherly kindness amongst degrees of men whom fortime had too much isolated." 96. "To shoot fair in bow or surely in gun," was an accom- plishment which made Englishmen for ages the terror of sur- rounding countries ; and Englishmen are still presumed to pos- sess the precious quality — the coolness in the heat of the fight ascribed to them by Foy. With fair play in the way of exercise, neither Frenchman nor American should be permitted to excel us in the use of the rifle. "While, in Robert Jackson's time, one trained British soldier was equal to thirty of the ordinary class, Americans were trained to knock the heads ofl' squirrels with their balls, so as "not to injure the skin." 97. But the life of the British soldier is so exceptional — so arti- THE PREVENTION OF DISEASE. 217 ficial, monotonous, and depressing — that nothing sliould be left undone which may tend to complete the means for exercise and amusement, wherever he may be cantoned, at home or abroad. According to the men's habits and inclinations, games, amuse- ments, trades, agricultural pursuits, libraries, and theatrical enter- tainments should be encoui'aged ; and none can encourage practi- cally but the officers. 98. Military labour should always be conducted as a means to advance the social condition, elevate the character, and improve the position of the soldier, both Avhile serving in the ranks and after retiring on the pension-list. The utter helplessness of the mere old soldier, on being discharged, and the miseries he suffers in con- sequence, are a great reproach to our system. The discharged engineer, on the contrary, finds ample eiuployment and good Avages, taking a high position among the working-classes. It is another remarkable deficiency of our system, that, where military instruc- tion is given to the soldier, it is almost entirely confined to the attack. 99. Although much has been done of late years in the East Indies, by Lord Dalhousie very especially, to improve the moral and physical well-being of the British soldier, there are still many things to be accomplished which are necessary to his health and comfort. Of these wants the removal to the hill ranges is the greatest. Here the soldier might be permitted to marry in some- thing like a reasonable proportion per company. Here he might pursue the occupations of trades, of gardening, rearing of domestic animals, &c., so as to prepare him for a return to usefulness in civil life, while, in the meantime, according to all experience, he would be making himself immeasurably a better soldier than the idler and laggard of the barrack-yard. 100. It is worthy of remark that while, in all European States, the amusements of the upper and middle classes of society have called into exercise the talents of artists and men of genius of the highest order, those of the lower classes remain confessedly too few, and such as are practised are very ill regulated. As to amuse- ments for soldiers, such things were suggested and written about by the surgeons of our fleets and armies of old ; but punishments were the ideas which obtained constant utterance from the mouths of the admirals and generals of those times. In their own persons our naval and military commanders have at all times been ready enough to subscribe to the justice and wisdom of Bacon's observa- tion, that " Perils commonly ask to be paid in pleasui'cs ;" but, in the persons of their men, they have, with rare exceptions, for- gotten this great and universal truth. In the dreary Sahara of the soldier's life, routine has seldom sought for an oasis in which to refresh or amuse him. The health-giving exercises which elicit the hearty laugh, have never yet been practically oftered to our men. Sir John Moore made proposals worthy of him in the West 218 THE PREVENTION OF DISEASE. Indies, and they were disregarded. The imitations of our com- manders since his time have been fitful and feeble in the extreme ; and thus must such important matters remain, dependent on the freaks of individuals, until they shall be made part of the system and permanent order of our land forces. 101. Robert Jackson, writing in 1791, observes that exercises are no less necessary to the soldier than a knowledge of the use of his arms ; and that, in fact, " the essentia] part of the art of disciplining troops consists in imparting sentiments of heroism and virtue to the minds of the men, in improving the exertions of the limbs, and in acquiring knowledge of the correspondence of their exertions when called into action. ^^ He adds, that the sub- ject of exercising soldiers has been but little regarded in the armies of Europe ; and that, with us, the ordinary exercises of the soldier " are flat and insipid in their nature — that they occa- sion no exertions and excite no emulation— that they neither im- prove the active powers of the body, nor inure the soldier to bear fatigue and hardship." 102. The Romans, who owed more to the discipline of their armies than any other people, were extremely rigorous and per- severing in their exercises. They practised their soldiers in every species of service that might occur ; so that nothing at any time happened with which they were unacquainted. Actual war was in reality a time of relaxation and amusement to the soldiers of this warlike people, who appear to have been trained for the ser- vice of the field, as horses are for hunting or the course. The Romans were not only sensible of the advantages which those habits of exercise procured them in action, but they had also the penetration to discover that they were eminently serviceable in the preservation of health. 103. The exercises now and at all times practised in the Eritish army, so far from exciting emulation, are esteemed, and have always been esteemed by the men themselves, as a mere drudgery ; but they might be induced to take an interest in pleasurable exer- cises, such as fencing, the broad-sword exercises, walking, running, leaping, wrestling, and swimming. Such exercises invigorate the powers of the body and limbs, and thereby impart confidence to the soldier; while indolence is the moth of the mind in all climates. 104<. Parades and drills are no exercise; they are generally, in hot climates, and, as now maiiaged, an unhealthy exposure of the men, and nothing more. The march and manoeuvre should not take place oftener than three times a week, with the interval of a day of complete rest and refreshment between each. 105. The exercise of marching in the early morning, in light marching order, and with appropriate dress, should be matter of regular regimental order in all tropical climates, and at all seasons, excepting the rainy. THE PREVENTION OF DISEASE. 219 TOG. The exercise of ball-praetice has excitement and emulation in it ; and it ought likewise to be made matter of regular order in all climates whatsoever. Robert Jackson, who urges the frequent and liberal recourse to ball-practice, says, that one soldier who is possessed of skill in the use of the musket is equal to thirty or more who have not practised in the careful manner which he recommends ; namely, the art of directing fire upon distant, and upon certain given points. No reasonable Englishman will hesi- tate between parsimony with imperfection and insufficiency, and increase of reputation with expenditure ; yet our authorities, until very recently, have always clung to the former. 107. It ought to be for ever in the remembrance of all classes of officers that indolence and sloth are the bane of the soldier in every climate, and that exercise of the mind and body constitute the best preservatives of health and vigour. 108. Soldiers previously trained to handicrafts should be prac- tised in their original trades. The very jollities, competitions, and exhilarations of the Avorkshop would conduce to health ; and sheds and huts should be constructed at the public cost to be used as workshops. 109. The use of camps, as opposed to suburban barracks, ought to be — to dispense Avith all trades, so that the soldier should do for himself everything that may not interfere Avith health and dis- cipline. The helplessness of the soldier, the forced, or regulation- helplessness, so loudly complained of by Jackson, and which con- tinues to the present day, is very much due to the neglect of sucli exercises and amusements as are here spoken of. 110. NotAvithstanding William Fergusson^s declaration that he never knew or heard of a reading army, it is nevertheless true, as he indeed admits, that in hot climates, in which the soldier is necessarily confined to his quarters for many hours of every day, during eight months of every year, reading, writing, the inspection of models and cheap maps, recitation, &c., will prove valuable aids toAvards dispelling ennui, and preventing recourse to drinking and other vices. 111. Dr. Arnott, of the Bombay Fusiliers, says, that in each European regiment of the Company's army in his Presidency there Avill be found a savings' bank, a good school, a Avell-selected library, a printing press, an excellent theatre, and good coffee-shops ; Avhile the soldiers are made expert tailors, shoemakers, smiths, farriers, carpenters, bookbinders, Avatchmakers, &c. ; and they meet with support and encouragement in their work. The games are chess, backgammon, cricket, skittles, quoits, long-bullets ; with rowing and fishing Avhen opportunity offi^rs. 113. "Under such beneficial operations," says the experienced officer already quoted, " our soldiers are as well behaved in quarters as braA'.e before the enemy ; and commensurate with the additions to their comforts has been the improvement of the 220 THE PREVENTION OF DISEASE. liabits of the soldier/^ He adds, that while sobriety is gradually taking place of drunkenness, sickness and mortality are yearly diminishing. 113. In justice to the memory of the Marquis Dalhousie it must be stated that many of the humane measures here described as the results of local arrangement, were systematically and generally ordered in regulations framed during his great administration of India. But those precautions against vice and sickness, those safeguards of discipline, and those sources of contentment and long good service which have been so effective in the East, we should be glad to see extended to the West also — indeed, to all our possessions. 114. Finally, and speaking more physiologically, exercises, by accelerating the respiratory and circulating functions, invigorate the nerve-forces, promote secretion and depuration, purify the blood, and strengthen the muscular system ; not to mention their great influence on the mind of the soldier, in advancing and con- firming his moral and military discipline. 115. Marching of Troops i.\ Hot CLiMy\TES. — The marching qualities of the British soldier have never been so nobly developed and demonstrated as by Sir John Moore — " that model soldier of England" — who taught a lesson which the Peninsular war com- memorates, but which the present generation may forget in our home railways. A railway, it is true, will bring the soldier to his post with a speed unknown to our ancestors ; but, if we neglect the march, we shall forget much for which the soldier is brought to his post, and be very little, if at all, the gainers by our mecha- nical speed. 116. In September, 1813, the Duke of Wellington writes : — " No disorders amongst the old soldiers. Kegiments recently arrived from England or the Straits are very unhealthy, and the loss by death is almost confined to them. I am afraid that the soldiers are not sufficiently exercised in marching when at home or in foreign garrisons ; and they become sickly as soon as they are obliged to make a march. The non-commissioned officers, and I am afraid the officers, are very bad, and they neglect to attend to the food of the soldiers." 117. The truth is that, as regards health and the results which health may secure to the commander, the march Avill prove, like other things, exactly what we may make of it. In actual war a march properlv conducted leads to vigour, health, and success : a march improperly conducted, ends in exhaustion of mind and body, in disappointment, sickness, and failure. lis. By the more ordinary and unreflecting of the military, the conduct of a march is deemed a matter of trifling routine in itself, and therefore most easy of accomplishment ! If conducted during war, and the march is performed without surprise or loss of bag- gage ; or, if in peacC;, and the operation is accomplished without THE PREVENTION OF DISEASE. 221 complaint on the part of the populations along the route, all is presumed to be well ; but indeed there are many other circum- stances which here demand a very careful consideration. 119. Previously to the march of troops, the regimental sur- geon shoidd institute minute and repeated inspections of the men, with the view to prevent weakly and diseased persons from proceeding, and with the purpose also of preserving the means of transport attaclied to the regiment for the inevitable contingencies only of the march. By such precautionary arrangements disease is prevented, and the slightest cases cured ; Avhile the soldiers, knowing that in sickness they incur the risk of being left behind, will use more than usual care against contracting illnesses. 120. Excepting under urgent occasions of service, European troops are not allowed to be moved in India dui-ing the hot and rainy seasons ; from the beginning of November to the beginning of !^^arch being usually regarded as the proper season. A disregard of this appropriate time for movement caused the 7Sth Highland Regiment, between August, 18il, and jNIarch, 1845, to lose 669 men. Even native regiments have suffered most severe losses from similar inattentions to season. 121. The hour of march should be so early as to enable the men to arrive at their ground of encampment before the sun has acquired power ; — say, an hour after sun-rise — regard being had to the nature of the country, and of the roads to be traversed by the troops. When conducting the march, care should be taken to place the least effective men in the front — the movement there being necessarily the most free. 122. In hot weather the soldier's neck should be bare upon the march, the head being kept as cool as possible, the face and head being frequently splashed with water. When flushing of counte- nance or giddiness appears, then the sufferers should be made to halt, and everything done to prevent sunstroke. 123. The pace of the soldier, during the first hour or two of the march, should not exceed the rate of three miles per hour ; and the rate ought to have no relation whatever to the walking power of the coloneVs horse. At the end of the first hour a halt of five minutes should be ordered, and at the end of the second hour twenty minutes. About half the march being now accomplished, the pace of the men for the remaining half may properly be some- what accelerated, and a halt of twenty minutes being ordered at the end of the third hour, a march of twelve to fourteen miles may well be performed in four to five hours. 124. In all hot climates the order of march should be open and easy to the men, the close majestic English formation being here something far worse than absurd ; unless it be in the very face of an enemy whom we desire to frighten. It is surely enough for dis- cipline and order that, on the line of march, every man may be ready to fall in on the first tap of the drum, as in the French army. 222 THE PREVENTION OF DISEASE. 125. In making forced marches, the halt of an hour, in addition to those ah'eady recommended, should be ordered at the end of the first twelve miles. Marshal Ney says of the march in Europe : — " If the enemy is far off, there should be a general halt of half an hour after every two hours of march. If it be a forced march, it shall continue four hours, and then a halt of an hour for refresh- ment.^' 126. As an example of well-sustained marching, I would adduce that of the heroic Polish commander, Dembinski, in the insurrec- tion of 1831, when he marched five hundred and fifty miles in twenty-five days, surrounded by a host of enemies, bringing his army into Warsaw intact. " The annals of war,'' says Alison, '^ do not record a more memorable exploit." The marches per- formed in our earlier campaigns in India, by Colonel Adams, Coote, and Lake, are very memorable, taking into account the climate in which they were performed. 127. Soldiers in active march, and Avhen the enemy is near, should halt, pile arms, and fall out in their order of march ; so as to unpile, fall in, and march oft' again at a moment's notice, without disorder or confusion of any kind. A slow rate of march with long halts, on the supposition that the men are thus spared^ is a great mistake ; for it implies solar exposui'e and much distress to the soldier, whether European or Native. 128. Movements in brigade or battalion are never made for the march, excepting in the presence of an enemy — the best mode of marching off being generally by fours ; and when the force is at all considerable, a signal-lantern should be hoisted at the starting rendezvous. 129. It is in devising and arranging the exercises and amuse- ments, and the march of the soldier, that the oflicer will find him- self sure of commanding the personal attachment of his men : it is only by inferior minds that drilling is mistaken for training ; — two things indeed widely distinct and separate. In the language of Marshal Ney, the officer must, without intermission, and with increasing solicitude, attend to the wants of his men, while he insures by the most persevering activity, the execution of his orders. 130. Persons in authority should also hold in careful recollec- tion the caution of this great commander against the too great number of evolutions, invented in time of peace for the soldier's torment, by officers often more systematic than experienced in war. 131. The great French tactician assures us that but "two essential conditions constitute the strength of infantry — that the men be good marchers, inured to fatigue ; that the firing be well executed." He concludes that " victory smiles in general upon those only who know how to command it by good preparations ;" and amongst " good preparations" none assuredly yield better returns to the State than the sanitary arrangements now so well vinderstood : — " Le bien Ic plus precieux est le sang du soldat." THE PREVENTION OF DISEASE. 223 132. TVTien entering on the Crimean campaign, the following intelligible, common-sense sanitary instructions were issued to the French soldiers : — " a. It is wrong to sleep in immediate contact with the ground. Perfectly dry substances not easily permeated by moisture should be interposed. For this purpose fresh branches of vegetable matters should never be used. " b. When the camp is pitched near a marsh, a tank, pools of stagnant water, or a valley, the chief openings of the tents should be in the opposite direction. In these bivouacs every possible means should be used to exclude the noxious vapours exhaled from %VLchfoci. At night the openings of the tents, or other coverings, Avith exception to those necessary for ventilation, should be closed. " c. The greatest care is needed for protection against the fresh- ness of the nights, even when the heat is extreme ; it is dangerous to remain clad only with the shirt during the night. At the bivouac and in the tent the soldiers should be very carefully covered. " d. The feet should noi be washed with cold water, especially when heated after a march. " e. "Whenever practicable, the face, and particularly the eyes, should be frequently washed daily, after exposure to the dust of the march. "/. Cleanliness of person, clothes, and dwellings is imperiously required by the nature of the climate. " (/. In summer the best protection against sunstrokes, which are often very dangerous, is never to leave shelter without having the head covered. " //. It is necessary to be always so clothed as to be proof against the sudden chills to which one is liable at all seasons, from the abrupt changes of temperature which frequently happen in nearly all parts of this country." These instructions were explained to the French soldiers. " T/ie March. — ?'. The pace should not on any occasion exceed three and a half miles per hour. " j. One of the junior medical officers, with a native attendant, should always be placed on the march between the column and rear-guard, prepared to administer Avine or other stimulant, or order means of carriage for men who may fall out from exhaustion. " /•. No man should for any purpose be allovred to fall out with- out a non-commissioned officer to accompany him, to secure his return to the ranks at the next halt, and to report him immediately to the surgeon, if sick. " I. An excellent suggestion of Dr. Barclay, of the 43rd regiment, is to have all the men who fell out on the march examined by the surgeon immediately on arrival at the encamping ground. He frequently detected disease in this manner which for a time might otherwise have escaped notice. 224 THE PllEVENTION OE DISEASE. '^ ))i. The tents should be pitched as quickly as possible, and they should even be carried on camels or elephants, not carts. " n. European soldiers on a march in India, especially in the hot and rainy seasons, should as much as possible be exempted from duties, and from those of sentries, where any native troops are present. " 0. When obliged to go out in the sun^ the soldiers should be ordered to place a damp cloth or towel under the forage cap, so as to protect the head. "^;. It were a true economy, in the hot and rainy season, to secure the very best description of tents for camp and hospital purposes." 133. Topographical Precautions — Localities to choose. — When military considerations do not imperatively forbid it, an elevated and dry soil should always be selected for bivouacs, camps, and cantonments, having undulating ground, or the declivity of a liill ; the most healthy sites being such as do not, from the natural fall or from the quality of the soil, retain moisture. a. Where we can obtain the power to choose our ground of en- campment, we should give preference to a dry but not hard soil, so that it may quickly imbibe rain, and thus become fit for military operations soon after the heaviest falls. Rapid absorption also saves the troops from the injuries caused by damp. b. Under great heats, wooded districts, if dry in the soil and subsoil, are good grounds for encampments, the lofty shade afford- ing cool refreshment and a free ventilation. c. Open downs, so called, are healthy. d. The elevated banks of rivers that have a sufficient fall either \^ay. e. Tongues of land, or slender promontories, jutting well into the sea. /'. It is said that wherever pure water is procurable, there the ground is generally fit for encamping or cantoning troops. ff. When marching, to halt, during wet weather, on ground somewhat elevated and sloping, and sheltered from the wind. h. In such case to increase the number of fires, and to keep them up to the hour of starting. i. To make the regulated halts where water is good, and to pre- vent the men from drinking it while heated by the march. ;'. In marshy localities the ground of encampment should be on the highest ground procurable. k. When encamped on a river bank, a station high up the stream should be appointed for drinking and cooking purposes ; next below it, the station for watering cattle ; and below that the station for washing. /. When river-water has become muddy, or otherwise unwhole- some, wells should be constructed under proper direction — sand or shingle being placed in the bottom of the springs. THE PREVENTION OF DISEASE, 225 m. In all convenient situations the men in health shonld be marched every morning to the bath, especially during hot weather. n. Encamped, through necessity, too near a rivulet or river having marshy banks, tlie extension of ague should be prevented by cleansing and deepening the river-bed, raising the banks, and increasing their inclination, removing the tents to a greater dis- tance from the river bank. 0. Choose a gravelly soil, and if elevated, so much the better — low-lying gravelly soils being less healthy. ^j. A chalk formation, with a sufficient inclination, if poor and barren, is very healthy, and the air from such soils proves generally dry and bracing ; but if the same kind of formation be level, and charged with refuse matters, it will become pestilential. 134. Localities to avoid. — All damp ground, whether sandy or other, to be avoided in all climates ; and where the surface may appear parched up and destitute of vegetation, if there yet be moisture underneath, as caused by previous rains or other percola- tion, it may be charged with the worst exhalations. a. Lands the Avoods of which have been recently cut down should be carefully avoided. h. Half-dried beds of rivers, of canals, tanks, or ditches ; narrow gorges. A camp should not be intersected by streams or ditches, nor enclosed by extensive forests. c. Marshy grounds, and such as are immediately above marshes, and grounds exposed to winds and currents passing over marshes ; the near vicinity of canals. d. Grounds covered with underw^ood, and the vicinity of such grounds. e. The low, jungly, or marshy banks of tidal rivers and lakes ; especially if the waters be impure. /'. The best ground, if long occupied by masses, becomes con- taminated, just as air and water become contaminated by abuse. It is therefore an established sanitary rule in all countries to change the ground of encampment as frequently as may be. g. Places of proved insalubrity in the estimation of the natives, and places in which troops have suffered on previous occasions of encamping or cantoning, should be carefully avoided. The first of these precautions was neglected, through ignorance, by the British commanders in the valley of the Guadiaua and in Bulgaria, and great destruction of life was the result on both occasions. h. Meadow-lands having vegetation of a marshy nature, com- bining the presence of amphibious animals, as frogs and tortoises. The presence of the Bara variahUls is considered an unerring indi- cation of an unwholesome and marshy locality."^ i. The presence of flies of various kinds, followed by flocks of insect-eating birds, points to an unhealthy locality; and the * Dr. Aitken's "Climate of Scutari," 9. 226 THE PREVENTION OF DISEASE. nature of the soil^ combined with these circumstances^ will generally indicate to the careful observer the presence of unhealthy districts. j. Alluvial grounds at the entrance and at the exit of lakes, especially if there be tracts of slime and mud. 135. Treatment of Soldiers ox board Ship. — The condition of the transport, the state of health of the crew, to be carefully examined. When ships of war are used, a frigate to be preferred to a ship of the line. a. Old and foul ballasting to be changed, and no fresh or green wood to be allowed in the ship's hold, or any matter capable of ready decomposition. h. The state of health of the troops to be carefully examined, and cases of contagious disease, or of old or extensive ulcers, to be left behind. c. The crowding of the men to be especially guarded against, and care taken that berths are secured for the sick and the married : the strictest care to be taken that the aggregate numbers of persons do not exceed the proportion of one person to two tons of measure- ment, at the least. d. The men should not be permitted to quit the ship, or to be on deck after sunset, when navigating rivers, or proceeding along level or marshy sea-coasts, e. Careful and especial examination of the provisions should be made, and it should be seen that the salted meat and biscuit are good and fresh ; the same care being taken in respect of the water, which, when possible, should be taken from springs, and kept in iron tanks. Quicklime should be provided for purifying the water, f. For distant expeditions there should be hospital ships, well- provided and cleansed, to allow for the proper and immediate separation of the healthy from the sick. g. Cold and damp in the ship's hold are to be guarded against, and the pumps to be frequently worked, so as to leave but a few inches in the well. 7i. Thorough ventilation, and a careful attention to cleanliness, to be promoted by every means ; and in bad weather, when the wind- sails cannot be used, portable stoves or firepots should be carried between decks. i. In fair weather the men should be much on deck, and they should be made to bathe daily. j. Moderate exercise, with amusements of every kind, should be encouraged by every means during the voyage ; and a union of kindliness and indulgence with good order and discipline should characterize the conduct of all classes of officers towards their men. k. It should always be remembered that soldiers who have voyaged in crowded and ill- ventilated ships are peculiarly liable to disease, both endemic and epidemic, on landing in a ucav country. New-comers are everywhere more prone to disease than residents ; but new-comers wdio have voyaged in pure air, having ordinary THE PREVENTION OF DISEASE. 227 care in other respects, arrive under liappy conditions, compara- tively. M. Scribe justly observes that such circumstances natu- rally suggest extra vigilance in the hygienic treatment of newly- arrived troops in foreign countries. /. The actual loss of British soldiers during the last half-century, reckoned for six months only from their landing in the East and West Indies, and resulting solely from the neglects here briefly stated, would shock the humanity of the present day. 136. Barrack and Hospital Accommodation. — It may be said with truth of all our intertropical possessions, that, next to the in- juries to health caused by the ill selection of localities for military stations, temporary and permanent, stand those caused by the ill construction of barracks and hospitals. Of structural errors to avoid we have endless examples throughout the British Empire, at home and abroad ; but not one unexceptionable example which might be adopted with advantage in any one of the infinitely various climates of our possessions, temperate or tropical. 137. "With a view to settle this most important question on a solid and scientific footing, it was proposed by me, in a memorandum drawn out by desire of Lord ]Metcalfe, and presented by him to the Colonial Minister in July, 1842 : — a. That a Commission be assembled in London, composed of medical ofiicers and of engineers, civil and military, to inquire into and determine, on sufficient evidence, the best plans for hospitals and barracks in the various climates in which the soldier serves. b. That, on a full and careful consideration of the whole subject, a standard plan be prepared suited to the various climates of our possessions, home and foreign. c. That, provided qualified persons were selected for this duty, the task of arriving at a satisfactory conclusion could not be one of much difficulty ; for that much the same kind of barrack and hos- pital accommodation would be suitable for the East and West Indies, the Cape of Good Hope, Mauritius, Ceylon, and Australia, and also in the jNIediterrancan stations ; while much the same plans Avould answer for the United Kingdom, and for our North American possessions, and so on. d. That, until something of this kind is done, the discussions on the subject become nothing more than an useless course of fault- findings and vain disquisitions. e. Pending the arrival of the proposed settlement, I would beg leave to suggest that barracks and hospitals, situated on the hot and pestilential plains of our hot climates, ought to be raised on arches, and have double roofs, the cubic space within being of the greatest. Here we can make no mistake, for the breathing-space cannot be too large. 138. Medical Officer of Health. — The author also suggests, and he has very long suggested : — a. That there be attached to the head-quarters of every field Q2 228 THE PREVENTION OF DISEASE. force, and specially to the office of quartermaster-general of sucli force, a highly qualified and selected medical officer in the depart- ment of medical topography. h. That his duties in peace be to examine and report on the proper sites, and on the sanitary condition of military stations and cantonments, convalescent stations and sanatoria ; — on the struc- ture and arrangements of barracks and hospitals, and on every- thing which may relate to the comfort and health of the soldiers. c. That, in war more especially, such a military-medical officer of health should be attached to the quartermaster-general in the field, and be always in. advance in company with that officer, so as to be master of the medical topography of the scene of action. d. That where military reasons of imperative necessity do not overrule sanitary considerations, the advice of the medical officer of health should be accepted, as to the sites of camps, whether temporary or permanent. Colonel Macdougall, in his excellent work on the " Theory of War," acknowledges what has for more than a hundred years been declared by our army sur- geons : he, at length, states distinctly, that " the choice of a healthy site for a camp" is one of those arrangements which is " peculiarly within the province of the medical department." e. That such an officer, so highly qualified, and possessing rank and station in the army, could not fail to prove of the greatest service, in peace and in Avar, in all countries ; and that there has not occurred an expedition or a campaign since the reign of Wil- liam III., not to go further back, in which such an officer of health would not have saved thousands upon thousands of our men, and millions upon millions of our money, not to speak of moral, mili- tary, and material savings. To furnish instances in example is altogether unnecessary. Our military history is full of them ; and they will present themselves by the score to every well-informed Englishman. 189. Sketch of Personal and Material Arrangement for Field Service. — (1.) If chemistry and physics, says a modern writer, enable us to commit more havoc among hostile ranks than was possible formerly, surely the advance of medical science ought to enable us to save more of our own troops ; or, in the language of the Times, " the duties of self-preservation are of primary impor- tance in war, not falling below the art of killing the enemy." (2.) The naval and military surgeon, under all circumstances of service, and especially during war, should have held out to him all the advantages and encouragements presented to other officers. The diflference between officers as combatants and surgeons as non-combatants must cease," says Radetzky, the great Austrian commander in Italy. "^I see everywhere military officei's and surgeons equally exposed to the fire, and therefore the sur- geons shall enjoy advantages and distinctions in every respect equal to those of the officers." THE PREVENTION OE DISEASE. 229 (3.) " Medical officers will not work well," says Guthrie, " Avitli- out some hope of reward. The promotion on all death and retired vacancies should be granted to those who have worked — not by seniority, but by desert. The medical inspector and the general commanding must judge of their merits; and the Director- General at home should not have a veto." (4.) For an army to enjoy the advantages of a thoroughly expe- rienced medical staff, it is necessary that a system of rotation of duties be rigorously enforced amongst its members — every mili- tary surgeon being employed successively in every department of the service ; in the stationary and in the field hospitals — in the field, in the trenches, at the ambulances. Wellington, writing to Sir John Malcolm, from London, in February, 1808, says: "I am employed in this country ver}'^ much in the same way that I was in India — that is to say, in everything ;" and so ought the army-surgeon to be employed. (5.) Of the surgeons who accompany an army into the field, those only acquire real surgical knowledge and experience who are de- tached in charge of the hospitals, and who thus have personal responsibility thrown upon them. Of the surgeons who move with the troops, those only who are attached to the ambulances become familiar with the performance of operations. (6.) Through a system of rotation the chief of the medical de- partment will readily discover the talents and abilities, and the particular kinds of services for which every officer under his orders may be qualified. Physical qualities with skill in operating will qualify for the field services — such officers being attached to the ambulances ; while such as possess peculiar facilities for tending the sick and dressing the wounded should be sent to the hospitals. (7.) Military qualities will enable the possessor to command, inspect, and superintend, and the mind fitted for organization will find employment in supplying the medical wants of the army and the hospitals, in keeping the registers, accounts, &c. (8.) The chief must control and direct the perso/n/ el and materiel of his department. The latter was properly designated the " im- pedimenta " by the Romans ; and our design should be to give to our stores as little of that character as possible. (9.) After an important action, the surgeons who have attended in the field or at the ambulances, should be sent to the hospital along with the wounded who have been under their care during or im- mediately after the battle. A surgeon will necessarily take more interest in his own acts than in the results obtained by others, and we ought to employ this tendency for the benefit of the wounded. — Brit. a^^For. Med.-CIiir, Rev., Jan. 18.56. (10.) In 1803, Jackson writes, that in the campaigns and expe- ditions conducted by Pitt, the " excess" of medical officers over the real wants of the army "was beyond measure great; not less than two-thirds :" in other words, " one-third, or less than one- 230 THE PREVENTION OF DISEASE, third, either has performed, or Avas capable of performing, all the service which has been done iu the hospitals during the war." (11.) He adds, that on the same scenes of action "two-thirds, or more than two-thirds of the medicines ordered for the use of the forces perished in store, before tliere was an opportunity of apply- ing them to a purpose;" just as our soldiers perished before they beheld their enemy. (12.) Writing in 180.5, the same authority proposes that for a battalion of a thousand men, stationed in Europe in time of peace, one surgeon and one assistant ought to be enough ; having a staff or superior medical officer to each brigade of three battalions. Employed on field service in Europe, or on distant foreign service, then an additional assistant to each regiment is declared neces- sary. (13.) Reckoning on the same principle, we should require for service in Europe in time of peace, 231 medical officers for an army of 100,000 men, and 388 medical officers with the same force when employed in the field, or in distant unhealthy climates. But upon Jackson^s estimate of what was a fit medical establish- ment, there was an actual excess over and above the real wants of 100,000 men, of 762 medical officers. (14.) Jackson estimated the average ordinary sick of his time at one in ten of the effective strength, and at one in five under extra- ordinary circumstances. (15.) But a just order with economy had no place in the public arrangements of those times ; and Robert Jackson, to his great honour, was the first and foremost to expose the ruinous conse- quences. The expedition of 1795 to the Cape of Good Hope con- sisted of 3000 men, for which 18 hospital staff were appointed, over and above the regimental complement of medical officers. (16.) The force sent to the Caribbean Islands under Sir Ralph Abercromby numbered 20,000 men ; for which 183 medical officers of all grades and descriptions were appointed. (17.) The expedition to St. Domingo, calculated at 15,000 men, 1 ad 91 medical officers of all grades and descriptions attached to it. (18.) The total troops employed on these three services, amount- ing to 38,000 men, had a hospital statt' of "two hundred and ninety-five ; or a medical officer for about every hundred and twenty-eight persons, exclusive of the addition of the regimental staff"." (19.) But, including the regimental medical officers, we have " the sum of four hundred and fifty-one medical officers, charged with the care of the health of thirty- eight thousand soldiers ; a high proportion, as affording one medical person for every eighty- eight men." Thus, "had the whole army been all actually sick at one time," the extra j^rovision of hospital staff, not to count the regimental, " was alone sufficient." THE PREVENTION OF DISEASE. 231 (20.) With this " enormous multitude of medical officers/* which left " two-thirds of the medical staff idle or hut half employed/* the sick and wounded suffered " loss in want of medical assistance.'* (;^1.) No wonder that this great authority should declare " a superfluous number of medical officers to he, instead of a benefit, actually an evil in an army /* and that it is the army surgeon who is " choice in quality and important in character'* that is wanted, and not a mass of persons " strong only in numbers.** (22.) Dr. Andrew Smith, presenting his views half a century after Jackson, suggested the following personal medical establish- ment in 1854, for thirty thousand men ordered on service to Turkey, under the command of Lord Raglan : — Inspector-general of hospitals 1 Deputy-inspectors general 4 Staff surgeons of the first class 12 ,, ,, second class 13 Staff assistant-surgeons 48 Chief apothecaiy 1 Dispensers of medicines 3 Purveyors 3 Purveyors' clerks 6 Medical clerks 2 Cutler 1 Total staff 94 (23.) To every regiment of infantry, averaging 850 men, was, besides, specially allotted one surgeon and three assistant-surgeons. To every two squadrons of cavalry of 250 men one surgeon and one assistant -surgeon. To every troop of horse artillery, one assistant-surgeon ; and to every field battery, one assistant-siirgeon. For the general duties of the Ordnance Medical Department, one surgeon. Here was personal provision for cure without stint. Had the same amount of care been given by authority to the per- sonal and influential means necessary for the prevention of disease, it is not too much to say that the national calamity of the Crimea would not have occurred. (24.) The total medical officers allotted to the 30,000 men was two hundred and five. During the Peninsular war it was found that more than one-third, but not quite one-half, of the medical officers of the army were generally iuettective from sickness, &c. ; therefore, as an equal amount of sickness might be expected in Turkey, sixty- eight medical officers were constituted a reserve to supply vacancies. (25.) After providing ample supplies of medical and surgical stores, the Director-General ordered the following material estab- lishment for the conveyance of the sick and Avounded ; — 232 THE PREVENTION OF DISEASE. Bearers or stretchers 780 Spring-carts on two wheels, Guthrie's 20 Spring waggons on four wheels 20 Flanders waggons 9 (26.) Each waggon was arranged to carry ten men^ — four severelj and six slightly wounded — each ha^dng a separate compartment ; while the Flandei-s waggons were intended for the carriage of field-hospital and other stores. (27.) In addition to a large general material establishment, each corps was provided with a regimental and with a detachment medicine-chest — each such chest being furnished with every re- quisite medical and surgical means, and also with a box of appa- ratus for fractures and dislocations. (28.) Besides the above, the surgeons of each corps had each a full set of capital instruments; the senior assistant a portable set — and the surgeon and the three assistants had each a pocket-case of instruments, with lancets, &c. ; and, for general use, there was likewise a set of cupping instruments and a stomach- pump. (29.) It is now proper to refer to the scheme of personal and material arrangement proposed by Guthrie, for a force of 12,000 men (twelve regiments of infantry, and four batteries of artillery), founded on Peninsular experience, on the completion of the war at the battle of Touloase, when the celebrated author believed that the medical department of Wellington's army had attained to per- fection. This plan, most maturely considered, was submitted for consideration of the Minister for War and the Commander-in-Chief, with reference to the then contemplated expedition to the Crimea. Its purely surgical character is plainly pronounced. (;30.) One surgeon and three assistants to accompany each regi- ment; one assistant-surgeon to accompany each battery of artillery; and one regimental surgeon to every four batteries. These officers should always remain with their respective corps, except the surgeon of artillery, and go into action with them. At a siege, one assistant-surgeon accompanies each relief into the trenches, and is also exposed like any other person. (31.) One staff surgeon should be attached to each division, to superintend and regulate its proceedings. He also accompanies the troops into action, but avoids musketry fire and cannon shot, if he can : once an officer loses his regiment at the commencement of an action, it has happened that he could not find it again until it was over, not even if he was a staff officer. (^32.) The staff-surgeon here mentioned, ought to be selected by the general, but should not consider himself permanent. He should form part of the division general's family, and it may be advisable to make him an allowance, as for an aide- de-camp. On this officer mainly depends the efficiency of the division ; he should THE PREVENTION OF DISEASE. 233 be a young and vigorous person^ equal to anything, and when he no longer possesses the confidence of the general, he should be removed. (3-}.) The staff surgeon of the division should remain with the wounded as long as he can be spared from the division ; and if the loss be great, one surgeon only should remain with each brigade. Surgeons of artillery should join the general hospital, and also the assistant-surgeons attached to the batteries, whenever their services are required. One deputy inspector-general should remain at Constantinople, with one staff assistant-surgeon, and one clerk. He should superintend the landing of the troops and the departure of invalids, apportion their supplies, regulate the hospital, and approve the contracts for it. He should correspond with the inspector-general at head-quarters, and have a separate correspon- dence on every point relative to the station with the director- general at home, copies of which should be sent to his superior at head-quarters. He shovild provide attendance for all sick officers arriving from the army, and report when they become fit for duty. The medical officer here should be of rank, as he will have to transact business with Turkish and other foreign authorities — perhaps even with the ambassador. (34.) The inspector-general in the field may be of any age, pro- vided he be not subject to back-ache, the gout, chronic cough, or other inconvenient ailment. " The inspector-general goes with head-quarters. He is almost entirely a pen-and-ink man.'^ .... (Here we have a most remarkable illustration of what had been regarded as perfection in the Peninsula.) All others will do their duty better if under thirty years of age. After six campaigns, invohang a larger share of practical labour than any one else, and, with one exception, a more responsible duty, I was, at the termi- nation of the war in the Peninsula, twenty-eight years of age. What I could do then any one else can do now. (35.) Medical officers are not to be computed according to the force employed, but according to the loss likely to be sustained in the first battle. If a force of 12,000 men should have 1500 wounded, including officers, they would require (Toulouse being taken as an example, and there is no other so good), fifty-two surgeons, besides four apothecaries, or dispensers. The whole medical force would be thus : — Inspector-general 1 Uejmty inspectors-general 2 Staff surgeons 8 Staff assistant-surgeons 10 Eegiinental surgeons 12 ,, assistant-surgeons 36 Artillery surgeons, four batteries 5 Total 74 (Exclusive of four apothecaries, or dispensers of medicines.) 234 THE PREVENTION OF DISEASE. Deduct inspector- general 1 ^ Eegiinental surgeons 12 [ Always in the field. Artillery surgeons 4 ) Deputy inspector 1 j Staff surgeon 1 | At Constantinople. Assistant-surgeons 2 ) Absent, or sick, of the whole .... 3 Total 24 (36.) If 24 be deducted from 74^ it will leave 50 — being two less than the number required at Toulouse for the first week, to take proper scientific care of 1359 wounded men, and twelve less than were present in the second week. (37.) If a second battle take place within a few days, there would be only twelve regimental surgeons to depend upon ; and if the loss were only half that which occurred in the first battle, all scientific treatment would be at an end. The proposed medical staff is therefore insufficient for the duties required when two battles are fought within a week ; yet, in the south of France, three large hosj^itals were established in less than four weeks — at Tarbes, Orthes, Toulouse, besides some smaller ones. If, in addition to this, any of the diseases common to the country be superadded, the medical officers will be totally unable for the duties — a sad and important consideration. (38.) If the reports of the inspector-general should, in May or June next, appear to indicate such an evil, twenty assistant- surgeons might with advantage be allowed to volunteer from the regiments at home, some of whom should find themselves promoted to unattached or second-class surgeoncies on their arrival at Con- stantinople. The general commanding should have authority to require the services of all medical officers from Corfu, Malta, and Gibraltar ; and the naval surgeons may, under such circumstances, be able to take charge of the hospital at Constantinople. (39.) If an addition of 1^,000 men be made to the original force of that niimber, then one deputy inspector-general, eight staff- surgeons, and twelve staff' assistant-surgeons should accompany it ; volunteers from regiments accompanying them, together with one spring-cart for each regiment, and six for a reserve — in all, eighteen spring-carts ; under the belief that 24,000 men will probably suffer more in one action than half their number, if opposed to a superior force. (40.) The inspector-general should make himself acquainted with the topography, prevailing diseases, and the capabilities of every kind of each place he visits ; what it can furnish which the army may require, and the price of each article ; so that nothing may be imported from England which can be procured on the spot. (41.) In the early part of the Peninsular war general hospitals were preferred to regimental and divisional hospitals ; but in the latter part, regimental or divisional hospitals were considered the most advantageous. General hospitals should be looked upon as THE PREVENTION OF DISEASE, 235 necessary evils, sometimes becoming even pest-houses ; and, unless under vigorous management, they very materially impair the efficiency of an army. (42.) The wounded of each brigade and division should, as mucli as possible, be placed together, under the assistant-surgeons aiul hospital establishment of each regiment, the hospital establishments remaining until they can be dispensed with. Regimental surgeons are, in fact, the men for work on such occasions : they understand their business, obey orders, and have an esprif-de-corps that carries them through everything. Under a staff-surgeon who knows his duties, and sets the example of them, the regimental surgeons never give in. (43.) All the accounts of general hospitals, whether on the field or afterwards, should be made up Aveekly, added together monthly, and finally settled quarterly, by an accountant of repute on the spot, and never reopened : the accountant should not be a person who contracts nor one who pays. (44.) Contracts should be approved as well as paid by the principal medical officer of each station, who should also examine and approve the weekly account of each separate hospital establishment of the station, whatever be their number. There is little difficulty in doing this, if the principal medical officer have a clerk who understands accounts, and a deputy-purveyor who is willing to do his duty. (45.) A building should be obtained for a hospital a mile at least out of town, near the place where the troops land. It should be airy, roomy, and capable of containing six hundred sick. It should be walled in, if possible, with a field or garden behind. Supposing 12,000 men to limd at Constantinople, there will be some sick, or men uuable to march, dependent on the time they may have been on board ship, on the discipline observed, and particularly on the ventilation on board ship during the night. (46.) The hospital should not only receive all the sick on landing, but all that are left on the advance of the army, and all that return from it as it proceeds. It should be so aug- mented, from time to time, as always to be ready to admit 200 more, whatever the number present. It may be the depot for apothecaries' and for all other stores. If the force sent should ultimately amount to 25,000, this establishment must be greatly increased. (47.) Bedding, less the straw, and all other hospital stores, should go out in the same ships for at least 1500 men. One staff surgeon and one or two of the best staff assistant-surgeons should be allotted to this hospital, with a purveyor and clerk, and two or three hospital Serjeants or stewards, if procurable from the pen- sioners attached to the hospital-conveyance corps. (18.) There -should be a military officer attached to the charge of convalescents, and to repress irregularities. If this officer should 236 THE PREVENTION OF DISEASE. not act cordially in concert with the principal medical officer, they should both be removed. (49.) The first principle of military medical movement in the field is, that wherever a gun can go an hospital- cart should be able to follow and keep up with it. The medical conveyance of an army in the field should be, as far as possible, independent of the com- missariat, although receiving assistance from that service on every occasion in which it can be afforded.^ (50.) An hospital-cart should be on two wheels, with shafts and outrigger for two horses, capable of being taken off the springs and easily put on again ; having also a light permanent cover and side curtains. It should hold a cot slung high, and a seat for two persons in front, covering a waterproof box for surgical instru- ments and stores. There should be a similar but narrower seat behind for two persons, affixed to the doors, and everything belong- ing to the cart should match with similar articles in the artillery, such as wheels, &c. Two horses and two men must be permanently attached to it, and it should carry eiglit spare horseshoes. (51.) One of these spring-carts should be attached to each regi- ment of cavalry, of infantry, and to each battery of artillery not serving with a brigade; while another should be specially attached to the horse artillery, and be capable of accompanying that service everywhere. (5a.) A quartermaster, or two non-commissioned officei-s, old hos- pital Serjeants, should, if possible, be attached to every twelve carts, the whole being under the orders of the staff surgeon of the division ; six of the twelve being in reserve. All the carts should be numbered ; and the six attached to regiments should carry nothing but the box aforesaid of medical and surgical stores, and a tent with six bearers, with poles and springs. It should follow the regiment into action at a convenient distance, but near enough, on any movement taking place, to pick up the wounded. (53.) The reserve carts should carry in addition two hard-pressed packages of ten sets of bedding, each set consisting of one rug, two blankets, three sheets, and one palliasse- case. These carts are to be with the staff surgeon, and as near as possible to the scene of action without incurring much risk. (54.) Twenty-four carts are thus required for the use of two divisions, and twelve more and a forage-waggon should be attached to the head-quarters of the army ; in all, thirty-seven. The forge- waggon should have two blacksmiths and a cutler, a handy man for all hardware work. These carts are intended to replace the de- fective ones with the divisions, or for particular services. One half should carry the same stores as before mentioned, with the addition of five caoutchouc bed-cases ready for inflation with air, * In the Indian army of the old Company, the commissariat department, con- ducted by selected officers trom the army at large, has always been the only organ of supply and tiansport ; and it has never been wanting, whether in peace or in war. THE PREVENTION OF DISEASE. 237 while the other six should carry such articles of material for a field hospital as may be immediately required. The inspector- general must take care that every cart should be provided with the best means of carrying Avater, whether by barrels or skins, &c., as the country will afford, the absence of water having frequently caused much suff'ering after a battle. (55.) Thirty-seven two-horse carts will require ninety horses. The non-commissioned officers and men on duty with the carts must walk whenever the carts are required for the use of the wounded ; and as servants for the medical staff" should be furnished from this corps, one hundred and fifty men Avill be required in all, although none, perhaps, need be fully efficient for service in the field. (56.) These carts, &c., should be under dii'cction of the inspector- general for their duties, and under the officer commanding the artillery for their discipline and payment. The great store of ma- terials for general hospitals should be carried on bullock-carts, at a sufficient distance in rear of the army. (57.) Each regiment should have two bullock-cars for the purposes of the sick only. They should be hired at Constantinople from such persons as can supply twelve for each division, with one superintendent, to be paid for at Constantinople at a fixed price, stipulated rations being granted to each driver and his two bullocks, the commissariat having the power to kill a lame or disabled animal, and to pay for it at a price fixed. The contractor must engage to supply all such casualties at fixed prices, his pay being stopped so long as any carts remain unserviceable. Such a system as this will prevent the irregular pressing found so prejudicial in the Peninsula. (58.) Return conveyances of every kind, belonging to the com- missariat of each brigade or division, should always carry sick to the rear, so as to leave the hospital conveyance as effective as pos- sible for field service. (59.) Every regimental surgeon should find a horse, mule, or camel out of his allowance, like captains of companies ; and two panniers should be furnished by the government for each beast, made with wicker-work, covered by hide Avith hair on, and having an additional covering or lining made of some waterproof material. A Portuguese field officer's tent should be carried above and be- tween the panniers, the Avhole being covered by a painted water- deck firmly girded by a rope. The animal thus loaded should never be seut to the rear with the baggage Avhen preparing for action, but should always march in front of the last section of the regiment, if not Avith the commanding officer at the head of the regiment. (60.) Each staff surgeon, and each surgeon unattached (absurdly called second class), should have an animal and pack- saddle fur- nished by the commissariat ; panniers, stores, and tent being fur- nished by the medical department^ and the man to take care of the 238 THE PREVENTION OF DISEASE. auimal being furnished by the hospital conveyance corps^ as ah'eady indicated. Sucli^ differently arranged and numljered, and with but a few verbal alterations^ is the " Sketch of Medical Arrangement'^ of Mr. Guthrie. Postscript. — I have thought it useful here to record the sub- stance of two intricate and laborious schemes of personal and material arrangement^ for forces of but very moderate strength^ then about to be employed in Turkey. The perusal will suggest many and varied reflections^ according to the characters^ oppor- tunities, and experiences of military medical officers ; but here I can refer only to one or two particulars. The confusion and col- lapse of all the departments in the field were, confessedly, amongst the more immediate and powerful of the causes of the loss of our army in the Crimea. " Shining civil qualities," appertaining ab- solutely to all official military command, according to Napoleon, were here wanting ; and thus everything went to destruction. To take one example out of the two medical schemes of arrange- ment, we find Mr. Guthrie suggesting that an animal shall be furnished to staff surgeons — the pack-saddle to be supplied by the commissariat, the panniers, stores, and tent to be supplied by the medical department, and the man in charge of the animal to be appointed by the hospital-conveyance department, not to mention the departments required to afford food and cover to man and beast. In India we have never jumbled our departments. The com- missariat there is the great organ of supply and transport. The duties are conducted by commissioned and carefully selected officers, selected under proti'acted competition and trial. There is not a greater or a more efficient department of an army in the world. That, after forty years of peace, and of military progress in other countries, the experiences of the campaigns of Wellington had taught us nothing practically useful, whether military or medical, was wofully proved in the Crimea. In India, the beast of burden ordered by Guthrie would have been furnished, with all its own requirements, and the tents by the commissariat; while the medical department would only be charged with the supply of the medical stores and panniers. With the utmost possible respect and veneration for the great surgical and military experiences and high manly qualities of Guthrie, with whose estimable general qualities I was personally well acquainted, it is most remarkable that in this formal and matured " Sketch of Medical Arrangement," so very little of the first and highest of medical arrangement — the prevention of disease — is to be found. The perusal of the entire document, formally transmitted by the author to the Secretary of State for War, the Commander-in- Chief, the Commander of the Field Force, the Director-General of the Medical Department, Generals Sir De Lacy Evans and Sir THE PREVENTION OF DISEASE. 239 George Brown, leaves tlie great blank above mentioned. It is left also in doubt Avhetber the perfections alleged to have been at- tained at the termination of the Peninsular war of six years, are really worthy of imitation. Sir De Lacy Evans states, in his evidence before the Sebastopol Committee, that " the medical department was quite as inadequate in the Peninsula as in the Crimea,'^ and sundry of the suggestions of Mr. Guthrie, above quoted, proved utter failures in the Russian war. 1-10. Transport of Sick and Wounded in India. — Whether in the field or in cantonment, access and free immediate coraraunica- tion should be established between the regimental and the staff medical officers, who, being responsible to authority for everything, ought to be invested with independent powers to order and to act for the good of the service, Avhether in the distribution of medical and surgical stores, means of carriage, dooly-bearers, tents, cattle, &c. 141. During active warfare, or on a long march through a country thinly inhabited, extra cattle and carriage means should be furnished, and there should always be an arrangement for tlie conveyance of sick officers, who sliould not, as now, have to depend on such as properly belong to their men. 143. In Bengal, one dooly, or litter, is allowed for every hundred soldiers, and for every ten men in a European regiment. It forms a comfortable bed, and can be taken to pieces so as to admit of dressing the wounded without the removal of the patient, while it affords protection from weather. 143. The comforts of tlie Indian dooly are so great, not only in sickness but in wounds, that Staff- Surgeon Williamson, in charge of the Museum at Fort Pitt, Chatham, refers to "the large number of cases of gunshot compound fracture of the femur, where patients have recovered with good useful limbs, as compared with the num- ber of thigh-stump cases, and the total by all wounds." 144. " This very satisfactory feature in the classified return of invalided wounded in the Indian mutiny, appears to me not un- common for Indian wars, but certainly very much so for European wars, as far as records enable me to make the comparison. The difference in favour of the results by Indian wars, I believe to be mainly due to the facilities afforded by the dooly for the successful treatment of this the severest of all forms of compound fracture. Eleven cases recovered, with good useful limbs, out of the total wounded men landed from India — viz., 743, or 1*9 per cent. This is a large proportion compared with the results of the Crimean war — viz., 8 out of 2296, or 0-34 per cent." 145. A field-hospital conveyance has been invented by Sir John Login, an able and experienced surgeon of the Bengal army, of which Sir Charles Napier spoke A^ery highly. The principle of this litter, or Uessie/e, is — " to provide such a conveyance for sick and wounded as may render the soldier^s removal from it unnecessary until 240 THE PREVENTION OE DISEASE. he can he completely lodged in a depot hospital. By forming the bearing-poles into shafts to be attached to a light frame on wheels, a single man with leather shoulder-straps can easily run with it at ' the double' on ordinary ground, even while two sick and wounded men are in the litter ; the weight of a pair of empty litters, with cover complete, being less than one cot/^ 146. While surgeons of regiments regulate the disposal and movements of doolies, they must likewise afford the most true and real protection to the hardworking, deserving dooly-bearers, who are otherwise likely to receive rough and injurious treatment on the line of march. Such unworthy treatment ought never to be allowed to pass without the most severe punishment of the offender, for it tends to produce desertion. 147. The regimental surgeon, too, while he looks to the order and care of his sick-carriage, and to the just and considerate treat- ment of the bearers and cattle, must be watchful of the safe con- veyaiice of the hospital stores and baggage of the sick of his corps, along the line of march. The reverse flank will be found a good position for the tents, hospital stores, and sick-carriage ; but, if this may not be, they should proceed in the rear of the reserve ammunition : marching thus in good order, without crowding or confusion, the halting-ground is arrived at without fatigue or damage. 148. Field Hospitals. — After the application of every means of prevention of disease suggested by reason and experience, the soldier who is wounded or falls sick has still to be cared for in the regimental hospital — there to receive the attention of his surgeon. On the field of battle the field hospital should be placed from four to six hundred yards in rear of the centre, and be distinguished by a flag. Field hospitals for all services, whether near or distant, should be complete in themselves, and have their establishments of officers, hospital attendants and servants, stores, tents, sick- carriage, &c., in readiness, so as to be independent of any occasion to draw upon the regimental establishments. 149. The field and regimental hospitals in India ought always to have a certain number of Peons attached to them, as a native medical police for the services of the camp, Avhere their excellent services will amply repay the costs. A mounted guard should as invariably be allowed for the purposes of protection. 150. To every European regiment in India on active service, one surgeon and three assistant- surgeons will be found absolutely necessary to the proper conduct of duty, while the establishment of well-trained hospital servants should be complete, including even extra hands as security against want in this last essential. 151. Independently of general professional knowledge, the staff and regimental surgeons should be well acquainted with military regulations and organization, and with the aids which may be derived from them towards preserving the soldier's health. No THE PREVENTION OF DISEASE. 241 British commander has yet produced any work approaching to the gi'eat and classical treatise of Robert Jackson, on " The Formation, Discipline, and Economy of Armies." Since the days of Marl- borough it has been a subject of remark that he who is best ac- quainted Avith discipline, and with the character and habits of the soldier, has always the smallest sick-list and the lowest rate of mortality. I trust that the introduction of the following brief notes, not strictly within the title of this article, may be excused, on account of the interest and importance of the subjects,, in a military medical sense : — 15-2. Fltrlougii, Ina^aliuing, and Pay. — Liberal in the extreme as has been the old government of India, in all its general arrange- ments for men and officers, its furlough and invaliding regulations, as aflecting the European soldier in the Company's employment, were until recently peculiarly harsh and ungenerous. AY hen we " have in conquest stretched our arms so far," and felt so nobly secure in our soldiers, we ought sooner to have perceived that to be generous is to be just and wise. The bulk of the nation will not fight in person, and all our ministers of all parties shrink from the ballot. 153. Good service pay, and pension, with permission to come home for the recovery of lost health, must be generally conceded to the European soldier of the army in India ; and even ordinary furlough must be granted to non-commissioned officers, and to selected soldiers also. It wiU not do to adhere any longer to traditional systems. 15-1. India, it must not for a moment be forgotten, is a country in which the military service is, according to Wellington, " of a severity unexampled in any army that is or that ever Avas in the world." 155. '' Every means should be taken," says Napoleon, " to attach the soldier to his colours. This is best accomplished by showing consideration and respect to the old soldier. His pay likewise should increase Avith the length of serAdce. It is the height of injustice to give a veteran no greater advantage than a recruit." If this be true of the French soldier of the first empire, what shall we say of the claims of the British soldier in India, under the conditions described by Wellington ? 156. To the British of the old Company's European regiments there was no good-conduct pension — no sick furlough to England with right to return, excepting under the rare circumstance of re covery during the voyage home. llegulations such as these, so mistaken and illiberal, increased the mortality greatly — the poor fellows preferring the risks of death in India to the horrors of being throAvn to starve in the streets of provincial towns in their native country. 157. " I have no doubt whatever/' says Dr. Arnott of the Bom- K 242 THE PREVENTION OF DISEASE. bay army, whose reports are here so often referred to, '' but that the illiberality of the invaliding regulations greatly augments the mor- tality of the Company's army/' Setting aside the question of humanity, this officer justly considers that a large gain in ready- made soldiers might be made by the indulgence of sick furloughs, retaining the absent men on the musters while regaining their health in England. 158. Furlough to Europe should be granted to all such British soldiers as, during a certain number of years, have exhibited good conduct : the extension of so reasonable and just an indulgence would render service in India popular in the United Kingdom, and ensure the enlistment of the best class of recruits ; it would hold forth an object to the soldier, and he would thus become frugal, temperate, and healthy, comparatively : the canteen would be less irequented, drunkenness would be less frequent, disease would diminish greatly, and crime would become rare. 159. The soldiers of her Majesty's army serving in India enjoyed, through the improvements introduced by Lord Howickand Sir Henry Hardinge, many advantages which, until recently, were unknown to the European troops of the Company. These last, until within the last few years, enjoyed no increase of pension for good con- duct ; and when incapacitated by sickness, they were for ever dis- chai'ged and cast adrift. To this rule the only exception was in the instances of men who recovered on the homeward voyage. They were sent back to their colours in India ; Avliile their less fortunate comrades, who were longer in recovering their health, re- enlisted into their old regiments, to which they were niiich devoted. These national errors ought not to be overlooked or forgotten ; for they were common to the Home and Indian administrations alike. Here the English administration happened to take the lead. 160. To preserve to his armies their vigorous temperament, their warlike manners, and to destroy their remembrance of their native soil. Napoleon, though ruling an empire placed in a very temperate climate, always fixed the residence of a large portion of his armies in Northern Germany; while England, possessed of rich but pestilential tropical colonies, sent her soldiers there to perish miserably in vast numbers, the survivors, languishing for years in unwholesome stations and worse barracks, becoming en- feebled and enervated in body, and fearfully depressed in mind, and rendered thus unfit for the hardships of military service in Eui*ope. It may reasonably be inferred that the sagacity of the incompar- able statesman and commander would have suggested to the French Emperor, had he possessed tropical continents and islands, the necessity for recovering his soldiers, by frequent reliefs, into neigh- bouring cool and healthy mountain ranges, without waiting for suggestions to this effect from the superior medical officers of his armies. 161. Napoleon judged wisely in his disposal of the French THE PREVENTION OF DISEASE. 243 armies. Because the greatest of his Continental enemies were of northern climate and race^ he cantoned his Frenchmen in large proportions in the higher northern latitudes ; and for this distri- bution of his forces he assigned moral and pliysical reasons of un- questionable truth. But for the army of the British Empire, occupying her varied and extensive foreign possessions^ the policy of frequent removal and consequent change of climate^ ouglit to become a State necessity, and must constitute ere long a fixed principle of military arrangement, as regards the soldiers of the line — the foreign ser^^ce and principal offensive force of the empire. It is quite different with the militia and volunteer force — the home-service and principal defensive force of the United King- dom ; this must be comparatively stationary, ruled on a different principle, and by a different class of officers. 1G£. The first part of these brief and necessarily imperfect me- moranda having now been brought to a close, in so far as they relate to the personal medical wants of troops employed on the march, avc may here with advantage take a glance at the character and capabilities of the object of all this care — the British soldier; a subject in the treatment of which our naval and military surgeons have at all times and in all places been masters. I say " naval,'^ because seamen are but soldiers on the waters, and because human nature is in the main the same in all situations and under all cir- cumstances and conditions of military service. 163. Miss Nightingale, who, with the highest powers of discern- ment, was at much pains to observe and appreciate the character of the man, says — " I have never been able to join in the popular cry about the recklessness, sensuality, and helplessness of the soldier. I should say (and, perhaps, few have seen more of the manufacturing and agricultural classes of England than I have before I came out here), that I have never seen so teachable and helpful a class as the army generally. Give them opportunity promptly and secui'cly to send money home, and they will use it. Give them schools and teachers, and they will come to them. Give them books and games and amusements, and they will leave off drinking. Give them work, and they will do it. Give them suffer- ing, and they will bear it. I would rather have to do with the army than with any other class I have ever attempted to serve ; and when I compare them with I am struck with the soldier's superiority as a moral, and even as an intellectual being,'' Again, she says — " I speak from experience of two things, viz., that unmurmuring as the soldier is, a more forlorn being does not exist than he, separated from his comrades in a general hospital, nor one who feels more the thought and care of his country, if, in such a situation, he is provided for by her in an hospital with the comforts of home. And such will always be the case with the Anglo-Saxon." • 10 1. The Dukeof Wellington, who condemned alike our military r2 2-14 THE PEEVENTION OF DISEASE. system, borrowed from tlie Prussians, and tlie soldiers it produced, but wlio never improved the one or tiie other, or mitigated, until forced to do so by public opinion, " the barbarity of the English military code/^ declared that our soldiers " were detestable for everything but fighting, and that the officers were as culpable as the men We are an excellent army on parade, an ex- cellent one to fight, but we are worse than an enemy in a country ; and, take my word for it, that either a defeat or success would dissolve us." It was said, on the other hand, of Gustavus Adolplms, that ''the carriage of his army made him to be beloved of the enemy them- selves ;" but Wellington was not beloved by his own men even, who regarded him always with a cold respect only. " In war, as in literature," says Napoleon, " each man has his own style." Wel- lington's style of making war was generally good, but, regarding his men without any feeling of sympathy, we can readily perceive how he came to do so little for them. 165. The historian Napier, commenting on these sweeping con- demnations of our men by their Peninsular commander, says, most justly, — "There were thousands of true and noble soldiers and zealous worthy officers who served their country honestly, and merited no reproaches. It is enough," he adds, " that they have since been neglected" (Wellington being then all-powerful) " ex- actly in proportion to their want of that corrupt aristocratic influence which produced the evils complained of." 160. It is unnecessary now-a-days to criticise these several judgments, the general voice of the country having determined both what is just and generous and what is absolutely true. " The Duke" did not know, he did not care to know, the real sentiments and character of the soldier. Being removed above him, he had no sympathy with him or with the class whence he sprung ; and he knew nothing of him but as a great instrument for battle. It was very different with Cromwell and Napoleon, and, I rather think, with Marlborough. From the narrow and unjust point of view v.'hence AVelliugtou regarded his men, it resulted that he knew neither how to improve or to reward them. 107. In the astounding declarations of the Duke of Wellington against granting a war medal to the Peninsular soldiers, that they had already received so many votes of thanks from Parliament, we discover the most astonishing absence of knowledge, not to speak of want of sympathy with the feelings and longings of both officers and men ; and all this while we find that the mere representations of his own medals and decorations are sufficient to fill a goodly volume ! Could the soldiers who had fought so nobly under him for six years feel, wear on their persons, or hand to their wives or children so many parliamentary votes ? Did " the Duke" rest satisfied in his own person with republican rewards? No; — he THE PREVENTION OF DISEASE. 245 claimed and lie obtained the most ostentatious and tlie most sub- stantive rewards, and he used both to his own purposes. IGS. The character of the commander, as stated over and over again in course of this work, is matter of primary consideration and importance, as relating to the physical and moral welfare of the soldier ; it is therefore a question everywhere proper to the medical topographer ; and on this score alone, as one of absolute duty, is the subject here noticed. It is, indeed, on all accounts more grateful task to recal atten- tion to the conduct of the great naval and militarj^ surgeons of the Revolutionary War — of oflicers who not only deeply knew their men, and warmly sympathized with them, but who went forth to advocate great moral and pln'sical reforms with the true portrait of the British seaman and soldier in their hands. It was on the ground of superior knowledge and experience of the hardest and severest kind — of a knowledge far in advance of that of all persons of their time — that Robert Jackson, Trotter, Blane, McGrigor, William Fergusson, Hennen, and Henry ^Marshall became naval and military reformers when reform w^as feared, and therefore unknown to and unheard of by our naval and military commanders. That the reward of Jackson, the most able, the most bold, and the most persevering friend of the soldier, should have been an unremitting, unsparing official persecution, throughout a long life, is nothing more than might have been expected from the times in which he lived. For any man, wearing the British uniform, to "wi'ite and act as Jackson did from 1791 to 1805, was to incur the constant risk of being degraded and ruined in his prospects ; and nothing but a moral courage quite equal to that rare physical courage which he had so often displayed in battle, could have sus- tained him in his conflicts against the most powerful and corrupt influences. At the head of Jackson's enemies was always to be found " the successful apothecary of Weymouth" — the approved of George III., Sir Lucas Pepys — who Avould have treated the great army physician as ]Muir and Palmer had been treated, if any law could have been perverted and corrupted to his purpose. 1G9. " The boldness and enterprise of medical officers," says Sydney Smith, " is quite as striking as the courage displayed in battle, and evinces how much the power of encountering danger depends upon habit." If by " habit " is here meant a peculiar education and training — a familiarity from early life with every kind of danger — a knowledge everywhere acquired and matured under the hardest and most severe circumstances occurring in civil life, and of the experiences of military service the most trying -—then the term " habit " has a real application to our course of life. Our naval and military surgeons Avere of the true caste. Tliey possessed, besides their native courage, that moral courage 246 THE PREVENTION OF DISEASE. Avhicli is engendered by liability to varied responsibility, and by constant exposure to all kinds of dangers by sea and land. 170. Towards the close of the last, but principally in the beginning of the present century, certain of the army-surgeons, and Robert Jackson, the foremost of them, denounced the British military code as foreign, un-English, barbarous, and cruel, while the discipline, they said, cramped and crippled the man, soul and body. Jackson, with an invincible courage, moral rectitude, and power of knowledge peculiar to himself, urged that, instead of the rule of the lash, the soldier should be treated as a reasoning being — that he should be free to do for himself whatever he could do without injury to his health, morals, or discipline. But the commanders of his day heeded him not ; so the government of the lash — of the lash in one hand and the rum-ration in the other, as Henry Marshall describes it — went on to the complete satis- faction of the generals for another half century. At length, the public press, backed by the " common sense of the country,^' decided the matter; in exact accordance, of course, with the humane demands of our army and navy surgeons. SANITARY PRECAUTIONS NECESSARY IN CAMPS, BARRACKS, AND HOSPITALS. 1. Camps."^ — The greater part of the diseases of camps, and the mortality resulting from them, are due in all countries mainly to zymotic affections, as fevers, dysentery, diarrhoea, and cholera. Soldiers just arrived in a new country are peculiarly liable to sufl'er from zymotic diseases ; and no given amount of reinforce- ments will compensate for the loss of the same number of the original force ; and hence the necessity for effective sanitary pre- cautions, and the discovery of immediate and efiective means for treating the earlier stages of disease. 2. But, besides the morbid peculiarities connected with general climate, and the powerful influences of locality ; making allowance also for the influences of the nature of the duties, the diet; and clothing, the prevalence of zymotic diseases will obviously be con- nected with the results of military discipline and hard military service, as well as with such local favouring causes as are con- tinually observed in civil life, as — The prevalence of damp. Impure air. Impure water. 3. Attacks of zymotic disease will be found to occur in con- nexion with the three following sources of dampness : — a wet soil — a retentive surface- soil — a confined locality ; and of these three * "The Report of the Crimean Sanitary Commission" is here followed, with certain alterations and transpositionsc THE PREVENTION OF DISEASE. 247 conditions, a wet subsoil will, as in the Criniea_, occasion the largest amount of sickness. I. One of the worst sites for a camp is that in which a thin but porous material rests upon an impervious bed, retentive of the Avatcr, and which keeps the subsoil charged witli it, while the sur- face may afford little or no indication of the fact. The evils of such a site have often been experienced by British armies ; and Holland, Walcheren, Portugal, Spain, and the Crimea are familiar examples. 5. Unhealthy sites of this kind are frequently marked by a greener and more vigorous vegetation than that of the sur- rounding district, or by water-springs coming to the surface, or by evening fogs settling over them sooner than over the country around. 6. Before fixing upon the position for a camp upon unknown ground, it will be found ad\asable to dig trial-holes a few feet deep, to ascertain the condition of the subsoil drainage, so as not to risk the health of troops b}^ encamping them on ground in which the trial- holes show the presence of water near the surface. 7. Where reasons of militaiy necessity require the occupation of a position having a wet subsoil, the whole should as speedily as possible be thoroughly drained by deep trenches ; and if there be a hill-side or water-shed above the ground, the surface-water from it should be tiirned aside from the site of encampment by deep catch-water drains, as in the Crimea. 8. If the position be such that deep trenching and draining cannot be executed, it is more than probable that such ground, if held long, will seriously affect the health of the troops. 9. Wet clays, from the retentive character of their surface- soils, keep the air near the ground damp and cold, so as injuriously to affect the atmosphere of tents and huts. Such localities proved very injurious in tlie Crimea. Where such positions are occupied of necessity, there should, besides the general drains, be hut and tent trenches. 10. Dampness of the air, arising from the confined nature of the locality, as from valleys, and especially from such as contain lakes, pi'oceeds from certain local peculiarities readily appreciated by the medical topographer. The resulting dampness, stagnation, and impurity constitute powerful causes of disease. II. It was observed in the Crimea that in certain hollows and valleys occupied by the troops, white damp mists settled down, and were followed by epidemic diseases, especially by cholera. Surface-water, stagnant lakes, trees, and brushwood, favour the formation and retention of such injurious collections of vapour ; and troops in occupation of such positions have often no escape from the consequent sickness, except by their abandonment. 12. The evils resulting from these local causes are not unfre- quently aggravated by the careless manner of erecting huts and 248 THE PREVENTION OF DISEASE. pitching tentSj the sites and the ground around being left undrained and uncleared. 13. Deep trenching round the tent-site is the best remedy, and, in the case of huts, the site should be isolated from the surround- ing ground, and the area to be occupied by the hut, drained by a trench dug around it of at least a foot below the level of the floor. 14. If it be not practicable to drain the subsoil, and if the position must be held, adequate provision should be made with every material at hand for raising the beds of the men above the ground. 15. Huts should never be banked up with earth against the wood ; Crimean experience having shown the danger of the prac- tice as causiug fevers. An interior lining, even of paper, affords a far better protection, being sufficient against draughts. 16. The flooring of the tents should be occasionally raised, the surface of the ground being cleaned, and strewed with quicklime and charcoal. 17. Various sources of atmospheric impurity are apt to accumu- late unless carefully guarded against; and of these tlie most frequent are : — manure-heaps and picketing-grounds, cattle-depots and slaughtering-places ; latrines having too large a surface, and that are kept too long open ; graveyards. When an army can shift its ground at w ill, dangers from such causes may always be avoided by doing so. 18. Filth of every kind is readily washed into the ground by the rains, and trodden into it by the steps of men and animals. To avoid such injurious consequences, the most scrupulous cleanliness is necessary all over and about the camp, all refuse matter being at once swept away and removed to a distance ; refuse blood and bones should be buried. 19. Manure-heaps and stable-litter should always be opened, to admit of being dried by the air to expedite their combustion — a process which should never be neglected. 20. All offal and carcases of animals should be buried at least three feet below the surface. If charcoal or quicklime be not pro- curable, the burned stable-litter should be thrown over the tainted ground. 21. The latrines should be made deep and narrow, earth being daily thrown into them, until they become filled up within two feet of the surface. They should then be closed over with earth, and others dug, and treated in the same manner. 22. When an army is to occupy the same ground for many months, it becomes unsafe to bury refuse matters, as thus the ground would become saturated with organic substances dangerous to health. In such case the construction of furnaces is a necessity towards the destruction and rapid removal of all organic products. 23. With a view to obviate overcrowding, and promote the THE PREVENTION OF DISEASE. 249 necessary ventilation of tents, tlie number of men sleeping in them ought to be dimiuislied as mueli as may be practicable ; but, con- sidering the limited means at the disposal of commanders in the field, the evils of overcrowding may be greatly obviated by a free general ventilation, such as that of Mr. Mackinuell, and by the introduction, under all circumstances of service, of a free means of escape of consumed air around the top of the tent-poles. In the case of huts wanting ISIackinneirs appliance, ridge-ventilation will prove tolerably efficient. 24. The usual practice of striking tents and shifting the ground, will prove an excellent means of avoiding the effects of saturation of the earth by refuse matters, and the emanations resulting from occupancy. 25. Lime-washing of huts inside, especially of hospital huts, purifies the air, and should never be neglected. The same process applied outside the huts cools them, and protects them in some degree from the intense sun^s rays. 26. All engineering works for the water-supply of camps shordd comprehend : — a. The selection of the purest obtainable source. I. The water on delivery to be as pure as at its source. c. When the pound is necessary, the tank should be covered. d. When practicable, water should never be drawn by dipping, as it is thus liable to become muddy. e. Where a water source of sufficient purity cannot be obtained, the water should be filtered ; and a good filter may be made with sorted gravel, clean sand, and charcoal. ,/. All troughs for the water-supply of horses should have sepa- rate inlets and overflows. 27. Barracks and Hospitals. — On taking military possession of a town, if troops are to be stationed there for any length of time — but, above all, if it is to be made the base of operations — a power- ful sanitary police should at once be established, the duties to be clearly defiued and vigilantly exercised, in the following order : — ■ a. To make a thorough sanitary examination of the whole town and neighbourhood, and to report thereon. h. To organize immediate measures for a thorough cleansing and removal of nuisances ; all offensive matters should be removed to a safe distance from the outskirts of the town, or burnt if inflam- mable, or buried. c. To provide for the daily cleansing of all streets, lanes, courts, alleys, and open spaces, as well as of back-yards, stables, cattle- sheds, &c., and for the safe disposal of refuse matters. d. In situations where the surface of the streets or roads is so defective as to retain and accumulate foul waters, and to interfere with surface cleansings, the defects should be repaired, and proper channels formed for carrying off such refuse liquids. e. In clearing out foul ditches, care should be taken not to 250 THE PREVENTION OF DISEASE. throw the mud over the surface^ and thus expose it to the action of the sun. The work is best done in the coolest period of the day, or under rain ; quicklime or charcoal being freely used under the operation. f. All buildings to be occupied by troops as barracks or hospitals should be treated as already mentioned, by a complete system of house drainage, ventilation, and cleanliness. g. All wells and sources of water should be carefully examined and guarded, to prevent pollution or waste, whether through de- sign or neglect. h. Wet and unwholesome grounds may be rendered less injurious by effective trenchings, and by covering them over with fresh earth ; but, besides such measures, additional precautions are re- quisite to prevent the evils resulting from the occupation itself. i. A sufficient number of latrines should be provided imme- diately, and regulations established for their management. j. Stable manure, offal, and carcases of animals should be daily removed, and buried or burned, Avhich latter is best. h. The dead should be buried far from the habitations of the living. /. Refuse charcoal-dust may be used with advantage for deodo- rizing latrines, and the filth which it may not be safe to remove. Quicklime prevents decomposition ; but sand and fresh earth arg very useful when used in large quantities. m. Deodorizing agents should never be used as substitutes for the removal of organic matters to a distance, or for their destruc- tion by fire. 28. That the impure air of barracks and hospitals, arising from defective ventilation and drainage, is sufficient to account for a large proportion of sickness, always existing under such defects, has been proved in all camps and cities. To obviate such occur- rences in buildings to be occupied as barracks or hospitals, it is requisite that the following circumstances be attended to : — a. The local position of the building must be carefully examined, to ascertain the sanitary topography of the site, with a view to the removal of every noxious element from within and from without. b. All buildings situated in low, confined, and malarious posi- tions, or where the ground cannot be easily drained, or where there is a damp, relaxing local atmosphere, having a depressing influence on health, should be carefully avoided. c. The sanitary condition in and around every building occupied by men and off-cers should be examined, with a view to the imme- diate removal of every nuisance. d. It is especially necessary to examine most carefully the state of the drainage and sewerage ; for, however spacious and suitable a building a barrack or hospital may appear, Avhen viewed exter- nally and superficially, it may nevertheless have germs of disease concealed beneath it to such an extent as to render it little better THE PREVENTION OF DISEASE. 251 til an a pest-house in certain states of weather and directions of Avind. e. Drains and sewers built of rough rubble stones, with a square section, or without proper attention to the fall, or too large for the volume of water to be carried away, are liable to accumulate foul deposits, and to generate poisonous gases. If, on examination, deposits be actiially found within sewers, it is quite certain that such sewers may at any time become dang-erous to the health of the occupants of the building, especially if they pass under or near an inhabited apartment, so that the air of the room become in- fected with the exhalations escaping through their sides. Deaths from fever and cholera occurred within the barrack-hospital at Scutari directly traceable to this cause. /'. Still more dangerous do sewers become when there is a direct communication between them and the interior of the buildings, by means of untrapped privies or sinks. In this way the air becomes tainted to a much greater degree, and may alone, or in combina- tion with other sanitary defects, give rise to disastrous conse- quences, g. To prevent such occurrences, it is always necessary, before putting men, whether well or sick, into buildings, to cleanse thoroughly the whole drainage, to provide a suitable apparatus, with water for flushing the sewers, to prevent accumulation in them, to trap the outfall of the sewer, to prevent the wind or tide, as the case may be, from driving foul air np inside the building, and to provide ventilating openings for sewers, in such positions that the offensive effluvia cannot reach the interior of the building. h. It may be necessary to destroy and relay sewers, giving them a better form and inclination. When made of stone or brick, the section should be as nearly oval as possible ; but whenever pipes of sufficient sectional area can be obtained, they form the safest and best drainage for buildings. /. The experiences of all the hospitals around Constantinople, during the war, go to show that it is not only possible, but highly advantageous for the salubrity of any military hospital, to substi- tute the pan-closets for any arrangement whatever of open privies, and that, with ordinary care on the part of the attendants, those closets act perfectly. j. Wherever practicable, water-closets should be under a separate roof, and in all cases they should have a ventilation distinct from and independent of that of the main bnilding. Box latrines, with flushing apparatus, may be used Avith advantage for barracks. They save water, but they require for their proper care a daily and strict attention. /-. The state of existing ventilation, as well as the capabilities for ventilation, of every building to be occupied as a barrack or hospital, should -be very carefully examined. /. It may be received as a principle that a building in which a 253 THE PREVENTION OF DISEASE. number of persons^ whether sick or well, are to be congregated for any length of time, should never depend for its ventilation solely on doors and windows. Doors and windows may be placed in wrong positions for ventilation ; they are liable to be opened and closed irregularly ; and they are generally closed during the night, when the air is pure and cool, and when the ventilation is more necessary for barracks and hospitals than in the daytime. m. Wherever there is want of freshness in the air of a barrack- room or hospital-ward, it may be concluded that there danger to health exists, and no means of ventilation ought to be accepted as siflficient which does not remove the evil. n. In carrying out an independent plan of ventilation for a barrack-room or hospital-ward, it is of primary necessity to afford a free and constant exit to the warm foul atmosphere, and this as near as possible to the ceiling of the apartment. Ventilating open- ings of sufficient size, whether through the walls into the external air, or by ventilating tubes through the ceilings and roof, are well adapted for the purpose. 0. The size of the openings must depend on the number of in- mates, and they should be somewhat larger for a barrack-room than for a sick-ward^ on account of the greater numbers inhabiting the former. /». But, while providing carefully for the removal of the con- sumed air, it is necessary to introduce means for the constant ad- mission of fresh air ; and this can be best effected by the removal of a sufficient number of panes of glass, or else by making openings through the walls near the level of the floors. q. In most cases it is necessary to moderate the current of air admitted, especially in the instance of sick wards^ by substituting for the glass removed, or opened on hinges, panes of perforated zinc, or of wire gauze, or by narrow, overlapping louvre-boards, which may be made of wood, or by nailing over the apertures pieces of open canvas, coarse gauze, or bunting. These means must be modified according to tlie season and weather ; but, in hot climates, the free perflation of the entire building, by opening both doors and windows, is most necessary. Such arrangement does not by any means obviate the necessity for other and permanent means, such as have already been mentioned. r. The cubic contents of any room or ward in which men are to be placed should be accurately ascertained beforehand ; and the number of inmates should not be apportioned solely on the basis of the cubic contents. Barrack-rooms and wards of hospitals may be very lofty, but if the beds be placed too near to each other, on the assumption that there is cubic space enough, the men may still suffer from all the evils of overcrowding. s. In large stone buildings to be occupied as barracks, or for hos- pital purposes, beds should never be placed nearer to each other than six feet, measured from centre to centre ; and the cubic space THE PREVENTION OF DISEASE. 253 allowed for cacli man sliould uever be less than a thousand cubic feet. t. The cubic space required for healthy men occupying stone buildings, depends on the climate and season, but above all on the presence or absence of an epidemic constitution of the air, indi- cated by a tendency to zyinotic diseases. A smaller amount of cubic space may be allowable in a colder than in a warmer climate, in a winter than in a summer season. It is unsafe, Avith a good constitution even, and in a temperate climate, to allow of less than five hundred cubic feet for an adult man in health ; and much more should be given in seasons of epidemics. In Turkey, as in all countries, cholera broke out in the barrack hospital when the allowance was between 250 and 350 cubic feet per man. V. "When the atmosphere is polluted with the foul emanations from sewers, or through defective ventilation, a small amount of cubic space is of course far more likely to dispose to disease than if these additional elements were not present. The only safe rule of practice, therefore, is, to attend strictly to cleanliness within and without the buildings, to coiTCct defects in sewerage and veu- tilatioii, and to spread the troops as much as the accommodation will allow. 29. It is far safer to encamp, or even to bivouac troops than to overcrowd them in barracks or hospitals ; for overcrowding and defective ventilation have at all times and in all countries been followed, in the British army, by disease and consequent danger to the efficiency of the forces, and the success of the military undertaking. 80. During seasons of epidemics especially, one or other of the above-mentioned evd conditions, or the two conjoined, will be certain to lead to immediate loss, and during ordinary seasons this loss is but protracted by being spread over a wider extent of time. 31. Should cholera break out under the ill conditions con- templated, the troops should at once be removed from the build- ings, and put under medical inspection, with a view to the imme- diate discovery and treatment of the precursory diarrhoea. The encampment of the troops on an elevated, dry, and healthy posi- tion, and spreading over a wide area, constitute the best secu- rities. 32. It is always hazardous to quarter troops in unwholesome localities, or in houses obviously overcrowded with inhabitants. Regiments, while on the march even, when quartered in filthy overcrowded towns or villages, especially during seasons of epi- demics, have, from the mere circumstance of this very temporary and intermitting exposure to overcrowding, become affected with fevers and cholera ; and have left these diseases in nearly every -toAvn and village through which they have passed. 33. The walls and ceilings of all apartments are liable to become 254 THE PREVENTION OF DISEASE. saturated witli organic matters, absorbed from emanations pro- ceeding from the bodies and breath of persons inhabiting them. This is one of the most ordinary and most overlooked of the con- sequences of filth, overcrowding, and defective ventilation, and it is a common predisposing cause of epidemic diseases. 84. It follows therefore that all buildings about to be occupied by troops, whether as barracks or hospitals, should have their walls and ceilings scraped and thoroughly cleansed, and then washed with several coats of fresh quicklime- wash to make them white throughout, and this last process should be frequently repeated. This simple proceeding has in numerous well-known instances been found to arrest and to avert the progress of zymotic diseases, Avhen nothing else aj)peared to be of use. The tools and the materials required are easily obtained, and every labouring man can be instructed to do the Avork effectually. 35. It is hardly necessary to specify that everything likely to give off injurious emanations, whether it be foul linen, the remains of food, or the excreta of tlie occupants, should be at once re- moved outside the apartments, whether of barracks or hospitals. 36. Ships, unless specially fitted up, and moored in healthy places, are not adapted for hospital purposes, and should not be used either for sick or convalescents, if suitable accommodation can be obtained on shore. 37. It may be mentioned, in respect of barracks and hospital huts, that an interior lining of boards, or building a rovigh rubble- stone wall outside, as done in many of the regimental hospitals in the Crimea, affords a good protection from the severity of weather and from external heat. 38. The result, lastly, of all experience goes to prove that the neglect of military hygiene, whether as regards the soldier^s person, or the sanitary condition of stations, camps, barracks^ and hospitals, has hitherto, in all climates and seasons, and in our various possessions, at home and abroad, been the cause of an enormous amount of sickness and mortality in our armies ; and the whole subject, as closely connected with the moral advance- ment and physical efficiency of the British forces, demands for the future a thoroughly practical development, commensurate with its importance to the general welfare. 39. " A man," says Lord Bacon, " owes a duty to his pro- fession." Had our commanders by sea and land held this simple truth in recollection, by assuring, as was their first duty, the wel- fare of their men, our statesmen and the legislature of the country would have been spared many unseemly and humiliating investi- gations. But want of knowledge in officers, and until recently, in the public at large, has been the parent of endless calamities. " Our army," says Lord Herbert, " is, perhaps, at present, the least professional of all our professions. The education for the THE PREVENTION OF DISEASE. 255 army, and tlie examination previous to admission^ lias been as yet but very superficially military/^ 10. The army, as a profession, having thus been behind all other professions, it resulted that the soldier was for ages made to inhabit pestilential stations, eantonments, camps, barracks, and hospitals ; that he was made to observe a most injurious sameness in diet, while the quality of his food was often deficient in nutri- ment; that he was ordered to w"ear clothing which in one country was insufficient, and in another country burthensome and injurious; that he w^as exposed to night duties under very unfavourable circumstances, as to climate, season, and protection; that his employments were insufficient, and that such as he had Avere monotonous and wearisome; that he was subjected to a foreign, barbarous, and cruel military code ; and that, owing to all these unhappy and unnatural circumstances, he became the reckless, in- temperate, and unmanageable man whom the Duke of Wellington described to us. 41. Peace is the time for perfecting the military system, and tlie military institutions of the country. Little indeed can be done in this way during the hurry of war ; for how can a man think in a mill ? The great and progressive prosjjerity of England has been but slow in reaching the soldier, whose fate has been the sport of commanders, and, until quite recently, of departments, negligent and ignorant of his requirements, and regardless of his value and deserts. Time, which, according to Shakspeare, gallops with some men, has moved sluggishly for the soldier's advance- ment; but, if we would guard against arousing the most dan- gerous spirit, we should lose no more of it. We would seem, in our military policy, for ages to have trusted very much to chance, and to the native " pluck " of our soldiers ; but such chance- medley will no longer answer our purpose. " We must confess," says Kapoleon, '' that fate, which sports with man, makes merry work with the affairs of this world.'' NOTE ON THE VENTILATION OF BARRACKS AND HOSPITALS. The following, amongst other memoranda, w^as, with some slight corrections, presented by the author, as member of the Eoyal Commission of 1857, appointed to inquire into "The Regu- lations affecting the Sanitary Condition of the Army ;" — " The suggestions respecting ventilation draw important but confounded distinctions, and which, I feel assured, have not presented them- selves to the minds of those who have advocated before this Com- mission certain favourite plans. A practically approved ventila- tion is the real question to be compared and determined. It is not the mere size of the barrack-room or hospital-ward which determines the excellence or the evil^ but its good or bad con- 256 THE PREVENTION OF DISEASE. struction in promoting or impeding a just plan of ventilation. A large ward, constructed like those which so long existed at Fort Pitt, Chatham, for instance, will be impure and unhealthy, while a large ward, with suitable appliances for natural ventilation, will be both pure and wholesome. There can, in short, be no just comparison between a separate and detached room, having separate and independent ventilation, with no thorough draught, exposed to, and with openings into, the external air, and other rooms forming portions of an extended mass of building having one common continuous roof. In commending without discriminating small huts, or hospital- huts, again, it is forgotten how great the number of doors and windows these last contain comparatively to their space, and that they are separate and detached, each having a separate and detached roof; but it is these united circumstances, and not the circumstance of their being small, which constitute the real advantages of small huts and hospitals. But, in a sanitary point of view, it is not possible to obtain a gradual and equable natural ventilation, or an equable temperature in a small room or hut. It must have the thorough draught which, though it kills a few, is better for the health of the many than the defective ventilation of ill-constructed large apartments, which injures all. Again, the defective ventilation of large rooms and wards is altogether of our own creation. It need not be. With the due proportion and dimension of doors and windows for summer ventilation, and with the ordinary ventilating apertures for use in cold months, a large room or ward w^ll be as pure, while it will be more healthful, because more equably warmed and ventilated than a small barrack-room or w^ard. No system of ventilation can prove, in reality and upon fair trial, successful, which does not work through an ascertained natural law or laws of aerial currents. Those who advocate the use of small rooms and wards do not appear to be aware either of their advantages or their disadvantages, because they are unacquainted with the causes of both. Nor do they comprehend the real advantages of large apartments over the smaller, both in adaptation for ventilation and for the regulation of temperature. 257 HABITS OF THE BRITISH SOLDIERY AND THEIR INFLUENCE ON HEALTH. The helpless, listless condition of organized bodies of men, as compared to the active, independent condition — the free agency, competitions, and private enterprise of civil communities, is a subject Avhich, with its moral and physical results, has not yet been appreciated either by ofl&cial bodies, or by the public, which pays for all the labour of naval and military organization. Well may the British grenadier exclaim with Antony, — " Ten thousand harms, more than the ills I know, My idleness doth hatch." In civil life, men are very much masters of their actions and of their habits of life ; while in the array and navy a man is neither master of his diet, exercise, clothing, fuel, hours of rest, nor of anything else, in short. The government that employs the seaman and soldier is the sole arbiter of their habits and customs, and of everything that relates to their condition. In all this the governing power incurs an obvious responsibility ; and it would prove a mournful as Avell as unprofitable labour to trace, since the days of Charles the Second, how this res]3onsibility has been used for the soldier's and seaman's moral and physical welfare. There was doiditless much in tbe former habits of the officers which provoked the very neglects of duty in the British soldier which all military men must condemn ; but much may be done, under modern im- provements in the habits of the officers, towards raising the moral standard, and giving a hopeful occupation and excitement to their men. The barrack-life of the British soldier in India, imprisoned as he is by the sun — what a world of wretchedness and misery, moral and physical, does that term bring to the memories of all who have witnessed it in our tropical possessions ! Here we find men at the mean age of twenty-six, " at the healtldest period of life, and selected from the healthiest of the population," yet " fallen below the health level of their native country, where all the chances are in their favour ;" and this, in part at least, owing " to the reckless dissipation incident to all military bodies," as we have managed them. The soldier, according to a British war minister, was to be found, a few years in-evious to 1856, either in the parade-ground or in the canteen. He would nowhere else be received. The sad sameness of the barrack-life and the dull routine of duties, in India and in all our colonies, have led, by a physiological s 258 HABITS or THE BRITISH SOLDIERY, law of necessity, to irregularities in the habits of life and in the conduct of the soldier. If not looked to in time, this want of attention to the healthy mental life of the men must end in some very serious events. In the barrack the British soldier has found until very recently no home — no employment for mind or body — no amusement — no varied society. Here he is still very much cut oflFfrom all industry and enjoyment — he has no solace when ill. Mr. Wilson, in his excellent work on malaria, says that when young soldiers thus circumstanced are exposed to the causes of epidemics, or to the intense malaria, it is no wonder they should " die off like fiies.'^ At home, and in many of our colonies, the soldier finds com- panionship in civil life ; but in India, if he would have his associates out of the barrack, he must fall into the snares of the vilest and worst class of natives, whose business is to plunder and minister to his worst vices. Much consideration is due to the soldier on this score. The barbarous restrictions on his marriage must ere long give way to a more just and humane system. This question, as regarded by Sir Charles Napier, " affects the health, morality, and strength of our army in various ways, such as desertion, population, and other points." The late Inspector- General of Hospitals, William Pergusson, says : — " I never saw a barrack that was not too crowded, or in other words, where, if the men had been lodged in separate cottages, or even in hovels, they would not have been healthier. '' Of the soldiers' life within these barracks there is much to be said, and much to be amended. To take his guards, to cleanse his arms, and attend parade seems to comprehend the sum total of his existence ; amusement, instruction, beyond the drill, military labour, and extension of exercises, would appear, until very re- cently, to be unthought of ; as it is impossible that the above duties can fully occupy his time, the irksomeness of idleness, that most intolerable of all miseries, must soon overtake him, and he will be driven to the canteen or the gin-shop for relief. " Labour in every shape seems to have been strictly interdicted to the soldier, as water for his drink. All, or nearly all, must have been bred to some trade or other before they became soldiers^ but they are to work at them no longer. Labour, the labour of field works and fortifications, strengthens the limbs and hardens the constitution, but that is never thought of in our military life at home ; so thought not the ancient Romans, whose military high- ways still exist, and who never permitted their soldiers to grow enervated in idleness during peace. Better, surely, would it be that every one should Avork at his own craft, or be employed on the public works, in regidated wholesome labour, than thus to spend his time in sloth and drunkenness. " But his exercises, without even going beyond the barrack pre- mises^ may be made manifold ; — running, wrestling, gymnastic AND THEIR INFLUENCE ON HEALTH. 259 games of every kind, swimmirig, leaping, pitching the bar, the sword exereise, that of the artillery, all that hardens the muscles and strengthens the limbs, should be encouraged ; and when the weather forbids out-door pastimes, the healthier exercise of single- stick, in giving balance and power to the body, quickness to the eye, and vigour to the arm, may properly be taken as a substitute for the drill, which, after the soldier has been perfected in his exercise, is always felt to be a punishment. So is the unmeaning evening parade, and perpetual roll-calling. " Surely, if the soldier present himself once every morning, cor- rectly equipped and in order, the most teasing martinet ought to be satisfied, and then no more shovild be required than to see that the men are all in their quarters on the beating of the tattoo. Surely the nse of the sword has been too much frowned doAvn, as if it had been a forbidden thing. In the night attack, the musket is worse than useless, its fire leading to every kind of confusion ; and at the breach it is little better, for it can only be presented against stone walls and ramparts that conceal the defenders j but it would cover the swordsman advancing to the breach, and a couple of chests of ship's cutlasses furnished to every regiment as regi- mental baggage — a single horse-load — provided the men had been taught to use them, would generally supply all that could be wanted for the exigency of the service. " Let any one reflect on the fearful expenditure of life at the breaches at Badajos and St. Sebastian, and say if some means should not, if possible, be devised to render it less costly hereafter. One is almost tempted to regret the times ' when,' according to the old song, ' our leaders marched with fuzees, and we with hand- grenades :' and could the good grenadier have carried a sword by liis side, to use after he had tossed the ball, he would, I believe, have done much more execution than with a musket and bayonet : and why shoukl the artillery be to him a closed book, as if in the course of his service he was never destined to handle or to suffer from it ? A couple of guns, even if wooden ones, in every barrack- yard, Avith an old invalid bombardier to teach the use of the rammer, and the sponge, and the match, would fill up many a vacant dreary hour, and open his mind to a most useful professional lesson. " The lesson, moreover, would be as useful to the infantry officers as to the privates. He would then, should he ever prove the captor of a prize gun, at least know what it was, and be able to turn upon the enemy the engine that had just been used for the pm'pose of destroying himself. Every sailor, even on board a merchant ship, where there are no idlers, must become more or less an artilleryman, and why should not the too often idle soldier ? " Foot-racing, too, the art of running, so little practised, and so supremely useful, should be held amongst the qualities that con- stitute military oxcellence. It was so held at the Isthmian games of ancient Greece, and deserves a better place than has hitherto 200 HABITS or THE BRITISH SOLDIERY, been assigned to it in the military pastimes of modern Britain. In our school books we are told that the youth of ancient Persia were taught to launch the javelin, to ride the war-horse, and to speak the truth. Let the young British warrior be taught to use his limbs, to fire ball-cartridge, to cook his provisions, and to dr'mlc water. The tuition may be less classical, but it will stand him in far better stead during every service, whether at home or abroad. "Barracks, from time to time, should be evacuated for purifica- tion. The evils and dangers of accumulation will otherwise beset them, inducing disease; and to obviate this, it would be well, when- ever practicable, to march out their inhabitants, in the summer season, to the nearest heath or common — always, however, without tents — and there make them hut themselves. No military lesson could be more useful than this. Every man so hutted would be advanced in soldiering to the full instruction of the campaign. The change, breaking the monotony of barrack-life — the novelty, would animate ; he would be taught how to live in a camp, how to cook and to forage, to use the mattock, the shovel, and the axe. " Tents, when the soldier lies upon the cold ground, with a crowd of comrades enclosed within a superficially heated atmosphere, loaded with animal exhalations, can oidy be considered hot-beds for the generation of dysentery. On their return to barracks, they will find everything healthy and refreshed, and they will know that they have been made better soldiers. " Some have strenuously recommended barrack libraries ; and surely, when we think of the dismal monotony that hangs over the soldier in barrack-life, no one with good feelings could object to them. Still, I must confess that I never knew or heard of a reading army. The military exercises and pastimes would seem better adapted to the soldier's character ; and I acknowledge I would rather see him a cook than a student, for on that art his very existence may depend ; but if he feel disposed to read, let him have every advantage and opportunity that the rules of the service can admit. " Music would seem far better adapted than even books to fire the soldier's mind, for when played in national airs, it aAvakens a chord which has often electrified armies ; and amongst all nations, at some period or other of their history, it has been the accompa- niment and incentive to war. The highly civilized English soldier now fights, and can fight, without it ; but if taught to feel its powers, would he not fight better with it ? To the Irish and the Scotch soldier it still speaks the language of the heart, and the Highlander, when he hears the gathering of his clan blown from the mountain war- pipe, becomes elevated and transported beyond himself; he will then encounter anything in human shape, un- appalled by all the forms of death that the engines of Avar can inflict.-" This admirable military physician concludes : — "■ Begular AND THEIR INFLUENCE ON HEALTH. 261 bodily pleasurable exercise has been said to be wortli a host of physicians for preserving military health ; and occupation Avithout distress or fatigue is happiness. The philosopher can make no more of it ; and every idle hour is an hour of irksomeness^ and every idle man is, and must be, a vicious man, and to a certain extent an unhealthy one ; for the mind preys upon the body, and either deranges its functions in a direct manner, or drives the pos- sessor to seek resources incompatible with health/' Thus spoke William Fergusson, after an experience of actual war of twenty years, and thus had spoken before him Robert Jackson; but in everything relating to the soldiers' welfare, Jackson, Fergusson, Heuncn, Henry Marshall, and Ballingall will be found to have been half a century or more in advance of all opinion, and especially in advance of military authority. That the warnings of such men should for so long have been urdieeded is but another instance out of many of the utter disregard of the subject by the authorities of the state, both civil and military, who for ages regarded the soldier as but a red -coated pariah. In France it is well understood that " the degree of perfection of military medical science is the true measure of the importance attached to the preservation of the soldier.'' It was with a rare sagacity and penetration of the subject in all its bearings, belonging only to an officer of the highest order of talent, that Sir John Moore — " that model soldier of England" — the intimate personal friend of Robert Jackson — declared, in addressing Sir Ralph Abercromby, that " a Roman army Avould have gone through their military exercises in the West Indies and have been healthy." The same distinguished commander added : — " The troops, I observe, which have been most active, are the most liealthy ; a proof that the sun is not the cause of sickness. But in general the greater part of the sickness proceeds from Avant of interior discipline and economj^ in regiments. Great attention should be paid in this country to the cleanliness and even neatness of the soldier's person and the regularity of his diet, an addition to the eating part of his ration instead of rum ; sea or river bath- ing, constant activity, and movement. In short. General (excuse the pedantry of the expression), but with a Roman instead of a modern exercise and discipline, the troops in the West Indies might, I am convinced, be kept healthy. A parade twice a day, consisting merely of an inspection and exercise of arms, is easy for officers ; it leaves them what they call more time, but it leaves the soldier also to lounge the whole day in barracks, where the air cannot be good, and where, from indolence, his body becomes enervated and liable to disorder." How much that is preventive of disease do these short sentences enjoin, and how applicable is the entire reasoring to the condition of the European soldier in the East Indies as well as in the West. No wonder that, living in the miserable manner here described; condemned formerly to a re. 262 HABITS OF THE BRITISH SOLDIERY sidence of twenty years in tlie East Indies — moving from bad sta- tions to worse — hope should have shed but a feeble influence over the soldier's enjoyment or future prospect^ and that he should thus yield, as he still does, to the temptation of momentary gratification. The description of the soldier's life given by Colonel Lindsay of the Guards, while it relates to his condition in the middle of the nineteenth century, might quite as justly have been given of the men of George the Second's time : — " Perhaps no living individual suffers more than he from ennui. He has no employment save his drill and his duties. These are of a most monotonous and unin- teresting description ; so much so that you cannot increase their amount without wearying and disgusting him. All he has to do is under restraint : he is not like a working man or an artisan. A working man digs, and his mind is his own ; an artisan is in- terested in the work on which he is engaged ; but a soldier has to give you all his attention, and he has nothing to show for the work done. He gets up at six. There is no drill before breakfast ; he makes up his bed and cleans his things ; he gets his breakfast at seven. He turns out for drill at half-past seven or eight ; his drill may last an hour and a half. If it be a guard day there is no drill, except for defaulters. The men for duty are paraded at ten o'clock ; that finishes his day's drill altogether. There is evening parade, which takes half-an-hour ; and then his time is his own till tattoo, Avhich is at nine in winter and ten in summer. This is the day of a soldier not on guard, or not belonging to the company which is out for Minie practice." Dr. Julius Jeffreys, writing in 1858 of the condition of the British soldier in India, says : — " If any one would see a picture of the gnome Ennui reigning absolute, not even the descriptive power of the poet Spenser will so well supply it as the scenes within a barrack compound in India, surrounded or not by the hot and dull mud wall. There is life there truly, for there is respira- tion and perspiration enough ; but life a blank ! Eyes looking upon nothing — minds caring for little and hoping less — thoughts of home long suppressed." Robert Jackson states, that " Planters, who may be said to work hard, experience good health comparatively ; even soldiers are healthy when actively employed ; they sufler when they remain immured in barracks in ease and apathy." Again : — " The writer ventures to say, by fair induction from fact, that if the soldier in the West Indies, instead of being restricted from labour, were permitted to do for himself whatever he is capable of doing, his health would suffer less than it now does ; the mind would be occupied, there would be satisfaction, and fewer of those causes of temptation which in idleness lead him into error." Tlie most complete army of modern times — in health, discipline, and equipment, Avas that mustered by Napoleon in 1805, on the shores opposite to England, and Avhich a popular historian declares AND THEIR INFLUENCE ON HEALTH. 263 to have " acquired a degree of perfection, in point of discipline, organization, and military liabits, unprecedented since the days of the Roman Legions/' This great army amounted to one hundred and fourteen thousand combatants ; and it is highly deserving of remark, that its ex- emption from disease was ascribed by its incomparable leader to habitual light and cheerful occupation of mind and body, short of fatigue. " Constant employment," says one of his Generals, " Avas the true secret both of their good health and docile habits ; neither officers nor soldiers were ever allowed to remain any time idle ; when not employed in military evolutions, they were constantly engaged either in raising or strengthening field-works, or in level- ling down eminences, draining marshes, or filling up hollows, to form agreeable esplanades in front of their habitations, and where their exercises were performed." The same army, according to Tardieu, marched from the sea- coast without halt to the field of Austerlitz, over nearly 400 French leagues, leaving hardly any sick behind ; but then it was an army of matured and seasoned soldiers, the youngest man in it being twenty-two years of age. We have seen Iioav the French soldier is made healthy and happy, and no one who knows him can doubt that the British soldier is quite as capable of both attributes as his gallant neighbour. Activity is the moral and physical type of the French soldier ; he is taught that while a certain amount of rest is good, too much of it produces weakness and disease ; that exercise is its contrast, its antidote. "What '' the interior discipline and economy" of jNIarlborough — England's greatest commander — may have been, I have no means of knowing ; but there must have been something notable in that order which, according to one who served under him, made his camp resemble " a well-governed city. Cursing and swearing were seldom heard among the officers ; a sot and a drunkard were the object of scorn ; and the poor soldiers, many of them the refuse and dregs of the nation, became, at the close of one or two cam- paigns, tractable, civil, sensible, and clean, and had an air and spirit above the vulgar." Such results were worthy " the head of European captains," as Napoleon termed him ; but how melancholy to look on the reverse of this picture, and to reflect that, in the middle of the nineteenth century, so much should remain to be done to render the British soldier healthy and happy. On the abuse of ardent spirits in our various colonies it were almost in vain to speak. Before that terrible vice can be overcome, some- thing far more powerful than medical reasoning on facts, or the warnings of experience founded on them, must be brought into active operation. Discipline must still further alter its direction ; — in place of being" active only to punish Avrong, it ought and must be exerted further and further in the encoui'agement to good conduct. 264 HABITS OF THE BRITISH SOLDIERY, Henry Marshall, speaking of the British soldier in the East Indies in his day, says : — " By the daily custom of imbibing spirituous potations, a new want is created, intemperance is estab- lished as a habit, and frequent intoxication is the consequence. The wretched drunkard must now have a large supply of liquor in the morning to recover him from the effects of the quantity drunk on the previous night. He perhaps has neither money nor credit, and his clothes are then sold at a small portion of their value. Some do not stop here; for, after having sold all their clothes^ they will rob their comrades^ and with the proceeds of their dis- honesty, provide the means of intoxication. Confinement follows upon confinement, court-martial upon court-martial, and punish- ment upon punishment, until tlie worn-out wretch dies in hospital of the ' HORRORS,^ fever, or dysentery ; or if he should for a time resist the fatal effects of disease, his constitution becomes broken down by the combined influence of the poison of spirits, an ex- hausting climate, and repeated attacks of illness, so that in a few years lie is found unfit for further service in India, and he is sent home to be invalided. " Death is the last, but perhaps not the worst consequence of in- temperance. This description of the life of a British soldier in India is by no means highly-coloured. But the evil does not fall on the heads of the unfortunate sufferers ; military discipline in all its branches becomes deeply affected by habits of intemperance. To the generally prevailing vice of drinking are to l)e attributed almost every misdemeanor and crime committed by British soldiers in India. " The catalogue of these, unhappily, is not a scanty one, for, by rapid steps, first from petty, and then more serious neglects and inattentions, slovenliness at and absence from pai'ades, follow disobedience of orders, riots, and quarrels in barracks, absence from guards and other duties, affrays with the natives, theft, and selling of their own and their comrades^ necessaries, robberies, abusive language, and violence to non-commissioned officers, and last of all, desertion, mutiny, and murder may be traced to this source. This frightful picture is not exaggerated. I have seen thirty-two punished men in a regimental hospital at one time, perhaps not a single individual of that number suffered for a crime which was not a direct consequence of the immoderate use of spirits. " I recollect attending to the punishment of seven men of the same regiment, Avho received among them four thousand two hundred lashes. Tbey had been all tried for crimes arising from habits of intemperance. Since the institution of the PLCCorder's and Su- preme Court at Madras, no less than thirty-four British soldiers have forfeited their lives for murders, and most of them were com- mitted in their intoxicated moments.^' Such were the ferocious punishments which disgraced our armies AND THEIR IiNFLUENCE ON HEALTH. 265 in former days ; pimishmcnts to be matclied only in an American merchant sliip^ or among the barbarities of a Virginian plantation. That these are not altogether tales of bygone days is but too apparent. In General Orders of the Commander-in-Chief in India, addressed to the soldiers of Her Majesty's army, and dated 2nd August, 184-t, 25th May, 1817, and Uth August, 1S52, the frequency of " violence to their superiors" is noticed in the most cogent and emphatic terms. These outrages, so disgraceful to the character of the army, and so subversive of its subordination and discipline, are stated, in some instances, to have been prompted by " a desire to get transported to the penal colonies." His Excel- lency adds, " The acts of which many of these men have been con- victed rendered them liable to a sentence of death ; and the Com- mander-in-Chief, therefore, deems it necessary to call the attention of all concerned to the remarks contained in the General Order of the 2nd of August, 1844." That much has been done, at home and abroad, to improve the condition of the soldier, all must admit ; but to account for de- pravity and insubordination such as this, we must refer again to the bai'rack life, and to the long and dismal catalogue of moral and physical defects and neglects which still remain unredressed. As to the difference in the treatment of military offenders in India, it consists only, according to Dr. Jeffreys, in the less severe cor- poral punishment now inflicted^ and the greater frequency of trans- portation. On these and other points it is as sure as Holy Writ, that " our neglects will find us out," and that the evil consequences can only be staved off for a time. There must come a day of reckoning with the soldier, as Avith other creditors. How, it may be asked, can courts-martial and officers in com- mand altogether reject the excuse of intemperance, so long as a soldier has it in his power to command the means of depriving himself of his reason ? Beccaria is of opinion that the punishment of crime cannot be just, or, in other words, necessary, if the laws have not endeavoured to prevent that crime, by the best means which times and circumstances would allow. AVe used to instil the moral and physical poison with one hand, and hold out the lash with the other, as the antidote against indul- gence. Coercive measures have at all times been found very in- effectual for preventing the evils arising from intemperate habits, partly because the soldiers do not generally regard dnmkenness as an ignominious Adce. Where punishment has no influence in checking a man from repeating a breach of discipline, or in prevent- ing others from committing a like offence, it is worse than useless. These truths should be repeated by us until the odious, foreign, and unnatural punishment of the lash shall be abolished from our armies. On the uses "of libraries, my friend. Dr. Julius Jeffreys, ofiers some just and discriminating remarks. " Enlisted as a soldier, there 266 HABITS or THE BRITISH SOLDIERY, are^ during times of peace, l3otli an end of the labourer's toil and an improvement in his diet in India ; but a hereditary organiza- tion cannot be changed in a day. So given to muscular action had he been by nature^ that, at tlie end of a long day of toil, as a labourer in England, you might have seen him of an evening, hy loay of relaxation, lying at his length and reading a book ! No, but playing at bowls, skittles, or even cricket ! When you shut him up in a barrack in India, and give him books, treat him how- ever kindly you may, he chafes from inaction. He would be happy to have to make the paper of your books, to pi-int them, press them, bind them, pack them, carry them, and do anytli'mg but read them. Exceptions of course there are; men whose brains would not generate toil-energy alone, but were apter for intellectual. Some of these have sought the greater leisure of military life. Invite more of such minds by promising them full play, and your ranks will be greatly improved, and will supply you with mighty commanders, if you will love war." But to return to our more immediate subject. Where endemic fevers prevail, the temperate, it is true, are attacked as well as the intemperate ; but it is universally admitted by medical men, that the former have a much better prospect of recovery than the latter. Desgenettes, in his medical history of the French army in Egypt, observes that daily experience demon- strates that all the soldiers who indulge in intemperate habits, and that are attacked with fevers, die; nay, we may go still further and say, that they have been more liable to an attack of disease. Sir James McGrigor repeats the same observations even more emphatically. The obvious purport of Henry Marshall's able report is, to re- commend the withdrawal of ardent spirits from the canteen, and the abolition in the East Indies, and everywhere, of the indiscrimi- nate and uniform issue of spirit rations to the troops, with a view of abating the extent of crime, of lessening the proportion of sick, of reducing the rate of mortality, diminishing the numbers dis- charged on account of disabilities, and of promoting the welfare, efficiency, and discipline of corps. But there is another habit respecting which I shall venture to say a few words, because it is both a bad one, and a comparatively new one, — I mean the immoderate use of tobacco — a habit brought amongst us from the continent of Europe, on the cessation of the French revolutionary war. Young military men are apt to regard the habit as a manly one, until severe dyspepsia, giddiness, shat- tered nerves, sallow complexion, disturbed action of the heart, and other symptoms show themselves, and then it is frequently too late to stop. " The sallow complexions, black, broken and unsound teeth" of the Germans are matters of notoriety to all travellers. " You may," says one of them, " smell a German in any part of the room, or scent him at a quarter of a mile's distance in the open air, if the wind be favourable." AND THEIR INFLUENCE ON HEALTH. 267 Much is talked of the good effects of tohaeco-smoking in damp and malarious localities, by persons Avho, in defiance of geographical differences, carry the habit wherever they go — from the marshes of Burmah to the arid plains of Hindustan, forgetting that, mean- while, in the language of Cassio, " they put an enemy in their mouths to steal away their brains •" but I think there is good reason to question the benefits of this habit of smoking even in the fatherland of fog and damp, or that tobacco ever acts as a pre- ventive to any disease, and least of all to fever. The truth is, that many persons puff themselves into the good graces of snobs and spoonies like themselves, and use cigars by the score now, as Lord Cliesterfiehl drank and smoked in his time, notwithstanding his aversion to wine and tobacco — " because he thought such practices \ery genteel, and made him look like a man." How his lordship may have looked under the united influence of Avine and tobacco, his biographers have failed to relate ; but we all know how our modern " spoonies" and " snobs'^ in our thorough- fares look, after a course of cigar-smoking alone. Damp and cold climates may confer a greater tolerance of, or partial immunity from, the evil effects of the drug, but this is per- haps all that can justly be admitted. Dr. A. T. Thomson, speak- ing of the medicinal effects of tobacco, says : — '^ Its narcotic power, when it is employed in excess, weakens the digestive organs, obtunds the nervous sensibility, and depresses the whole vital energy." Of the empyreumatic oil of tobacco, which is produced in minute quantities in the ordinary process of smoking, the same author says that, when introduced into a wound, " it causes instant death." Of the other active principle, the nicotina, he states that it is a direct sedative ; and that, medicinally, under all circumstances, tobacco must be employed Avith the utmost caution. If such checks and cautions are necessarily put on the use of this powerful drug, in the hands of the physician, what need be added on the continuous and unlimited use of it by the reckless and ignorant soldier. Of hookah-smoking I need say nothing, as happily its day is nearly gone ; but I have seen many cases of severe constitutional and cardiac disturbance from its abuse, with perfect recovery of health on the discontini;ance of the habit ; the digestive functions, those of the heart and nerves, having been seriously affected in the most inveterate smokers. Of the miseries, mental and bodily, which I have witnessed in the persons of young officers, from the abuse of cigars, I will only say that they very far exceed those detailed in the " Confessions of an Opium-eater." INIany persons flatter themselves that by long use such habits become a harmless second nature — the truth being that they can never become a second nature, ./cr the)/ have nothing to do ivlth the Jirst, as has been said of graver matters. Lallemand has reported, on an extensive personal observation. 268 HABITS OF THE BRITISH SOLDIERY, that the use of tobacco deadens the generative functions. " I am convinced," he says, " that this must be much more frequent than is generally believed, if I may judge by the torpor into which the organs of generation fall, as soon as the narcotic action of the to- bacco is experienced, and by the habitual indifference evinced by confirmed smokers for the society of woiuen." Professor Lizars of Edinburgh, after enumerating the modes in which syphilitic ulcerations of the lips, mouth, and throat are pro- pagated by the short pipe and cigar, and how carcinomatous ulcer- ation of those parts is produced })y the same cause, states that the constitutional effects of tobacco are numerous and varied, and occasionally truly deplorable. Amongst these he enumerates dyspepsia, vitiated taste, a loose condition of the bowels, con- gestion of the brain, loss of memory, amaurosis, deafness, ner- vousness, palsy, emasculation, and cowardice, or want of moral courage. " The physiological operation of nicotine," says Van Praag, " is at first stimulant, and at last depressing, not only to the circula- tion and respiration, but also to the nervous system. Accele- rated circulation, increase of respiratory movements, and excessive irritation of the muscular system are the phenomena observed first ; the concluding symptoms are those of general depression, both of animal and organic life." There can be no question, I think, as to the injuries inflicted on health by the protracted or excessive use of tobacco in any of its forms. It may assuredly be classified amongst those substances which produce chronic poisoning. Mr. Solly, of St. Thomas's Hospital, regards smoking as the curse of the present age. " Amongst the various insidious causes of general paralysis, smoking is one. He knows of no single vice which does so much harm as smoking : it is a snare and a delu- sion ; it soothes the excited nervous system at the time, to render it more irritable and more feeble ultimately." That the habitual abuse of tobacco leads certainly to mental and physical degradation is becoming daily a fixed impression in both France and England. In the Ecole Polytechnique and other public schools of France it has been proved that the youths who smoke fall behind in their studies, and that their healths are injured. " A hundred pounds of tobacco-leaf," says Professor Johnstone, ''yields about seven pounds of nicotine. In smoking a hundred grains of tobacco, therefore — say a quarter of an ounce — there may be drawn into the mouth two grains or more of the most subtle of all poisons ; and this dose, frequently repeated, cannot fail to injure the strongest constitution." This authority adds that, besides this poison, many other hurtful agents and gases are carried into the mouth and lungs, in the act of smoking tobacco. Dr. Prout states that " tobacco disorders the assimilating func- AND THEIR INFLUENCE ON HEALTH. 269 tlons ill general, but more particularly, as I believe, the assimila- tion of the saccharine principle. I have never, indeed, been able to trace the development of oxalic acid to the use of tobacco ; but that some analogous and equally poisonous principle, probably of an arid nature, is generated in certain individuals by its abuse, is evident from their cachectic looks, and from the dark and often greenish-yellow tint of their blood. The severe and peculiar dyspeptic symptoms sometimes produced by inveterate snuff- taking are well known; and I have more than once seen such cases terminate fatal])' with malignant disease of the stomach and liver. Great smokers also, especially those who employ short pipes and cigars, are said to be liable to cancerous affections of the lips.'' Dr. J. P. Murphy states most truly that there is nothing more injurious to a flaccid heart than smoking, many cases being traceable to this cause alone. Were I to relate but a small portion of the results of my personal observation, as to the effects of the abuse of tobacco, I might be suspected of exaggeration, I therefore prefer to place before the reader the results of other men's observations. It must not be supposed from what is here stated that I would place the stout British soldier on a diet of vegetables, treacle, and tea : far from it ; I would take nothing from him which constitutes a liberal, nutritious, and wholesome diet ; not even a moderate spirit-ration to the seasoned soldier — especially when in work or in full exercise. Cooped up in barracks, however, the present plan of dieting in the East Indies is too uniform and unvarying, and much too highly stimulating; and the spirit-ration, whether in or out of the canteen, constitutes ''a pernicious bounty" to the men. The whole of the dieting of the army requires revision and regu- lation, so as to adapt it to the wants of the soldier under the various climates in which he is called upon to serve. " Exercises Avhich might inure the body to hardships," says Robert Jackson in 1791, "have not been sufficiently enforced; and such sorts of diet, and such modes of life as might obviate the danger of diseases, have been little attended to." William Fergusson justly observes, that a great physiological principle seems always to have been overlooked, and that is, the natural appetite for change and variety. " It is ever the same, and no man, even if he will, can be satisfied with this. His stomach and digestive organs will be heard in their own cause ; and if they be not attended to, their owner will fly to alcohol in solace of his disappointment. There is a mistake here ; for if we wish to wean the soldier from drunkenness, we should be careful to place within his reach more wholesome indulgencies, of which a diet suited to his taste (and it cannot be suited without variety) must ever be the first. Were he allowed to cater for his own mess (always, however, under due superintendence) , there can be little doubt of his better relish for his meal, besides learning 270 SELECTION OF LOCALITIES EOR EUROPEAN TROOPS that most useful of all lessons, the art of subsisting himself. In the case of the soldier, to cook is to live ; for if he cannot prepare his food, he will be poorly fed, even with flocks and herds at his command. In all this the soldier ought to have been trained and supported by the wisdom of the country. But has it been so ?"'^ These most excellent because practical suggestions, if they evince less learning than some chemical rules of diet which I have seen, nevertheless contain more knowledge. They are also highly important and interesting in another sense, as showing how far the author was in advance of what is called professional opinion. While naval and military men, scouting and scorning all opinion but their own unauthorized dicta, and asking the old worn-out ques- tion — " not being a naval or military man, what can he kiioAv of naval or military affairs ?" we have here a most eminent and ex- perienced army surgeon calling upon " the wisdom of the country" to " train and support" the soldier. The miseries and horrors of the Crimea, with their disastrous results, have at length roused the people to a sense of the national danger ; and the common sense of the country, guided by the common interests of self-preserva- tion — in other words, "■ the wisdom of the country" is brought to bear on naval and military organization — not, however, before it had become an urgent state necessity. Referring, in conclusion, to the more especial subject of this article, we Hnd that Dr. William Fergusson, whose " Notes and Recollections of Professional Life" were published in 1846, says : — " The exceeding vulgarity of the prejudice that ardent spirits impart strength and vigour to the human frame, is disgraceful to educated men ; yet true it is that many of our most experienced commanders of the army and navy still attempt to justify and con- tinue the practice." ON THE SELECTION AND IMPROVEMENT OF LOCALITIES FOR THE EUROPEAN TROOPS IN OUR INTERTROPICAL POSSESSIONS. It has been justly observed by an able military surgeon of old — a survivor of climate and English club-house generalship — that " where the hygiene of an army is judiciously regulated, the soldier may be kept in health and vigour; but allow an ignorant general to encamp on a marsh, let filth stagnate, fatigue exces- sively the men, crowd them in low damp rooms, and, despite of * Neglect in the use of fruits and vegetables has at all times proved a source of injury to the health of our soldiers in India ; and the subject of an ample supply of these requisites has not, even in our own day, received the attention from authority which, from its importance, it deserves. IN OUR INTERTROPICAL POSSESSIONS. 271 drugs, they will fall as uuripe and blasted fruit, not by the sword, but by the fever." Sufferings and sacrifices such as these have at all times been regarded by the army and navy surgeons with sympathy and sorrow : nor have thev ever been slow to offer cautions against their causes, nor to censure the criminal neglect of their cautions. Robert Jackson, writing in 179 J of the expeditions to, and occupa- tions of Carthagena, the Havannah, Martinique, Guadaloupe, St. Lucia, St. Juan, and even Jamaica, declares that much of the destruction of life arose " from the inexperience or ignorant inat- tention of those who conducted the expeditions. AVe have many instances of expeditions apparently well concerted which have failed from the excessive sickness of the troops ; and too many proofs of this sickness proceeding from a neglect of such precau- tions as might have contributed to the preservation of health." From the days of the occupation of Carthagena and the Havannah, to those of the occupation of Varna and the Crimea, the sacrifice has been consummated with all the cruelty of ignorance and mis- management. Truly has our great military historian, Napier, declared of the British soldier, that he " conquered under the cold shade of aristocracy : no honours awaited his daring, no despatch gave his name to the applauses of his countrymen; his life of danger was uncheered by hope, his death unnoticed." From the utter ignorance of our commanders of what is neces- sary for the preservation of the health of their men, they frequently propose to stay an e\\\ by increasing it. Our surgeons, on the contrary, have at all times been quite unmilitary in the efficiency and completeness of the sanitary measures they have proposed. Frederick of Prussia has stated that fever cost him as many men as seven battles ; so that, between the fever and the battles together, it must have fared badly with " the tyrant's counters" in his day. It were well if we could be assured that in our own time the external causes of fever have become less rife in our camps, and that our commanders by sea and land have become more vigi- lant and better informed as to the means of preventing them ; but I fear that neither can be affirmed with any confidence. As to commanders, we would appear to cling, as of old, to men ignorant of, and disinclined from learning the most simple rules affecting health : we hug our mismanagements. "NA hen shall we have done with the times when, according to Hughes's" History of England," " British troops were led to slaughter by generals scarcely fit to conduct a review ?" When shall we have done with commanders wanting in strategic power, in admi- nistrative capacity, and in knowledge of, and willingness to apply, the means of sa^dng their men. The experience of all our wars shows that the worst economy is not to be prepared, and that it costs more than doiible to make up for a bad beginning. The truth again is, that, under an inefficient commander, every kind of disaster is not only possible but very practicable. 272 SELECTION OE LOCALITIES FOR EUROPEAN TROOPS We have lost an army in every quarter of the globe^ and prece- dent has consoled us : it has always been so in our campaigns, and in our colonies. We have often appointed unproved men, and men of proved insufficiency ; and we have retained them in their places, Ijccause it has always been so with us. Our principle has been " that nothing bad should be mended." But a better order of things is at hand : in truth, matters could not continue much longer as they have been. To the neglect of healthy localities for camps, cantonments, and stations — to the absence of proper str\ictural arrangements in bar- racks and hospitals — to inattention to the sviitable feeding and clothing of the men — the neglect in promoting and cultivating better habits of life — the absence of instruction in cooking, hut- ting, exercising, and bathing — to the neglect of change of air and of climate in the remote stages of the diseases of seamen and soldiers ; — to these neglects, which it must at all times rest with governments and commanders to remedy, we must refer the con- stant and terrible losses of the British army in our intertropical possessions. I venture to say that, from the causes here briefly enumerated, we have in every score of years, during the last century and up- wards, lost unnecessarily, in our fleets and armies, more men than have fallen in our battles from the landing of Julius Csesar to the present time. Sir A. Tulloch has stated to me, as the result of his investiga- tions in the War-office, that amongst British officers and soldiers of the Queen^s and Company's armies, serving in the East Indies alone, there occurred, from 1815 to 1855 inclusive, exclusive of casualties, a total mortality of about one hundred thousand men, " the greater portion of whose lives might have been saved, had better localities been selected for military occupation in that country. '^ Estimating each soldier at the minimum value of 100/., we here arrive at a loss in money of 10,000,000/.* Nor are the causes of such destruction of life difficult of being discovered and prevented. Robert Jackson says that, " There are instances where the sick-list in armies amounts to one-third of the total force, and others, where it docs not exceed one-fiftieth, even one-hundredth part. The causes of such difference are sometimes visible and obvious. To discover their sources, and to prevent their operations, is important ; and it is frequently a work of no great difficulty." Samuel Johnson, in his " Political Tracts, 1771," referring to the contests of his time with France and Spain, states, that " The wars * It was my intention, in the present edition, to have quoted largely from the valuaLle and admirably prepared works of Dr. Norman Chevers, on "The Means of Preserving the Health of European Soldiers in India," and of Dr. Ewart, on "The Vital Statistics of the European and Native Annies of India ;" but I was reminded that I had already exceeded the limits prescribeil for my volume, and thus, much to my ret'ret, my purpose was fiustratcd. Both works do much honour to their authoi's, and to the medical corps of the Indian army. IN OUR INTERTROPICAL POSSESSIONS. 273 of civilized nations make very slow changes in tlie system of empire. The people perceive scarcely any alteration hut in an increase of deht ; and the few individuals who are benefited are not supposed to have the clearest right to their advantag-es, " The life of a British soldier,'' he adds, " is ill represented by heroic fiction. War has means of destruction more formidable than the cannon and the sword. Of the thousands and tens of thousands that perished in our late contests M'ith France and Spain, a very small part ever felt the stroke of an enemy ; the rest languished in tents and ships, amidst damps and putrefactions, pale, torpid, spiritless, and helpless ; gasping and groaning, unpitied among men, made obdurate by long continuance of helpless misery ; and were at last whelmed in pits or heaved into the oceap, without notice and without remembrance. " By incommodious encampments and unwholesome stations, where courage is useless and enterprise impracticable, fleets are silently dispeopled, and armies sluggishly melted away. Thus is a people gradually exhausted, for the most part with little eflect. In the last war llavanna was taken ; and at what expense is too well remembered. May my country be never cursed with such another conquest." The attack on Cartliagena is yet remembered, where " the Spaniards from their ramparts saw their invaders destroyed by the hostility of the elements, poisoned by the air and crippled by the dews ; where every hour swept away battalions, and in the three days that passed between the descent and re-embarkation half an army perished." Nor can these events be regarded as matters of a bygone history, for Waleheren, the Peninsula, Arakan, Rangoon, China, Sindh, A'arna, and Sebastopol have brought them back to our very doors; and they have occurred always from the same causes. The maxim that Avhat cannot be remedied ought to be forgotten, does not apply to the conduct of war. On the contrary, all our errors should be treasured in our memories, with a view to their avoid- ance for the future. The masses must learn wisdom from retro- spection ; they are of the very few who possess prospective wisdom. Although the past cannot be redeemed, the experiences of the past ought to suggest lessons and cautions for the future. The ancients held the prudent maxim never to pardon the second blunder in the conduct of war. Let us hope that England may eventually learn this necessary lesson. In the Crimea it should seem as if all the bunglers of the British army had been assem- bled, each in his respective line, to try what mismanagement could do — how far mismanagement could be carried — how far, in short, the forbearance of the country could be made to extend. " It is passing easy," says the Rrawuiei; ''to talk of putting the saddle on the right horse, but here the saddle is one and indivisible, and the horses to be saddled arc many." T ,274 SELECTION OF LOCALITIES FOR EUROPEAN TROOPS Sir Gilbert Blane^ speaking of the neglect of the seaman's health in his earlier experience, says : — " In former times they had not the attention paid to them which would have been due even to inanimate machines of equal utility ; for there seemed to be much more anxiety about preserving arms from rusting and cordage from rotting, than about maintaining men in an effective state of health.'^ The naval commanders here referred to were not men of the school of Lord jVIetcalfe, who always urged his maxim — " Economy in the department of stores is ruinous. We ought to be lavish of the contents of our arsenals, and saving of the lives of our men/' A soldier lost in India costs at the least 120/., so that the neces- sary reinforcements to keep an army of 100,000 men, which some think necessary, will cost 1,200,000/. per annum. We have, in the instances cited, witnessed our armies scourged and wasted away as of old, through the ignorances and incapa- cities of authorities at home and abroad; but a higher order of intelligence is dawning upon us, having its origin in the sanitary investigation of our naval and military surgeons. " The wisdom of the country," too, invoked to her soldiers' aid by men like Robert Jackson, William Fergusson, and Henry Marshall, is being- manifested through a free press and a Parliamentary inquiry ; — sharpened, perhaps, by a sense of the common danger resulting from abuses and ignorances without end. We are said to have acted hitherto as if armies had been made for generals, and not generals for armies; but let us hope that the time is not distant when soldiers and seamen shall cease to perish without necessity, and without results. Let us hope also that Englishmen may not again witness, as in the instance of Walcheren, the degradation of the sovereign's grant of " approbation" for " perseverance and celerity — for the promptitude with which he had commenced, and the vigour with which he conducted " and consummated the destruction of an army. One such humiliation — one such shameless laudation of a commander who ought in justice to have been cashiered by sen- tence of a court-martial — ought to be enough for one century.* The practical working of the British military system in the Crimea was regarded by tlie public with alternate indignation and sarcasm ; and of Walcheren we have all heard how — " The Earl of Chatham, with his broadsword drawn. Stood waiting for Sir Richard Strahau ; Sir Richard, anxious to be at 'em, Was only waiting for the Earl of Chatham." * The expectations here hazarded have not as yet been fulfilled, commanders of the most lordly degrees of ignorance having been rewarded and decorated for similar ser- vices to those of Lord Cliatliam — the destruction of their men. There is no country in the world in whicli the responsibility of public servants is so little felt as in England ; and so long as this state of tilings holds, great public cala- mities may be looked upon as certain of occurrence. IN OUR INTERTROPICAL POSSESSIONS. 275 The pestilential island of Walclicvcn received the largest expe- dition whieh had ever, np to that time^ left the shores of England,, amonnting in seamen and soldiers to seventy thousand men. The eliniate into which this most powerful and admirably disci- plined force was thrust — during the months of its titmost insalnbriti/ , tho^e of summer and autumn — was such that the Scotch regiment in the Dutch service had been known to bury their whole numbers in three years ; a climate in Avhich the French army lost annually one-third of those employed, or 33 per cent. ; and in which a Dutch corps, which on arrival, three years previously to the British landing, amounted to 800 strong, numbered but eighty- five men on this occasion. Such was the country and such the climate — all within sixty hours' easy sail of us — in which our ministers and commanders proceeded to make war. The climate and its diseases had been accurately described by Sir John Pringle so long ago as 1761; yet nothing was known to our ministers, who sent the imbecile toilet-loving Chatham in command of the finest army that England had possessed since the days of Cromwell. How often have folly and factious ignorance paved the way for the death of the British soldier ! With us, when a question was raised in Parliament on the subject of the soldier's wants, the stereotyped reply used to be — " it is under consideration " — and there it was allowed to remain. Tlie conduct of our enemy, on the occasion of our very charac- teristic expedition to Waleheren, was characteristic of his sur- passing genius : " Only keep them in cheek," said Napoleon, " and the bad air and fevers peculiar to the country will soon destroy their army." The forces sailed on the 28th July, and were landed on the 31st July and 1st August; and by the 10th October, 587 per thousand of the strength had fallen sick, while there died 112 per thousand. Such inquiries as these ought certainly to " contribute greatly to direct us to the best means of promoting the welfare, improving the efficiency, and preserving the health of the soldiers," as stated by Henry jSIarshall ; but, somehow or other, governments and com- manders are peculiarly slow of deriving lessons from experience. Marshall concludes with the following quotation from the '' Edinburgh Review :" — " The expedition to IValcheren, planned and conducted as it was, was the fruit of statistical ignorance in even/ one, eve rytvhere, from the Prime Minister to the Commander-in-chief, and from him to the surgeon's mate. That ignorance tohich everi/ Middlctjurghian and Dutchman could have enlightened or di>ipelled, cost us ten thousand brave men, not a little money, and not a little credit, and not a few tears and inconveniences to those whom statesmen never consider." This miserably conducted expedition cost the country twenty millions sterling, and imposed a burthen of one million of annual taxes. Its other consequences, in the language of a popular historian, T a 276 SELECTION OF LOCALITIES FOR EUROPEAN TROOPS were ignominious retreat, pestilence, and destruction — because, according to custom, the worst possible general was selected to command the finest of armies. Again, we have the experlition to St. Domingo, in which, according to Dr. Maclean, the British force was reduced in three months to 1100 men, from an original army of 10,000 ; and all this " without striking a blow or seeing an enemy. ^' In round numbers, there were treated in the Peninsular and other hospitals, according to Sir James M'Grigor, for disease and wounds, from the 21st December, 1811, to 21tli June, 1816 — 346,108 men, of whom 232,553 were discharged cured. Of these last, so-called cured, how many thousands were harassed and dis- tressed, during the whole course of the war, by the habitual recur- rence of the fevers of Walcheren and the Guadiana, so as to weaken them and render them frequently unfit for duty ? How many, in after years, in our various colonies, suffered cruelly and perished miserably and prematurely, from sicknesses resulting from the same original ills ? Thus, death is the last but not the only result of " incommo- dious encampments and unwholesome stations, where courage is useless and enterprise impracticable." It had long been a subject of complaint and remonstrance on the part of Robert Jackson and other military surgeons, that, in the West Indies, facilities of accommodation for trade — the polar star of British policy — had condemned the soldier to the scourge of disease without a necessity ; and whoever looks at the distribution of the European military force in the East Indies will come to the conclusion that the soldiers have been exposed to disease there on grounds even less justifiable than have held sway with the autho- rities in the West. " It is positively true," says Robert Jackson, '^ proved to a demonstration, in numerous instances, but proved by accident, not by avowed experiment, that European troops may be so stationed in the islands of the West Indies as to retain health nearly as well as they could be expected to retain it in their native country. The air of the interior and mountainous parts of the larger of the iutertroi^ical islands is comparatively cool and pleasant, and not unfriendly to the European constitution. " The exj)ense of filling up the military ranks, thinned by sick- nesses which arise from bad position and badly constructed quar- ters, actually amounts, in course of a few years, to a greater sum of money than would be required to erect barracks of the best form of construction at the most eligible sites in the country, even at the extravagant price of government contract." The truth of what was here many years ago advanced, Jackson proved in a statistical summary of the " Inspection Reports of Military Positions, Barracks, and Hospitals," submitted to the Commander of the Forces on the West India station. His repre- sentationSj though so true and so easy of comprehension, met with IN OUR INTERTROPICAL POSSESSIONS. 277 no attention whatever; and after a public life of the highest honour and of the most noble labour and usefulness, extending over half a century, every day of which, during peace and during three great wars, was devoted to the moral and physical good of the soldier, Jackson concludes with a pathetic appeal to " the legislative branch of the government ;'' there being " a presump- tion amounting almost to proof that it has no chance of obtaining attention from the executive ;'' that is, from military Or naval authority ;* and after the lapse of another half-century of terrible experiences, the watchword with our commanders is still, '^ As you were.'^ With the ordinary run of commanders by sea and land it must be so : they are but servile formalists. Referring to the fact that in England " much opposition was raised by the subordinate authorities" to his suggestions for com- piling statistical reports on the sickness, mortality, and invaliding among the troops in the colonies, Henry Marshall adds that " ignorance of the principles of military hygiene, and an inveterate * I have already suggested that if, by the usages of war, tlie puuishment of death be applicable to a disgraceful capituhition on the part of a commander, some heavy punishuient ought in justice to await the man who, through wilful neglect, and a wanton ignorance, causes his army to perish. It was once a rule of English and Fi'ench history that " responsibility meant death." Bat in these days of canting speculative or pseudo-philanthropy and dreamy senti- mentality, death must not be so much as mentioned for the liolocaust even of an entire army. Yet death has been awarded, and suffered too, for very minor crimes compara- tively. Certain am I, that the very first Sir Michael or Sir Peregrine who shall be made to suffer the mild sentence of cashiering for such a crime, under the award of a court-martial composed of medical and military officers in equal numbers, will prove the last of his class who will venture on the same course of shameful neglect in time to come. From the day that this act of common justice shall be done, we may hope never thenceforth to hear again of armies being planted in marshes, there to die, while the surgeons had for fifty years urged their removal to the hills, where they would have lived well and happily ; of soldiers being thrust into barracks and hospitals urifit for the reception of convicts. Let this be done, and we shall no more be told by a statesman in Parliament that " nearl}' one half of the lives that used to be sacrificed in the West Indies was sacrificed through neglect," and that ''this mortality might have been prevented by the most ordinary precautions ;" that " while the soldiers, who were unstained by crime, were condemned to five days' salt provisions weekly, the convicts were allowed five days' fresh meat ; and that while the troops were suffering, the convicts were in good health." I say, let the right judgment be brought to bear on the right man, and we shall hear no more of such atrocities. Commanders, in short, must be rewarded or punished in like manner as other public servants ; and as they always receive the highest rewards, so they should be made responsible in the highest degree. They accept the advantages: with the disad- vantages. It should be remembered, also, that the sacrifice of a fleet or an army might prove the ruin of the empire. For such crimes excuses and soft names must no longer be found. I have long been strongly impressed with the conviction that, of all the responsible servants of the public, the responsibility of those who undertake the management and command of fleets and armies should be made the most direct and immediate.^ "Where there can be no responsilnlity beh)w, there should be double responsibility above," says Lord Macaulay. Hitherto they have been the most irre- sponsible of public servants. There was hardly a chief or a subordinate actor in the Crimean tragedy of horrors who did not receive some reward or honorary distinction from the Crown. They have each and all been, in fact, rewarded in proportion to the injury they have done to their country. " Dat veniam corvis, vexat censura columbas." The culprits were rewarded first, and tried by a sham commissioa afterwards, which was assembled and indeed designed only to whitewash them. 278 SELECTION OF LOCALITIES FOR EUROPEAN TROOPS prejudice in favour of former usages^ seemed to be tlie leading cause of the opposition to the measures recommended, the adop- tion of which has proved so singularly beneficial.'^ Very different was the conduct of the generals of Napoleon. On the landing of the British forces on WalchereUj and on the capture of Flushing, there was found a Memoir by the French commander. General Monnet, on the preservation of the soldier's health. It was a document full of interest, and of much scientific and practical value. But, referring to our subject, the removal of the British troops from the pestilential plains to the healthy mountain regions of Jamaica was at length ordered by a man who united the most active and enlarged benevolence to the most invincible firmness and resolution in carrying out every measure that was right — Lord Metcalfe. And, strange to say, the result has been to the very letter as Jackson foretold ; the British soldiery now retaining their health in the mountains ^' nearly as well as could be expected in their native country." The result as regards the mortality of British troops is^ in simple figures, as follows : — From 1803 to 1816, and for how long before we do not know, the soldiers perished in Jamaica at the rate of 130 per thousand per annum, while bj^ the simple and easily arranged measure ordered by Lord Metcalfe, the mortality has, since 1842, been reduced to 35 per thousand per annum. This beneficent act, so becoming the generous and noble nature of the Governor of Jamaica, was " characteristic of Metcalfe. He made the first movement on his own responsibility, and ofiered himself to pay the expense. He saw that the troops under his command were being sacrificed to ignorance, negligence, and false economy ; and he exerted himself, not without success, to establish a new order of things, by locating on the high healthy grounds of the island the European regiments which perished miserably on the plains."'^ Detachments of British troops were stationed at INIaroon Town at different and uncertain times between 1795 and 1839, by direc- tion of Lord Grey and others ; but nothing fixed or determinate was arranged until Lord Metcalfe gave the final order. When will any of our great foreign possessions fall under the charge of such another governor ? Robert Jackson speaks also of the value of military labour in securing military health — a subject not yet sufficiently taken into consideration by our authorities. Fort King George, he says, in 1803, stood in lee of a swamp, and the exhalations from it being considered by Colonel Macdouald, commanding the Royal Scots Regiment, to be injurious to the health of his men, he ordered them to drain it. " The planters lent the tools, the soldiers of the Royals drained the bog;" and Fort King George, which formerly * Kaye's "Life of Lord Metcalfe." IN OUR INTERTROPrCAL POSSESSIONS. 279 stood noted for iinliealthiness, is now " one of the healthiest quarters in the Windward and Leeward Islands Station, as ap- pears hy a comparative view of the sick returns of the army.^' In Jackson's varions writings tliere are nnraerons instances of similar results from the gratuitons labour of the soldier ; and^, Avhat is ver}^ important also^ this most eminent military physician always concludes by declaring that " the thing Avas done — with obvious effect upon health, morals, and happiness, while the work was under execntion/' With reference to the purposes for which British, soldiers are sent to the East Indies, and to the efficient exercise of their powers when called into action, it has always surprised me that so large a portion of the European army has been retained in the plains of Hindustan. It is justly observed by Drs. Hooker and Thomson, that India presents more contrasts and varieties in climate than any other area of equal extent in the world. Hold- ing this fact in view, we must take advantage of the irregularities of surface, and varieties of soil, to found healthy stations. With urgent political reasons or state necessities I do not pretend to deal; but if these do not exist, I know of no defence that can be set up, on the score of humanity or of expense, in plea of the cruel and un- necessary sickness and mortality — of '^ the serious loss in the balance of national accounts," consequent on the loss of men. *' The case is important, and the sovereign power will be false to its own interests, if it do not apply a remedy when furnished with proof that a remedy is attainable, and particularly when informed that it is not difficult of attainment.'^ Independently of the revenues of British India, England, pos- sessing property to the amount of nearly ten thousand millions of pounds sterling, and an annual produce therefrom of about four hundred millions, need surely not descend to haggling about the money-value of tlie soldier, nor yet about the cost of means necessary to his health and efficiency. Dr. Julius Jeffreys observes justly that, " costly to India as a large British force must necessarily be, it is the most profitable investment she has ever made, and it is not at present quite costly enough to satisfy the demands of justice and sound policy." And now that extensive lines of railway are about to be laid down thi'oughout the lengtli and breadth of Hindustan, the time, I trust, is at hand when the British soldier may have the advantage of recourse to the moun- tain ranges and solitary mountains scattered over the several pro- vinces of India, not only as sanitary stations, but as places of per- manent residence. But the evils resulting from neglect in choosing proper sites for our colonial emporiums do not end here. The choice of such sites having, as stated, reference to trade only, and not to health, the sickness which is ever present is not referred to its true cause, the inhereut unhealthiness of the place, but to the arrival of some 280 SELECTION OF LOCALITIES FOR EUROPEAN TROOPS trading vessel from some otlier equally insalubrious locality ; and hence quarantine, with all its evils. Sickness is always prevalent in such places, ships are always arriving ; and people always dislike to believe that they are living in a pestilential locality ; so, disease is readily ascribed to impor- tation. With the unreasoning many, the suppositious foreign ill is always more dreaded than the real home-bred pest. In the East, as in the West Indies, the loss of military life from endemic and epidemic diseases has always been unnecessarily great — sometimes enormous. "^If the subject be viewed correctly and without prepossession, the loss sustained will be found to have been principally owing to mistake, that is, to inattention to truths furnished by experience for the choice of healthy positions.^' These just and manly sentiments are quoted from the celebrated work of Robert Jackson on the " Formation, Discifline, and Economy of Armies," and especially from that portion of it which is devoted to a " General View of Service in Tropical Climates ;" wherein, though he speaks in special reference to the West Indian colonies, there is necessarily much Avhich applies with equal jus- tice to all hot countries. This admirable work, which I had the pleasure to get republished, ought to be in the hands of every officer, whether militaiy or medical."^ I may here mention that I prepared, by desire of the late Lord Metcalfe, without previous notice, a memorandum relating to ar- rangements for constructing barracks and hospitals, and which he handed to Lieutenant-General Sir George Murray at a meeting, held by desire of Lord Stanley at the Colonial Office, on the 16th of July, 1842. This note was of a purely suggestive character, no time having been allowed me for entering into details ; and the following quotations are here presented : — '' 1 . The author of this note has satisfied himself, from an ex- tensive range of observation in the East Indies, that great loss of * The gi-eat military work of Robert Jackson is not sufficiently known to the British or to the Indian army ; and as I am desirous that military men should have a better warrant for its excellence than my opinion, I subjoin that of one of the highest and brightest of military critics— that of tiir John Moore : — "My dear Jackson,^! have perused your military book, with which I am much delightevliiv Mie constitution of the patient and the symptoms are at once more ^ubdued, bi'ought more into a common level, rendered thus less variable, and for the manage- ment of which ample time is given to the inexperienced for con- sideration of means, for reflection on their eftects, and for consul- tation with the elders of the profession. In chronic disease, again, no sudden changes occur, as the result of youth, constitution, influence of season, or of epidemic conditions — all which exercise powerful, immediate, and varying effects in acute disease. We caunot put off" to the morrow the treatment of a case of fever, dysentery, hepatitis, or cholera ; duty requires that we should act on the instant ; and to do so with justice to the patient requires at least a knowledge of general pathology and of the prin- ciples of medicine : we should not have to rely on a guide or case- book. A detail of cases, describing the fevers and dysenteries of parti- cular seasons and localities, will not represent faithfully or truly the fevers and dysenteries of other localities and seasons ; neither can the treatment which may have been found applicable to the first-named, prove always justly so to the second. A care- ful detail of symptoms, and a treatment founded on general pa- thology and on general therapeutic principles, can alone represent remittent and intermittent fevers and dysenteries. Surgeons who purpose to deal with general principles, never write out prescrip- tions, and for good reasons : all treatment by means of medicines is but provisional j and the very reputation of many drugs is very variable and very much matter of fashion. Nothing, therefore, but well-founded principles can represent that just reason which, as our greatest historian assures us, is the same in all countries and in all ages. Huxham, writing of the fevers of his time, says : — " I have given few or no Formula or Peescriptions ; for, as Hippo- crates says, he that knows the disease knows what is proper to its cure." This is, in fact, but giving expression in other words to the dictum of Rostan — that all medicine consists in diagnosis. It is not by a routine detail of eases and of set formulae that we may hope to advance those general principles of theory and prac- tice which can alone give assurance and sanction to the name of ]\Iedical Philosophy — those principles of tliought, observation, and conduct which, according to Sir Henry Holland, may most con- duce to the progress of medicine, and to the honour and usefulness of those who profess it. Finally, fevers, endemic and epidemic, are frequently changing their types, but recorded cases always remain the same. 352 THE REMITTENT FEVER OF BENGAL. MANAGEMENT OF CONVALESCENCE. I cannot conclude these observations without adverting to the importance of the management of convalescence from fevers^ re- mittent and intermittent — not the least serious of the duties im- posed on the naval and military surgeon. In all cases of recovery from fever, but especially in those wherein the complications have been severe, or where important organs have been aflfected in the course of the fever, or as a sequel to it, it is impossible to be too careful in the diet, and in attention to the activity of the secreting functions ; and this vigilance must not be relaxed until perfect health shall be established. How often do we see patients who have been sufficiently well treated during the acute stages of dis- eases, but on whom a neglect of this important rule of practice has entailed enlargement of the liver and spleen, or other visceral dis- eases, requiring a protracted voyage at sea, or a return to Europe. I have, both in India and at home, seen much injury done by a too liberal and protracted use of quinine in convalescence accom- panied by abdominal congestion. In such cases, and imder such treatment, the liver often becomes swollen and painful, and the mucous digestive surface red and irritated. The proper treatment for such states is an emulgeut and alterative course of treatment by alkalies with taraxacum, or by the nitro-muriatic acid bath, using a spare diet, and having recourse to change of air. In con- valescence from fever and dysentery, quinine is very beneficial, if given in small doses and during a short period only, but when we exceed this measure we aggravate congestion, and sometimes we even produce it. The just management of convalescence is a subject that shoukl always be present to the minds of those who have the regulation and control of naval and military hospitals, wherein the perfect re-establishment of the sailor^s and soldier's health, before their return to duty, should be a maxim never to be swerved from. It must not be su.pposed that with the medical management of acute diseases our duties towards those intrusted to our care have termi- nated. It ought to be in the recollection, also, of medical officers, that, after every serious or protracted illness, the blood is necessarily impoverished — that all the organs and their respective functions are as necessarily enfeebled, sometimes nearly exhausted. To send a soldier in such a condition to the temptations, the diet, and the duties of the barrack, is an injury to the service, and a cruelty to the individual. A small sick-list is pleasing to commanding officers, but the dis- charging of men from hospital in a partial state of convalescence, is a crime in the surgeon. The meclic'ma mentis, and the benefits to be derived from change of air, oiight to be as available to the soldier as to the officer ; but they are matters that scarcely receive from THE REMITTENT FEVER OF BENGAL. 353 ns tlic attention they deserve from their great importance. In the Latter stages of remittent fever, when the patient does not con- valesce, owing to a slight feverishuess towards eveniiig, Avith warmth of the head, followed by restless nights and by increasing de- bility, then it is that the astonishing benefits deriva])le from change of air, and of gestation in the open air, are manifested. They save the patient's life ; and many are worn ont and die for want of them, beeanse the friends and relatives, and perhaps the medical atten- dants too, consider the patient " too weak to be moved.'' I never saw the fever patient that was too weak to be moved at the proper time ; and it should be remembered that movement does not here mean violence. During the severe and fatal remittent fever of 1833 in Bengal, an eminent member of the Bench fell into the condition here re- ferred to, so that I had little hope of his recovery ; and I directed his removal to sea. INIy friend, the late Mr. John Turner, the most able in the management of fever of any man I have ever known, said : — " You are mistaken in this instance ; he is so feeble that he will die before he reaches the boat, and all the people of Cal- cutta will declare that you have killed the Chief Justice." I per- sisted, nevertheless ; and the removal to the river, which was about 500 yards distant, was accomplished without accident. But, in the act of being hoisted from the boat into a 7 t-gun ship at Khidgeree, notwithstanding my warnings to the contrary, the head and shoulders were raised to near the sitting posture, w^hen the pa- tient fell back in a fainting condition, which for some minutes looked like death. But from this sunken state he recovered rapidly in the fresh breeze ; and in ten days he reached Madras, whence he was reported to be eating mutton chops. I have always been of opinion that but for the timely removal from malarious inliuences_, this distinguished gentleman must have died. Next to the benefits to be derived from early and effective treatment, come those which secure and maintain convalescence ; and this truth will be found to apply whether we refer to organized bodies of men, or to individuals. It is to the mismanagement of convalescence principally that Ave must refer the numerous and fatal relapses iu the fevers and dysenteries of our seamen and soldiers, not to speak of ill health contracted through the sequeiie to those diseases, in tlie form of visceral affections. In India I have continually seen that almost all the relapses in fever, so often fatal to the soldier, were caused by mismanagement of tlie stage of convalescence, and by his too early discharge from hospital. The mean age of a British regiment maybe taken to be twenty - six years — a stage of life when the rallying powers of the consti- tution may be assumed to be at their aeme, and Avhen, therefore, the tendency of nature towards convalescence is at its height. But in the individual cases of older men, and with. such of the A A 354 THE REMITTENT FEVER OF BENGAL. young men as have been exhausted by the violence of disease and the activity of depletory measures of cure_, wine, porter^ and bitter tonics will be requisite^ together with more time^ and a longer exemption from duty, for the purpose of maturing health. This latter consideration is of great importance. It is true that the authority of the naval and military surgeon does not extend beyond the hospital ; but better days than those of Robert Jackson are coming, both for the soldier and the sur- geon. Humanity is now at length pretty sure to have a powerful press on its side ; and no governor or commander, by sea or land, can any longer venture to do or leave undone, the things which I have seen done and left undone. When the disease is endemic, whether it be fever, dysentery, or hepatitis, the first means towards maturing convalescence, and obtaining the complete restoration of health is — a removal from the local and endemic influences. This measure, coupled with great attention to diet, clothing, exercise, and bathing, will fill the ranks with healthy soldiers ; while leaving them in crowded or otherwise unhealthy hospitals is too often but condemning them to wait for death. In all our in- tertropical possessions we should establish convalescent depots, conveniently situated ; and where practicable they should be in some near mountain range, or other elevated ground, or in well- selected positions on the sea, which latter are, I think, always preferable. I know that in the East Indies one or other of such positions may generally be found by the intelligent medical topo- grapher ; and, for the rest, everything will depend on the authori- ties, civil and military. Nor are the advantages of such positions to be confined to convalescence ; for where the locality is pesti- lential, or where barracks, camps, or hospitals are badly situated, the sick should at once be removed to the elevated or other selected site. Such early removal will be found to modify the progress of disease, aiding thus the medical treatment, and saving the patient from those congestions which are so liable to occur in the progress of fevers, especially in malarious situations. GESTATION IN THE OPEN AIR. Gestation in the open air presents itself at once as one of the most refreshing restorative means for maturing convalescence^ and it is seldom ditficult of application under willing authorities. It should never be neglected in the late stages of fevers ; for it gives tone and vigour to the flagging functions, and conduces to refresh- ing sleep where medicine has failed of securing rest. Of gestation in the open air, Robert Jackson observes that it is neither useful nor safe in the early stages of fevers, while plethora exists ; but that in the late stages of concentrated endemic fevers, it consti- tutes the " last anchor of liope^^ to the sinking invalid. He com- THE REMITTENT FEVER OF BENGAL. 355 plains justly that this powerful remedy has not been applied generally and systematically ; for he had frequent opportunities of directing gestation in the open air, and of observing its beneficial results, in the first American war, in the West Indies, and in Holland. He says that '' moving the body rapidly in an open cart or carriage through Avoods, or on the green turf; or in defect of woods, shaded, if in the daytime, Avith boughs of trees, exposed, if in the night-time, to all the freshness of the air, and all the dews of heaven, has appeared to do what no other means were capable of doing." Jackson considers that airings for an hour or two in carriages, where the subject is defended from the weather, or but partially touched by the salutary influence of the air, con- stitute but a feeble substitute for journeys of six or eight hours in open conveyances, even when the patients are exposed to wind and rain, to heat and cold, and other apparent disadvantages. Where, as in the retreat through Holland, in 1795, this measure was adopted from necessity, he says that " it often succeeds ; for the operation is continued till the effect is confirmed." Under all the disadvantages of this retreat, Jackson declares that the benefits to the sick were demonstrably felt. " Where due attention was bestowed in disposing the sick in waggons, the travelling was agreeable during its continuance even in cold and rainy weather ; the good effect was strongly manifested at the end of the journey ; even the most enfeebled acquired an e\ddent accession of strength. Where the diseased action has actually ceased, but where the com- mencement of healthy movement is slow, and the healthy action imperfect, more benefit is visibly derived, and more strength visibly gained, by travelling for six hours in an open carriage, exposed to all the chances of weather, than by the best treatment that can be densed in a crowded hospital for a space of six days." The bene- ficial effects, he adds, are confirmed and rendered permanent by a continued application of the means. This great authority expresses his regret that gestation in the open air — a means that has the smallest chance of any other medical appliance of doing harm — is not numbered among the regular means of physicians in the cure of fevers ; and this regret must be shared by all who have seen and served in the sickly camp. The old 71st Regiment, orFraser Highlanders, with which Jackson served during the first American war, was forced to retire before a large body of the enemy, carrying along with them a heavy sick list of men suffering from remittent fever. " The sick, during the march, had little opportunity of taking medicine ; yet no one had died; some had got entirely well; and in others, indeed in all, where the disease had not yet ceased, the form Avas changed to that of distinct intermittent." In the latter stages of fever, dysentery, and hepatitis, while morbid influences are in operation, medicine will do something, A A 2 6 THE REMITTE>^T FEVER OF BENGAL. hut will not cure ; and it is here that change of air proves so supreme in eflect, just where all other means prove unavailing. " When, some years ago/' says Boudin, " the French troops who had heen in Spain were recalled, there were in hospital at Madrid about 160 wounded men labouring under po?irnli! re tVhopttal, &c., who were deemed unfit to bear the hardships of a march, but who, at their own urgent request, were taken away. When after two days' journey the wounds were uncovered to be dressed, it was found, to the general surprise, that nearly all were healed, or rapidly healing, shoAving the effect of escape from the poisoned atmosphere of the hospital into the fresh air.'' Those very few survivors Avho, like the writer of this work, marched with the miserable remnant of the European army orginally sent to Rangoon, during the first Burmese war, will never forget the drooping, attenuated form and haggard eye of the British soldier on the day we broke ground from the last-mentioned town, and the amended condition of the same man on entering Prome two months afterwards. Yet here the soldiers were moved under every con- ceivable disadvantage, excepting in the matter of diet; for, as we advanced into the interior of the country, we procured some fresh meat, and occasionally some fruits and vegetables."^ It may now prove both useful and interesting to take a glance at the prominent points of the treatment of tropical fevers by the following authors, all British but the first-named, in the order of their respective dates : — 16£9. Bontius : — Bleeding, general and topical, and repeated as occasion required — purgatives — opiates — extract of saflron. 1751. Cleghorn : — Bleeding, repeated according to occasion — cathartics — bark. 1757. Dr. Bogue, Bengal: — Bleeding — emetics — purgatives — mercury — bark — camphor in the cold stage. 1757. Dr. Huxham : — Bleeding — purgatives — diluents. 1760. Dr. Huck : — Blood-letting, repeated according to occa- sion — ipecacuanha and tartar emetic, so as to vomit and purge — bark dm-ing the remission. 1762. Dr. James Liud — "Putrid and remitting marsh fever :" — cautious blood-letting — vomits of tepid water, occasionally of * There perished, in the first year of the first Burmese war, at Rangoon alone, of the British portion of the force, 484 P^'' cent., of wliom 3^ per cent, were killed in action, or (lied of their wounds, being within one-half per cent, of the annual casualties from wounds in the I'eninsular war, during forty-one months of the most active service. The total European loss within tlie Burmese teiritoiy, during the two yeai .s of the war, was 720 per thousand of the strength — being the greatest mortality of which as j-et there is any record. I was very young when employed on that service ; but it ap- peared to me as if I had lived many weary years in passing through the experiences, the personal sufferings and privations of those two dismal campaigns. I\Iy hmding on the coast of Pegu was through an appalling shipwreck, rnd my departure, at the close of the war, was through a fever which nearly destroyed me : but all personal conside- rations vanished in the general scenes of which I had been an active witness. THE REMITTENT FEVER OF BENGAL. 357 emetic tartar and ipecacuanha — saline purgatives — cooling acidu- lated drinks — bark, speedily and freely administered. 1768. Pringle, Sir John: — Bleeding, repeated according to occasion— active purgatives — antimonials — bark, as an occasional means. 1781-1811. Balfour — ''Putrid intestinal remitting fever of Bengal :" — Blood-letting, general and local, for the removal of " local affections" — calomel, 6 to 12 grains at bed-time, as a febri- fuge and cliolagogue, followed in the morning by an active saline purge ; emetic tartar as a sudorific, every hour or two during the day ; and this treatment to be persisted in so long as acute symp- toms remain — adding, " on the morning of the third day," bark and opium, so as ''to throw in twelve drachms or two ounces before the expiration of the second day." Opium is added to the bark with the view to prevent vomiting or diarrhoea, while calomel and purgatives are used throughout the fever. Panada was given as diet, and great attention was given to purity of air and of dress. 1791-98, 1820. Robert Jackson: — Blood-letting, copious and repeated, according to the severity of the symptoms — the operation always performed in the recumbent posture, while the head and shoulders are dashed with cold water, and heat applied to the feet — purgatives followed by moderate doses of calomel, antimonial powder and cathartic extract, so as to keep up " effective evacua- tion " — bark — blisters, largely and freely applied when local con- gestions require them — gestation in the open air — change of air. In fevers with congestion of the cerebral and abdominal viscera, calomel as a remedy " of the first importance," one which " repairs mischiefs which no other means with which we are acquainted are capable of touching." 1795. Dr. Chisholm : — Calomel and opium to salivation. 1796. Dr. J. Hunter: — A strong saline purgative, followed by James's powder till remission took place — then bark freely admi- nistered throughout the disease, and during each remission — blisters — cordials — opiates — change of air. 1 797. Dr. John Clark: — Mercurial purgatives — bark — anodynes. 1799. Blane, Sir Gilbert : — Bleeding— vomits and purges— su- dorifics — bark — anodynes. 1799. Dr. Lempriere : — Blood-letting — active purging by mer- curials and cathartics perseveringly used— diaphoretics — blisters — pediluvia — saline draughts along with the bark, to allay nervous symptoms— ether, camphor, and wine — in doubtful and dangerous cases, mercury to affect the system. 180i. JNI'Grigor, Sir James : — Emetics occasionally — blood- letting — cold affusion — calomel with purgatives — mercury to aftect the system — ])listers — nitric acid — opiates — bark. 1807. Mr. Curtis: — Evacuants and diluents, in the first stage — calomel, ipecacuanha, and purgatives in protracted cases. 358 THE REMITTENT FEVER OF BENGAL. 1808. William Fergusson : — Early and copious blood-letting — calomel to affect the system — sudorifics — purgatives. 1811. Dr. Bancroft: — Bleeding — cold affusion — calomel — pur- gatives — bark. 1813. James Johnson: — Blood-letting, general and local — mer- curial purgatives — diaphoretics — calomel, according to severity of symptoms, to affect the system — bark — change of air. 1816. Burnet^ Sir William: — Bleeding both general and local — purgatives. 1818. Ballingall, Sir George : — Blood-letting, general and local — purgatives — cold affusion — moderate use of calomel — occasional emetics — bark. 1819. Dr. Dickinson: — Vomits — blood-letting — active purging — cold ablution — diluents. 1827. Dr. Geddes : — Blood-letting, mercurial and other purga- tives — diaphoretics — diluents — opiates before the paroxysm — quinine. 1828. Annesleyj Sir James: — Blood-letting, general and local — emetics — full doses of calomel — purgatives — diaphoretics — cold affusion and cold lotions to the head — bark during the remissions. 1832. Mr. Twining : — Blood-letting, local and general, repeated as occasion required — calomel, followed by purgatives — calomel so as to affect the system in severe cases — quinine in the remission. 1833. Dr. Joseph Brown — " Cyclopaedia of Practical Medicine :" — Bleeding, general and local, aided by warm baths — mercurial purgatives — cold affusion — cold to the head — cold acidulated drinks — in the advanced stages opium — change of air. 1835. Copland — "Dictionary of PracticalMedicine :" — An emetic — blood-letting, general and local — " full doses of calomel followed by purgatives" — evaporating lotions to the head — cooling diapho- retics — quinine during the remissions. From the conp-d'oeil here presented we learn that he who under- takes to determine this great practical question must be careful to separate real from spurious science ; that to the cure of fever there is neither a short path nor a royal road, and that a disease so vary- ing in its nature, so general and complicated in its influence on the system, is not to be justly treated by one remedy. Bark and calomel, each a remedy of great power, will nevertheless not succeed in the cure of fever, if used exclusively ; and so it is with the most powerful of all means, blood-letting. We must, therefore, give to each remedy its proper place in the treatment ; we shall thus be as nearly right as is possible. No one can be found now-a-days to follow Dr. Clark or Dr. Chisholm in their exclusiveness. Men of science cannot be induced to believe that because one practice is wrong, its very opposite must be right, thus meeting one extreme by another extreme. The truth is, that exclusive doctrines and practices never take any general or permanent hold on the mind of the medical profession ; and even the names of Brown and Brous- THE REMITTENT FEVER OF BENGAL. 359 sais have secured them but few followers in Europe. For the great mass of the profession extreme doctrines are " writ in water ;" or, as Samuel Johnson says of Sterne's writings, " No- thing odd will do long." According to Dr. Forget, " Science, like representative government, is a system of balancing. Brons- sais dethroned Brown ; and now behold Brown avenging himself on Broussais." GENERAL REMARKS IN CONCLUSION. If tropical fever and dysentery Avere always simple morbid actions, or mere inflammatory states of the system or of particular organs, no doubt bleeding and purging, as recommended by some writers, might often prove of themselves sufficient to the cure ; but unfortunately, in both instances, we very seldom find this unmixed condition of disease in actual observation in Bengal, where, be- sides the morbid condition of the entire system, including a violent disturbance of the nervous and vascular systems in particular, we have in our fevers continually to combat dangerous abdominal complications, congestive and inflammatory; in the fevers of the hot season, too, thecerebro-spinal system becomes involved, and all these conditions demand a more or less complex and careful treatment, a speedy diminution of the force and frequency of the heart's contrac- tions, and of the circulating current, followed by an unlocking of all the secretions and excretions of the body, which the most ample experience proves that bleedingand purging (7fo;/ewill notefi^'ect. Tro- pical fever, dysentery, and hepatitis are produced by the action of specific causes, and such diseases are noAvhere cured by the exclusive use of blood-letting and purging, as in the instance of common or sthenic inflammations. Yet here, as in dysentery and hepatitis, bleed- ing is generally tlie standard remedy, subject to considerations of age, constitution, and length of residence in India. In acute hepatitis it is a necessity, if we would save the life of the suff'erer. Bleeding, whether general or local, should in remittent fever be practised to the extent of reducing the force and frequency of the pulse, and of relieving the loaded and oppressed abdominal viscera. It precedes all other means of cure, both in order of time and in importance. The fevers of Bengal are not a mere inflammation, although they present the same types as both sthenic and asthenic inflammation ; and also intermediate conditions between those types. Thus our fevers have for a length of time been treated according to indica- tions grounded on explanation of the symptoms, on the physio- logy, and not on any exclusive plan. Accuracy of diagnosis and simplification of treatment, the true aims of the practical physician, have very generally been held in view ; the symptoms being traced to their causes — in other words, the leading rules of practice being founded on general views of diseased function and structure, on general and special pathology, in fact. Pathological and therapeu- 360 THE REMITTENT FEVER OF BENGAL. tical induction ought mutually to elucidate and sustain each other, so as to conduce to an assured hope of recovery. Blood-letting has been had recoiirse to, to moderate the force ■ and frequency of arterial action, and to relieve congestions ; free purgation, by means of mercurials conjoined with cathartics, to remove accumulations or vitiated secretions, and to aid in correct- ing the latter ; calomel with sudorifics to act on all the secretory and excretory functions : bark or quinine during the remissions, to arrest the coming paroxysm ; cold affusion in the ardent con- tinued fevers of the hot season — these have long been in use with us ; and by their just application we may generally cure the fever, and obviate visceral disease — the token of bad practice — the mea- sure of the insufficiency of the treatment. Subject only to the limitations already stated, bleeding — early bleeding — whether general or local, and always practised at the very onset of the stage of reaction, is very generally necessary in the severer forms of Bengal remittent fever ; then come full doses of calomel and sudorifics, short of producing salivation, with saline purgatives, antimonials, and refrigerants, and quinine in the inter- Aals. If under such treatment the disease does not speedily yield, but, on the contrary, if the secretions become of a watery natvire, or if they be suppressed, and the paroxysms recur at shorter intervals, or with increasing severity, leaving but imperfect remissions, then there is imminent danger, and inflammation or congestion, more or less acute, in some important abdominal or cerebral organ, may be more than suspected ; indeed, the justice of the suspicion is con- tinually verified in our examinations after death. For the cure of this aggravated state, in addition to topical bleeding and cold applications to the head, when it proves the seat of disease, calomel in small and repeated doses, with antimonials, must be exhibited so as mildly to aflect the system ; its judicious use, and that of quinine, constitiite the only known means of saving the patient by anticipating the destruction of some organ essential to life. I have seldom had occasion to urge mercury to the extent of salivation, during the whole period of my service in India; and where there is much irritability of the nervous system, or tendency to sinking of the vital powers, the union of camphor M'ith the calomel, as recoumiended by the Indian surgeons of old, will be found useful. In such conditions it v/ill be found more safe than opium, especially in the hands of the inexperienced ; for it does not favour congestion or lock up the secretions as opium is too apt to do. But opium is necessary in some cases, and given with care and judgment, it will then save life. In treating seamen and soldiers suffering from tropical fevers and other acute diseases, we should very carefully inquire into the previous habits of the patient, for when these have been dissipated, including the free use of ardent spirits and tobacco, we must be on (nir guard against tiie complication of delirium tremens more or less masked by the THE REMITTENT FEVER OF BENGAL. 3G1 fever. This is a delicate point to determine by the young surgeon ; but, looking to the history of the man's life, and to the predomi- nance of nervous over vascular disturbance, he will soon perceive that tartar-emetic and opium, and not the lancet, are the remedy ; the latter would indeed be fatal. Here the nervous system has been rendered feeble and irritable, Avhile the blood has been de- praved, by habitual excess. When, again, through the duration of the disease, congestion or inilaunnation has taken its seat in some important abdominal or cerebral organ, and the fever has established itself in the system, then measures less heroic, but more persistent and varied, must be employed, the fever having now become established and compli- cated. Here the physician must neither give way to a feeble timidity, nor to a reckless audacity — courses alike dangerous to the patient. We must remember, too, in laying down rules of treatment, as indeed in all medical reasoning, that we err not so much in the upholding of false views, as in upholding one truth to the exclusion of many other truths. Tlie tendency to sinking of the vital powers is another most important consideration, never to be overlooked in treating the remittent fever of Bengal. This impending event is the reason why all our active antiphlogistic measures of cure, as blood-letting, purgatives, and sudorifics, must be so cautiously regulated as to the time of using them ; for what was a saving means at the com- uencement of the paroxysm, is as surely destructive at the end of it. In every fever, as in every battle, there is a decisive point, a de • cisive moment, which, once past, never returns. In remittent fever, that point and that moment present themselves only once, and that early in the first day — that is, if we would pretend to cut short the disease at once. On the subject of blood-letting Eobert Jackson's works abound in valuable injunctions, such as ought to be present to the recol- lection of all who undertake the onerous duty of treating tropical fevers. After the exposition of admirable rules as to the "just point of time" for the application of this most powerful means, he concludes by declaring that " the same remedy, after the delay of a few hours, not only ceases to be usefid, but the application of it even sometimes becomes unsafe :" further on he adds, with equal truth, that *'it requires much discernment in many cases to dis- cover the cause, a very correct judgment to measure the means, and even no small degree of knowledge to be able to ascertain that the end is attained." That our fevers in Bengal alter their types under different seasons — nay, that instances both endemic and epidemic occur in which blood-letting is not only unnecessary but injurious, the pages of this work sufficiently attest, and death even from its ill- timed use has more than once come under the author's observa- tion j yet the fact remains untouched that blood-letting, practised 362 THE REMITTENT FEVER OF BENGAL. with, the care and thoughtfuhiess which should mark every step we take in this disease — at the proper time^ and apportioned to cir- cumstances of constitution^ age, sex, season, and length of residence in India — forms the principal means of cure in our severer endemic fevers, and of preventing those organic lesions which otherwise so frequently follow them. We must, however, remember with care that the condition of the blood in the newly-arrived European and in the old Indian differs ; and that while the first-named bears and demands the free use of the lancet, the last does not always bear even moderate depletion ; and this, owing to antemic tendencies, being frequently manifested. Leeches are a ready and powerful means in the treatment of tropical fevers of every type ; but I would caution the inexperienced against this mode of abstracting blood as a general rule, or as a substitute for A^enesection ; and I would likewise place him on his guard against the ill effects of pro- longed oozing from leech-bites, especially in the instances of persons at the two extremes of life — the A'cry young and the aged. I have seen the most serious results from carelessness in this respect. The great and pervading tendency of malaria to deteriorate the blood has been commented on in various portions of this work. But, l^esides these acknowledged morbid operations, it has been alleged that in the cycles of years since the outbreak of cholera in the East, in 1817, not only has that very disease undergone changes there, implying a progressively greater depression of the nervous functions, but the endemic diseases of the country, as fevers and d^^senteries, have been supposed also gradually and imperceptibly to have become less and less sthenic in their natures — the compli- cations of these diseases having in like manner become less inflam- matory and more congestive. Analogous changes have been observed in England since the visitations of influenza and cholera in 1831-32. Some generally depressing influence is supposed to have been in operation ever since, lowering the tone of the nervous system, and injuring the quality of the blood, here as in India, so as to cause a marked alteration in the types of fevers and inflam- mations — the former having become more adynamic, while the latter have assumed moi'e of the erysipelatous and suppurative characters, general plethora being less frequent and anaemia more prevalent than formerly. The great increase of population in our English cities — the great and rapid extension of the great town system — without any commensurate improvement in the sanitary condition of towns, these cases have doubtless contributed their shares to the general deterioration at home. Altogether, the con- siderations here briefly referred to are of the highest interest and importance, as subjects to be attentively investigated; for, if founded on truth, they must necessarily tend, in no small degree, to influence our estimate of the physiology, and modify to a like extent the principles of our treatment of all classes of diseases, at home and abroad. Thus we perceive that, as years roll onwards^ THE REMITTENT EEVER OF BENGAL. 3C3 certain clianges in our climatic ecliptic arise to view, suggesting changes in physiological and pathological doctrines, and in prin- ciples of ciu'e, appropriate to their several epochs. But this great subject has need of minute and extended investigation, in order to its being verified. Dr. Watson states his conviction " that there are waves of time through which the sthenic and asthenic characters of disease prevail in succession, and that we are at present living amid one of its adynamic phases.^' The depressed condition of tlie public health is shown also in the altered nature of erysipelas, the acute phlegmonous form of the disease with inflammatory fever, familiar to our fathers, having disappeared. The unceasing competitions, the jar and bustle of an overcrowded manufacturing and trading nation, with their enormous wear and tear of the nervous system in '' the battle of life,'^ and the consequent excite- ments and depressions of the vital energies, must have their injurious effects. In regard to the next most poAverfiil remedy in paroxysmal fevers, namely, the Peruvian bark ; — where the remissions are becoming sufliciently well marked, quinine should be given in full doses without waiting for a perfectly favourable condition of the system : — in bad fevers we should seize the very first dawn of re- mission to exhibit quinine in doses of five to eight grains every second or third hour, according to the urgency of the symptoms, and repeated up to tlie period of the next accession ; but in any case not repeated more than four or six times. Some practitioners re- commend that before this drug is used we obtain a clean tongue, natural secretions, and the absence of all heat of skin, and of local complication. I believe this to be a very dangerous practice : if we are to wait for everything favourable, we shall often have to wait too long, and till it has become too late. It is in diseases as in critical circumstances, political and commercial — everything is for him who can wait ; but, unhappily, in the formidable remittents of the tropics we can wait for nothing, for there is not a moment to lose. I have always given quinine in the more favovirable cases now under consideration, in disregard of certain abdominal com- plications (those of the cerebral cavity, in plethoric subjects, in whom inflammation or congestion is suspected, should exclude its use), believing that if I arrested the paroxysms, the progress towards curing the disease as a whole greatly outweighed any harm which the quinine could possibly do to the local affection, the treatment of which, by local depletion, by mercurials, or by counter-irritants, is not interfered with by the means in question. Again, all tenderness on pressure, or local pain, does not neces- sarily constitute inflammation : and even where such is actually present, its character is often so modified by age, length of residence in India, by malarious influences, and by anaemic states of the general habit, as to constitute a state very dif- ferent from idiopathic and uncomplicated inflammations, such 3G4 TEE REMITTENT FEYER OF BENGAL. as may demand only the kind of treatment liere immediately referred to. On the other hand, the power of all antiperiodics is quadrupled when exhibited before the advent of visceral complica- tions ; and hence the value of immediate recourse to antiphlogistic means — to be followed again, immediately it has become pro- per, by the exhibition of bark, or other equally powerful means. It is thus, if at all, that fever may be cut short ; but the prepara- tion must in such a case be a prompt, and not a protracted pro- cess. In respect to quinine, I have often combined it with calomel and with sudorifics, and I think with advantage ; where there existed depression of the vital powers I have added small doses of laudanum. It is also usual with us in Bengal to combine this powerful antiperiodic with common purging mixture, a mode whereby it aj)plies itself to the entire and extensive surface of the mucous digestive organs, so as materially to add to its influences. When it is seen that, by such means, the periodical febrile move- ment has been checked, and that no recurrence takes place, then quinine — no longer necessary in antiperiodic doses — becomes nevertheless useful in smaller and less frequent doses, as a general tonic, to promote convalescence, and to prevent relajise. It is' well known in the history of the treatment of the fevers of India — a history so instructive that it ought to be known to all of our profession Avho may serve there — that at diff*erent times bark, calomel, blood-letting, purgatives, and sudorifics have, each in its turn, been in almost exclusive favour with some individual practitioners ; but such partial plans of treating so formidable and complicated a disease have never, for any length of time, held in- fluence on the more thinking portion of the profession. Some authors, again, have troubled themselves to prove that blood- letting must in all times have been injurious; — an unprofitable research — " a perverse idolatry. '' I would guard and caution the younger medical officer alike against the adoption of exclusive raeasures of cure, and against the over-treatment of fever, both being equally mischicA^ous. In truth, it is only by a rational and well adjusted plan, which shall call into operation all the aids suggested by science and by experience, that such a disease as fever can anywhere be justly treated. At this time of day it cannot surely be necessary to write chapters of heavy solemn dulness, to warn and convince well- educated medical officers that generally or locally to bleed, or otherwise reduce, old, worn-out, emaciated, or drunken men, or infants — anaemic, scorbutic, or otherwise sickly persons — would be neither good nor safe practice. If such persons were dying of apoplexy, no well-informed surgeon would propose to bleed them from the little toe— so carefully would he treasure up the watery blood of such subjects. Huxham indicates the just principle of action for all times and places, when he says that " each parti- cular disease in every individual patient is to be considered by the THE REMITTENT FEVER OF BENGAL. 3G5 attending physician ; not according to the nomenclature, but accord- ing to the nature, causes, and symptoms in that particular person." A\ c must here, as in all other instances, be careful not to confound the abuse of a great principle with the principle itself. Finally ; it cannot be too much or too often impressed on the Indian surgeon that it is on his careful attention to the phenomena and treatment of fever that nine-tenths of his usefulness depends. 1 have here presented the reader with a summary of the nature and treatment of the Bengal remittent fever : it will be found to correspond in most of its details with the history of endemic fevers generally, with the bilious remittents of the Indies, whether East or West : — they all have a pathological community, they are all fevers of locality, and do not by any means differ so much as medical writers of partial views and partial experiences would have us believe ; their supposed difl'erences, or nosological divi- sions, are more frequently the work of man than of nature : — they may and do difl'er in degree of intensity ; but their essential phenomena, and the organs affected in their progress so as to endanger or ultimately to destroy life, are the same, and so like- wise are the essential parts of their treatment. The remittent fever of Bengal is a disease of much danger to health, and of no small danger to life also ; but, under a rational plan of treatment, I know of no disease in which the resources of medicine are more effectual. General principles in physiolo:ry, pathology, and therapeutics, so far as these may be understood in our time, ought to be the aim and purpose of us all ; and the difference between one physician and another must in all times and places consist in the relative power to balance and de- termine such principles. This is indeed all that the best of us can do. I have now concluded this, the most important article in this work; and I trust that, provided I have treated the subject wor- thily, the reader will not consider that I have devoted too much space to the discussion of it ; for he who can successfully combat the formidable remittent fevers of tropical climates need not de- spair of acting with a like success in the treatment of the equally formidable dysenteries and hepatic diseases of those regions. The principles here inculcated will, if I mistake not, guide the medical officer to such favourable issues, under every variety of type and complication of remittent fever, as may reasonably be attainable in the present state of our knowledge. The means of cure recom- mended by me may appear to some persons to be of unmeasured power ; but the more I consider the nature of the three diseases naiued, the more assured I feel that the measure of cure, to be efiective, must at least come up to that of morbid action. A mode- rate and hesita^ting imbecility will never effect anything in medi- cine — and, least of all, in the treatment of tropical diseases. To treat efltectively one of the most acute and dangerous of fevers^ the 366 INTERMITTENT FEVER. mind of the army surgeon must be prepared by mucli foreknow- ledge and reflection ; for now the practical judgment must be formed at once^ there being no time for scientific deliberation. The decision to be arrived at must be the result of such matured fore- knowledgCj in order that the patient may receive at once the benefits of that compression of thought^ instantaneousness of con- ception^ and simultaneousness of grasp of the different bearings of a practical question^ which are so necessary to the army surgeon. For the following table, exhibiting the comparative frequency and the intensity, as shown by the relative mortality of remittent fever, throughout the wide extent of climate occupied by British soldiers, I am indebted to my friend Sir Alexander Tulloch : — Stations. Windward and Leeward Command Jamaica Gibraltar Malta Ionian Islands Bermudas Nova Scotia and New- Brunswick Canada Western Africa Cape of Good Hope St. Helena Mauritius Ceylon Tenasserim Provinces... Madras Bengal Bombay Period of obser- vation. 20 SO 19 20 20 20 20 20 18 19 9 19 20 10 5 5 5 years. Aggregate strength. 86,661 51,567 60,269 40,826 70,293 11,721 46,442 64,280 1,843 22,714 8,973 30,515 42,978 6,818 31,627 38,136 17,612 Remittent fever. Attacked. YF, YF. 17,799 38,393 * 314 1,522 384 6,934 * 19 277 15 294 1,601 15 25 6 4,643 594 1,139 1,311 2,854 Died. j Proportion of deaths to I admissions. 1,966 5,114 28 423 16 623 6 101 18 739 1 1 1 22 54 114 1 in 9 1 in 8 lin 11 1 in 3| 1 in 24 1 in 11 1 in 3 1 in 23 n 15 n 16 n 2 n 15 n 25 n 6 n 54 n 27 n 21 nUa n 25 INTEEMITTENT FEVEE. The proportionate amount of sickness from intermittent fever, in any given communities, will depend on the relative amount of local sanitary improvement, or of the neglect of it, in the districts, stations, and cantonments occupied by them throughout our inter- tropical possessions. The geographical distribution of the class of * The prevalence of epidemic yellow fever is here indicated. INTERMITTENT FEVER. 367 fevers here treated of will be found to be very much the same with that of remittent fevers ; where the one form of fever jirevails, there we generally find the other likewise; and whether an Euro- pean is to be afiFected by a remittent or by an intermittent fever will depend on length of residence in a tropical climate, on age, constitution, and previous habits of life, on season, and the in- tensity of the exciting causes. Intermittents, which are most frequent throughout India in the rainy season, attack the European and the native soldier in nearly the same proportion, the mortality in both, according to Mr. AVaring, approximating very closely. He adds that, in hot cli- mates, the quotidian is by far the most frequent type, the propor- tion being greater in Bengal than in Madras : tertians rank next, and quartans are the least frequent. The proportion of deaths in quotidians exceeds that which is observed in tertians and quartans. The usual history given by Europeans who have resided in malarious districts or stations is, that they had first been affected by remittent (jungle) fever, and that then followed the inter- mittent form. Dr. Bryson, in his Statistical Beports on the health of the navy serving in the East Indies, says of the fevers of China : — " A large proportion of, or nearly all the cases of intermittent, were the sequelje of fevers which had first appeared in the continued or remitting forms ; still there were a few which seem to have been intermittent from the commencement, although it is probable they were connected with preceding attacks which were not observed, or had been forgotten. ^^ In Calcutta, tlu'ough the hitherto gradual improvements in its ill-ehosen site, intermittent fever has become, for many years past, a mild and infrequent disease comparatively, especially among the better classes of society, and amongst Europeans of better habits of life. This simple fact strongly illustrates the beneficial influ- ences resulting from local sanitary improvements, while it con- stitutes a powerful inducement to the government and the public of the city in question, to proceed in the same course of ameliora- tion which has already secured to its inhabitants so great an ex- emption from disease. At home, and in our own capital, we find that the sweating sickness, scurvy, dysentery, malignant ague, and other formidable diseases, have yielded to the slow progress of sanitary improve- ment in modern London ; so, in our Eastern capital, Ave have no longer "the obstinate putrid intermitting fevers'^ described by the older writers, with their cold stage of " twelve hours'' and their long list of sequelae in the form of tumid livers and spleens, diar- rhoeas, dropsies, &c. &c., a condition of public health which we now regard, even in the capital of British India, with horror. Dr. Bogue, who practised in Calcutta in 1757, speaks of this form of fever " as the most fatal" of that time. It began with the 3C3 INTERMITTENT FEVER. rainy season, and continued with increasing violence during its continuance^ and " for some time after/' the paroxysm recurring daily, so that " the patients had not above four or five hours respite from it.'' Thus he says, " we had sick at the same time, in this place, one half of the men of the squadron under the com- mand of Admirals Watson and Pocock." The fevers here described would seem to have possessed the malignant character of ihefehres intermittenfes a/yidce of Torti, in which the power of generating heat was so impaired, that the patient died in the cold stage at the end of two or three accessions. Immediately, our modern intermittents are in general not dan- gerous to life, but consecutively, the dangers arising from Adsceral diseases, in after years, are considerable. Of this latter fact I have had presented to me in England very numerous instances, and a very remarkable one will be found under the head of Chronic Diarrhoea. In certain districts of the East Indies, as in others of our colonies, the type of intermittent fever assumes a malignant form, and then the dangers of a rapid dissolution, or of visceral disease and a broken constitution, are very great. I have said that ague is an " infrequent" disease in Calcutta, and strangers will read with surprise that I do not think I saw above a dozen cases in a year, on the average ; and these occurred in persons who went into the neighbouring jungles on hog-hunting and other such excursions. But this disease is of frequent occur- rence in the marshy and jungly portions of Bengal Proper, as well as of all such countries throughout India. I remember attending a mercantile gentleman who contracted his ague in the Sunderbunds, about the middle of October. On his return to Calcutta, about the 2Gth of the month, he experienced a good deal of malaise, and took medicine from a chemist with partial relief. Towards the end of the month the native servants who accompanied him fell ill of ague one after the other, and on the 20th of November their master was seized Avith a violent paroxysm of the same disease. Here we perceive the superior power of resistance to the morbific influence exhibited by the Eiiropean over the natives, as shown by tlie difference in the period of latency or of the abeyance of the fever in each, being more than thirty days in the former, as compared to ten and fifteen days in the latter. This gentleman was temperate in his habits, and inured to the climate ; and both master and servants entered the Sunderbunds in good health, and neither had been previously affected with ague. CAUSES. That the emanations from marshes produce agues is the universal belief of mankind in all ages and countries ; and the accordance of the medical profession in this opinion has always been quite as ueneral. INTERMITTENT FEVER. 3C0 !Many authors believe with Cullen tliat, in the climate of Eng- land, this fever can alone be produced by exposure to marsh ex- halations ; and Sir John Forbes has shown, in a very able memoir on the medical topography of Land^s End in Cornwall, "that neither impure air simply, nor wet, nor the alternations of cold and heat, nor all these combined, can give rise to fevers of this type." This I believe to be quite true in respect to ajirsi seizure, but ((/7er thai, and when the disposition to relapse is once established in the system, such a combination of influences will certainly, in tropical climates, prove an eflfieient cause ; and even Cullen admits " the concurrence of other existing fevers," when the malaria is not " strong enough to produce disease." In support of this latter ^dew I quote the following important passage from Sir James M'Grigor. " After the effluvia from marshes or the exhalations raised by a powerful sun acting on a humid or luxuriant soil, we found that in those who were convalescent or lately recovered from agues, the causes next in power to reproduce the disease were exposure to a shower of rain or wetting the feet, exposure to the direct solar rays, or to cold, with intemperance and irregularity, or great fatigue, ^lany other causes would excite the disease in the predisposed, but these never failed to do it. In marching troops in a country where the disease is endemic, particularly if they have been lately dis- charged from hospitals, the above causes should by all means be avoided, since the whole of our experience in the Peninsula showed that relapsed cases seldom or never get completely well in the country in which they were contracted, under all the circumstances of a soldier^s life. In making calculations of efficient force, this description of men could not be depended on for operations long continued in the field." Pringle, the father of British military medicine, writes to much the same effect : — '' After the frosts of November the intermittents never appeared unless upon catching cold, and even then such only as had been ill of them in autumn were seized in that manner." The important observation is continually repeated, also, by this great author, as to the excessive liability to attack of those who occupied the lower floors of houses and barracks, and this happened all over Flanders. SYMPTOMS AND PROGRESS. The symptoms of intermittent fevers are well known to consist, like those of remittent fevers, in paroxysms of three stages — a cold, a hot, and a sweating stage, the succession of such events following each other every day, when the fever is termed quotidian ; or every other day, when it is called tertian ; and when two days intervene, then it is termed a quartan ague ; the intervals being respectively twenty-four, forty-eight, and seventy-two hours. The intermittent differs from the remittent fever in this, that in B B 370 INTERMITTENT EEVER. ague tlie stages are generally complete and well marked, while they are followed by a complete intermission of disease, or state of health, which allows of time and opportunity for the application of means of cure, having for their object the arrest of further progress of the fever. Unchecked by medicine, however, the paroxysms of intermittent fever recur at regular or irregular intervals, for weeks, months, or even years, so as eventually to prove more or less de- trimental to health. The types of intermittent fevers change so that the quotidian becomes tertian, and this last again a quartan ; and so likewise do the paroxysms occasionally change their hours of invasion — sometimes coming later in the day, when they are said to be postponed — while by coming earlier they are said to an- ticipate. In all fevers of the paroxysmal form the former is re- garded as a favourable, while the latter is held to be an unfavourable event, in the progress of the disease. All the types of intermittent fever are to be found in the East, but by far the most prevalent is the tertian ; and we very generally find that the first seizure of this fever ensues upon an attack of the remittent form. It was so in my own person : — after a dangerous jungle fever, which I contracted on active service in the hill ranges of Gondwana, and from the violence of which I must have speedily sunk but for the profuse hsemorrhage from the nose, during the height of the two first paroxysms (the moment when I ought to have been bled, had there been any other medical officer pre- sent), I was left in a very emaciated and enfeebled condition.'^ In this state, while sitting to be dressed, near the door of my tent, a shower of rain came on, accompanied by a very slight reduction of temperature; and on the instant I was seized with violent shivering, which proved an intermittent fever. This disease in its tertian form harassed me greatly during eighteen months subse- quently ; and I only got rid of it by proceeding to the Isle of France, and by being absent from Bengal during eight months. But so severe were these fevers, that, in my after life, the suscepti- bility to malarious fever has remained so strong on me as never, up to this very day, to have left me. The average duration of a paroxysm ranges from six to twelve hours, the severity of the disease, as well as its amenableness to treatment, depending very much on the duration of the cold stage ; for where this last proves of two hours' duration, or more, and the disease is protracted, the patient incurs much risk of disease of the abdominal viscera. PATHOLOGY. All the organs and functions which are disturbed or oppressed during the paroxysm of remittent, are likewise more or less affected * I was bled by Nature — an effort without which I must, hke many others employed on this disastrous service, have sunk at once. An occurrence of this kind ought to suggest reflection, and imitation too. Nature bled me — at first not enough ; but on the second day sufficiently to save my life. INTERMITTENT FEVER. 371 in that of the intermittent fever. During the cold stage of the latter the brain is occasionally oppressed by congestion, while all the abdominal organs are similarly affected ; and in the succeeding hot stage the same organs and functions are more or less seriously disturbed in the tumult of vascular reaction. There is flushing of the face, headache, and sometimes delirium, the patient being at the same time distressed by general uneasiness, restlessness, and epigastric anguish. It is no Avonder that morbid actions and alternations such as these, repeated during weeks, months, or even years, should result in organic diseases of a formidable character. " The great influence of the malarious poison,^' says Dr. Golding Bird, "is in all probability essentially and primarily exerted upon the nervous system, especially on the organic or ganglionic struc- tures, which preside so importantly over the function of secretion. Thus all the secretions elaborated in the body become affected ; and, as is well known, a remarkable tendency to congestion is observed in the portal circulation, destined most particularly for tlie depuration of matters rich in carbon. There can be no doubt that the unhealthy secretions thus formed become active agents in keeping iip in the body the impression of disease.^' Agues which have become habitual by repetition will also im- part a character of periodicity to other ailments, such as neuralgic affections. A few years ago I became subject to facial neuralgia, which came on regularly at eleven a.m. — the very hour at whicli ague used to commence with me in India more than twenty years previously. Further, when the intermittent fever has been severe or long-continued, the disposition to recurrence of the same disease seems to last with many persons for life. After a residence of ten years in Europe 1 happened to pass three nights at the best hotel in Strasburg, at a time when ague prevailed in the garrison amongst the French soldiers who had served in Algeria ; and two days after quitting that town I was seized at the accustomed hour of eleven A.M. with ague, and I was the only person of the party who was so afl'ected. We have in the East not only every variety of type of inter- mittent fever, but every degree of intensity also — certain districts and provinces being noted for the malignity and fatality of their agues ; and even in Bengal Proper we have often to combat severe and obstinate visceral diseases, the sequelse to these intermittents. Under neglect of early and effective treatment such cases termi- nate in permanently broken health, through disorganizations of the liver, spleen, or mesentery, or of all three. In the malignant intermittent fevers of Aracan and Gondwana, and of provinces of a like unhealthiness, we perceive such remote ravages of disease as to prove at once conclusive, both of the original intensity and danger of the disease, and of the ultimate serious consequences, even after the lapse of years. One such case I will adduce by way of illus- tration : — B B *^ 372 INTERMITTENT FEVER. Captain Y r contracted the intermittent fever of Aracan in 1837j which was speedily followed by great enlargement of both liver and spleen. At my recommendation he was sent from Cal- cutta to England for the recovery of health, whence he returned to India in 1839. His health continuing very indifferent under various changes of climate, he was constrained to resign the service in 1847. But even in England he was always an ailing person; and in October, 1852, I was consulted on the state of his health, which was then desperate. He died two months afterwards in a state of universal dropsy. For the following post-mortem record I am indebted to Mr. Pollock of St. George's Hospital : — " The peritoneum was covered throughout its free surface with an opaque, white false membrane. This membrane was thin on the siirface of the abdominal wall and small intestines, but was very thick elsewhere, as on the surface of the stomach, transverse colon and liver, from which viscera it could be peeled off. Erom the peculiar manner in which it was spread over and attached to these organs, when the abdomen was opened, the small intestines were the only viscera that could be observed. The large intestine, stomach, liver, and spleen were hid from view by the false membrane glueing them together ; and the only indication of their situation was an irregular nodulated mass, covered with this membrane, and situated at the upper part of the abdominal cavity. The membrane on the right side was con- tinuous from the abdominal wall over the ascending colon to the spine, and so bound down the ascending colon that, until the membrane was removed, the situation of the bowel was not ascer- tained. Erom the surface of the bowel the membrane passed to and attached itself to the mesentery of the small intestine over the vertebrae, in some parts thicker than others, so that it might almost be said to consist of bands, and, from their attachments, thc}^ must have much compressed the ascending colon. On removing the membrane from the irregular mass, the stomach, transverse colon, omentum, and spleen, with the liver, were brought into sight ; but all these viscera had been compressed, as it were, into the mass by the false membrane spread over them — the membrane being strongest in this situation, and equal to three or four sheets of paper in thickness. The membrane here was readily removed. The liver was enlarged, but chiefly on its left side ; and between the longitudinal fissure and the extremity of the left lobe and its anterior margin, there was a whitish yellow mass of hardened de- posit, which dipped some two inches into the substance of the liver, and was some three inches broad. When cut into, it was firm and consistent, and appeared to consist of fibrous tissue, with portions of fatty matter, somewhat resembling the character of scirrhus, but less hard. The spleen was healthy, but larger than usual. The kidneys were healthy. The other viscera were not examined.'' INTERMITTENT FEVER. 373 The reader Avill now be able to appreciate the original violence of the intermittent fever in this instance, and the necessity there Avas for the most active antiphlogistic means, including general blood-letting, to overcome inflammatory complications. Such means were not applied — or, if applied, they were of but in- sufficient poAver ; — and hence, assuredly, the unfortunate issue. In all the scA^erer intermittent fevers of India, such as that by which the European and Native force under General Morrison Avas destroyed in Aracan, during the first Burmese war, we find the sequelse of diarrhoeas and dysenteries to be very frequent also;''*' and it is justly observed by writers on the diseases of Turkey, that where there is ague, dysentery is not far o&. Con- gestive and inflammatory aftections of the spleen and liver, diarrhoeas and dysenteries, the results of intermittent fevers, are most frequent and most severe during the cold season in Bengal. The influence, real or supposed, of splenic disease in keeping up the morbid train of actions of the original fever, and in producing relapses, is a subject Avell deserving the careful attention of the tropical practitioner. M. Piorry, on his attentive examination of the state of the spleen in more than five hundred cases of ague, has come to the conclusion that that organ is invariably enlarged during the pro- gress of the fever ; and he has ascertained with equal accuracy the fact that, by the use of quinine the spleen is diminished in size. INI. Piorry states : — * The devotion of the medical officers attached to this portion of our invading army was most notable. Mr. Grierson, of the Bengal Medical Department, says : — "Of the first five deaths that occurred among the European officers, four were in the medical branch of the service. This blank was severely felt ; but twice the above number were soon on the sick list ; and at length only eight medical officers remained for the whole duties of the division, the sick of which at tiiat time amounted to near 5500 men, besides the sick of the various public establishments and the camp-followers." All who were not dead were in hospital. From this simple statement, the hopeless nature of the duties devolving on the few surviving surgeons of the army of Aracan may be in- ferred ; and it will be matter of no surprise that in a few months three-fourths of the entire force, European and Native, perished on the spot, while the suffering survivors were ruined in health. Mr. Lewis Grant, of the Bengal Medical Department (brother to the gallant Sir Colquhoun Grant), was the principal medical officer. It is related of him that '' he was attacked by the fever, and recovered. When told by the surgeon who attended liini, that to save his life he ought to go, he replied, ' No, Sir, this is our post, and I will not set the example of leaving it.' He soon afterwards had a relapse, which proved fatal." The native officers of Gardiner's Horse tried to cause the authorities to intei- fere with their surgeon to take care of himself, and be less iu hospital. " The death of a dozen of us does not matter," they said; "but if he dies, the whole corps will perish." Mr. T. C. Robertson, the humane and most able commissioner on the spot, says, in his " Political Incidents of the First Burmese War :" — " The devotion of all members of the medical staff to their duties was most exemplary. Not one of them, however ill, withdn-w from the Province, where many of the number died. I have myself seen some of them, in the intervals of their own agues, wrapped up in cloaks and busied iu visiting the sufferers under their charge." Tlie commissioner, who subsequently rose to be Governor of Agra, might well designate the conduct of Mr. Grant as "a fine example." 374 INTERMITTENT FEVER. 1st. That the reduction in the size of the spleen bears some pro- portion to the quantity of the medicine taken. 2nd. That the effect produced by quinine upon intermittent fevers is proportioned to the reduction of the spleen. 3rd. That the fever is cured simultaneously with the cure of the splenic disease. 4th. That, on the other hand, the fever will be liable to recur so long as the spleen exceeds its proper size. M. Piorry believes that as the spleen attains its greatest size at an early period in ague, the paroxysm does not produce the hyper- trophy, but rather that the enlarged organ maintains the disease. He and M. Bally are of opinion tliat no other remedy is so certain or energetic in agues as quinine ; its powers being equally remark- able in the ascites that results from long-continued disease of the spleen. There are cases of intermittent fever, however, complicated with hepatic and other engorgement, and which continue to recur with deplorable perseverance and tenacity, despite of all means, until a few doses of calomel, followed by purgatives, are admi- nistered : then the quinine, which before failed, will speedily cure the disease. It would thus appear that certain morbid conditious of both liver and spleen will certainly produce and maintain the tendency to recurrence of agues. Ramazini relates the case of a patient harassed by an obstinate ague, and who was cured by mercurial frictions administered for syphilis. '' The cause which prevents the cin'e of ague," says Dr. Billing, " is visceral disease, which may either have existed before the intermittent, or have arisen during its continuance. The ague and the visceral disease, whether of bowels, liver, spleen, or lungs, &c., act reciprocally as cause and effect — the ague aggravating the visceral disease by causing congestion during each paroxysm ; the visceral disease, by keeping up morbid sensibility during the in- termission (or even a pyrexial state between the paroxysms, when the disease is named remittent), which prevents the cure; but if, by mercury, or bleeding, &c., the visceral disease be removed, the cinchona exercises its influence on the nervous system, and finally arrests the disease.'^ Following out this principle, though by means of a different class of remedies^ Dr. Golding Bird shows how, in persons having the sallow, dirty aspect of malaria, they may be made to exchange it for the cleaner and brighter complexion of returning health, by a course of alkaline treatment, including the renal dejmrants, and how visceral engorgements may be overcome, and the sufferer thereby prepared for the beneficial use of antiperiodics which had been previously ineffective. " In agne/' he says, " nothing is more easy, as every one is aware, than to check the paroxysm by means of antiperiodics, especially quinine, and in many cases the patient is cured by the remedy. But any one who has had an opportunity INTERMITTENT FEVER. O/O of seeing mucli of the effects of marsh miasmata^ is perfectly aware that if a patient has been long exposed to their influence, although paroxysms of ague may for a time be checked with qui- nine or arsenic, the unhealthy state of the blood is not removed. The sallow aspect — the depressed health — the visceral engorge- ment — all indicate that the poison remains in the system and is continuing its work, although its influence has been blunted by our remedies. After a time, however, imperfect paroxysms, the ' dumb ague,^ as they are often graphically called by the patient, appear again, requiring the antipei"iodic to check their further development. This is a common history, and many persons are thus not really absolutely freed from miasmatic poison for months or years. " I do not claim for the acetate of potass the ^drtue of an anti- periodic, but I do unhesitatingly declare that it will effect that which quinine and its allies cannot do. It will enter the blood, and as a nascent carbonate (possessing a far higher state of " chemical tendency" than ready-formed carbonate of potass) in the capillary network of the body, aids the metamorphosis and excretion of the unhealthy elements of the blood, and their conse- quent elimination by the kidneys. " When to a person suffering from the effects of marsh malaria, this drug has been administered to the extent of two drachms in the course of twenty-four horn's, largely diluted, and continued for two or three weeks, not only is no injury effected by the remedy, but the most marked benefits are observed to result. The patient's skin becomes less dusky, the expression more healthy, the dull aspect of the eyes changed for one of cheerfulness, the engorge- ments of the liver and spleen lessen, and the paroxysms of ' dumb ague' disappear, or merely require a few doses of arsenic for their complete cure, and thus to effect the complete restoration of the patient." We now perceive that, whether we have to treat the acute mala- rious fevers of hot climates, or the dumb smouldering fevers, the sequelse of the former, as they appear in temperate regions, we must, to obtain the full powers of tonic and antiperiodic remedies, first remove active or passive congestions of the abdominal viscera, and secondly, we must establish a free depuration, as necessary preliminaries. It is thus, and only thus, that we may justly com- bine the two objects we have in view, and lead to the safe and perfect cure of such diseases. This rule of practice applies, indeed, to the use of all general tonics — their effective application requiring a certain amount of previous depuration. The principle is founded on the acquired experience of ages ; yet it is not so well understood, nor carried out in practice, as it ought to be. Let us hope that a due consider- ation of its practical worth may never be lost sight of. The course of treatment here recommended I have found to be 376 INTERMITTENT FEVER. sound in principle and in practice during many years past^ in the chronic agues of European climates^ and in the cure of the sequelee to the intermittents of the tropics. TREATMENT. We shall be led to the most effective treatment of intermittent fevers^ by an early and close attention to their complications, such as the splenic and hepatic congestions, and the inflammatory affections of these and other organs, which occasionally arise during their progress, and towards their termination. The utmost attention should be paid, during and subsequently to each pa- roxysm, to the condition of the two important organs referred to, as well as to the state, whether congestive or inflammatory, of the cerebral and abdominal organs generally. It is easy in the average of cases to cure a simple uncomplicated ague ; but it is not so when the type of the fever is malignant, or adynamic, or where the complications are severe. In every case of ague there will be more or less of simple turgescence of both liver and spleen during the cold stage, especially if this last prove of long duration; but this turgescence disappears in mild cases with the sweating- stage of the fever. It is different, however, under concentrated endemic influences, and where the ague is consequently pernicious ; for here the spleen and liver, if they do not become immediately affected, are sure to be so eventually. Repeated over a succession of months or years, even simple turgescence may terminate in organic disease, from want of early or of proper treatment. In truth, the difficulties encountered in the treatment of agues consist in the presence of the original malarious influence, and in the existence of the complications above mentioned. Wanting these two, or, in other words, under change to a purer air, and in the absence of cerebral or abdominal complication, agues are very easy of cure. Emetics would seem to be indicated in the cold stage of this fever, with the view to restore the balance of circulation and re- lieve oppression resulting from congestion of the viscera ; but here, as in the remittents of Bengal, emetics are not, and never have been in favour with practitioners in the East. Warm drinks, am- monia, ether, camphor, and other diffusible stimuli, and warmth externally applied, are preferred by the great majority. When the hot stage has come on, a full dose of calomel with James's powder should be given at once, and in three hours this should be followed by a brisk cathartic — diluent drinks being freely used meauAvhile, along with some cooling diuretic : the tartarized antimony with nitrate of potash answers the double purpose of determining the fluids to the skin and the kidneys. On the following morning, the intermission being complete, the sulphate of quinine is to be administered, at intervals of three INTERMITTE?«T FEVER. 377 hours during the day, the patient being kept in bed, and supplied with forinaceous food only. The treatment here briefly indicated will speedily cure a mild and uncomplicated ague. In the simple cases here contemplated it may not be necessary to administer mercurials more than once or twice ; but active purgatives are always beneficial in relieving the full and congested state of the abdomen generally dui'ing the continuance of intermittent fever. But where the disease is severe, and accompanied by precordial oppression, pain, or fulness of the spleen or liver, or of both, or where there is severe headache, or headache with giddiness, or an oppressive fulness of the chest, a general or local blood-letting, or even both together, will be necessary as a means of present cure, and as a preventive of future ills. Measures of depletion are as necessary here as in remittent fever, and repeated applications of leeches, with several doses of calomet and strong purges are required, in these severe cases, to prepare the system for the anti- periodic power of bark, quinine, or arsenic. " Depletions/' says Copland, " are almost indispensable preli- minaries to the quinine or bark, especially in the complicated and congestive forms ; for, without them, it will either not be retained on the stomach ; or, if retained, will convert congestions, or slight forms of inflammatory irritation, into active inflammation, or into structural change.^' He adds that it is chiefly from a neglect of this practice that complications and unfavourable consequences so often follow the use of bark, quinine, or arsenic ; for these often interrupt secretion, and over-excite and inflame loaded, obstructed, or congested organs. As in the milder instances, mercurials with sudorifics, occasional diuretics followed by powerful cathartics, and quina, are here necessary ; and on their proper application the efficiency and the speed of the cure will depend. Blood should be drawn here, as in the remittent fevers, at the very onset of the hot stage, or that of reaction ; and it should be regulated by the constitution, age, and habit of the patient, as already explained. By such timely depletion congestions and inflammatory conditions will be removed, and much future disease and suffering will be prevented. Where, on the other hand, the intermittent fever assumes a low adynamic form, or where the subject is in a state of anaemia, with or Avithout enlargement of the spleen, mercurials should be most carefully avoided in the treatment, and reliance placed on change of air, quina, chalybeates, and improved diet. Under the condi- tion of the general habit now referred to, mercury must not be administered for the cure even of hepatic enlargement : — the nitro- muriatic acid must be used instead, both internally and externally. ]Mercury would here be at once ineffective and injurious — indeed dangerous — Avhile the mineral acids are most powerful to good. " One of the great elements of siiccessful treatment," says Dr. Golding Bird, " must of necessity be the depuration of the blood. 378 INTERMITTENT FEVER. and thus by freeing tlie system from the depressing influence of these vitiated matters, allow the vital powers to throw off the in- fluence of the poison which for a time oppressed them. The influence of small doses of mercury in the treatment of ague is well known ; by a gentle but persistent appeal of this kind to the liver, the patient is immensely relieved, and his ultimate cure expedited. Cotemporaneously with this, the aspect generally becomes less sallow, and sufficient indication of the liver becoming active in depurating the blood of carbon. Then, under the influence of that very curious class of remedies, the antiperiodic tonics, the paroxysms become less, or quite vanish, whilst ample e'sddence is afforded of the kidneys performing the important duty of filtering from the blood highly nitrogenized substances, in the rapidly in- creasing amount of solids existing in the urine." Those who advocate the exclusive use of antiperiodic means appear to forget that in fever a poison has been imbibed, and that for its elimination — to subdue the resulting visceral complica- tions, and to remove the poison from the system — we must, as often stated in this work, at first act upon, and through, the depu- rative functions ; and that, without such preliminary process, we necessarily leave behind some form of organic lesion. To arrest the periodical movement of fever merely for a time, is not to cure the disease ; and soldiers in this condition discharged the hospitals are harassed with relapses, and afflicted with abdominal conges- tions, too often to terminate in permanent injury to the structure of important viscera. When chronic disease of the liver eventually destroys life, the fatal result is principally brought about through the destruction of its deparative function. In the low form of ague, in the anaemic habit, and where there is chronic enlargement of the spleen, with the splenic cachexia, blood-letting, general or local, should also be avoided ; but even in weakly persons who are not anaemic, local blood-letting by means of leeches will be found extremely beneficial, under the cautions as to subsequent oozing already pointed out. In removing epi- gastric oppression or tenderness, or similar states of either or both hypochondria, fomentations followed by leeches will always, in a tolerably sound state of the constitution, be safe and proper, as will occasionally blisters. Warm- baths, used at bedtime, are likewise very beneficial. The condition of the spleen should be carefully observed during the entire progress of intermittent fever. In persons of plethoric habit, leeches and purgatives in the stage of reaction, followed by quinine in the sweating stage, and in that of intermission, and given in a larger dose two hours before the attack, will conduct the patient through in safety; while, in anaemic patients, the quinine ought to be conjoined with iron, and animal food should take the place of depletory measures. The sulphate of quinine is exhibited variously by various prac- INTERMITTENT FEVER. 379 titioiiers — some, as Maillot, giving very large closes, sucli as twenty and thirty grains four hours before the expeetcd paroxysm — while otliers begin to administer the quinine on the subsiding of the paroxysm, and during the sweating stage. But the most rational plan, so far as my experience extends, would appear to be that of ex- hibiting the quina every three or four hours during the apyrexy, and in such doses as the urgency of the symptoms may demand. In this manner a sufficient quantity of the antiperiodic will be best borne, Mhile the risk of injury by overdosing Avill be avoided— seeing that during the intervals of exhibition we can watch and measure the effects. I have always exhibited the sulphate of quinine in this manner, I believe with an average amount of success ; and it can hardly be necessary to observe here that I have seen, over a long range of years, and in various countries of the East, very severe types of intermittents. To cure the patient by means of the quina is all that is wanted ; and to exhibit more of that medicine than is needful to this object, or to protract the use of it beyond the occa- sion, is to injure him. I always administered the quinine in solution, with the addition of a small quantity of dilute sulphuric acid, and with the other occasional aids already mentioned. In the instances of plethoi'ic subjects, I conjoined the quinine with antimonials and diuretics ; and where the patient was feeble and irritable, with symptoms of exhaustion, I added small doses of tincture of opium to the antiperiodic. In robust subjects, newly arrived from Europe, the calmative and depurative measures were thus advantageously followed by a cholagogue and brisk cathartic ; and then came the tonic and antiperiodic influence of quinine, in its proper time and place. Several very able medical officers are in the habit of giving quinine in the intermittents of the East Indies, in doses of twenty-five to thirty grains '^as soon as the patient begins to perspire freely after the hot stage." They declare that this plan has proved in their hands more effective, and more economical of the medicine. Arsenic has for ages been known to, and largely exhibited by the Native doctors throughout India, in every form of fever, continued as well as paroxysmal ; and they are in the habit of exhibiting the mineral in very large doses, and for a long continuance — frequently with permanent injury to the health, as mentioned at page 341. When arsenic is preferred in the treatment of ague, it should be given in the College formula of solution, not in bitter infusions, as recommended by some writers, but in some aromatic water, with or without a few drops of laudanum to each dose of the arsenical solution, as may be deemed necessary. From six to eight drops given in this manner, every three hours, during the apyrexy, and continued only for a few days, prove very effective in many cases. Arsenic may also be given with safety during the paroxysm, as well as in the stage of intermission ; but the dose should always be taken after meals, as then the mineral is disseminated through 3S0 INTERMITTENT FEVEE. the food and absorbed along with it^ without the risk of causing irritation of the stomach. It will always be found to effect its greatest results where the spleen is not enlarged ; and this is a fact of importance to note. After the force of the fever has been broken by the use of quinine, or where relapses in lesser degrees of violence still harass the patient, the arsenical solution will be found a valuable aid and sub- stitute ; and this becomes an important consideration in the field of active service, where quinine may be scarce. The Swietenia Febrifuga, and the kernel of the Csesalpinia Bon- ducella, and the Chiretta, are much used by the native practi- tioners of Bengal, as antiperiodics and tonics. Mr. E. F. Sankey, of Beckley, Sussex, has for some years treated the ague of his district with iodide of potassium, and he states, on his experience of a large number of cases, that he " has never yet failed in curing the disease very quickly." His formula is a drachm and a half of the iodide to twelve ounces of peppermint water; and of this mixture the patient took two tablespoonfuls every four hours. In chronic cases, where the patient was much reduced, two grains of quinine were added to each dose ; but, in general, the iodide alone was relied upon. Another treatment, and a successful one according to report, has been by chloroform. M. Delioux, professor in the French Naval Medical School, forms a syrup by adding five parts of chloroform to a hundred of syrup ; of which he gives from one to three drachms in a mixture at the same intervals at which quinine would be given. The febrifuge powers of chloroform are stated to have received ample verification in the hands of this gentleman, in the cure of intermittent fever. The question of the proper substitutes for quinine acquires great importance in the East Indies, owing to the great cost of the drug, to the difficulty of obtaining it in remote districts and stations, and to the extensive adulteration of it by the natives. Where the intermittent fever has become chronic, or when as secondary results there is organic disease of the liver or spleen, or of both, change of climate becomes a measure of necessity ; and it is one that should never be neglected in such cases. I trust I need not add to what has been written in the last article on this subject. As, notwithstanding its scientific claims, fashion unhappily still holds some influence in medicine, and as bleeding in the cold stage of intermittent fever may again come under professional review, in the rouiid of medical opinions and practices, I think it right to notice the subject. My own personal experience will not allow of my speaking in favourable terms of this practice j neither will a reference to authority prove more encouraging, as the fol- lowing comparative quotations will show : — INTERMITTENT FEVER. 381 DR. MACKINTOSH. " The practice prevents debility in a direct manner by saving the vital fluid." MR. TWINING. " I may say that in all regular inter- mittents, with cold, hot, and sweating stages, and tolerable uniformity in the hours of accession, the practice of bleeding in the commencement of the cold stage, has proved always safe, and generally more successful than any other remedy." DR. MACKINTOSH. " I believe bleeding in the cold stage, conjoined with the occasional use of sul- phate of quinine and laxatives, to be as certain a mode of treating intermittents as any other set of medicines can be said to be certain in the treatment of any other class of diseases." DR. MACKINTOSH. " The practice may be adopted in the first stage of all fevers." MR. TWINING. " The recent practice of bleeiling in in- termittents, as recommended by Dr. Mackintosh, not only accords with the acknowledged pathology of that class of fevers, but seems to bring our system of therapeutics, as applied to them, within the limits of those established principles adapted to the treatment of other fevers, DR. ELLIOTSON. "It is not at all right to take away blood, and thus impair the power of the patient ;" when, as he adds, he " never saw a case which he could not cure by the sulphate of quinine." DR. W^ATSON, " I object to bleeding because itappears to me quite unnecessary ; because it is not such as the nature of the symptoms would suggest ; because it tends to produce sub- sequent debility, which we should not needlessly inflict ; and because the expe- rience of other sober-minded men, who have given the method a fair trial, does not bear out the statement made by Dr. Mackintosh in respect to its usefulness. If in this country bleeding be requisite at all, it is in the hot stage." DR. STOKES ' ' Bled in the cold stage, and found it useless and injurious ; and, after all, was compelled to give quinine sooner or later." DR. ELLIOTSON. " The quinine, which cures it best, in- terferes with no other measures." THE CELEBRATED DR. GREGORY. "Blood-letting, which at another period of the disease," namely, intermittent fever, " might have been proper, if em- ployed in the first stage never fails to be attended with the most dangerous conse- quences ; or it is, to use the words of Celsus, hominem jugulare." DR. COPLAND. "In a case where I directed blood- letting before reaction supervened, the loss of three or four ounces caused pro- found and prolonged syncope, yet within four hours, when reaction had come on, fifty ounces were taken before any effect was produced upon the pulse ; and before the sun of the same day had*gone down, forty more were abstracted at one time, in all ninetj'-four ounces within twelve hours." DR. DENMARK, PHYSICIAN TO THE FLEET. "In these instances venesection was never had recourse to till the vascular system had fairly emerged from the depressed state incident to that stage of the fever, and reaction had clearly mani- fested itself by the returning glow of the skin, the filling of the previously shrunk 382 INTERMITTENT FEVER. from whicli, formerly, intermittents were almost excluded." MR. TWINING. " The safety and efficacy of this practice have been so far established by Dr. Mack- into.sh that I have not hesitated to adopt it." . . . . ''The great advantage of V. S. in tiie cold stage of ague appears to me to depend on the prompt and decided relief it affords, guarding the patient agamst the ulterior results of repeated congestions of internal organs." .... " It appears to me that V. S. in the cold stage of intermittent fevers deserves to be classed among the best remedies which we possess for the effectual cure of many of the most obstinate cases of these diseases in Europeans." DR. MACKINTOSH. "Bark has been long in use, and al- though I never denied that it Iiad virtues, yet when given in substance in the large doses which are admitted to be necessary, I have so frequently seen it do mischief that the question has often suggested itself to me, whether it was not more injurious than beneficial ? It seems to be injurious in many cases by overloading the stomach and bowels with indigestible ligneous fibre, and I have seen it cause serious intes- tinal irritation, as displayed by griping pains in the bowels, diarrhoea, and painful tenesmus. On examining the stools in these cases, they seem chiefly to consist of bark, with a considerable quantity of mucus occasionally tinged with a little blood. " The preparation of bark, which is known by the name of the sulphate of quinine, is the greatest improvement in modern pharmacy, and the knowledge of its beneficial effects in simple intermit- tents affords sufficient proof of the virtues of tlie substance from which it is ex- tracted ; yet this remedy, all-powerful as it is, is useless in the cold stage, and must also fail in cases complicated with organic disease. .... My youthful readers may rest assured that the same observa- tions are generally applicable to the sulphate of quinine ; yet they will most probably meet with many practitioners who will assure thein that they have never seen a case in which bark, exhibited in and dejected features, and the firm though frequently oppressed beat of the pulse. Former experience not only taught me that an earlier abstraction of blood was never borne to an extent productive of ultimate benefit, but, on the contrary, seemed to be injurious by tending to pro- tract the first stage of the paroxysm." DR. WATSON. "Drs. Townsend and Law, of Dublin, found it fail in the majority of cases. In Dr. Stokes's hands the most usual effect of blood-letting was to check the shivering ; and, next to this, to mitigate the severity without abridging its duration. In most instances no modification was produced of the hot and of the sweating stages. In Dr. Kelly's experience the general effect was to shorten the cold stage, and to render the hot one milder ; but in some cases it seemed to aggravate the symptoms. Mr. Gill found that although the blood- letting might cut short the cold stage, it appeared to lengthen the period of febrile disturbance." DR. STOKES. "Having now described the effects of the practice on the paroxysm and on the local symptoms, I must next mention some very untoward circumstances which appeared to follow the bleeding in the cold stage — these were the occidrrence of neiv local injlammatory symptoms, and the supervention of a low irritative fever. From the examination of the cases, I apprehend that an impression will be received against the indiscriminate or even frequent use of bleeding in the cold stage of ague. It may be remarked that in the great majority quinine had to be administered before the disease was eradi- cated ; that many of them had an ex- tremely slow and dangerous convales- cence ; that in several instances the disease, so far from being relieved, ap- peared exasperated by the practice ; that local inflammatory affections occurred several times after the operation ; and lastly, that the bleeding appears to have a tendency to convert intermittent into continued fever. In one case, that of Caseley, death from pneumonia and softening of the brain occurred. In none of my cases did any bad effects from sinking of the powers of life follow the practice immediately ; but I am informed that in the practice of a highly respect- able individual, there occurred two cases in which the patients did not recover from the collapse ])roduced by bleeding in the cold stage. These facts should make INTERMITTENT FEVER. 383 substjince, or in any other form, has failed in their hands. When they hear such statements they may be satisfied that such practitioners never met with a severe case, or that there is some subterfuge. Some medical men, it is but charitable to sup- pose, are in the habit of deceiving them- selves. In the instances which fell under my own observation, and to which I have already alluded, fever and violent cereljral symptoms succeeded, and, in tioo or three instances, local inflainmatioiis." us very cautious how we interfere with nature by means of the lancet in simple intermittent, where we have so certain, and as far as I have seen, so infallible a remedy as the sulphate of quinine. I do not deny that cases may often occur where venesection may be proper, such as intermittent complicated with severe in- ternal inflammation ; but shall only re- mark, as these cases have not come under my own immediate observation, that to offer my opinion on a purely practical point connected with them would be wholly useless. I may mention that I have been informed by my friends, Drs. Townsend and Law, of this city, that they have given the practice a trial, and have found it to fail in the majority of cases." DR. JAMES JOHNSON. " What kind of inflammation must that be which explodes, as it were, the moment the clock strikes a particular hour, and this for days and weeks together ? What kind of inflammation is that which, every second day, terminates in profuse perspi- ration from head to foot, and yet is renewed after an interval of forty-eight hours with the symptoms as before, and so on ? Do we see real and unequivocal ivjlammations pursue this course ? Never. Are the causes of these intermittent phlegmasicB (if such an expression be not a solecism in medical language) of a pe- riodical or intermittent nature ? No. They do not accommodate themselves to any particular theory. " DR. HUGHES BENNETT, " I usually give five grains of quinine three times a day, and a scruple two hours before the occurrence of the attack, and have never seen a case which resisted this treatment." Thus it appears, at least in Europe, that the treatment of inter- mittent fevers by blood-letting in the cold stage, whilst it has the show of being prompt and energetic, proves in eflect haphazard, systemless, operose, and tedious ; and, from all that I have seen and heard in the East, the result there has not been more favour- able. Modern science, indeed, is steadily though slowly achieving a signal victory, in the treatment of fevers especially — namely, that over exclusive systems. It is no longer with us as with the cliaracter in Moliere — " A dead man is but a dead man, but rules * The italics in the two last quotations are mine, and I have added them with a view to mark the vagueness and want of precision in both writers when they speak of inflammation, whether as affording an explanation of the physiology of this disease, as some writers would have it, or as applicable to mere occasional complication. It is to the former notion that Dr. James Johnson's observations apply. MR. TWINING. " In the early stages of intermittent fevers, or to speak with more precision, within two or thj-ee weeks of their com- mencement, in persons of robust habit, there is ver}' often disorder of the func- tions and secretions of the digestive organs, and particularly of the stomach, co-eKistent with congestion of the brain, and attended in some cases with toleraUi) distinct evidences of inflammatory condi- tion either in the cei'ebral membranes or iu the brain itself."* 384 THE CONGESTIVE CONTINUED FEVER are everything/' Exclusive doctrines in medicine liave become like exclusive privileges in common life — tliey cannot be maintained. To conclude : — The rule of practice laid down by Pringle and Cleghorn has received little or no addition in more recent times. Where general blood-letting is had recourse to^ in the treatment of intermittent fevers^ whether simple or complicated, it should, as in the case of all other fevers, be performed at the very onset of the stage of reaction. Practised at this period of the febrile movement, it will diminish the force and frequency of arterial action, relieve venous congestion, usher in the sweating stage, and thereby pave the way for the administration of purgatives, sudorifics, diuretics, and quinine, on the just application of all which the prevention of recurrence must depend. In the milder forms of ague, in feeble habits, or in the cases of persons who may have resided long in India, local depletion, by means of leeches, will answer every purpose. THE CONGESTIVE CONTINUED FEVER OF THE COLD SEASON IN BENGAL. This fever, like all the diseases of the cold season in Bengal, is dangerous from its insidiousness. It is a frequent form of disease ; and none are exempt from its seizure — not even the prudent of the better classes of Europeans. It attacks persons of all ages, and of both sexes ; but men are, from their habits of life, far more ex- posed to it, and that in its graver forms. Its approach, unlike the fevers of the hot season and rains, is very gradual, being generally but little noticed either by the patient or his friends ; or, if noticed, it passes for catarrh, or dyspepsia. At this stage, the functions of circulation and secretion are but little affected ; yet, there is a harsh dryness of the skin, especially of that covering the abdomen, coupled with a sense of fulness and oppression at the epigastrium, which will not fail to attract the notice of the careful medical observer. In the course of a few days, provided these symptoms receive no professional attention and treatment, the circulation and respiration become hurried ; head- ache is present, together with lassitude and anxiety, loss of appe- tite and rest, the tongue indicating disorder of the digestive func- tions. The loss of more time brings with it serious complications in the form of abdominal and cerebral congestions, as indicated by increased fulness and oppression of the pra^cordia — tension of the whole abdomen — intense headache, with occasional delirium — and sometimes with yellowness of the whole surface of the body, jaun- diced eye, and a surcharged state of the urine ; in short, there are iil OF THE COLD SEASON IN BENGAL. 385 present all those morbid conditions wliich we miglit, a2^riori, anti- cipate as likely to arise from neglect^ nndcr the influences described at pages 57 to G3^ and which cannot be too deeply impressed on the recollection of all who have to encounter the cold season in Bengal; for the same neglect may, according to circumstances^ induce the fever here described, dysentery, or the still more dange- rous, deep-seated and insidious hepatic inflammation common to the cold season. It is believed that in animals whose pulmonary system is compa- ratively less perfect, there is a greatly increased quantity of blood transmitted through the liver. In hot climates then, where respi- ration is less perfectly carried on than in such as are cold, owing to the greater rarefaction of the air in warm regions, according to Tiedemann and Gmelin, a vicarious deearbonization of the blood is established by an increased flow of bile ; and hence it is that the liver, now weakened and rendered torpid, in proportion as its function has been unnaturally excited during the previous hot and rainy seasons, becomes disposed to congestion and inflamma- tion of its parenchyma during the cold season^ and thus are pro- duced the dangerous states of disease noticed. An irritaljle or inflamed state of the mucous digestive surface is a frequent complication ; and these combined circumstances con- stitute the great dangers of our congestive fever of the cold season in Bengal, as well as those of the autumnal fevers of the more un- healthy countries of Europe. The form of fever is generally continued ; but, when protracted, it may and does frequently assume the remittent character, parti- cularly where the patient has recently been exposed to malarious influences, as during the sporting excursions made during the cold season into the districts around Calcutta. In cases where we have to lament the neglect of early treatment, cerebral congestion with delirium prove occasionally long-continued and troublesome, espe- cially when to these states are added retention of urine — all demand- ing much care and attention : but serious as these cerebral aSections appear, I have generally seen that the patient recovered, provided they were not associated with abdominal complication of a grave nature. But when we have the attendants of yelloAV suff'usion, parched and black tongue, jactitation, and a generally typhous con- dition, we must perceive that the condition of the sulferer is one of imminent peril. The appearances on dissection are such as tlie nature of the disease and its complications might lead us to expect ; various degrees of acute congestion, or of inflammation, with their results, being very generally found within the abdominal and cerebral cavities. In neglected cases we find hepatic abscess, and some- times ulceration of the mucous digestive surface. This latter con- dition I found to be very prevalent amongst the labouring classes of natives, whom I had continually to treat at the Native Hospital c u 386 THE CONGESTIVE CONTINUED EEVEIl of Calcutta on account of neglected fevers of from fifteen to twenty days' duration ; and yet a large proportion of them re- covered. The treatment of the continued fever of the cold season in Ben- ga\, amongst Europeans^ is conducted on the same general prin- ciples which guide us in our management of those of the other seasons. We have to diminish arterial action, and relieve local congestions, by blood-letting, suited to the age, sex, and length of residence in India of the patient, and to the urgency of the symp- toms. Having effected these primary objects, we proceed, without loss of time, to promote the secretions by a full dose of calomel with James's powder, followed in a few hours by active saline ca- thartics. Where no complications exist, one or two moderate bleedings, followed by brisk purgatives, and tartarized antimony with nitrate of potash, will suffice for the cure, when these have been accompanied and followed by total abstinence from food, and by cooling diluent drinks. But where the brain, or liver, or both, have become the seats of diseased action, then our remedial means must increase in vigour ; the general and local blood-letting being larger in amount, and more frequently repeated — the calomel with antimony, and the purgatives, must be more largely and more fre- quently exhibited — until relief fi'om the fever and from all local congestion shall be obtained, together wdth a restoration of natural secretion ; for these are the only true signs of recovery. It frequently happens in the course of this fever, that, with or without cerebral oppression, we have a sluggish condition of the bowels, with defective hepatic and intestinal secretions. In order to elicit these secretions, I was in the habit of combining plain scammony and the James's powder with the calomel, exhibiting them thus united overnight, and following them up in the morn- ing by a brisk draught of infusion of senna with simple jalap powder ; or, where viscid mucus impacted the bowels, by a tere- binthinate draught. In the fevers of cliildren especially, we often find that the most alarming cerebral symptoms, with a doughy, inelastic state of the abdomen and torpid bowels, are removed at once by the night exhibition of medicine here mentioned, followed in the morning by the rectified oil of turpentine. When the patient is seen after having been many days ill, with- out previous medical aid, congestion having proceecled unrestrained within the cerebral or abdominal cavity, or within both, blood-let- ting, general and local, calomel, sudorifics with diuretics, and strong purgatives still constitute the means on which we must rely ; and we shall frequently have to exhibit the calomel so as gently to affect the system. These means, powerful as they are, will not, under the circumstances of neglect here contemplated, prove so prompt in their results as when applied earlier; but, nevertheless, they must be used^ powerfully and repeatedly in bad cases, otherwise OF THE COLD SEASON IN BENGAL. 3S7 the patient will be destroyed — all the functions being overpowered by tlie force of congestive disease. Where, on the other hand, we have e\adence of irritation of the mucous digestive surface, we must determine to the skin freelj^ by mild diaphoretics in the form of antimon}^ or ipecacuanha, together with warm baths, relieving the bowels when necessary by the most unirritating aperients. Natives of liengal were daily brought into the Native Hospital in the most advanced and neglected stages of this form of fever ; with tumid aljdomens, confirmed stupor, and tongues black and dry as charcoal ; and it was surprising how many of these poor people recovered under the following plan of treatment, which, after a large amount of experience, became at length the settled manage- ment in such cases. On admission into hospital, the patient Avas put into a warm bath, while the entire surface of the body was purified by the free use of brush and soap — the head being shaved at the same time, and cold applied to it. A large sinapism was then applied to the abdomen ; and where the state of the pulse admitted of it, a few leeches were applied to the epigastric region, or behind the ears, or to both regions, followed in a day or two by blisters to those parts. A very mild aperient draught was always administered on admission, aiding its operation by eneraata. A course of treatment was then commenced, of alkali, mild ape- rient and sudorific, all conjoined. The formula which I ordered was generally as follows : — Sesquicarbonate of soda ^j Powdered rhubarb grs. v. Powdered ipecacuanha grs. j to ij. This medicine was exhibited three or four times in the twenty- four hours, according to the severity of congestion, while the diet consisted only of iced barley-water ; and, as 1 have already stated, the result from these simple means was such as to surprise medical officers ha])ituated only to the treatment of Europeans. The pro- gressive recovery of sense, and gradual restoration to health, of persons who, a week or ten days before, had appeared in a hopeless state of disease, were very remarkable : but the natives of India will recover from Avouuds, and from advanced states of diseases result- ing from fevers, which would destroy any European. The cases of fever here referred to were those of persons of the hibouring class of natives, in whom fever had gone on unrestrained by any treatment for fifteen or twenty days, and in which, consequently, the period for more active measures of cure had long passed away. We were therefore content to work on gradually with nature — to see the patients improving ; as any heroic endeavour to hasten the operation of cure would only have endangered their safety — so reduced were the powers of life. c c 2 388 THE ARDENT CONTINUED FEVER To conclude : — it is scarcely necessary to urge that where this fever assumes the remittent character^ whether in the instance of an European or native, quinine in proper closes, and administered during the remissions, will prove of signal advantage. THE AEDENT CONTINUED EEVER OF THE HOT SEASON IN BENGAL. I HAVE placed my notice of this fever last in order, hecause, though very dangerous to persons of irregular habits of life, it is yet by no means so frequent of occurrence as the forms of fever previously noticed. A consideration of what has been said on the general influence of a high range of temperature at pages 45 to 52, will have prepared the reader for an unusually severe and dan- gerous disturbance of the nervous and vascular functions, under the united influences of direct, and of long-continued solar exposure, especially where there has been intemperance of habit ; and so we find it in the European soldier, in whom this ardent form of fever often merges in coup-de-soleil, or heat-apoplexy. It cannot be necessary to enter into all the minute details of symptoms in the milder forms of this disease, seeing the graver type of remittent has already been described. It is always easy to bring the mind to the comprehension of simple and uncompli- cated diseases, when once Ave have been rendered familiar with their concentrated and more complicated states. The type of this fever is usually continued, but sometimes re- mittent : it seizes with suddenness and violence, the heat, thirst, throbbing and frequent pulse, restlessness and racking headache, coming in rapid succession. The complications are generally cerebral, with occasionally severe forms of gastric disturbance, as indicated by pain, oppression of the prsscordia, and vomiting; sometimes the liver is involved. We have not here the tendency to collapse so characteristic of the true Bengal remittent fever, as it occurs in the rainy season, but the ardent rapid progress of the disease, together with the cerebro-spinal and gastric complica- tions, render this fever of the hot season one of very considerable danger. The appearances on dissection are such as might be anticipated from the symptoms during life ; they consist of inflammatoiy and congestive states of the cerebro-spinal organs ; and Avliere the stomach, lesser bowel, and liver have been implicated, we per- ceive the morbid appearances common to our other fevers of the climate. Serous effusions are frequently found in the cerebral and abdominal cavities, more rarely within the thoracic cavity. The treatment consists in active blood-letting, practised to the OF THE HOT SEASON IN BENGAL. 389 extent of allaying tlie vascular disturbance, relieving tlie pain of the head, and reducnig the temperature of the body ; these are the tests and the proof that the operation has been successful. Leeches applied behind the ears, cold aftusions, continued cold to the shaved head, and calomel and antimony, followed by very- active purging, will generally confirm the relief of the patient and complete his cm^e. In this fever, as in that of the cold season, the skin will generally be found harsh to the touch, compacted, hot and dry, so as to require a more free use of antimonials and refrige- rants, antimonial diaphoretics, united with cooling diuretics, than we find to be necessary in the fevers of the rainy season. When remissions take place, provided the head be relieved, quinine must be had recourse to for the purpose of preventing the recurrence of paroxysms ; and should symptoms of exhausted nervous power, or of delirium tremens, make their appearance, from half a grain to a grain of opium, united with calomel and antimony, will soothe and procure sleep. But here, as in all diseases which tend towards coma, we must be guarded in the use of opium : it masks the real state of the disease, deceiving both the friends of the patient and the surgeon. In this, as in the ordinary remittents of Bengal, where an anaemic irritable coudition of the brain has become manifest, symptoms occur which prove very embarrassing to the young surgeon ; and the treatment of them by camphor, or by camphor and opium, becomes an important practical question. Let it be carefully noted, that the indication for the use of opium is, the existence of well-marked nervous symptoms. " For the congested state of the nervous centres in fever," says Dr. Billing, " syrup of poppy, or a few drops of laudanum, will produce an effect equal to that of a larger dose of opiate medicine in other states of disease." The same authority observes that narcotics are frequently useful during fever, nay, necessary, as may- be understood by referring to the essence of fever, and knowing that sleep is nature's restorer of deficient nervous influence. The obstinate wakefulness which takes place in some cases of fever must have a deleterious tendency to produce collapse, hence the benefit of gentle opiates. Drs. Corrigan and Gordon, of Dublin, have for some time past exhibited chloroform internally to procure sleep in fever, to re- lieve pain in painter's colic, and to overcome nervous agitatioi and restlessness in delirium tremens. " The affections of the cerebral functions," says Dr. Gordou, '' frequently assume great importance in fever; their derangouent is sometimes indicative of disease in the respiratory apparatus, or in the digestive canal ; more commonly, however, it is owing to the organic nervous influence produced by the fever on the brain and nervous tissue itself. One of the most prominent character- istics of this lesion is insomnolency, causing, or, at all events, followed by delirium, subsultus, &c." It is in such highly dan- 390 THE CONTINUED FEVER OF THE HOT SEASON. gerous states of disease that cUoroform internally administered produces tlie happiest effects. Dr. Corrigan states truly that '' the loss of sleep, if continued, is of itself sufficient to kill ;" and he adds that, " if even the shortest sleep is procured, some advantage is gained.^' His for- mula, of which one ounce is the ordinary dose, is a follows : — Chloroform 3v. Pulv. glycyrrhizae 3v. Mist, camphorse 5'xss. To afford sleep in fever, to relieve pain in painter's colic, the minimum dose exhibited is half a drachm of chloroform repeated every two or three hours. In delirium tremens the dose at first is a drachm, and is often increased to two drachms. It may with Hafety be given in larger doses, and, unlike opiates, it does not lock up the secretions. Speaking of the use of wine in fever. Dr. Billing says, that the person who best understands the nature of delirium treipens will be the quickest to discern the propriety and necessity for the ad- ministration of wine and opiates in fever, erysipelas, &c. Even in inflammations occurring in debauched and debilitated constitutions, it is absolutely necessary to give more or less stimulants at a very early stage. Where wakefulness threatens injury during the course of, or in the more advanced stages of tropical fevers, or where symptoms indicative of delirium tremens arise, opiates are not only safe but necessary ; but the inexperienced medical officer must be on his guard against error in diagnosis. He should feel his way with small doses at first, given at intervals ; for, as remarked by Dr. Latham, it is a fearful thing to strike a heavy blow in the dark, where the alternative is of such magnitude. It is in this fever that cold affusion exerts its greatest power in abstracting heat and subduing nervous and vascidar excitement. I remember the case of an officer who had been much exposed to the direct rays of the sun, and who was not subjected to treatment until the advanced stage of his fever. His sufferings and distress were beyond description, and he appeared to be rapidly sinking. His reduced state rendered blood-letting in any form inadmissible ; but the skin being of a pungent dry heat, I had him soused with cold water, and the relief was, excepting in one other case already narrated, the most surprising of any that I have ever witnessed. This person, to all appearance lost, was, through cold affusion chiefly, speedily restored to health. HEAT- APOPLEXY, COUP-DE-SOLEIL, OR SUN-EEVEll. 391 HEAT-APOPLEXY, COUP-DE-SOLEIL, OR SUN-FEVER. HISTORICAL NOTICES. Allied in some degree to the ardent fever of the hot season in Bengal^ and frequently merging into it, is the disease above desig- nated. Under the appeUations of insolation, coup-de-soleil, mort subite, heat-apoplexy, heat-asphyxia, ictus solis, sun-fever, and erethismus tropicus, this fatal disease has been long ago noticed by various Avriters, British and French, as especially ^^siting Europeans of intemperate habits, with impacted skins and gorged viscera^ during the hot and rainy seasons of tropical climates. It is one of the most deadly of the " thousand natural shocks that flesh is heir to.'' Two instances of this sudden seizure are related in the Bible : — '' And INIanasses was her husband, of her tribe and kin- dred, who died in the barley harvest. For as he stood overseeing them, and bound sheaves in the field, the heat came upon his head, and he fell in his bed, and died in the city of Bethulia." Again, we have the case of the son of the Shunammite : — " And when the child was grown, it fell on a day_, that he went out to his father to the reapers. And he said unto his father. My head, my head. And he said to a lad, Carry him to his mother. And when he had taken him, and brought him to his mother^ he sat on her knee till noon, and then died." The exuberant nomenclature of this disease offers an indi- cation of the somewhat various forms under which it makes its appearance ; varieties in morbid association and complication rather than in essential differences, and resulting from the in- fluences of locality and climate, of season, diet, clothing, and nature of the service on whicli the soldier may have been employed. The truth is, that the terms above cited have been applied loosely to designate physiological and pathological changes or alterations in the functional connexions of the organs principally involved — as the brain, lungs, and heart ; and these vary in degree according to the sanitary circumstances under which the sufferers happened to be placed at the time. Not one of the terms can be said to be founded on a strict pathology ; and this fact has been variously commented on, especially by the French authors. As justly observed by Mr. ]\Iarcus Hill, of the Bengal Army, " the nomen- clature of the disease requires careful sifting." Dr. Dowler, of New Orleans, makes a distinction between " solar asjilii/xia," and " solar si/ncope ;" — adding that '^ solar asphyxia is always fatal ;" but that "this 'might be curable if the patient were bled imtan- taneouslij .'^ A close and careful consideration^ however, of the 392 HEAT-APOPLEXY, COUP-DE-SOLEIL, sanitary conditions^ the history^ and tlie pathology of the several recorded instances, will shoAV that they have each and all been bound together by the one necessary condition of an unnatural sun-heat, more or less directly or more or less intensely applied. The main errors, in fact, appear to have arisen from an inattention to the true medical topography and statistics of the disease ; and these neglects, again, have led to an uncertain pathology, and a more uncertain treatment. But we have still in medicine, as in less important branches of knowledge, observers by whom everything is assumed and classified before anything is known ; and thus words take the place of things. In defect of a more special and determinate pathology, it may be best, therefore, in respect of this disease, to leave its terminology to be settled by the results of future research ; meanwhile, the terms are sufficiently copious for the purposes of selection, when the proper time for it shall arrive. CAUSES. "When the strong S.W. monsoon ceases, and the sky becomes obscured by a film of dark, negatively electrified clouds, and the atmosphere hangs like a weight on the mind and body of the soldier, then it is, as remarked by good observers, that epileptic seizures have always been most prevalent in India. In countries near the equator, where the heat throughout the year, though high, is uniform, sun-stroke is said to be of but rare occurrence : — a certain amount of variation in the temperature of the seasons vv^ould therefore se'em to dispose to this disease. For instance, in Sierra Leone, according to Dr. Winterbottom, sun- stroke is unknown, in the infant " not a month old," as in the parents, although in all three the head is exposed uncovered at all seasons ; while in the East Indies, children and grown-up persons are everywhere, but more especially in the more northern divisions, struck down by the sun, or, as they conceive, by the wind. " Even Europeans," says Dr. Winterbottom, " are not liable to sun-stroke in Africa ;" and " when they are said to die from this cause," he concludes that it occurs more " from the abuse of those destructive liquors, ardent spirits," than from the sun. This author states that in the year 1743, between the 14th and 25th of July, up- wards of eleven thousand persons perished in the streets of Pekin from heat-apoplexy. It is worthy of remark that sun-stroke is very rare in the pilot service of Bengal, whose members enter on duty very early in life, although exposed continually in the chains as leadsmen during the first five or six years, in a frightful glare, and under the direct rays of a sun, amounting in July and August sometimes to a heat of 140°. Instances of sun-stroke, on the other hand, are frequent amongst the crews of ships from Europe, when being piloted up the river to Calcutta ; another confirmation of the fact that the newly-arrived and robust are most liable to OR SUN-FEVER. 893 attack. Officers of the Indian navy have assured me that, not- -vvithstandiug- the terrible heats of the Persian Gulf, sun-stroke was rare amongst the European crews. Direct solar exposure has been too generally and too exclusively assigned as the cause of this form of disease; but Campet speaks of it, under the term mort suhlie, as resulting in Europeans (given to excesses in eating heavy suppers, and in the use of Avine and ardent spirits,) during sleep under a high temperature, especially if, by closed curtains, they rendered the imprisoned air polluted and suffocative, thus depraving the circulating fluid, and producing a mortal syncope. In the East as in the West Indies, direct solar exposure is not necessary to the induction of sun-stroke, men con- fined in-doors during the hot season being also liable, especially under intemperance in diet, and in a calm, sultry atmosphere. The able and experienced Mr. T. E. Dempster, of the Bengal army, speaking of the prevalence of heat-apoplexy in the Mooltan divi- sion, under Sir William Whish, in the hot season of IBM), says: "^During the first few marches, a number of men fell victims to that fearful disease, and it is here worthy of remark, that the fatal seizures usually occurred about three o'clock in the morning, and long before the sun was above the horizon." Dr. Dick, of Bengal, in a letter to Dr. Duncan, published in his Commentaries so far back as 1785, describes this disease as having been prevalent in a detachment of European artillery then serving in the Carnatic. In April, May, June, and July, the land wind blew so exceedingly hot and dry, that life was hardly sup- portable at noon. The cholera morbus, dysentery, inflammations of the liver, and ardent, or what they call bilious fevers, became frequent in camp at this season. A species of apoplexy which seized the men when fatigued by marching in the heat of the sun proved, however, more fatal to the Europeans than any of the above. They complained first of great headache, in a few minutes a vertigo and bilious vomiting came on ; they dropped down breathless, turned comatose, and unless immediate assistance was given, the face swelled, and turned almost black ; the pulse, Avhicli was at first full and quick, sank; and after some hard struggles for breath, they expired. Such is the substance of one of the earliest descriptions of coup-de-soleil in the East Indies. The increased feebleness of the heart's action, as the disease advances, has been noted by several of the American writers ; and there can be no doubt tlrat feebleness of the respiratory function advances in corresponding accord, so as speedily to overwhelm the sufferer. In a recent hot -weather campaign in India, it Avas prin- cipally amongst the newly-arrived corps, composed of young men, and who had been exposed to much fatigue, that the mortality was the greatest. Regiments pre"viously stationary, as in cantonments, or during the ease and inaction of a sea- voyage, when called into sudden 394 HEAT- APOPLEXY, COUP-DE-SOLEIL, and active exertion^ witli loss of night-rest, especially under ex- posure to heat and malaria, and under deprivation of water, will be sure to suflFer on the march from sun-stroke. These unfavour- able conditions will receive much aggravation from heavy arming and marching in close order of the soldier, and from unsuitable clothing. The dining and sleeping under the greatest diurnal heats must also prove injurious to the digestive process, and favour cerebral and other congestions, constipation of the bowels, &c. TOPOGRAPHY AND STATISTICS. While making an examination of the records in the office of the Army Medical Department, to which, through the kindness of Sir James M'Grigor, I had access, the clerk who assisted me said: " Here, sir, are twenty-two admissions into hospital at Berham- pore in one season from apoplexy, and twenty-one deaths. ^^ They were, apparently, examples of the most violent cerebral fever, amounting in many cases to actual and deadly apoplexy. The history of these fatal cases, as given by Drs. Henderson and Mouat, the able medical officers in charge, will afford a fair sample of certain forms of this fatal disease. " Where the line was to be drawn,^' says Dr. Henderson, " between apoplexy and remittent fever, is here hard to say." The soldiers consisted of older men, of damaged constitutions, who had recently returned from the first Burmese campaigns, and of recruits but recently arrived from England. The corps (H.M. 13th Light Infantry) was marched in two detachments from Nuddea to Berhampore, a distance of sixty miles, during the hot season — cruelly, because unnecessarily. The recruits had been drilled in the sun, in the approved cocked-hat system, three times a day, before quitting Calcutta, so as greatly to injure their health ; in short, both classes composing the regiment were in but indif- ferent health on commencing this unfortunate march ; and though it was chiefly conducted during the night, with every care within reach of the medical officers, the effects were fatal in a remarkable degree; " ivhile none of the Natives were taken, ill during the trij).''* Such of the Euroiseans as could not reach the ground of encamp- ment by nine a.m. " were seen to drop down and instantly expire ; others, less severely attacked, were saved by a timely and copious bleeding." But presently Dr. Henderson became seriously ill, and this day closed with a sick-list of sixty-three, and eighteen deaths, out of the right wing alone; both tlie sickness and the deaths occurring principally amongst the recrviits. Dr. Milligan, H.M. 63rd Regiment, describes a similar outbreak of this disease, on the occasion of a military funeral at Madras — * "1 have never as yet met with sun-stroke affecting a negro, though told that such cases are not uncommon in the South." — Dr. Levick, of PhUadel^hia. OR SUN-FEVER. 395 as badly arranged an affair as the otlier. '' The greater number of the men were in the prime of life ; but there were amongst them some old soldiers who had served twenty years or upwards, some of it in the "West Indies, and were much broken down by scrviee and intemperate habits/^ The entire corps had just ar- rived from Australia, " where spirituous liquors were to be had on easy terms.^^ The regiment landed in INIadras in May ; and from the date of the " untoward circumstance " of the funeral, " the hospital became filled with cases of fever.'^ Two men dropped down dead on the very day of the funeral, and for several days afterwards the fever eases augmented considerably. " I have reason to believe that the effects of this exposure to the rays of the vertical sun did not rest here, but laid the foundation of future mischiefs in assisting to originate fever, hepatitis, and dysentery, from which the regiment afterwards suffered much." All these observations are highly important, as establishing the great value of sanitary precautions, and the fact of the functional connexions of the morbid condition induced by direct solar exposure. Examinations after death were, unfortunately, impracticable in both the cruel instances cited, the sickness of many of the medical officers, and the harassing duties imposed upon all, leaving no time for these customary investigations. During the fatigue and severe exposure of the Bengal detach- ments, it has been remarked that, while the Europeans suffered so fatally, '' none of the natioes toere taken ill ;" and such will, I dare say, generally be the case. I recollect an instance, however^ Avhere morbid insolation proved the reverse of this in the Governor- GeneraVs body-guard of cavalry, with Avhich I served during the two caaipaigns of the first Burmese war. We mounted at eleven A.M. of the 12th May, and, with one short halt only, we made a forced march of forty miles, under as powerful a sun as ever shone in Burmah. The heat oppressed us almost beyond endurance, and many powerful men, native officers and troopers, fell off their horses, vomiting, convulsed, cold, and covered with profuse clammy sweat. ^Yhere a tree could be found, I had the men placed under its shade, and they were dashed over with water, the detachment pushing on in pui"suit of the enemy, leaving the men thus affected on the roadside ; i/et not one of us Eurojiean officers, whether commissioned or non-commissioned, Jell sick, either on the march or after it. But we were all young, healthy, and temperate in our habits ; in the high, hopeful spirits of an active pursuit ; we were also well seasoned to the climate ; and such men, it is well known, will bear with comparative impunity fatigue and ex- posure almost beyond belief. By seasoning no more is here meant than the gradual accommodation of the constitution, through the operation of physiological changes, to unnatural and extraordinary ranges of temperature, and which accommodation we everywhere observe to occiu' during the first few years of residence within the 39G HEAT-APOPLEXY, COUP-DE-SOLETL, tropics, wlien sanitary considerations obtain a careful attention. This, and no more, is meant by the term acclimation ; in short, as stated in the article on " Climate," it is the ill habits of life of the European soldiery, and the sanitary neglect to which they are exposed, that give such fearful activity of power to tropical heat. In the two wings of the IStli Regiment, for instance, we hear of no officers having fallen sick, excepting Dr. Henderson ; and his fatigues of body and mind will sufficiently account for his illness. There was this difference in the probable and actual event, as observed by me in the body-guard : that had any of us Europeans fallen, our saddles would have remained unoccupied ; whereas, of the natives, all were up (although feverish) and doing well, when next day we marched back upon Prome. The daiigerous character of the disease is sufficiently exempli- fied in all the medical narratives which speak of the sun-stroke, and is statistically shown, by Mr. Marcus Hill, in the fact that, out of 504 seizures, there occu.rred 259 deaths. Of the remaining number, this intelligent and promising officer (since killed by the mutineers) states that eight were doubtful ; leaving the deaths to seizures at 51"38 per cent., while the recoveries were but 45'03 of those attacked. The statistics of Dr. Gordon, of the 10th Eoot, are still more melancholy. Out of 28 cases treated by this able officer, but one recovered, and that imperfectly. He estimates the mortality amongst European soldiers at 80 per cent., and that of officers at 66'66 per cent. Dr. Lindsay, of Bengal, again, states that, " once seized, he has never saved a patient." His patients, and most of Dr. Gordon's, must have been beyond the reach of cure when cure was attempted. This would appear the only fair construction. Let us but contrast these declarations with that of Dr. Castello, of the Bombay army, and we shall perceive at once how great the varieties, how vast the differences which occur, under different conditions of service. This officer says : — " Under the head of ' diseases of the brain,' a large number were sun-stroke. I have been fortunate in the treatment of these cases, not having had a single death." During the mortal and ever-memorable struggle within the intrenchments of Cawnpore, under Sir Hugh Wheeler, where " death and mutilation, in all their horrors, were daily before the garrison," the sun did its worst by the British soldier. The heroic Captain Moore, writing " by order " of his commander, says : " Our loss has been chiefly from the sun and their heavy guns." Colonel Liddell, of the Bombay army, told me, that in the action at Coonah, May, 1857, thirteen dogs perished in the field, convulsed, and with all the symptoms of sun-stroke. Nowhere else, unless it be on the field of battle, do we behold so sudden and violent destruction of life as in the heat-apoplexy. OR sUx\-rEVER. 397 Here, indeed, '^iu the midst of lifcAve are iu death." As described by ^Ir. Straker, of the Bombay army, " life does not ebb, but rushes torrent-lilie away." SYMPTOMS AND PROGRESS. The suddenness and fatal character of the seizure, leading, as it so frequently does, to the speedy death of men previously in health and in the midst of active employment, necessarily implies a de- fective knowledge of the earlier and less remarkable symptoms and stages of the disease. First we have vertigo and headache, with sense of burning in the eyes, the conjunctivae being injected ; a full and frequent pulse, vomiting, great heat, sometimes floridness, of skin, a devouring thirst, oppressed respiration, and swollen face. Then come lividness, sinking and running of the pulse, clammy sweat, exhausted nervous energy, faltering of the tongue, coma, convulsion, and speedy death ; — these constitute the course of events in the true heat-apoplexy : the tale is soon told. The gorged, apoplectic condition of the lungs, as of the brain, is made apparent during life by the oj)pressed and difficult breathing, with the '' curious catching at the chest" — a hesoiii de resjnrer — observed by various of our surgeons, and by the racking headache, lividness, coma, and convulsion, manifested in other cases. In such instances the pupils are contracted and insensible to light, and there is frothing at the mouth, while the abdomen is swollen and tym- panitic. A medical officer, a survivor from two attacks of heat- apoplexy, has stated to me that his greatest distress arose from constriction and oppression of breathing. Overpowered by these feelings, he fell off his horse, but did not altogether lose conscious- ness. It would seem as if the sun-stroke in some persons produced pulmonary engorgement and apoplexy, and in others the cerebral form of that disease. Others, again, have mentioned pain along the spine as occurring with intense headache, and that the former pain proved the more enduring of the two, recurring on subsequent occasions of exposure to the sun, while the head remained free from pain or giddiness. There is great and peculiarly intense heat of the epigastrium, with much oppression of the respiratory and cir- culating functions, all indicating lesion of the great central ganglia, analogous to that of the most concentrated forms of remittent fever ; in fact, when the seizures are of the milder nature, the case pro- ceeds into the stage of fever. The differences in the symptoms and progress of the ardent fever of the hot season in Bengal and of the heat-apoplexy, consist principally in the more defective aeration of the blood in the last-named ; in the consequent stagnation and spoiling of the blood in the lungs and brain ; in the greater rapidity of the processes which lead to destruction attaching to the disease. In the most aggravated forms of heat-apoplexy, the morbid changes run their coiu'se in a few minutes apparently, and in cases of less 398 HEAT-APOPLEXY, COUP-DE-SOLEIL, fatal tendency in a few hours ; while in the most severe forms of ardent fever, those changes, whether favourable or otherwise, are much longer in arriving at their termination. In the worst forms of the former disease, death comes, in fact, with all the rapidity of strangulation or of suffocation. PREMONITORY SYMPTOMS. The persistent marching of European soldiers in the night, how- ever necessary as against insolation, deprives them of refreshment by sleep, and thus disposes to the subsequent stupor of the disease. One entire night's rest, at stated intervals of time, should be afforded during the hot weather march, whenever the nature of the service may admit of it. The want of this natural refreshment, and the evils attending the withholding of it, are shown in the fact that lassitude, yawning, with urgent desire for, but inability to sleep, extreme dryness of skin, with frequent micturition, very small quantities of urine only being voided, drowsiness, with heavy sleep, leading to stupor, and extreme general languor, constitute the most ordinary of the premonitory symptoms. These disorders result from continuous marching in the night, but they are greatly in- creased when the march is protracted into the forenoon or mid-day. THE AFTER SYMPTOMS. These, often melancholy in their nature, are of extreme interest ; and they, as well as the more chronic and subdued influences of insolation, throw much light on the pathology of the disease under consideration. From the actual sun-stroke I have seen the follow- ing results, after the return to England of the sufterers : — 1. Severe mental depression, with sense of weariness along the spine. 2. Impression of the sun being always shining on the person, with tinnitus aurium. 3. Distressing formication, sometimes accompanied by a peculiar and general eruption and desquamation of the skin, 4. Deafness, more or less severe, with impaired vision and in- ability to use the eyes in reading and writing. 5. Various paralytic affections, more or less general, as hemi- plegia, and local palsies, as of the eyelids, cheeks, or upper extre- mities, with and without loss of sensation. Heaving and difficult breathing. 6. Distressing hysterical states of the nervous system, with absence of self-control in laughing and crying — the paroxysm being followed by great prostration of nervous power. 7. Interruption to natural sleep, with incapacity to any kind of business. 8. Impression of alarm on any sudden movements of the body, and upon the occurrence of sudden noises. OR SUN-FEVER. 399 9. Sudden epileptiform seizures^ without loss of consciousness, followed by great nervous prostratiou. 10. In India we are familiar with the acute sequelae to sun-stroke, as ardent fever with acute delirium, remittent and intermittent fevers, complicated witli dysenteries, hepatic inflammations and congestions — all more or less dangerous to life and to future health. PATHOLOGY. The post-mortem appearances in this disease vary remarkably ; so much so, indeed, as to show that out of several casualties the causes of death are difterent, the inconstant nature of the morbid results depending on the constitution, condition of the blood, the duration and intensity of the solar exposure, the amount of fatigue, the habits of life, and the duration of the disease. In the French West Indian colonies, Campet declared justly that the cases in which false polj^pi were found in the heart and great veiious trunks, constituted examples of the worst form of this terrible disorder. In other reports an absolute rise in the temperature of the blood and solid tissues has been stated ; while others describe the blood as being fluid and frothy. Cases are again reported as '^ simple con- gestion, without any lesion of the brain ;" while in others, " effusion of blood external to the membranes of the brain, extensive eftusion of blood between the dura mater and arachnoid,^^ also, " enormous venous congestion of the scalp, with blood extravasated betAveen the membranes," are noticed. The result of cerebral congestion must be to diminish and some- times to overpower the functions of the brain, and thus to enfeeble the actions of both lungs and heart. What is cerebral syncope, and what its eff'ects on the nervous system, on the heart and lungs ? It is curious to observe that the sardonic laugh is common to the extremes of cold as well as of heat. Examples of the former are frequently mentioned by the historians of the French retreat from Moscow. In India, alternate crying and laughing, of a hysterical character, is a subject of frequent ob- servation, during the attack and in convalescence. In all the recorded instances of heat-apoplexy, we have per- ceptibly presented a great, and, to the European, a most unnatural elevation of the external temperature, a proportional rarefaction of the air, and a consequently diminished supply of oxygen at each inspiration ; a resulting deterioration or venalized condition of the blood; a depression of the nervous functions, with augmented animal heat, and an impacted skin. Malaria and other atmospheric impurities, with their consequences, are occasional accessories, with the superaddition, also, of fatigue and its results. These cir- cumstances, often acting on a system previously injured by im- proper diet and Other intemperance, by disordered or diseased viscera, defective excretion, and the deprivation of sleep in the 400 HEAT-APOPLEXY, COUP-DE-SOLEIL, night marches^ "will go far to account for all tlie plienomena of this suddenly fatal disease. The condition of the lungs^ heart, and brain^ immediately resulting from the extremely rarefied air and intense solar heat, appears to be one of extreme venalization of the blood, with acute congestion at first, proceeding rapidly to passive congestion and greater depression of the nervous and vascular energies, to consequent narcotism of the lungs, heart, and brain, and to exhaustion of nerve-power as the last event. A great majority of the favourable cases which occur during a march under a May tropical sun, present a mixed condition, par- taking of the sun-stroke, or cerebral syncope, at first proceeding rapidly to congestive apoplexy, and ending in feverish reaction, or sun-fever ; those who die outright being extinguished by the shock to the brain, heart, and lungs. In persons who are seized in the shade, or under cover, again, the symptoms generally advance with diminished rapidity comparatively, the patient complaining of feverish debility in the morning, and being found in a state of stupor in the afternoon. The more or less rapid course in each description of case will generally determine the post-mortem results : tlie first-mentioned cases, owing to the extraordinary force and quickness of the shock, and of the consequent cerebral syncope, presenting but slight traces of disease within the cerebral cavity, but exhibiting intense pulmonary engorgement, ending sometimes in pulmonary apoplexy ; while in the last-named cases we shall find the vessels of the dura mater gorged almost to bursting, and the lungs more or less congested. Sometimes we shall find a copious and extensive serous effusion on the surface and within the ventricles of the brain ; while in many of the cases tabulated by Mr. Marcus Hill, and mentioned by other authors, enormous congestion with- in and without the cranium was generally observed after death. I conceive that death may occur in one of two ways ; either by de- struction of the functions of the brain by stagnant and venalized blood, or by stagnation of the circulating fluid in the heart and lungs, overpowering their actions by engorgement, or extreme dis- tention. In all the instances of recovery from this disease, and in all the milder seizures, the patients have passed through a more or less marked stage of feverish reaction, assuming the characters of the ardent fever of the hot season frequently, but occasionally, and along with it, the association of the paroxysmal or malarious sign. These are facts which appear on well-recorded evidence, and they are of high importance to the right apprehension of the subject. In Mr. Longmore's history of sixteen cases of heat-apoplexy in the i9th Regiment of Foot, which occurred at Barrackpore between the 2ord May and 14 th June, 1858, he notices that, of " other prevalent diseases,^^ fevers were by far the most common. During the period here specified there occurred ninety-four cases of fever, ninety of them having been admitted into hospital between the OR SUN FEVER. 401 23rcl May and 11th June — the day on which a rain-storm with reduced temperature put an end to the progress of heat-apoplexy. Two circumstances are here worthy of notice : — that, out of the sixteen men seized with heat-apoplexy, six were at the time iu hospital suffering from remittent fever, and that no case occiu'red amongst the officers. This last circumstance — the exemption of the commissioned officers — is so uniform of occurrence, that tlie thorough investigation of its causes ought to prove both interesting and important. The more temperate liabits, the better ventilation of their quarters, and the more suitable dress of the officers, made much, if not all the difference. Thunderstorms have ofteu been observed to arrest the progress and recurrence of heat-apoplexy iu barracks and hospitals in which the disease had prevailed for days, and this even where the atmospheric temperature had not been reduced by the storms. I am not aware that any observations have been made in India respecting the amount of ozone. The late Inspector-General IMurray supposed an essential patho- logical difference to exist between morbid affections resulting from exposure of the hare head to the direct rays of the sun, and siicli as may result from over-exertion under great heat, or such as are induced by the same degree of temperature in the shade, the former producing strong excitement in the brain by the direct stimulus of the cause. The scalp being protected by hair, and peculiarly constructed, does not blister under the sun like other parts of the body, but its temperature becomes exalted, and the caloric travers- ing it and the skull, gives immediate rise to active hyperemia. Heat in the shade, again, acting on the general sj^stem, the cerebral affection appeared to Dr. INIurray to be induced in a different, but unexplained manner : — " At first there is nervous depression or collapse, and sanguineous congestion, upon which the reaction follows." This doctrine would ascribe to the brain the same suscep- tibility to palsy, and consequent congestion, that is now generally believed to constitute, in the great central ganglia, the essential cause of fever. It would appear probable, on the other hand, that the sun-shock to the cerebrum and central nerves may, on occasions of great mortality, have proved so sudden and violent as at once to paralyse the brain, heart, and lungs; and thus the numerous instances of quick death, which left no trace behind, may be accounted for. Such sudden extinctions of life have all the ap- pearance of death by the shock of lightning. INIy friend Dr. Julius Jeffreys believes, in common with many tropical practitioners, that the special heat by direct rays of the sun not only produces sun-stroke, but generates more remotely, fever, dysentery, and hepatitis ; Avhile the long continued application of general heat debilitates the cutaneoiis function, so as to predispose the system to the influences of malaria. " The skin's debility is malaria's opport-unity." A venalized state of the blood, and general impairment of the functions of depui-ation, with supjprcssion D D 402 HEAT-APOPLEXY, COUP-DE-SOLEIL, of tlie cuticular discharge^ constitute the earliest appreciable features of tlie disease ; some of tlie sufferers declaring that for days previously they had not perspired. Scorbutus, in which the blood is already spoiled, constitutes one of the most serious com- plications. Dr. B. W. Kichardson concludes that excessive heat destroys the magnetic power of oxygen and its power of combination — coup- de-soleil resulting from an asphyxia commencing in the blood. Hitherto, the coitp-de-soleil has been too exclusively regarded as a primary affection of the brain — as an inflammation or congestion of that organ, in fact ; but the more recent and careful study of the post-viortem appearances Avould tend to show that the more general, prominent, and enduring affection consists in an extreme engorgement, leading to a true apoplexy of the lungs, the result of an imperfect aeration of the blood, the brain being similarly affected by congestion, although in a less degree. INIr, Hill states that in " a great many post-mortem inspections, where the lungs had been examined, there was found the most extensive congestion, often amounting to engorgement, and sometimes even to extrava- sation or pulmonary apoplexy ;" and in a fatal case reported by this officer, the upper part of both lungs is stated to have been immensely congested, the bronchial tubes being filled with frothy, serous blood. Dr. Russell, of her Majesty's 73rd Regiment, relates, that in three fatal cases of this disease he found the lungs " congested even to blackness, through their entire extent, and so densely loaded that complete obstruction must have taken place.'' Drs. Mortimer, Shanks, and Green, in various stations throughout India, record similar observations ; and a pale, blanched, cholera- like condition of the mucous membrane of the small intestines has been noted in some cases by Mr. Hill. False polypi, or fibrinous coagula, in the heart, are mentioned by Catnpet, thus constituting an association in pathology with the yellow fever of the West, and with the malignant remittents and intermittents of the East, as of Aracan in the first Burmese war. The enormous transudation from the skin, with the subsequent collapse of its function, and dryness of the entire surface of the body, under great solar heat, cause a concentration and diminution of all the internal excretions, and a consequent diminution of the depurative functions. Referring to the action of the sun upon the skin, I have very recently seen a medical officer from Central India, in whom a strange erratic form of oedema appeared on dif- ferent parts of the body, from head to foot. The CEclema was some- what solid, and of small, circumscribed extent. An occasional burning heat of the epigastrium, complained of during life, and an unusual pungent heat of the surface of the body after death, have been noticed by various writers ; and I had occasion to remark both^ at the General Hospital of Calcutta, in OR SUN-FEVER. 403 the instances of European recruits lauded from England in the month of May, and who had free access to the vile rum and arrack of the bazaars, and were seized with what was then termed the sun-fever. These reckless young soldiers exhibited in death the true calor mordicaus of the older writers. TREATMENT. The treatment of this imminently dangerous disease, in a large proportion of cases, is in truth but, as in violent forms of cholera, an attendance upon death. INIany soldiers die outright, or before the stock or neckcloth can be untied ; many more die within a few hours of being knocked down, and of falling insensible out of the ranks. All such cases are at once almost beyond the reach of our art to cure, yet we dispute about their treatment ; and the result being nearly the same, under every variety of management, we find fault with all alike. The American physician Dowler says, for instance, that there exists a distinction between solar asplij/xia awl solar si/ncojje ; — adding, that " solar asphyxia is always fatal;" but that this even " might be curable, if the patient were bled histanUineouslijJ" Another observer will declare that if cold affu- sion had been but persevered in, the fatal result would have been averted; and thus extremes meet. Campet, who practised in French Guiana a century ago, urges a careful attention to the habit and constitution of the patient, prescribing free and early general depletion in such persons as are of sanguine temperament ; adding a cautious regard to the practical maxim that Ijlood-letting kills, if it do not cure, the disease, concluding with anotlier maxim, that for great ills there must be great remedies. But here, as with Dr. Dowler, it is a question of time ; or, in other words, of rapidity of morbid progress. Campet bled, vomited, and purged freely, at the very accession of the disease ; and his measures in the latter stages were prudently measured to induce convalescence. Dr. Dick, of Bengal, while serving on the Coromandel coast, " removed the patients under the shade of trees, bleeding them freely in time, and giving them water, which generally cured them ; but as the stomach and bowels were often overloaded with bilious and putrid matters, it was necessary to give them in the evening a small quantity of tartar-emetic dissolved in saline mix- ture, which answered better than any other evaeuaut." Dr. Dick concludes his practical observations by stating that, though the sufferers seldom required any other medicines, they Avere a long time thereafter unfit for duty. So much for the earlier notices of sun-stroke by Eastern and Western practitioners, who were more in accord as to the nature and treatment of the disease than we are at present. That the treatment ought to be determined by the immediate pathological condition of each individual case, few will question ; 404 HEAT-APOPLEXY, COUP-DE-SOLEIL, but to discern on the instant the actual morbid state is difficult, and rather than solve this difficulty, many of us seek refuge from it, and betake ourselves to any easy system of generalization in treatment. Like other difficulties, this one must be fairly looked in the face. We cannot blink it if we would ; and to blink a question is not at all to solve it. Without believing with La Bruyere that " discernment is the rarest thing in the world after diamonds and pearls,^' I still think that to discriminate justly is not here so very difficult as many would have it. With a full bounding pulse, a hot pungent skin, and a flushed or livid face, the patient ought to lose some blood generally or locally ; w hile, with a sunken countenance, a sunken arterial action, a passive venous congestion, and oppressed respiration, such abstraction would prove injurious. Local depletion, as from the nape of the neck or temples, must act in direct relief of congestion, internal and ex- ternal ; and such states are not difficult of being recognised. With a view to the treatment of persons under sun-stroke, we should first distinguish and separate the subjects which admit of depletion, and those which do not ; holding mainly in view the con- stitution, age, previous service, and previous health, habits of life, &c., of the soldier, and also the duration of the disease. We can thus very speedily determine the nature of the treatment of eacli individual case, and the extent to which such treatment may be carried. For want of such preliminary arrangement, much con- fusion has often arisen. If the subject come under treatment before the advent of vas- cular oppression and nervous collapse, the application of leeches behind the ears, or arteriotomy, as preferred by some experienced surgeons, Avill relieve the cerebral and thoracic organs overpowered by congestion, give time and place for the influence of cold appli- cations to the head, and for the derivative efiects of heat, and of persistent friction with w^arm flannels applied to the extremities — all being aided by the exhibition of an active and stimulating pur- gative. At the same time that local blood-letting is being prac- tised, dlfusihle sthnnli, with ten-minim doses of laudanum, should be administered, with a view at once to rouse and support the nervous and vascular energies. The earliest evidences of successful treatment are, reduction of the temperature of the surface, followed by relaxation of the skin, restoration of the nervous and vascular powers, and of the functions of depuration. When local blood-letting proves bene- ficial, it acts in relief of the head, heart, and lungs, oj)pressed as they were by the most overwhelming congestion ; but, to further and maintain this beneficial result, the difi'asible stimulants, hot applications and frictions, already mentioned, must be perseveringly used. But in too many instances the time for the application of active measures, along with the season for sjieedy reaction, has gone by ; and in such cases nothing remains in the way of remedial OR SUN-FEVER. 405 means but dashing; the face, neck, and upper part of the chest with cold water, while stimulating enemata and stimulating frictions to the abdomen are used in aid of the internal means already indi- cated. On the tone which we may impart to the nervous and vascular systems, all must depend ; and whatever is to be done ought to be done quickly. A good way of applying the cold water is by a douche of moderate volume falling from the height of a few feet, while the patient is on a cot in the recumbent posture. From the earliest notices by our Indian surgeons, as well as from the recent observations of M. Guy on, and other able surgeons of the French army in Algeria, it has been made sufficiently eWdent that active measures of cure, to have a favourable prospect of success, must be practised as soon as possible after the soldier has fallen out of the raidvs ; and the great balance of testimony speaks to the fact that, when thus used, the proportion of reco- veries has been considerable, counting only such as were within reach of cure. But we must remember that minutes are here of vital importance, and that it is to the disregard of this circum- stance, and to the use of blood-letting, general or local, after the time for its use has passed away, that we must refer the differences of medical opinion on this head. The opening of the temporal artery, when practised at the proper time, is said to have proved very successful in the hands of the American practitioners, and I have seen this operation very efficacious in India in the febrile stage of reaction from sun-stroke, and when the brain was oppressed by congestion. Mr. Dempster's experience in Bengal accords entirely with that of the American physicians ; and Mr. Scriven, of the same service, an able officer, and no friend to blood-letting in this disease, says — '^ Six leeches to the temples often give marked relief j'^ and in the case of a sea- man, twelve leeches were applied by him on two separate occasions. Mr. Chappie, of the Royal Artillery, found that "in cases not treated by leeches to the head, the scalp, on being cut into, four or five hours after death, bled profusely ; and in one instance more than twenty ounces of blood Avere thus poured out.'' There can be no doubt that the Brounonian doctrines and practices, as lately revived in some of our schools at home, have had their influence, and an injurious one, on the younger, and upon the more timid of the older surgeons, in deterring them altogether from the use of depletory means in this and in other tropical diseases. But exclusive doctrines and practices, of what- ever kind, have never maintained any permanent hold on the pro- fessional mind ; and Brown must share the fate of Broussais in this respect. But the course of the army surgeon on the field of actual service must not be one of mere theory, or of speculative suggestion. His difficulties are actual and great. At a moment of terror to the 406 HEAT-APOPLEXY, COUP-DE-SOLEIL, looker-on^ he has with a deliberate and firm mind to determine on the instant what can be done and what cannot be done ; to be useful he must be considerate^ prompt^ and bold. He must at once balance all the circumstances of each individual case, and then he must use all the effective means which reason and experience suggest. In the treatment of sun-stroke he must not be content with too simple or too easy a generalizing course of sousing by cold water, applied without discrimination or distinction to all cases, to all constitutions and stages of disease — to all ages and conditions whatsoever, under the ever-varying conditions of climate, habit, and service. It is true that to use properly so powerful a means as blood-letting, requires all the mental qualities above-mentioned, especially if the abstraction be general; and so does its application to remittent fever, dysentery, and hepatitis. Indeed, all the unqualified, exclusive, and absolute arguments against depletion in any instance of sun-stroke (and they are very easy to adduce) are founded only on its ill-timed application — on its misuse in fact. E ven cold water, when applied in cases of exhaustion of the nervous system, is an agent for good or evil of much power, and therefore not one to be used without care, any more than blood-letting. That there are cases of sun- stroke which must be treated with cold affusion, and others which ought not to be bled, we all know ; but the two instances together do not by any means constitute the whole of the cases to be treated on any one field. I am here anxious to state that, far indeed from underrating the value of cold affusion, there may be danger of its recommending itself in the treatment of all cases, acute as well as passive, as a chief means of cure j and this, with many persons, on the score of the ease with which it can be applied : — any one can do it, and it is quite as easy to rely upon it ; but such are not here the questions. That cold affusion has been misused and abused, in common with blood- letting, and continued too long so as injuriously to depress the nervous and vascular energies, and repress the action of the skin, is what I am assured of; and this is another serious error to be guarded against. There are cases in which the persevering appli- cation of heat and of stimulating frictions to the body and extre- mities has proved powerfully restorative under apparently hopeless aspects. Such cases, and they are not infrequent, would be de- stroyed by the protracted or over-use of cold. Oxidation being more or less completely arrested, and coma being one of the results of the deprivation of oxygen, Avere I again to treat a case of sun- stroke, I would use the nitro -muriatic acid internally and externally. If the suitable abstraction of blood, cold applications to the head, neck, and chest, a full dose of calomel with antimony or Dover's powder, an active stimulating purgative, a free ventilation, cold drinks, darkness of the apartment, and rest, be employed early, and while the nervous and vascular systems retain sufficient tone, we shall, as in Dr. Henderson's practice, obtain a large amount of OR SUN -FEVER. 407 success * But if the same means be put in practice later, and Avhen the vessels of the lungs and brain have lost their tonicity, they fail of relieving the oppressive congestion ; and, so far from making a favoura])lc impression, they tend powerfully to the con- trary I'csult. This is an all-important consideration to mark ; it is the case here, as in remittent fever, the measures which, if applied early, may save life, will, if misapplied, as surely destroy it. When, on the other hand, the surgeon, on the most careful balance of all the circumstances of tlie case, sees that the constitu- tion of the patient is unfavourable, or that the time for active measures has passed away, those means which, in the first or earlier stage of the disease, would have been but adjuvant, become the principal — indeed the sole means. Heat to the abdomen and extremities, sinapisms to the epigastric region, and cold affusion to the head and chest, must be perseveringly applied, while brisk aloetic and aromatic purgatives are being freely administered. The capillary circulation being stagnant, like that of the great internal viscera, frictions all over the body — such as shampooing — have proved of great efficacy ; indeed, the restoration of the func- tions of the skin is a cardinal point in the treatment. By such means, persistently used, cases wearing a hopeless aspect sometimes turn towards convalescence. For many years, both in the French and British armies, the course here described has been that generally pursued ; and we surely have not now to learn that, when a patient is anremie, or when the circulation has ceased, the heart being filled with coagula, the functions of the brain having ceased, we are not to bleed the sufferers ; that we may not bleed dead men, in fact. Finally, a reference to the recorded histories of this disease leads to the conclusion that the means of cure have long been, and are now, tolerably well known generally — as well known as the mean« of cure of most other diseases ; and it is on the relative value of each remedy, its time and place of use, that I apprehend any real diflFerence of opinion to exist. One thing is absolutely essential to the due estimate of the results of treatment — viz., that we confine our statistical records to curable cases — to cases possible of cure ; for it is from the neglect of this necessary separation of the incurable from the curable instances, that a serious statistical error has arisen ; just as the neglect to determine the proper time for the application of active remedies has thrown difficulties in the Avay of a determinate cuie. * Such men as could not reach the shelter of the camp by 9 A.M. " were seen to drop down and instantly expire ; others less severely attacked, were saved by a timely and copious bleeding." Just so; the first-named were death-struck, but the ca.ses which were of a curable nature obtained relief and safety in the " timely" ahstractiou of blood. When, again, in the practice of Drs. Henderson nnd Mouatt, "sinking of the vital powers, or kind of collapse, occurred, a grain of opium was given to produce reaction, after the occurrence of which they were largely bled ; and with these precau- tions, although thirty were admitted into hospital after the first march, none died," 408 HEAT-APOPLEXY, COUP-DE-SOLEIL, A notice of coup-de-soleil would be wanting in interest which should not refer to Sir Charles Napier's most able and characteristic account of his personal seizure and treatment when serving in Sindli : — " I had hardly written the above sentence ten days ago when I was tumbled over by the heat with apoplexy : forty-three others were struck, all Europeans, and all died within three hours except myself ! I do not drink ! That is the secret. The sun had no ally in the liquor amongst my brains. Unable to talk, I flung myself on a table, and luckily one of my staff came in. He called the doctors ; two or three were with me in a twinkling ; wet towels rolled round my head ; feet in hot water ; bleeding, and two men rubbing me. I was so drowsy as to be angry that they would not allow me to sleep. Had they done so, it would have been hard to awake me.'' PREVENTION. Of all the means of prevention of heat-apoplexy, the avoidance of spirituous liquors and of excess in the use of animal diet must take the lead. In the language used by the great general. Sir Charles Napier, he gave expression to a physiological fact, the sug- gestion of his own acute perception. The sun and its various in- fluences, and the ill habits of the men and their consequences, con- stitute the causes and chief accessories. On the line of march, deficiency of water-supply stands next in order of evils to the sun itself. I believe that, with temperance in diet, avoidance of so much direct solar exposure as may be compatible with the nature of the service, attention to tent-covering and ventilation, and to head-dress and body-clothing, British soldiers may be made to march well under the hottest sun of India ; just as suitable pro- visions of a somewhat opposite nature might have saved the French army on the retreat from Moscow. Sundry of the French surgeons in Algeria, and M. Scoutetten pre-eminent amongst them, urge the importance, and indeed tlie necessity, of wearing a neck-cover as a protection of peculiar effi- cacy against the sun's rays, declaring this article of dress to be as indispensable to the soldier who may have to serve in that country as the very head-covering ; and in this they follow the instinctive habit of the natives of hot climates. On the subject of the quality and arrangement of the soldier's dress when serving under great heats, there can be no difterence or question. The head-dress should be light, of slowly-conducting materials, and constructed so as to command ventilation. Dr. Jeffi'cy's helmet gives protection by slow radiation, slow conduc- tion, reflection, ventilation, and evaporation. The body-dress should be of cotton ; and from head to foot everything should fit loosely, to allow the most perfect freedom of respiration and to the movements of the body, so as nowhere, but especially about the OR SUN-FEVER. 409 neck, to press on or interrupt the circulation of the superficial vessels. Everywhere throughout the "world, whether east, Avest, north, or south, the army surgeons urge the use of the flannel roller to protect the abdomen ; and a complete dress (shirt and drawers) of flannel, to Avear on coming in from the march and whilst the uniform is being dried in the sun, is no less requisite. Parades, formalities, the majestic English march, " Regulations'^ and appearances, must here be utterly and at once discarded ; for it is a question of life and death. The open, disorderly-looking order of march, however slovenly it may seem to the lieutenant- colonel, must here be used, the close order being nothing short of stifling and sickening the men " by Regulation. '^ The genius of pipe-clay must here concede something. While on the march, the face and hands should be frequently bathed ; and on such halts, which should be ordered every hour, the men should be urged to refrain from drinking the impure W' aters so general in the hot season. It is hardly necessary to say that the ordinary march should be conducted slowly, and always during the night, wdien the service will admit of it. In cantonment barracks and hospitals the most free ventilation should be secured. Mr. Longmore states that the greater portion of seizures and deaths of the men of the 19th Regiment at Barrackpore, in May and June, 1858, occurred in those avIio had occupied a low ill-ventilated building ; while Dr. Butler, of the 3rd European cavahy, at Lahore, referring to May and June, 1859, notices that the bai'racks which were most crowded and worst A'entilatcd, and least provided with punkahs, furnished the greatest portion of fatal cases. In the French, as in the British army, the newly-arrived soldier from Europe, over-fed and over-drammed, has been observed to be the most subject to attacks ; and this circumstance Avould indicate the necessity for an especial precautionary regard to the new-comer and the plethoric. Here, indeed, in the words of Marshal iSTey, the attentions of all classes of officers to their men should be un- remitting. Temperance is the great point to be attended to. Tea for drink has been suggested by Dr. Edward Smith, since, by its powerfal influence in increasing respiration and the action of the skin, Avithout increasing pulsations, it is particularly fitted to coimteract the influence of heat in its tendency to induce heat- apoplexy. Dr. Edward Smith's researches on the influence of exercise and labour on respiration, possess an extreme interest in reference to our subject. He has shown that walking at one mile per hour will double the respiration ; at two miles per hour it is increased two and three-quarter times; and at three miles per hour it is more than trebled ; while at four miles per hour it is five times as great : in other words, one hour's walking at four miles per hour causes as much" respiration as Avould have occurred in five hours of the quiet-lying posture. 410 HEAT-APOPLEXY, COUP-DE-SOLEIL, OR SUN-FEVER. As applicable to tlie march, the soldier carrying from forty to sixty rounds of ammunition, the law deduced by the author is as follows : — '' For every pound borne at three miles per hour, there is an increase of seven cubic inches per minute in the quantity of air inspired ; but the pulsation is increased in a yet higher ratio. Thus, if a soldier carry thirty pounds, he will breathe 200 cubic inches in excess ; or if sixty pounds, 400 cubic inches in excess per minute, the former being equal to one half, and the latter to the whole influence of the quiet recumbent posture. But since in the carrying of weights the pulsation is increased disproportionally beyond any other exertion, it is fair to assume that respiration does not alone measure the whole effect ; and hence, although the wear of carrying sixty pounds at three miles per hour would be each hour equal to that of nearly four hours in the quiet-lying posture, as deduced from the respiration, it is probable that the true effect would be beyond that amount." In a letter from a distinguished staff-surgeon serving in India in the hot-weather campaign of 1S58, I am informed that in his force they lost in a month one hundred or more British soldiers by sun-stroke. The men at length became absolutely terrified at the overwhelming power of the sun, though " not at all of the enemy, for whom they had a great contempt. But all dreaded the sun, and the hospitals became crowded, as well with men really ill as with men ailing but little, and anxious only to escape solar ex- posure." Here the moral and military effect of the protective helmet of Dr. Julius Jeffreys would be almost of as great value as its admirable chemical action : it would not only save the lives of some twenty men on the long day^s march under an Indian July sun, but it would impart new courage to the drooping battalion. Its influence, small though it looks, would stand in fair comparison, in moral and military power, with that caused by the first sight of Larrey's ambulances on the grenadiers of the French revolutionary armies : " Behold," said they, as they ascended the breach, " we shall no longer be neglected in our wounds and our sickness." Dr. Jefi'reys, speaking of his own admirable suggestions, says : " We know too well what the climate of India can do while im- perfectly opposed; we have yet to learn what may be the immu- nities conferred by the most perfect protection at our command." The protective influence of temperance in diet, as against the dangers of insolation, was never so thoroughly demonstrated as during the recent siege of Delhi, and indeed throughout the hot • weather campaigns, everywhere, against the great Bengal mutiny. Officers before Delhi describe themselves as marching all day in the sun of June, July, and August, and serving in the burning trenches for weeks together ; and yet they preserved their health, under a temperature of 130° or more, through temperance, to a wonderful extent. Dr. Barclay of the 43rd Regiment states, as the result of his THE FEVERS OF THE NATIVES OF INDIA. 411 observation^ that men whose nervons system had been injured by previous intemperance " Avere much more disposed than any others to attacks.'' When many men are struck doAVu, and the healthy have become nervous and dispirited, change of locality should instantly be solicited ; and the benefits attending such change were exhibited in a remarkable manner in Baroda, in June, 1859, — a movement made at the instance of assistant-surgeon Chappie. Here, as in every instance of endemic and epidemic disease, where mental depression results from the suddenness and frequency of death, the soldiers should be removed to the hut located within reach. All experience, finally, points to the propriety of limiting the issue of the spirit-ration to the time of sunset — the proper hour, also, for the principal meal of the soldier in the hot months. NOTE ON THE FEVEES OF THE NATIVES OF INDIA. The subject of the diseases of the Natives of India deserves a separate treatise, and I trust that the time is not distant when we may hope to possess one worthy of so important a question. But the scope, purport, and very title of this work do not admit of any further discussion on the subject than the most cursory. A know- ledge of the diseases of Asiatics is intrinsically of great importance, while, contingently, it will present an interesting and extensive field of comparison with the diseases of Europeans, and their causes. The Natives of India generally are amiable and respectful in their intercourse with Europeans ; and towards no class of their rulers do they show more real kindness of feeling and gratitude than to such of our medical officers as may prove deserving. British India, divided into four great portions— that of the Ganges to the east, of the Indus to the west, of the Dekhan to the south, and of that bounded by the great Himalayan range to the north — is inhabited by nations differing in religion, but sup- posed by some authorities to be descendants of the same great family , they are distributed over the vast extent of what is termed the Peninsula of Hindustan — the widest extent of empire, Avdth the smallest and most easily defensible line of frontier, of any existing on the globe. All the physical featui'cs of nature are in India truly colossal. There is reason to conclude, from the notices by the Greek authors, that no change whatever has taken place in the institu- tions, character, or manners of the Hindus from the age of 413 THE FEVERS OF THE NATIVES OF INDIA. Alexander to tlie time when tliey were discovered by tlie nations of modern Europe. The extreme length of Hindustan from south to north is 18S0, while its breadth from east to west is 1620 miles, or 37 degrees of latitude and 25 of longitude ; — all its features being on the most magnificent scale. Washed by the Bay of Bengal on the south-east, and by the Indian Ocean on the south-west, it is bounded on the north and east by mountains of prodigious eleva- tion, from whence the two great rivers of India have their sources, and floAv to opposite points of the continent. " India," says Professor Eastwick, '^ presents every imaginable variety of scenery, from the loftiest and most sublime mountain ranges to the gentle undulations and velvet swards of an English park. Its natural products are equal, if not superior, to those of any region in the world, and would furnish endless materials for the pen of the describer. It is rich in historical associations, and there is scarce a hill which is not crowned with picturesque ruins of some old fortress, little known, or altogether unvisited by Euro- peans, but bound up in the Native mind with many a strange tale and legend. India is a land of ruined cities, and in one of these the antiquities of a whole European province might be collected. The ruins of Brahmanabad, the Pompeii of Sindh, extend for twenty miles, and wherever the mattock of the excavator falls, curious relics come to light. The deserted city of Bijapur pre- sents from a distance the appearance of a populous capital, and it is not until the desolate streets are entered that the illusion is entirely dispelled. " But Indian architecture can boast not only of what is curious and surprising, but also of what is eminently beautiful. The Taj excels all buildings in the world in symmetry and rich decoration. The temples of A'bu are not to be surpassed in ornamentation. The palace of Amber is a structure before which the Alhambra shrinks into insignificance. " India lies between b° 4' and 36° N. lat. and 66° 44' and 99° 30 E. long., and contains a million and a half of square miles, with about a hundred and eighty millions of inhabitants. This vast region, says our authority, is, more than any other, formed by nature to be the storehouse of the world. The magnificent chain of mountains that encircles it from N.W. to N.E., consisting of the Himalayas to the N. and N.E., with the Sulaiman and Hala ranges running down to the sea on the west, supplies abundant water to irrigate the whole of Upper India ; as, in like manner, the Vindhayan range, joined eastwards by the Rajmahal hills and other lower ranges, and the East and West Ghats, furnish sufficient water for the requirements of the Dekhan or South India. " Thus India exhibits a series of great water-sheds, in which, or on the adjoining hills, grain of all descriptions, rice, oil-seeds, coffee, sugar-cane, tea^ indigo, cotton, opium, tobacco, pepper, THE FEVERS OF THE NATIVES OF INDIA. 413 cardamom^ ginger, capsicum, coriander, turmeric, and all kinds of vegetables and fruits, are or may be produced iu inexhaustible quantities. In its forests, India possesses resources superior to those of any country in the world. The teak-tree, the cocoa-nut tree, the sago-palm, and the sandal-tree are first of their kind in utility ; and innumerable trees, only second in value, might be mentioned. " Iron, the parent of all other metals, abounds ; and coal exists in untold quantities. Precious stones of all descriptions are found iu different localities ; and in the number and variety of animals, no region of the earth is comparable with India. To man, the climate of India is less favouralile than that of the temperate zone; yet, amid the variety of races which is found from the Himalayas to Cape Comorin, some are not inferior in beauty to any that exist, as e.g. the people of Kashmir, the Rajputs, the Biluchis, and Jats of Siudh, and some of the Brahmans,^^ — Handbook for India. Our Eastern possessions are said to contain, independently of the descendants of conquering races and strange settlers — men conquerors in creed and banditti by profession — some fifteen or more indigenous nations, different in race, different in religion, and different in language. From the great elements from whence to recruit our armies, it might have been expected that during our hundred years of rule in Hindustan we should have associated, or fused by a rigorous discipline, or ranged in battalions according to religions and languages, an army, if not worthy our name and power, at least one desernng of some trust. It was indeed sup- posed that, although the formation of our Indian army had always been encumbered by a sort of foreign European chance-medley, so much of the better British element of skill, discipline, and unity of action had been imparted to it by its European officers, that its fidelity might be counted on ; but recent events in India have shown such expectations to have been utterly fallacious. In India there is no nationality — no union, political or other — the nations and the individuals inhabiting Hindustan having about that kind of cohesiveness which belongs to marbles in a bag. The people have thus been the ever-ready slaves of despotism, civil, religious, and military. Ethnologists have pronounced the races of the East and West to be one in origin ; but how vast the differences and distinctions which have arisen in the progress of time ! What dift'erences in religion, morals, government, diet, institutions ! How differently do the two races regard what is true ! Varying in physiology of constitution as they may be, divided by geographical distinctions of latitude, quality and elevation of soil, or by differences in diet, the natives are separated, Hindu from Hindu, and Hindu from Mahomedan, by impassable barriers of caste and of religion ; yet, under British rule, this wonderful aggregation of subjects has attained to a degree and kind of union, 414 THE FEVERS OF THE NATIVES OF INDIA. such as no antecedent rulers^ wlietlier ancient indigenous Hindu, or more modern conquering Maliomedan, ever could conceive,, far less accomplish. "^ Out of the enormous mass of the population, every description of person enters eagerly into the various public employments pre- sented by the British government, whether civil or military, and natives of every caste and class are thus brought into familiar and friendly communication with their European superiors. Not only is this the case, but natives, both Hindu and JNIahomedan, undergo laborious and protracted courses of education, the better to qualify themselves for the various public duties offered to them ; and here, to the honour of the medical profession, it has taken the lead, and accomplished a noble triumph of education. Always prominent in every endeavour to advance the moral and intellectual condition of the people, youths may now be seen by the hundred, trained and instructed by our medical officers at the three Presidencies, who but a few years back, had they touched a dead body, would liave become outcasts. Now these youths are seen to go through years of the dissecting room, and to kave their colleges able phy- sicians and expert surgeons. The relative proportions of the followers of the two dominant religions of India, the Hindu and Mahomedan, may be taken as about eight of the former to one of the latter, for the whole of Hindustan; Pegu and the Island of Ceylon being inhabited by Budhists. It is estimated that, throughout India generally, there are 3400 Natives to one European; but insignificant as this pro- portion appears, the presence of the European offers to the Hindu and Mahomedan the only hope of ever attaining to truth in reli- gion or in science. The complexion, stature, bulk, and weight of the body vary in the several nations, as they may inhabit the south or the north of India, as they may occupy countries near to or far from the Equator ; the advantages in all the above respects being generally much in favour of the northern nations. But of high or low stature, the trunk of the Asiatic, whether Hindu, Mahomedan, or Budhist, will be found slender as compared to that of the European. Tlie Siah-Posh, an undoubted branch of Hindu race, and who inhabit the cold mountain region of Kohistan, have, according to Sir Alexander Barnes, arched eyebrows, a fair com- plexion, blue eyes, and Grecian features, while, on the contrary, the descendants of fair Persians and Affghans have, in the course even of a few centuries, become of darker and darker shades as we trace them into the farther south of India. Generally speak- ing, the Mahomedan, whether of Persian, Affghan, or Baluchi descent, will everywhere, but in the north especially, prove the * The Mahomedan conquest of India was completed A.D, 1215. THE FEVERS OE THE NATIVES OF INDIA. 415 fairer as compared to the Hindu ; but this distinction will be found to have gradually disappeared under a foreign climate, and the fairer ^Mussulman will have become more and more dusky with advancing generations. The various natives inhabiting Hindustan appear to differ from Europeans less in feature than in the more trifling cir- cumstances of colour, size, and form. They are nevertheless moulded by a great vai'iety of climates, localities, habits of life, diet, occupation, &c., so as to constitute in reality a people vary- ing exceedingly in moral and intellectual qualities, in physical powers and appearances. The medical ofiicer will therefore have peculiarities to investigate in almost every state and province throughout the whole extent of ovir Eastern possessions. Placed under few of the rigorous necessities which, in northern latitudes, impart energy to the mind and body of the inhabitants, the people of the East are handed over by the richness of their soil, the power of their sun, and by climate and institutions of religion, to a state of indolence and inactivity as compared to western nations. Of Caucasian origin, but exposed during countless generations to the same succession of external influences of high temperature and corresponding habits of life and diet', receiving the same reiterated impressions peculiar to climate and religion, an acquired temperament is formed which constitutes the Hindu and Maho- medan — men diftering widely, morally and physically, from Euro- peans, while from each other they difi'er principally in religion and in diet. These general causes, together with the premature development of the generative function, produce an excitability of the nervous system, diminished volume, enervation, and relaxation of the muscular system, as compared to Europeans, all which dis- pose the natives of India generally, and those of Bengal Proper in particular, to tetanic aflections under wounds, surgical operations, and the impressions of cold and damp. If we would understand India, Ave must study well its physical geography and its great influence on the habits and customs of its vast population. In some countries everything tends to exalt the human race, while in India everything has tended to depress it. The climate and the religion have together stimulated the imagination far beyond the cultivation of the intellect; thus allowing the imagination to run into licenc?, infusing into the people a spirit of reverence instead of a spirit of inquiry, and encouraging a disposi- tion to neglect the investigation of natural causes and ascril)e events to the operation of supernatural ones. Improvement in Asia has been wilfully arrested by the self-imposition of an arbitrary standard, beyond which it is considered a dereliction or a superero- gation to pass. Hence the Asiatic too often limits the just growth of improvement by his habitual neglect of morality, honesty, and 41G THE FEVERS OF THE NATIVES OF INDIA. justice* No Asiatic race has ever shown that it possessed the power of resistance or the power of progress. Generally speaking, the agricultural and the mechanical arts are in but a rude state with the Hindus, both being supposed to have remained stationary for two thousand years or more. " India," says Dr. Royle, " vast in extent and diversified in surface, is re- markable as the cradle of one at least of the nations who earliest practised the arts and cultivated the sciences which characterize civilization, and from whence these travelled to the west, and perhaps also to the east. Its present inhabitants continue to venerate sciences which they know only by name, and to practise arts of which they know not the principles, and this with a skill not only remarkable for the early period at which it attained per- fection, but also for the manner in which it has remained stationaiy for so many ages. This can be explained by the fact that the son was unable to add to the manual dexterity of the father, and could not improve an art which he knew only as a routine process. But when commerce was in its infancy, or dealt only in the most precious commodities, these arts could not have been practised unless India had contained within itself all the raw materials which art could convert into useful articles or elegant ornaments. With- out cotton the so-called ' webs of woven hair' could have had no existence. Without numerous woods, barks, and Howers, dyeing could not have been practised, and calico-printing would pro- bably not have been invented. If an Indlgofera had not been in- digenous, indigo would never have derived its name from India, nor have afforded us the proof, in the stripe of mummy-cloth, of the early commercial intercourse between its native country and Egypt. Neither would sugar have been arranged by the Greeks with honeys, nor the Indians described as those who ' h'ibimt terwra dulces ah aruudirie snccos,' unless they had had the cane-like SaecJ/a- rum as a plant of their country. Neither in Persia would the proverb of ' giving an Indian answer' have been considered equi- valent to a cut with an Indian sword, unless the Hindus had pos- sessed the ore which enabled them to manufacture the far-famed wootz steel ; and gunpowder is likely to have been invented at an early age only in a country where ' villanous saltpetre' is abundant." Another ancient saying amongst the natives, repeated to this day with glee by the Sepoys of Bengal, exhibits alike the warlike character of the people, and their readiness at all times for mer- cenary service : — " Jis ka Deg, oos ka Teg." Tliis popular and admired proverb is translated by Colonel Hodgson of the Bengal army, as follows — "He who can keep the pot boiling, Will never want for trenchant blades." His salt is, in fact, the banner and the country of the native soldier. * Buckle "On Civilization." THE FEVERS OF THE NATIVES OF INDIA. 417 The mention of an Indian answer^ wootz steel, trencliant blades, and gunpowder, brings ns natui'ally to consider the native army of India, the proper subject in the present article. The native soldier has been held to be brave, obedient, cheerful and patient under labour, fatigue, and privation, abstemious by religion and habit, honest and amiable in all his dealings, and possessing a very high sense of military honour ; attached to his Em'opeau officer, and grateful for kindness shown him, he never until now abandoned his colours ; and when kindly and justly treated, and properly commanded, he has never disappointed the reasonable expectations of his commanders. He is cheerfully resigned in sickness, never exhibiting any unmanly qualities under suflFering ; he thus stands forth an object deserving the special and high consideration of his European medical officer. A fine ex- ample of the kindly feeling of the sepoy towards his surgeon w^as afforded after the battle of jNIahidpore, when the Commander-in- Chief of the Madras army. Sir Thomas Hislop, on visiting the hospitals, was addressed by the wounded sepoys, who " made a personal request of his Excellency that he would now take care of the surgeons who had been so kind and attentive to them.^^ Colonel Blacker, in his history of this war, referring to the " unanimous petition^' of the sepoys, adds, that " unassuming merit could not have a more gratifying and appropriate reward, intrinsically more estimable than any formal commendations flowing from authority .'^'^ That the qualities here recorded of the men forming the native ai'my of India are derived from the domestic circle and habit of civil life, shared by the sepoy with his brothers, is as certain as that all the qualities of a great military commander are civil qualities. A soldier is a citizen and something more ; the addition being but the result of military discipline and military habit. To form a just estimate of the soldier, we must everywhere trace him back to the recruit. How, after a centiuy of faithful service, the Bengal sepoy came all of a sudden to rise in murderous ferocity against his master ; treacherous, faithless, and fiendishly cruel ; how the Bengal army, once so distinguished for good conduct, became a huge band of dexterous traitors and disciplined assassins, turning against us in all the wantonness of Indian ferocity, so as to disgrace even savage humanity, it is not the business of this work to relate. I can only say that we are painfidly thrown back for our future guidance and practice upon the maxim of Bacon, containing a suggestion which must never again be absent from the minds of our statesmen and commanders : — '^ Neither is money the sinews of war, as it is trivially said^ when the sinews of man^s arms, in base and effemi- * Colonel Blacker is quite philosophical and even kind on the subject of handing over the surgeons of his army for rewards to the bare contemplation of their own merits ; but he does not say that, in his own person, he would prefer such mode of recompence to the companionship of the Mihtary Order of the Bath. E E 418 THE FEVERS OF THE NATIVES OF INDIA. nate people^ is failing. As for mercenary forces^ which are the help in this case, all examples show, that whatsoever estate or prince does rest upon them, he may spread his feathers for awhile, but he will mew them soon thereafter." " If we look through history,''^ says Lord John Russell, " we shall find no parallel case, nor anything at all resembling the native Indian army. The Romans held Spain with a single Roman legion. With a like force they held Africa and Egypt. It is true that auxiliaries were attached to those legions, but the really armed and effective body was the Roman legion itself, and the Romans would never have dreamt of having a large native army to rely upon in case of emergency." The monstrous perils of the Indian army, as constituted on the principle condemned by the Romans, and by all history, ended in treason, havoc, and massacre ; nevertheless, " By the fame of our conquered difficulties, by the discovery of the might that slumbered in our arms unsuspected by ourselves, by the proof of the fiery ordeal through which we have passed triumphantly, by all the buffetings of a terrible experience, we are a greater nation to-day than we were at the beginning of the struggle." To have placed implicit confidence in Mahomedan mercenaries was a most fatal mistake ; for no Mussulman who does not abso- lutely renounce his religion can ever be trusted by a Christian government ; he must, as a Mahomedan and a native, hate our race, our religion, and our rule. The Hindus, on the other hand, are tolerant on principle ; but the wall of caste separation between the individual Brahmin and his British officer is impassable to any consideration, human or divine, according to the natives^ own notion. Butj as regards the service of the state, high caste is, in the language of Sir Charles Napier, actual mutiny. When a soldier alleges his caste as a reason for non-compliance with orders, it is nothing more or less than mutiny ; and the word caste should never again be so much as mentioned between the employer and the employed. In India we must not expect, for years to come, that " the harmony and married calm of states " shall prevail ; and therefore its armies must not only be in the main British, but they must at all times be perfectly organized and equipped, and so placed as to be ready for instant action. Henceforth English hands must guard what they have conquered. " A population constituted of two races, one of which was the victorious, and the other the van- quished race, each retaining its own religion, and habits Avhich that religion has imposed upon it — each to the peculiarities of religion adding the peculiarities of blood, and both, moreover, impressed with those distinct characteristics which a common origin has transmitted to the whole Oriental family — this population, which numbers 110 millions of human beings, which is scattered over an area equal to three great European kingdoms, which for two THE FEVERS OF THE NATIVES OF INDIA. 419 tlionsancl years has been exhausting the experience of Eastern despotism, -which has never knoAvn, nor till lately heard, of a standard of public morality or public opinion, Avhicli has grown up generation after generation in the abject awe of power and the abject adoration of its trappings, which has recognised revenge, and cruelty, and lust as the legitimate attributes of successful con- querors, or the legitimate retaliation of offended and triumphant tyrants — this population is to be governed by the deputy of a remote sovereign, whose crown rests upon the broad basis of law, freedom, and opinion, and whose European subjects apply to the government of her dependency the principles and maxims of Runnymede and St. Stephen's. To reconcile those extraordinary exactions — to govern India so that native subjection may not be jeopardized, or native respect destroyed, or native prejudice outraged on the one side, or English opinion offended, or even English fanaticism alarmed, on the other — so that we may still remain the lords of that varied and uncombining people, but without the reproach of the crimes which follow conquest — to make a gigantic empire not only not onerous and disreputable, but honourable and profitable — such is the task that the British nation devolves upon those on whom it confers the ad- ministration of India, and more especially upon the foremost man among them — the Governor-General.^' Hitherto, and in our self-complacent notions of our " empire of opinion," and of the cordial " attachment'' of the natives to the British rule, we forget Napoleon's wise estimate of Spanish attach- ment to French domination. " Remember,'^ he said to King Joseph, " that what a nation most hates is another nation." Tho truth is that the empire of opinion never had any real existence in India. The native impression of our invincibility was the only public opinion Avhich stood of avail to us, and which can avail to us for the future. Hanng sIiomti the chief cause of our recent dangers in a too well- organized native army, the best mode of obviating these dan.o-ers for the future by means of a well-appointed European force, and the difficulties at all times inherent to our dominion over India, I will now revert to more strictly professional considerations. !Medical officers in the East Indies, holding as they do military commissions, have been principally employed in the duties of the native armies ; a certain small proportion being allotted, or "^'lent," to the civil department of the State, for conducting the medical duties of ciA-il stations. But the great body of the medical corps, numbering for the three Presidencies of India about eight hundred officers, are under the direct and immediate orders of the Com- mander-in-Chief, and are thus placed much more in contact with the native soldiery than with the civil population at large. Nor is the social position of the medical officer less befitting a man of science. Entering the Indian army with rank correspond- ing to that of lieutenant^ his position is at once established as that E E ^ 420 THE FEVERS OE THE IfATIVES OE INDIA. of an officer and gentleman, and it depends on the conduct and character of the individual how he shall uphold such privileges. To secure the confidence and respect of his brother officers of the army, and to become distinguished in his profession, he must possess knowledge, indefatigable industry, judgment, energy, reso- lution, address, and an untiring patience ; and to all these qualities he must add a courage not fed by excitement in the heat of con- flict, nor buoyed by any hope — a courage that does not look to rewards, a courage of the highest order : in truth, " the two o'clock in the morning courage,'' which Napoleon prized so highly, is quite as necessary to the surgeon as to the captain. To be useful, the surgeon must possess all the experiences of the camp. Towards natives of all classes his conduct should be just, kind, and liberal ; while in his intercourse with superiors and equals of his own country, his conduct should be that of a modest unpretending man of science. He must learn that familiarity in the mess-room or elsewhere is not friendship, and that such conduct is never sup- ported by real friendship. And let not these observations be con- sidered irrelevant, for they have in truth much to do with moral as with professional efficiency. Against a vain discontent with his position of army-surgeon, I would warn my brother officers, no state of mind being more use- less or unprofitable. To take counsel of the son of Sirach — to feel that " to labour diligently and be content is a sweet life" — is the most truly wise course, whether as servants of the State or as men of science. It was the practical rule of life of Robert Jackson and Henry Marshall — medical officers to whom the British soldier owes more than to all the commanders who have been placed over him from Cromwell to Wellington, both included. Excellent as are the native qualities of the sepoy, his usefulness to the British government depends mainly on good discipline, aided by a just and kind treatment on the part of his European officer. Taken from the middle class — the pith and marrow of British society, whether for peace or for war — the officer of the Indian array is at once a gentleman and a soldier by profession ; but he is neither a titled amateur, a dilettante, nor a holiday soldier. He is recruited generally not from the wealthier of the middle class ; and the less wealthy, the better soldier, provided he be still the gentleman ; but he is not of the class of fine gentlemen who dislike real soldiering. He generally continues his studies after he has obtained his commission. In the Indian army there is as yet, happily, no place for " the destitute aristocracy." He does not enter the army to make it an amusement rather than a business ; he is not a moneyed idler ; and wherever he is placed in command, he is not found wanting. Freed from the weaknesses of class or caste, which for a long time have damaged certain branches of the British army ; freed, also, from the democratic in- fusions of the armies of continental Europe, he stands in a middle THE FEVERS OF THE NATIVES OF INDIA. 421 position between the two extremes. He comes from the highly- educated, high-minded middle class of the United Kingdom ; and if at any future time he is to exhibit well-intentioned weakness and incapacity, it will be from causes which are not now in operation in the armies of India. After fifty years' service in the Uritish army, Robert Jackson declares that, "for any great purpose of peace or of war, the middle classes of the empire are the saviours of their country.^' From the earliest formation of the Indian army, its officers have remembered, in a proportion which does them honour, that in reading, and the command of that reading, which opens the mind to the abandonment of error and the adop- tion of improvement, consist the most important part of education, and that no officer can deserve the name without such mental discipline. They will therefore generally be found neither idle nor incompetent. On the stafi^, too, in which they serve through merit and with little support from interest, we seldom find the ofi'ensive peculiarities against which Shakspeare has warned ns in your " dog in ofiice.^^ Nor are they of a class to depend on others for what is necessary ; for they are continually under a necessity to make provision for the most minute details, and they never exhibit a childlike helplessness. They know that to be of ready resource and contrivance, that to make the best of difficulties, is the business of campaigning. In short, the staff and regimental officers of the Indian army rise in skill with the occasion — the true test of excellence everywhere and in aU callings. This is very generally true in respect of Indian officers, especially in the junior grades, and well up even into middle life, notwithstanding the baneful in- fluences of a system of seniority promotion. Finally, the officers of the Indian army do not as yet know the contamination and degradation of official influences ; and while for the display of their talents they enjoy a fair field and no favour, there is, at present, no power which can step between the Avrong- doer and his punishment. In short, the officers of the Indian army, whether stafl" or regimental, do not regard military life as a mere dashing and casual pastime, but as " a serious and permanent profession." It follows from what has just been stated, that the medical officer who has the good fortune to serve in the Indian army will find the criticisms of its officers an his general and pro- fessional conduct, matters not to be disregarded. But, with all these advantages, there remained until very re- cently a source of affliction and of debility to the medical officer of Bengal especially. The medical department was there ruled, as in the other Presidencies, by the three oldest men in the service. To attempt the defence of such an institution were to build its tomb ; to endeavour to instruct members who counted forty years' service under tropical influences, or to make them understand the true purpose and oljject of their official calling, or even to comprehend their own true interests, were about as hopeful 422 THE FEVERS OF THE NATIVES OF INDIA. as to send forth missionaries to convert tlie Pope to Pro- testantism, or the Emperor of Russia to representative govern- ment. The strength of the native armies varies with the exigencies of the State; that of Bengal, in 1825, mustered 153,843 men of the several arms, infantry, cavalry, and artillery; while, in 1832, the same army was reduced to 78,346 men. The following is stated by Colonel Sykes to have been the dis- tribution of castes in the Bengal army which revolted. Christians. Mahoraedans. Brahmins. Rajpoots. Inferior castes. Hindus. 1076 12,411 24,849 27,993 13,920. Grand total 80,249. The average admissions into hospital of this army, during twenty years, was for each soldier one admission in two years ; while the average mortality for the same period was 1"79 per cent., and the invaliding 1*5 per cent, per annum. The strength of the Madras army varied from 71,488, in 1826, to 48,571 in 1837. The average mortality in this army, during twenty years, was 2*09, and in the invaliding, 1*96 per annum. In the Presidency of Bombay, the strength of the native army varied from 49,873 in 1844, to 25,782 in 1833. Six-eighths of this army are natives of Hindustan, there being in the proportion of eleven Hindus to one Mahomedan ; and low-caste men consti- tute about one-eighth. The mean per-centage of deaths during twenty years gives 1*29 — a remarkable degree of health — while the invaliding during the same period was 3*3 1 per cent, per annum. The mean mortality dviring twenty years, for the whole native army of India, as given by Colonel Sykes, is 1"80 per cent, per annum, and the invaliding as 1"93 — exhibiting a remarkable con- dition of health even in troops serving in their native climate. It is with native as with European troops in the East, fevers and bowel complaints constituting by far the greatest amount of sickness. The maximum of admissions into hospital of Bengal troops occurred in 1842, when 98,936 men were treated medically out of a strength of 113,020; the minimum occurring in 1827, when only 30,903 were treated medically out of a strength of 130,303 men. In the three Presidencies of India we have the following mor- tality among the British and native soldiery per cent. : — Bengal. Madras. Bombay. European troops .... 7-38 . . 3-846 . . 5-07 Native troops 179 . . 2-095 . . 1-29 Thus a European regiment is renewed in Bengal in ten years, in Bombay in twelve years, and in INIadras in seventeen years. To account for the circumstance that in the Madras Presidency the native mortalitjr is greatest while the European mortality is the THE FEVERS OF THE NATIVES OF INDIA. 423 least, Colonel Sykes states that the constituents of the INIadras native troops are the reverse of the other two Presidencies. In the jNIadras Cavalry there are from six to seven Mussulmans to one Hindu; and in the infantry there is one Mussulman to li or If Hindus ; but amongst the latter there is a considerable number of low castes, without prejudices of caste ; therefore the majority of the native troops of the Madras army can eat and drink like Europeans, and the mortality returns show us that they suffer from cholera as much as Europeans, and that the mean mortality from all causes is 2-095 per cent., or more than | per cent, beyond that of the Bombay army for twenty years. " I never followed," says Colonel Sykes, " a farinaceous or vegetable regimen myself in India, nor do I recommend it to others ; but I ate moderately and drank little, and I have a strong conviction that much of European disease in India is attributable to over-stimulus, and that the mortality among the European troops will not be lessened until the European soldier is improved in his habits, until he is made to understand that temperance is for the benefit of his body, libraries for the benefit of his mind, exer- cise for the benefit of his health, and savings' banks for the benefit of his purse. The climate of India is less to blame than indivi- duals ; for in the case of foreigners, the people of a country being healthy, they should, to a certain extent, conform to the habits of the natives, to be healthy also.'' The same authority adds : — '' The natives of India are generally considered to be very temperate in their habits ; but it is quite a mistake to suppose that they all live upon farinaceous or vegetable matters, and do not drink fermented liquors ; it is equally a mis- take to suppose that the general food of the people is rice, which is only very much the case in low lands subject to inundation, and along the coasts. In the interior rice is generally so much dearer than the bread grains, of which there are many (wheats, millets, the genera holcus, panicum, paspalum, &c. &e.), that rice is rarely consumed, at least in Hindustan and the Dekhan. The Hindus- tanee soldier lives almost exclusively upon unleavened cakes of wheaten flour, daily baked upon an iron dish, and washed down with water. On the other hand, all Mahomedans, and all low-caste Hindus are consumers of animal food, spirituous liquors, opium, ganja, or hemp-water ; and many castes of the Sudras, the Mah- rattas for instance, eat mutton and fish when they can afford to do so ; but meat is not essentially necessary to health and strength. Liebig says, that only those substances can possibly be called nutritious which are capable of conversion into blood, and that farinaceous food has also this nutritious principle in high de- gree. The truth of this profound assertion of Liebig is established by the food of the great majority of the native soldiers of the Bombay and Bengal armies. I have shown that six-eighths of the Bombay army consists of Hindus, and considerably more than half 424 THE PEVERS OF THE NATIVES OE INDIA. of the whole army are Hindustanees. These men never taste meat, fishj or spirituous liquors, but live, I may from personal observa- tion venture to say, almost exclusively upon unleavened cakes of wheat, or other cerealea, baked upon an iron dish, and eaten as soon as cooked/^ In 1857, the year of the great mutiny, there were in the three Presidencies of India, 155 regiments of native infantry, the army of India being then composed as follows : — Of Europeans 45,522 Of Natives 232,234 Henceforth the garrison of India will consist of: — Europeans about 70,000 Natives ,, 140,000 being a reduction in the latter force, including military police, of 200,000 men. The natives generally are very subject to the influences of the various climates contained within the British empire in the East, and none more so than the sepoys of the Bengal army, recruited as they are almost exclusively from the plains of Upper Hindustan ; but wherever circumstances admit of the use of artificial means, both Hindus and Mahomedans, though born and bred on the soil, take greater precautions against both heat and cold than the stranger European. "To brave the climate" forms no part of native disposition or habit. The climate of Bengal Proper is, for instance, most prejudicial to the health of the " up-country" sepoy ; for although, accord- ing to Colonel Henderson, but one-foin^th of the Bengal army is stationed there, the deaths of that fourth are more than a moiety of the whole mortality reported. Much of this mortality is doubt- less due to the excessive humidity and to the malarious character of the climate ; but much is also due to the great change of diet from wheaten bread to rice, which latter the sepoy vtdll use, not because be prefers it, but because it costs so much less. The native dealers in grain, taking advantage of the sepoy's frugality, offer cheaper and worse qualities of rice, or mixture of rice and wheat flovir ; so that within two or three years' residence in the Lower Provinces, what with the injuries from climate and the infe- rior and imperfect nutriment, the robust sepoy wastes, and falls a sacrifice to the fevers, dysenteries, and diarrhoeas of an unnatural climate ; and thus it is in many of the low malarious countries throughout India. As with the European soldier, so with the sepoy of Hindustan Proper transferred to the malarious low regions, both shared a common fate when, through the feebleness and incapacity of General Morrison of her Majesty's army, the united force under his command Avas planted by him in the marshes of Aracan, in the first Burmese war. Those native soldiers who did not perish on THE FEVERS OE THE NATIVES OF INDIA. 425 the spot sank soon afterwards from general cachexia and enor- mous enlargements of tlie spleen, followed by dropsical eftusions, colliquative white flux, or lientery; in fact, all perished alike — tlie native and the European. In Ava, again, in the same war of 1824-25, where I was witness of what happened, and where the climate generally was good, the sepoy, by a proper diet and clothing, was preserved in compara- tive health through two severe campaigns ; but the British soldier, the instrument of the power and glory of the Government, was suflFered, by its criminal negligence, to perish miserably through want. Dr. Finch, of the Bengal army, in an able report on the effect of climate on the health of the native army of that Presidency, gives the folloAving comparative \iew of the influence of the climate of Hindustan, and of Bengal Proper : — Average per cent. Bick to strength. Hindustan . . . . I 1836 ^ . . 753 . . 354 . . . 46 Average Averag Years. strength. sick. 1835) 1836 V . . 753 . . 354 1837) 1838) 1839 V . . 899 . . 649 1840) Bengal Proper . . . M839 V . . 899 . . 649 . . . 79 " During three years at Mynpuree,^' he says, " the corps lost by death but twenty-six men; while during its stay in Bengal Proper the casualties amounted to not less than 203 \" The manner of locating native troops, with reference to the country of their bii'th, the period of service in climates which are unnatural to them, and the proper time for relieving corps and divisions, so as to presence the soldier's health, are matters that as yet have not received from the authorities the attentive consider- ation due to them. As with the European, so with the native soldier, the season of greatest amount of disease is from June to January — cholera being most prevalent in April, May, and June. During the rainy season fevers, remittent and intermittent, prevail the most; and towards their decline, bowel complaints, which in low malarious situations prove very intractable, become frequently associated with splenic cachexia. Again, as with the European, so with the native soldier, fevers, remittent and intermittent, generally constitute the first inroad on his health ; after which, successions of recur- rences ensue, followed sooner or later by enlargement of the spleen and general cachexia — the disease which closes life being dysentery or diarrhoea. Amongst the natives in civil life, the bazar preparations of arsenic and mercury, so freely administered by the bazar empirics, prove a source of much broken health, causing severe rhevimatisms, diarrhoeas, and dysenteries, especially during the cold season. Of all this I observed much in the Native Hospital of Calcutta, of which institution I was surgeon during ten years. 436 THE FEVERS OF THE NATIVES OF INDIA. The fevers of tlie natives, whether remittent or intermittent, present the same events in the same succession as in the European, differing only in degree ; and in the Indian army the patient, like his western comrade, has the advantage of coming under the care of his surgeon on the instant he falls sick ; and within the first twenty-four hours much may he done to place him in a position of security, and to prepare him for convalescence. I generally began the treatment by an em eto- cathartic, com- posed of from one to two grains of emetic tartar, from three to four grains of calomel, added to two scruples or a drachm of com- pound jalap powder, according to the age and strength of the patient. This powder, placed dry on the tongue and washed down with water, produced a speedy and free action of both stomach and bowels, followed by copious perspiration, and a more or less complete remission of all the symptoms. Generally speaking, the patient was next day in a condition to use bark, quinine, or some of the native bitter tonics to complete the cure. Such of my servants as had served me long, and been with me when in the army, always asked for what they called '' the fever powder" whenever seized with the disease, and the other servants soon learned to follow their example ; and my European friends, whether civil or military, when going into camp, or on a long march, always carried with them a supply of the same medicine for the use of their native establishment. It continually happened that in the milder cases of fever no tonics of any kind were necessary, the triple action of the emeto-cathartic and sudorific proving sufficient for the cure ; and this was especially the case in the sudden and acute febrile seizures of the hot season. I may here add that mercury in any form, beyond the first moderate dose, I seldom if ever adminis- tered. When heat at stomach, with urgent thirst, is complained of, the greatest relief will be obtained from the use of saline effer- vescing draughts. Dr. Macpherson, of Bengal, in his excellent Essay on '' Quinine and Antiperiodics,^' observes that he who does not know how to employ other medicines does not understand how to make the best of quinine. But he adds, that " in many instances a great deal more quinine is given than is at all required, and the slighter forms of fever can be satisfactorily treated without its aid." The febrifuges of India, he observes, have been neglected : — " In truth, the great enemy of other febrifuges is quinine. It is so superior to others that it saves much trouble to use it in prefer- ence. But a numerous list of native tropical febrifuges. East and West, has now become familiar to us, of which the Rusut, or Ber~ beris Lyc'ium — ' the most promising of our Indian febrifuges' — the Swietenia fehrifuga, bebeerine, cinch onine, narcotine — an Eastern drug, for it is not known as the product of other opium — may be mentioned with confidence, in the treatment of intermittent fever ; and we must agree with Dr. Macpherson in declaring that THE FEVERS OF THE NATIVES OF INDIA. 427 the power of all the native antiperiodics, notwithstanding their excellence, must be tested by their proved influence in arresting remittent fevers : this is the experimeritum crucis. The general practice by the natives throughout India of adulte- rating quinine to the extent of 30 and 40 per cent., will go far to account for the discrepancies observable in the reports on the use of quinine in the military hospitals, European and native. The patients had not the doses alleged to have been administered, by one-third or thereabouts. In Europe salicine is largely em- ployed in adulteration, and the natives add magnesia. Mr. Day, of the ^Madras army, treating of the intermittent fever of ^Mysore, as it prevailed in the 12tli Native Infantry, concludes : — ■ 1. That in the treatment by bark, or its preparations, those cases in which large doses of quinine are employed are the most easily cured ; and that next in value come small doses — and lastly, bark. 2. That in the employment of quinine as a medicine, a sa^dng in the expenditure is efi'ected by using large doses. 3. That great saving of time and trouble to the subordinate hospital servants is gained by giving one dose of quinine only. 4. That by large doses must here be understood, five grains of quinine and upwards, given in combination wdth tincture of opium. But in malarious countries adynamic forms of fevers, both re- mittent and intermittent, will occur, accompanied very generally by abdominal congestions with enlargement of the spleen. Here, in addition to bark and other tonics, warm aromatic aperients, chalybeates, improved diet, and change of air must be had recourse to. The sepoy of Upper India is bound by warm ties to his family, to which he never fails to remit his pecuniary savings. In sick- ness he eagerly looks to rejoining his relatives ; and, where the exigencies of the service admit of it, such indulgence should always be recommended by the medical ofl&cer, whatever the colonel may think. In treating the fevers of the natives we must not expect to find in them the sustaining powers of constitution of the European ; acute disease subsides in the former much earlier than in the latter, requiring, therefore, antiphlogistic measures of much less energy in the case of the Asiatic, while a much earlier recourse may be had to quina and other tonics in conducting his cure. "Whenever we feel satisfied also that acute disease has been over- come, an improved diet may be allowed at an early period — the native constitution not bearing a severe and protracted abstinence ; and condiments may be allowed, especially during the rainy season. Finally, let the surgeon be careful that the sepoy is not dis- charged from the hospital too soon, out of a small, narrow, or mistaken notion of military efficiency, or of what an unreflecting adjutant or crack colonel may designate '^ keeping the eflective list complete." The effectiveness of convalescents amounts only 428 ACUTE DYSENTERY OF BENGAL. to deceptive numbers borne on the muster-roll ; and sucli sham efficiency will bring disgrace on the medical officer, stamping him at once with want of knowledge, want of firmness, and want of humanity. The medical officer who would hold his place worthily in the army of India must possess other qualities as well as talents. ACUTE DYSENTEEY OE BENGAL. This is at once a dangerous and a frequent disease throughout our intertropical possessions ; so much so that no medical officer should be permitted to enter on the duties of the public services without a careful previous study of its nature and treatment. Dysentery has at all times proved one of the most severe scourges of our fleets on foreign stations, and of our armies in the field, even when campaigning in temperate regions. It is truly desig- nated by William Fergusson an army disease. " The soldier,^^ he says, " when in the field may escape fever, but never dysentery, if he lie on the ground. ^^ It is the disease of the famished garrisons of besieged towns, of barren encampments, and of fleets navigating tropical seas, where fruits and vegetables cannot be procured. Dysentery has occasionally been found to assume a malignant character in low damp situations, so as to prove very deadly ; but on the sufferers being removed to elevated sites, and a better air, the disease has been rendered amenable to treatment. In tropical climates dysentery, though most prevalent during the hot and rainy season, will be found to exist at all periods of the year ; but in European countries it is almost exclusively a disease of summer and autumn : it stands thus associated with a high range of temperatm'c, and atmospheric changes. The Euro- pean soldier in India, as compared to the sepoy, is peculiarly liable to dysentery — eleven of the former to one of the latter being treated in the hospitals. The temperate man who holds a middle course appears here, as in fever, to be the least liable ; but the chances of recovery are stated by Mr. Waring to be in favour of the man who observes total abstinence. Sir Alexander Tulloch states, that out of an aggregate force of 25,433 men of his Majesty^s army serving in periods of eight and ten years respectively, between 1823 and 1836, in the stations of Calcutta, Chinsurali, and Berhampore, all in Bengal Proper, there occurred 8499 cases of dysentery and diarrhoea ; and though the years within this return were subsequent to the first Burmese war, still the proportion of dysenteric cases is excessive, making every proper allowance for such unfavourable influence. The climate of Lov/er Bengal has always been very unfavourable to European ACUTE DYSENTERY OF BENGAL. 429 health, as compared to Upper India ; but making allovrance for all circumstances, including the ill habits of life of the soldiery, the amount of sickness from dysentery and diarrhoea here exhibited is enormous. In the Presidency of Madras, again, out of an aggregate British force of 82,ot3 men, ser\dng there fi'om 1842 to 1848, there oc- curred 10,531 cases of dysentery, and 9180 cases of diarrhoea, making a total of 19,720 cases of bowel diseases, exckisive of cholera. It thus appears that, next to the malarious fevers of India, bowel complaints are the most prevalent diseases, while the danger to health and to life from these last is even greater than from fevers. There were admitted into the European General Hospital of Calcutta, according to Dr. Macpherson, in the years 1830 to 1850, 2044 cases of dysentery, of whom there died 457, or 22-3 per cent. The extremes of mortality were 148 in 1833, and 34 in 1845. Robert Jackson regards dysentery as '' one of the most im- portant of the maladies that occur among troops, particularly in the "West Indies, where, in some of the islands, it amounts to one- half, even to more than half of all the forms of acute disease which appear in the hospital return of sick." This great authority adds : " It is dangerous in itself; more fatal, in fact, among the mi- litary in the West Indies, either primarily or secondarily, than any other, the concentrated fever, as incident to strangers, ex- cepted." The losses of the French army in Egypt were greater by dysentery than by the plague — the deaths by the latter disease being 1689, while by the former they amounted to 2468. During two years and a half only out of the time occupied in the war in Por- tugal and Spain, the British army, according to Sir James M'Grigor, lost 4717 men by dysentery. Of the diseases which destroyed the European portion of the expeditionary force in Ava, during the first Burmese war, dysentery — scorbutic dysentery — was by far the most prevalent and fatal disease. " The per-centage of mortality," says Miss Nightingale, " in acute and chronic dysentery, was perhaps greater in the Crimea than ever has been known in any disease except the worst form of epidemic plague. It was no less than 7 '8 per cent, of the cases. This, too, was of the scorbutic form principally, and was caused solely by bad food." PREDISPOSIXG CAUSES. "Whatever causes predispose to fever will exercise a like influence in producing dysentery, but more especially the following : — The various duties of the fleet and of the camp, which necessarily expose seamen and soldiers to wet and cold, suppressing the secretions — to high ranges and to sudden and violent changes of temperature, causing checked perspiration especially ; — the use of crude, ill- prepared, indigestible, or otherwise unwholesome diet — excesses in 430 ACUTE DYSENTERY OF BENGAL. the use of wine;, spirituous liquors, or tobacco — the use of impure water — retained excretions — fatigue and privation — endemic, epi- demic, and malarious influences — previous fevers, of the remittent and intermittent types especially — diseases of the liver or spleen ; all these circumstances will, severally or individually as may be, dispose the subject to the invasion of dysentery. The causes of scorbutic dysentery are : — Deprivation of fresh meat, vegetables and fruits — sameness in diet^ — crowding — mental depression — hardship and fatigue — exposure to damp and foul air — the use oi impure water. The salt-meat rations of old were a source ol enormous aggravation of dysentery, if they did not actually produce the disease. SYMPTOMS AND PROGRESS. The immediate and urgent symptoms in tropical dysentery are — sense of constriction of the skin, followed by irregularly developed febrile movements, more or less marked according to the season of the year, the length of residence in India, the constitution and previous habits of the patient. The amount of attendant fever is very variable ; — in some cases it hardly excites attention, while in others it amounts to heat and dryness of skin, flushed face, furred tongue, and hard frequent pulse. Fever is most considerable in the hot season ; while in that of the rains it is less declared, the tendency being here, as in remittent fever,to congestion and collapse. In some forms of malarious dysentery there is considerable fever, with but little hepatic complication comparatively; at least it proved so in China. But here, as in all the diseases of the stomach and bowels, the power of the pulse rapidly fails as the disease ad- vances. Soon the patient experiences, during from twelve to twenty-four hours, the uncomfortable feelings attending upon frequent loose discharges from the bowels ; when at length irregular pains, at first of a griping nature only, along the course of the large intestine, becoming gradually more severe, shooting, or " cutting," as the soldiers designate them, with sense of heat ascending from the rectum, and pain extending sometimes to the hypogastrium, until the whole abdomen becomes involved in soreness and feeling of dis- tress, accompanied by" frequent purging, griping, and straining, all aggravated during the night and early morning, and leaving behind them the wearing sensation that there has always remained in the bowel something which has yet to be discharged. At this time the discharges are generally scanty, and consist of mucus * I have long been of opinion that sameness of mental occupation, prosecuted for a long continuance, proves as injurious to the functions of the brain as sameness of diet to the health of the blood. The unvarying character of the occupation, and the inten- sity of application required in arithmetical and mathematical pursuits, have, in many instances, appeared to prove most detrimental to the brain, damaging the entire nervous system in the most serious manner. ACUTE DYSENTERY OF BENGAL. 431 and blood, or bloody slime as the soldier calls it ; and tins is a matter of the utmost importance to investigate, as from the cha- racter of the discharge we derive important information as to the extent and nature of the disease. Towards a right estimate of the condition of the tubular, as of the associated solid viscera, we may also receive much aid from a cai'eful exploration of the caecum and colon, including its sigmoid flexure ; and a careful examination of these regions, as of those of the liver and spleen, should never be neglected ; for pain, fulness, or thickening of the bowel may always be detected, unless the subject be inordinately stout. AY hen pain and fulness are absent from the regions named, and there is, nevertheless, much local distress, such as m'gent and constant tormina and tenesmus, Avith sense of fulness and heat along the bowel, and with strangury, the seat of inflammation and thickening will be found to be centered in greater degree along the rectum ; but this circumstance does not render the case less severe, or less diflicult of cure. The matters voided in the dysentery of India consist at first of liquid fteces, generally of unnatural colours, streaked with blood or mixed with blood and mucus. If the disease advances in the absence of treatment, or in defect or insufficiency of it, then we shall find all the symptoms, constitutional and local, much aggra- vated, while the intestinal discharges contain more of blood and mucus, togetber with exudation flakes, shreds, or larger sloughs of mucous membrane, so as often to assume the appearance of putrid blood, or of the washings of raw meat. Scybala are rarely seen in the dysenteries of the East. When to symptoms such as these are superadded a pungent heat and dryness of the skin, with furred tongue, an urgent thirst, high-coloured and scanty urine, an in- creased frequency of the pulse, and an increased urgency and frequency of call to stool — all augmented towards night — they in- dicate considerable danger. When, again, patients sufl"ering from the tropical dysentery present the further retrogression of a cold clammy siu'face, a cadaverous smell from the body and intestinal discharges, an anxious and oj^pressed countenance, and a sinking pulse with hiccup, and motions voided involuntarily, the case is generally hopeless. Such are briefly the symptoms of acute dysentery, which will be found to vary in degree according to the severity of the inflamma- tion ; and of this last the medical officer will best judge by an at- tentive observation of the constitutional symptoms, together with a careful daily examination of the nature of the discharges from the bowels : this, indeed, cannot be done too often, or too minutely. The duration of dysentery varies with the force of the predis- posing and exciting causes, the age, constitution, length of resi- dence in hot climates, the season, and other contingent circum- stances. Some cases will go through their course even unto death 432 ACUTE DYSENTERY OF BENGAL. within tliree to five days ; while others will be received into hos- pital after having suffered during periods of from five to twenty days, with appearances the most unfavourable, and yet they recover. The progress of the disease will, in fact, depend on the condition and circumstances, past and present, of the individual case. The scorbutic form of dysentery may be recognised at once by the dusky hue and dull melancholy expression of the countenance; the livid complexion of the surface generally, but especially of the extremities, which are cold and spotted over with petechiee, which the least scratch will convert into an ulcer. The tongue is dark in common with the gums, which latter are spongy, and bleed on the slightest touch, or blood oozes spontaneously from them. There is a disrelish for the previously uniform diet, and especially for the use of salted meats, while there is an urgent craving for vegetables and subacid fruits of every description. The pulse is feeble and frequent ; in short, all the symptoms, general and local, indicate an extreme and aggravated cachexia — a dissolved, diseased condi- tion of the blood. The purging soon exhibits the true scorbutic character, the discharges being composed principally of grumous putrid bloody matter, and even the urine has a bloody hue. The progress to recovery from dysentery implies a healing of ulcerated surfaces. Dr. Parkes accords with the German anato- mist Sebastian, and others, as to the fact of the reproduction of intestinal mucous membrane ; while Dr. Bleeker regards cicatri- zation as the normal termination of dysentery ; but the number and extent of the cicatrices " may withal produce a condition of the colon which renders it unfit properly to perform its function. Cicatrices, be they ever so completely formed, cannot make good the loss of the mucous membrane, with its absorbent and secreting organs." COMPLICATIONS. "^ Dysentery is found in all climates to complicate readily with the prevailing fevers, and within the tropics it is frequently associated with fevers, remittent and intermittent : it is also occasionally complicated with scurvy. The connexion between epidemic dysen- tery and various pestilences has been a subject of observation by many writers in different ages and countries ; and the severe and fatal dysentery of London followed closely on the influenza of 1763. In the East Indies we find that, either from the beginning, or during the progress of the dysentery, diseases both functional and structural are apt to arise in the liver. Amongst the European patients in the General Hospital of Calcutta, Dr. Macpherson found that, out of an hundred and sixty acute cases, the liver was altered in eighty-four cases — containing abscess in twenty-one cases — being enlarged in forty cases, &c. ; while in fifty-five cases of chronic dysentery the proportion of hepatic diseases was nearly the same. This able officer states ACUTE DYSENTERY OF BENGAL, 433 that, on a comparison of acute with chronic dysentery, the liver is more frequently altered in the latter, that abscess is about equally frequent in either form, that in acute dysentery the liver is fre- quently enlarged and soft, while in the chronic it is more gene- rally small and indurated. He adds, that the stomach and small intestines suffer also more frequently in the chronic form, and the mesenteric glands are more frequently altered in it. In the ]\Iadras Presidency, out of fifty- one cases of acute dysen- tery there were twenty-six hepatic abscesses ; and in Bombay, out of thirty cases of acute dysentery, twelve cases of hepatic abscess occurred. " It is worthy of remark,' ' says Dr. Macpherson, '' that the liver has been fomid, in the General Hospital of Cal- cutta, to have been altered in 118 out of 215 cases ; in the Medical College Hospital in thirteen out of thirty cases, while Sir James M'Grigor found it in India altered sixteen times in twenty-two cases, and in Egypt, as in India, he found it diseased. '' Dr. Arthur found the hepatic complication so prevalent amongst the soldiers of the INIadras European Fusiliers serving in Burmah, that "on admission into hospital nearly as much attention was directed to the hepatic region as to the abdomen." The hepatic complication can in some cases be perceived from the commencement of the dysentery, while in others it prolmljly arises in the course of the principal disease. The daily exploration of the hepatic region, and of the course of the large intestine, will therefore be necessary in every case, to arrive at a just apprecia- tion of all its attendant circumstances. It sometimes happens that enlargement of the liver is not manifested till after the dis- appearance of the dysentery; and we observe also that hepatic abscess is discoverable only after the cessation of the primary bowel disease. The association of hepatic diseases with dysentery would seem to be most frequent in the climate of the East Indies, and in such as have a common influence. Dr. Morehead of Bombay found, that out of thirty fatal cases of dysentery, twelve were attended with hepatic abscess ; and out of twenty-five dissections of dysen- teric patients at INIoulmein, in Burmah, Dr. Parkes found hepatic abscess in seven cases, while the same proportion of complication was observed in Ceylon by Henry INIarshall. " As functional disease," says Dr. Parkes, " implies a propor- tionate certain amount of change in the molecular structure of organs, either primary in the organ itself, or secondary to changes in the blood or vessels, the most delicate test of the condition of an organ will in time be the chemical constitution of its secretion, when this knowledge is obtainable. We already see this test beginning to apply itself in the case of the kidneys and urine. Judging from this test, the liver is found to be more or less diseased in every case of dysentery." In the province of Oran, Algeria, the French surgeons stats 434 ACUTE DYSENTERY OF BENGAL. that hepatitis and consequent abscess were frequently coincident with dysentery. Of 157 deaths^ in two-thirds of which diarrhoea and dysentery had prevailed during life, " there were in sixty-five cases notable marks of diseases of the liver, including twenty ex- amples of abscess.^^ The tendency to hepatic complication was found in Algeria to increase with age, and with the length of ser- vice in that country. The coincidence of disease in the caecum and liver was noticed by me in the wards of the General Hospital of Calcutta; and, reporting on the diseases of Bengal in 1839, I find the following statement : — " I have seen many cases in which morbid action was co-existent in the liver and caecum, and I would beg to call attention to the subject." This official record referred to cases which terminated in recovery ; and the '' calling attention to the subject" had reference to the verification of the fact in dissection.'^ Severe illness obliged me to quit Bengal before this opportunity had been afibrded me ; but the fact of the morbid coincidence in question has since been ascertained both at home and abroad. It is now established that disease is frequently " co-existent in the liver and csecum" — that an intimate connexion exists in chronic cases between ulceration of the mucous membrane of this portion of the intestine and hepatic abscess, owing to suppurative phlebitis, to purulent absorption, and to contamination of the portal blood, in chronic cases. In diseases so complicated as dysentery and hepatitis it is often difficult, when the histories are uncertain, to determine with accuracy where morbid action begins ; but the extension and coincidence of serious evil, in all the associated organs, is early dis- cernible to the careful observer of symptoms in both diseases during life, and we can readily trace the results after death. Here, as in many other instances, we arrive at an ultimate fact, but can proceed no further with certainty : — we can see and examine the co-relation, and infer a common cause ; but we do not, therefore, understand which is the cause, and which the eftect. We know not, in too many instances, which of the diseases is the primary — that in the bowel, or in the liver. There are cases, and they are numerous, in which we can plainly discern hepatic disease and hepatic abscess as primary, concomitant, or secondary affections in the time of their occurrence ; but whether they are to be regarded as a cause, a concurrence, or a consequence of dysentery, it is not so easy to determine : practically, a prompt and accurate diagnosis is here of much importance ; for, by a speedy removal of hepatic disease, in the first and second instances cited, we may obviate suppura- tion of the liver while we cure the dysentery ; and by the early * It is worthy of remark that in the only dysenteric case of a Hindu, in which " the caecum, with its appendages, was totally destroyed by a sloughing ulcer per- forating in some places all its coats — similar ulcers being formed in the colon and its ascending portion, and sigmoid flexure, as well as in the rectum, " there were found, by Dr. Parkes, in the liver, "throughout its substance, numerous small abscesses filled with viscid pus." ACUTE DYSENTERY OF BENGAL. 435 healing of ulceration of the bowel, in the third instance cited, we may cure the dysentery and perhaps prevent the occurrence of hepatic abscess, or purulent deposit of any kind. I would direct the special attention of pathologists to the state of the lining membrane of the ducts and gall-bladder, as affording, perhaps, some clue to the pathology of hepatic abscess in association with dysentery. Diarrhoea, easy of cure, occasionally results from vitiation or redundancy of bile ; but not so dysentery, as suggested by An- nesley. It is an every-day occurrence, on the other hand, to find that diseases of the liver, and consequent siijjjjressiou of the biliary function, will cause both diarrhoea and dysentery. The whole question, however, is still an open one. " The con- nexion between abscess of the liver,^^ says Dr. Ballard, " and dy- sentery, as a clinical fact, is indisputable. Dr. Henoch, however, refuses his assent to the explanation of it by Budd, who views it as a result of phlebitis, the pus from which, carried by the portal blood, is arrested in the liver, and becomes the focus for the for- mation of an abscess. Apart from the debated question of the capability of the inner membrane of veins undergoing inflamma- tion at all, Dr. Henoch considers, as opposed to this explanation, the fact that Dr. Parkes, on the most careful examination of such cases, never found the slightest trace of inflammation in the small veins of the intestine, while no direct proof has been advanced of the mediation of the portal blood in the process.^^ Dr. Henoch concludes : — " I believe we must give the preference to that view which regards the two diseased processes, dysentery and abscess of the liver, as without mutual relation, but as running their course together, dependent upon one and the same cause ; in favour of which view is the circumstance, that in hot climates abscess of the liver also very frequently occurs associated with remittent fevers, or consecutive to them, without dissection exhibiting any ulceration of the mucous membrane of the intestine." A\Tien dysentery follows upon, or is associated with intermittent fever, the spleen will frequently become enlarged. We then per- ceive a general anaemia, or splenic cachexia, with a low asthenic type of dysentery. This complication augments the difficulties and embarrassments in treatment, and greatly increases the dangers of the original disease. A writer on the climate of the Danubian provinces observes justly, that where agues are present, dysentery is not far off. In temperate climates dysentery is found associated occasionally with continued and typhoid fevers, and then it becomes sometimes contagious. The scorbutic complication may be expected to arise in seamen and soldiers, when, in tropical climates especially, they have been supplied for some length of time with unwholesome rations, or with such as -consist in whole, or in chief part, of salted meat. Sir Gilbert Blane asserts that the disease " has been known to i' p ;i 436 ACUTE DYSENTERY OF BENGAL. arise among prisoners of war living entirely on fresli diet, and solely imputable, therefore, to confinement in bad air, a dull uni- formity of life, depression of spirits, and indolent habits naturally belonging to a state of captivity.'^ The most terrible instance of suffering from this cause was that of the European portion of the force employed in Ava, during the first Burmese war, where they were fed on salt rations for six and a half months, and where forty- eight per cent, perished within ten months, principally by scorbutic dysentery. The symptoms noted by all the medical officers were as follow : — swollen, loose, and livid gums, with ulcerated and sloughing edges, and fetid breath, pain and hardness in the calves of the legs, constriction of the hams, and purple discoloration of the skin of the lower extremities — cedematous swelling of the feet and legs — • anasarca — ascites and hydrothorax. When to such a condition of the system, scorbutic dysentery was added, the speedy and fatal character of the disease may be inferred. The bowel complaint was characterized by green, or greenish- yellow discharges, becoming by degrees sanious ; then dark, bloody, grumous, and putrid. A sudden and universal dropsy marked the latter days of the sufferers : I saw one of Her Majesty's regiments at Prome, in the second campaign, lose forty men in one night from this cause ; and at Rangoon, in the first year, the Madras European regiment, containing many old, hard-drinking soldiers, was the first corps to be destroyed by this dropsy, which, from its suddenness and fatality, resembled the worst form of the Beribery of Ceylon. From such a hopeless state of disease as has here been described, there are many grades, down to the very minor degrees ; and the medical officer who finds his men fed on bad, poor, and insufficient diet, under tropical influences, should be on the watch for scorbutic taints. They are all dangerous, and they mount rapidly from the least to the most aggravated grades. PATHOLOGY. As the symptoms of acute tropical dysentery, during the progress of the disease, will depend on the nature and power of the cause — on the condition of the general habit — on the amount of plethora, of congestion, or of actual inflammation in a portion, or in the whole of the abdominal viscera; so the results of these morbid actions will, after death, be found to vary with the form and degree of the disease. Acute tropical dysentery consists in inflammation, com- mencing generally in the mucous membrane of the large intestine — sometimes in the follicles — and proceeding rapidly to exudation, ulceration, and sloughing, if not promptly checked by art. The disease is always associated with disturbance of the functions of the skin and liver. '' Dr. Parkes considers it to be a pro- ACUTE DYSENTERY OF BENGAL. 437 cess of ulceration universally commencing in the solitary glands of the large intestine ; others, with Mr. Raleigh, consider it to be a simple inflammation of the mucons coat of the large intestine ; but if it were simple in its nature, it would be more amenable to treatment. Whatever of truth or error may be in these opinions, the appearance presented to ns in uncomplicated Bengal dysentery, is that of an inflammation of the large intestine, which may be diffusive, ulcerative, purulent, hremorrhagic, or gangrenous, ac- cording to circumstances V . . "It should be borne in mind that the state of the solitary glands, as observed by Drs. Murray and Parkes, exactly corresponds with their usual appearance in cholera, and that all INIurray's and most of Parkes^ cases occurred in dysenteric patients suddenly carried ofl" by that disease." — Ur. Mac- ])herso)i. The train of pathological events in acute tropical dysentery may be summed up as follows : — Congestion succeeded by inflammation of the follicles of the large intestine — lymphous exudation and in- filtration beneath the mucous membrane— degeneration of the in- filtrated fluids, and ulceration first of the follicles and then of the mucous membrane ; — all the morbid processes described, including diff'used inflammation and softening, rapidly extending to the mucous membrane, so as to destroy by ulceration both its structure and its functions — those of the glands having first undergone the same injuries. In states of antemia and scorbutus, or under epidemic conditions and typhoid associations, there will occur phagedoenic and rapid destruction of all the textures, accompanied by an extreme amount of mortality. It is not at all a colonitis, as Ballingall termed it, but a disease of a specific pathological character, influenced by the epidemic conditions of the atmosphere, by malaria, by the previous habits, duties, and diet, and by the states of the blood resulting from such conditions and habits. Such is acute dysentery, specially and pathologically considered, with- out waiting here to describe various complications. In the milder cases which yield to treatment within two or three days, we may fairly presume that diseased action has not proceeded beyond plethora, or the mildest form of vascular congestion or of inflammation of the mucous surface and glands. In severe cases the inflammatory action, far from confining itself to the mucous membrane, extends to the serous covering, and even to the solid viscera, wdiile ulceration, and even sloughing of the mucous surface and its glands, may be in extensive pro- gress ; and all this, occasionally, without that amount of corre- sponding fever which might, a priori, be anticipated — a circumstance which gives a character of peculiar insidiousness to a disease already very dangerous in its nature. Abrasions, ulcerations, and sloughs are but varying degrees of the same morbid process, the slough- ing sometimes involving all the stnictures alike. Again, ulcera- tion is found to result from deposits of pus, lymph, and scrum, 43S ACUTE DYSENTERY OE BENGAL. below the mucous membrane^ as well as from inflammation of this tissue. " Omental congestion or inflammation/^ says Robert Jackson, " accompanies dysenteric fever not unfrequently. The indications of its existence are obscure ; and its foundations are not moved without difficulty — not without the most extreme measures in bleeding, blistering, &c.^^ When much tumidness with tenderness of the abdomen is asso- ciated with irritability of stomach and vomiting, inflammation of * the peritoneal covering may be more than suspected, andji^o^f- inortem appearances will frequently confirm this view of the case. "When again, from want of treatment, or through unskilful treat- ment, the disease has proceeded unchecked for a considerable time, the best that can generally happen will be the merging of acute into chronic dysentery — or imperfect healing of the ulcerated bowel. Certain portions of the large intestine have always appeared to me to be more affected when the complication in dysentery has been of the hepatic nature — namely, the caecum and the rectum. In the General Hospital of Calcutta, a government institution for the treatment of Europeans, I observed so frequently as to attract my special notice, that, when the crecum was the principal seat of pain and swelling, the liver was generally enlarged ; but whether as cause or efl'ect I could not say. As with the natives of India, Hindu and Mahomedan, so with British-born subjects in their native climate, hepatic abscess is found to be but very rarely asso- ciated with dysentery; whereas with Europeans placed out of their native climate, and under great heats, as in the East Indies, hepatic diseases and abscess have been found to be very frequent complications in dysentery. In the Millbank Prison, out of '' many hundreds of cases," which occurred during seven years, " not one has been complicated with hepatic abscess,^' says Dr. Baly. These facts would lead to the conclusion that a foreign climate mainly, and its unnatural influ- ences, and more particularly heat and malaria, produce the dif- ference of result as respects IBritish subjects; but it is most difficult here, as in other diseases, to determine what is cause and what coincidence. The other seat of irritation and of aggravated disease, associated with, or derived from, the hepatic complication, I observed to be the rectum ; and in this portion of the bowel two causes appeared to me to operate unfavourably : the first consisted in the arrest of circulation in the hsemorrhoidal veins consequent on congestion or enlargement of the liver, producing' internal or external haemor- rhoids, or both : the other depended on the constant state of irri- tation in which the rectum is kept by the passage over it of acrid discharges. Through inflammation, thickening, and adhesion, the caecum speedily loses its tone and contractile power, thus be- coming the passive receptacle for the lodgment of vitiated and ACUTE DYSENTERY OF BENGAL. 439 decaying matters ; while the angle of the bowel at its sigmoid flexm'e becomes, through the incessant drainings of the same matters over its surface, the special seat of soreness. Much of the suffering and distress of the patient may always be traced to the irritated states of the sigmoid flexure and rectum, kept in con- stant tormina and tenesmus by the passage of such matters^ often with the addition of acrid scalding bile. The same distresses I have seen produced by the misapplication, or by the protracted use, of calomel and drastic piu'gatives — by over-treatment, in short. Death being presumed to occur only in the severer forms of dysentery, and in the worst cases only, we perceive, on removing the abdominal parietes, a turgid and congested state of the vessels, with adhesions of the serous coverings of the omentum, mesocolon, and mesentery, with varied and more extended adhesions between the different ^ascera ; enlargements and inflammations of the glands of the mesocolon and mesentery, with occasional suppura- tions in them ; inflammation and its results, such as thickening of the coats of the large intestines, softening, ulceration, or sloughing of the mucous membrane of the ileum, or of a portion, or of the whole of the larger bowel — the ulcers having the appearance of variolous pustules, and being, in fact, glandular ulcerations, some- times perforating the coats of the intestines into the general cavity ; thickening of the coats, and contractions of the bore of the intes- tines, fi'om effusion of fibrine and lymph, especially of the larger bowel, and most frequently at its sigmoid flexure. Adhesions of the omentum to the cfecum, and abscess in the vicinity of the caecum, are occasionally observed. In the hepatic complication the liver will be found congested, inflamed, suppurated, or indurated, according to the degree and duration of the disease. In the dysentery of the Peninsular army, under the Duke of Wellington, the spleen^ liver, and mesentery were generally found diseased ; and in the epidemic form of the disease, as it prevailed in Ireland, the liver was diseased in half, the spleen in a fourth, the small intestines in two-thirds, and the colon and rectum in all the dissections ; but I do not recollect any mention of hepatic abscess from phlebitis, purulent deposit, or other cause, an event so frequent in the East. In the scorbutic complication the post-obit appearances are altogether of an asthenic character, indicative of a diseased condi- tion of all the fluids. The inner surface of the large intestine, and of the ileum likewise, generally exhibiting extensive disorganiza- tion and decay, the bowel being in many cases filled with shreds and sloughs of mucous membrane and grumous blood, while the liver has a blue appearance externally, and when cut into, the blood which flows is atrabilious and dissolved ; but where haemor- rhage from the bowel has occurred, the liver will be found softened and. anaemic. The spleen crumbles under the slightest pressure, like a mass of grumous blood. Ecchymosed patches 440 ACUTE DYSENTERY OF BENGAL. are to be seen on tlie outer skin, on the external and internal sur- faces of the bowelsj while congestive patches of diseased blood and softening of textures are found in the heart and lungs. Appear- ances such as these indicate — either that the forces of diseased action have been invincible in their nature, or that the treatment intended for their removal has been inert or insufficient. TREATMENT, The first and greatest care of the medical officers of fleets and armies should be directed to the prevention of this formidable disease, by securing such attention from the authorities to matters of diet, clothing, protection from weather, and the conduct of duty, as may preserve the men in the vigour of health. There is no disease in which an early preventive and remedial attention is of more importance than in dysentery — the very great mortality of the disease in many of our tropical possessions being in consider- able degree referable to the neglect of early measures of prevention and cure. Soldiers and seamen, when left to their own ways, will go on with their duties under seriously advancing disease ; and it is only when " bloody stools, with cutting pains," affiict them, that they will " report sick." It is here that the all-powerful influence of commanding officers should be solicited by the watchful sur- geon. An inspection-muster, morning and evening, should be ordered, with a view to the earliest detection of advancing disease. This simple measure will save vast suff'ering and many lives. But however watchful the sanitary precautions, a certain amount of sickness from dysentery will always occur in naval and military service within the tropics. It therefore behoves all who have to treat this disease to bear in mind that the destruction of those placed in their charge is at hand— indeed imminent — unless the disease is promptly relieved by appropriate medical means. Every conside- ration of humanity and of duty to the State should concur and unite in directing our eflbrts to the speedy and efiectual arrest of the sufiierings and dangers attendant on tropical dysentery. For- tunately we have, both in the army and navy, to treat men in the vigour of life, with the further advantage that the patient comes under our care immediately he falls sick. A speedy and secure convalescence therefore results from a timely well-regulated and decisive course of treatment, while chronic dysentery, with lingering suff'erings in hospital, or permanently broken health, will follow on feeble and indecisive attempts at cure. Let it be remem- bered also that cases, bearing the appearance of the mildest cha- racter of disease, are occasionally found to exhibit, in course of a few hours, the real characters of destructive inflammation. Nothing therefore but the most watchful care, guided by intelligence in the selection and use of means^ can lead to the patient's safety. In ACUTE DYSENTERY OF BENGAL. 441 the treatment of dysentery, as of fever, our first and most special regard must be given to the character of the type, whether sthenic or asthenic. It will be found with acute inflammatory or congestive dysen- tery, as with fever, that a sufficient abstraction of blood by vene- section, practised at the very onset of the disease, will simplify and render easy all the subsequent stages of the cure ; so much so that, in mild and uncomplicated dysentery, as in the violently acute and inflammatory type of the disease, blood-letting is the primary as well as the cardinal measure. In acute uncomplicated dysentery, a moderate bleeding from the arm, followed by a full dose of calomel and James's powder, or ipecacuanha, say ten grains of the latter to ten of calomel, given at bed-time, a warm bath, or hot fomentations to the abdomen — a morning aperient, followed during the day by sudorifics conjoined with diuretics — the moderate use of demulcent drinks, allowing no other sustenance — wiU, in a very few days, bring about convalescence. Where pain remains in any particular region of the abdomen, as that of the c?ecum, sigmoid flexure of the colon, or the rectum, leeches should follow the general abstraction of blood, guarding carefully against subsequent oozing from the leech-bites, and using warm fomentations or poultices only when the bites have been thoroughly dried up. While any irritation of the bowels remains, as indicated by frequent stools, containing mucus and blood, the nightly dose of ipecacuanha, diminished in amount as the symptoms mitigate, must be continued, followed during the day by cooling diaphoretics with diuretics, as recommended in the treatment of fever. In the use or the withdrawal of calomel or blue-pill at night, along with the sudorifics, we should be gviided by the presence or absence of fever with a furred tongue, and by the healthy or depraved condition of the intestinal discharges. ]Mercury ought not, in short, to be regarded, in every case, as a necessity in the treatment of dysentery. It is not a remedy of necessity in all cases or in all climates : in the West Indies, for in- stance, the hepatic complication is by no means so frequent as in the East. While the use of sudorifics, with some mild mercurial, is indi- cated by the continuance of dysenteric symptoms and hepatic dis- order, with more or less vitiation of the secretions, a mild aperient in the form of castor-oil, or of compound powder of jalap, should be exhibited every second or third morning, while in this mild, as in every form of acute dysentery, the diet must be of the very lowest, presuming that the time required for the cure will not comprehend many days. In the highly inflammatory type of dysentery, on the other hand, we shall find that, after free blood-lettings, the occasion for the use of calomel with the sudorific will depend on the amount of com- plication, and on the constitution of the patient ; and when he is 442 ACUTE DYSENTERY OF BENGAL. youthful and robust, -with fever, tumid abdomen, and furred tongue, the repetition of blood-letting, and that of calomel and sudorifics in full doses, will be called for ; the mercurial sudorific also must be rejaeated every night, reduced in dose as the disease yields, until the discharges from the bowels assume a natural appearance, when calomel may be discontinued, and blue-pill or mercury and chalk substituted, if any mercurial should still be necessary. The circum- stance too that, in certain cases, much blood is voided by stool should not deter the surgeon from the use of the lancet ; for, on the con- trary, the early and free employment of depletion will greatly con- duce to safety. Of blood-letting and mercury it must be observed also that, although they prove most beneficial when used early in the disease, they will still be found necessary, in their just pro- portions, where the disease has even existed for some time, or where treatment has been neglected. Blood-letting was repeated by Robert Jackson " until all that was expected from it had been attained." But all the circumstances of each individual must be so weighed, in reference to constitution, age, habits of life, and length of residence in India, as to guide the medical officer in the amount and measure of every means employed. It is impossible to fix an arbitrary rule or gauge for every case beforehand, and it is better that a young practitioner should reflect seriously on all that relates to his patient, and act on principle according to his judgment, than that he should betake himself to a pattern such as is occasionally afforded in narratives of published cases. He must learn that, in our management of an ever-varying disease, we are unable to lay down any catholic rules of treatment which shall be suitable to every case. When we feel assured that inflammation has been subdued, a full opiate may be added to the night dose of sudorific, or the two may be combined in the form of compound powder of ipecacuanha; and thus, provided we have been so fortunate as to see the patient immediately on his being taken with the disease, a few days of treatment, such as is here described, will prove eff'ective of cure. Used in this manner, opiates conduce powerfully to the cure ; and their free use, in the manner here recommended, should never be neglected. Robert Jackson fre- quently ordered the Dover's powder, in doses of eight grains thrice a day. In persons of a less robust constitution, again, and even in such as are of delicate habit, in whom dysenteric purging, griping pains, and pain on exploration of the abdomen are present, re- peated abstractions of blood generally, and by means of leeches, will be requisite ; the measure of blood-letting, as well as the occa- sion for its repetition, being estimated and determined by the amount and degree of the disease. In every case dysentery must be speedily overcome by treatment, if we would save our patient. It was a maxim of Hippocrates that " in desperate diseases, desperate remedies, energetically pursued, are the most efiicacious ;" and we everywhere find this principle ably supported by Robert ACUTE DYSENTERY OF BENGAL. 443 Jacksou, who urges that " when the state is inflammation, and the termination congestion, suppuration, or gangrene, the physician must not hesitate in striking a bahance between the chances of de- biUty and the almost certainty of death. There is here no safety in half measures." But while without blood-letting there is no safety for the suf- ferer so long as evidences of inflammation are in existence, no sensible person would, on the other hand, practise such an opera- tion, or continue the use of powerful remedies, after the subsiding of symptoms has indicated the approach of convalescence ; and here we limit ourselves to the use of ipecacuanha as a sudorific, cooling diaphoretics with dim-etics, mild aperients, cold water enemata, with or without lead and opium, anodynes by the stomach and rectum, warm baths, demulcent drinks, and farinaceous diet, all which means must follow upon depletion, and their exhibi- tion must be persisted in until we shall have obtained to conva- lescence, but no further. The most cm'sory view of the special pathology and of the associations of dysentery, ought to satisfy the medical officer that no one exclusive mode of treating a disease so complicated in its nature can be rational in itself, or successful in its results. Dysentery, as it may occur in the plethoric, hale, newly-arrived, or older Evu'opean resident in India with damaged constitution, is often simple and inflammatory, and, after a few days, complicated by con- gestion or inflammatory states of one or more of the surrounding viscera j it is to be seen associated with low adynamic malarious fevers, remittent, intermittent, and continued, with scorbutus, with phagedenic ulceration and haemorrhage. Nay, in temperate climates, we find typhus and scorbutus engrafted on dysentery, as with the French troops in the Crimea, so as to present a mortal combination of all three diseases. Under such varied aspects, it is obvious that our means of cure, to be appropriate, must be diflerent, and grounded on the true patho- logy of each condition. In the acute inflammatory seizure of the young and plethoric European, whether simple or complicated, the abstraction of blood must be immediate, and so impressive as at once to arrest indammation and congestion, after which come a few cholagogue doses of calomel, and a few aperients, sudorifics, opiates, demulcents. In the older European the same means will be neces- sary, but in abated vigour and force. In the adynamic associations of dysentery, other and opposite means must be employed, such as may coustringe, support, give tone, and improve the condition of the blood. When, after the removal of inflammation, soreness along any portion of the large intestine exists, with a suspicion of ulceration of the mucous membrane, the use of washed sulphur alone, or in combination with- the bitartrate of potash, Avill prove the best aperient given every other morning. This combination seems to 444 ACUTE DYSENTERY OF BENGAL. liave a detergent and healing influence, and even the sulphur im- combined acts as a most gentle and soothing relaxant. Enemata are here also most powerful to good, either in the emollient and anodyne form, given at bed-time, or as an astringent and refrige- rant in the form of cold water, having eight or ten grains of the acetate of lead, with two of opium, in solution. This last form of injection, with diminished proportions of lead and opium, may also be exhibited three times a day where great tenderness and irritation exist in the rectum. It is always desirable that the in- jections should be retained, and to this end they should not exceed three or four ounces, and the operation of injecting should be performed in the most gradual and gentle manner ; as to the temperature, whether cold or warm, we should be guided by the feelings and wishes of the patient, these being the true tests. It is important to pay attention to such adjuvants, for tormina and tenesmus are very wearing and depressing to the nervous system, and they are aggravated during the night so as not only to prevent sleep, but by the frequency of the calls to stool the patient is exposed to the additional risks of checked jjcrspi ration and chills. To guard against such evils it will always be proper, in the case here under consideratioii, to add the enemata to the night opiate, or Dover's powder. Suppositories of lead ointment, with two grains of opium, will likewise be found calming of irri- tation in the rectum, and therefore very grateful to the patient. On the subsidence of inflammatory action, when fulness, tender- ness, or thickening of the bowel exists at any portion of its course, blisters are always beneficially employed. Robert Jackson states, Avhere tenesmus is urgent, with pain and heat in the rectum, ac- companied by ofl^ensive discharges, he found the following powder very efficacious : — Finely powdered charcoal 9j ,, ,, rhubarb gr. x. ,, ,, ipecacuanha gr. v. A drachm of charcoal powder in rice-water he also states to be equally eff'ective as an enema. " These,''^ he says, " of all means known to me, have had the most instantaneous good eff'ect in this form of disease. When the subject has been prepared by previous evacuation, &c., two or three doses of the powder by the stomach generally efiect a cure." In severe cases he gave this preparation every five or six hours ; but he adds, with characteristic candour, that " where the action of the disease is chiefly upon the exterior membrane, or in the more remote organs within the abdomen, it was of no value. '^ The force of disease having been subdued by depletory means, Robert Jackson says, that " the application of very cold salt-water to the abdomen, particularly to the fundament by cloths or sponges ; or immersion of the lower part of the trunk in a tub of cold water ACUTE DYSENTERY OE BENGAL. 445 is singvilarly refi'csliing. It alLays the torments of tenesmus, and gives a respite from local sufferings, whieli, if properly valued and improved, lays tlie case open to the action of general remedies, so as that tlie disease may he conducted to a safe and speedy issue with something like calculahle certainty." In the instance of inflammatory dysentery, as already stated, we cannot he too sparing in the use of food, or even in the use of liquids. Thirst is rarely urgent, as in fever, and there is no craving for food. We shall therefore do well to require the most rigid abstinence on the part of the patient. During the first ten days of convalescence also, the most careful attention should be paid both to the quality and quantity of the food, else relapse may be apprehended. The healing of ulceration and the absorption of effused fluids are processes likely to be seriously retarded by anything approaching to a full stomach. "When convalescence has been established, quinine, or some other preparation of cinchona, should be exhibited as a tonic, con- joined with the dilute sulphuric acid, and with the tincture of opium if necessary. Exhibited in this manner, quina gives tone to the digestive functions, and obviates adynamic tendencies. A most dangerous form of hemorrhagic dysentery appears occa- sionally under the influence of causes the most concentrated, re- mote, and exciting, and chiefly amongst seamen and soldiers of reduced health, when exposed to tlie joint actions of the deleterious compounds of intoxicating liquors sold in the bazaars of Calcutta, and of severe exposure by night and day to the influences of the climate. This is the form of dysentery termed retrograde by Robert Jackson. So imminent is the danger, that death may take place within a few hours of admission into hospital, or it may be protracted to the third or fourth day ; but, even in a disease so frightful to behold, it is surprising how eases wearing the most unfavourable aspect will sometimes recover. The patient generally presents the appearance of collapse with a sad, anxious, scorbutic-looking countenance, much restlessness, a cold damp surface, a small quick and feeble pulse, and a cada- verous odour exhaling from the body, the matters voided consist- ing of grumous blood, or of fluid largely tinged with blood, with sloughs and patches of mucous membrane, and having an offensive cadaverous smell. Increase of collapse with hiccup, vomiting, and the involuntary passage of copious bloody dejections, end in speedy death. The fatal hsemorrhagic dysentery in the Bengal European Fusiliers and II.M.^s 80th Regiment in 1849-50, is said to have been preceded by bad malarious fevers of various types ; but the fact of the dysentery being confined to the soldiery would imply also the additional disadvantages of neglects in the food and drink — neglects in the sanitary condition of the localities, resulting in 446 ACUTE DYSENTERY OP BENGAL. bad air^ and other injuries. These circumstances resulted in a deadly dysentery, accompanied by sanguineous discbarges from the gums, nose, fauces, and bowels. On dissection, an excessive deposition of coagulable lymph is found between the coats of the large intestine, and most gene- rally in the caecum, sigmoid flexure, and rectum, while large irregular patches of sloughing ulceration pervade the mucous membrane, and sometimes give rise to large perforations of the bowels. In treating this hsemorrhagic form of the disease we must have instant recourse to the most powerful astringents in the largest doses, aiding their efiTects by the free addition of opiates ; and both must be frequently and freely administered by the mouth and anus. Lead may be used more liberally and more safely than is generally supposed. Dr. Christison of Edinburgh has given six grains of the acetate of lead daily for several months, without any ill effects, while Mr. Webber of Norwich states that, '' in severe cases of bronchitis he administers from three to ten grains of the same medicine in pill, with a mioctufe containing three drachm closes of distilled vinegar every four hours till symptoms subside, which frequently takes place after the third or fourth dose." In hsemorrhagic dysentery the lead should be given every two hours, so as speedily to establish its influence, while to each dose a grain or more of opium is added, using at the same time strong enemata of solution of acetate of lead with opium, thrown with sufficient force to enter the course of the colon ; and this plan of treatment must be persisted in till the discharge of blood shall have totally ceased. Dr. Kenneth Mackinnon of Bengal has for many years advocated the use of large doses of opium in the sloughing and heemorrhagic dysentery ; and Mr. Taylor, surgeon to H.M.'s 80th Regiment, when treating of the haemorrhagic and phagedsenic types of this disease at Diuapore, Bengal, says : " The medicine of most constant avail in those cases is opium ; and it is astonishing the great quantity of it required to produce any effect. Fifteen to thirty grains a day may be given without producing stupor or even headache. When the case is less severe, allowing of more time, quinine is resorted to by all who have treated this disease, showing the general suspicion of its febrile nature." This is a revival of the practice of Sydenham, folloAved more than fifty years ago by Sir James M'Grigor and others in the East Indies. In a form of the disease characterized by a rapid destruction of the organs immediately involved, and by general collapse of the nervous and vascular systems, such a diet must be allowed as may nourish while it supports the sinking powers of the patient ; and with these views soups should be added to the farinaceous articles, while wine and even brandy with opium must be allowed, in order to guard against sinking. Convalescence will be greatly ACUTE DYSENTERY OF BENGAL. 447 promoted by the exhibition of quiniue with nitric or sulphuric acid, with the addition of a few minims of laudanum. The value of opium in sloughing phagedaena points it out a priori as an efficient remedy in this terrible disease, and so it proves in fact — opium and lead, with suitable diet, constituting the only means on which we can rely. Dr. Wilraot, of Tunbridge Wells, in a severe epidemic dysen- tery of a scorbutic character, and attended by sloughing ulceration of the mucous membrane, while he exhibited by the stomach the decoction and compound tincture of bark with sulphuric acid, administered in the form of enema a drachm of creosote in twelve ounces of thin starch ; and to this latter means, exhibited every night at bedtime. Dr. Wilmot ascribes very decided results, as a stimulant, antiseptic, and styptic. Oil of turpentine, in small and repeated doses, has for many years been recommended as useful by Dr. Copland and others in hsemogastric and low typhoid fevers, in typhoid h?emorrliage from the bowels, in hpemorrhages from the mucous surfaces, dependent on an atonic state of the vessels, and in hsemorrhagic dysentery. The physiological actions of turpentine are, in fact, very analogous to those of creosote. But whether we have to treat dysentery in its milder or most severe form, complications will meet us, either from the com- mencement of the disease or during its progress, and Ave must then be prepared to meet each contingency as it may arise ; — and first, of the hepatic complication. The liver will be found involved, in some instances, from the very commencement of the disease, while in others it palpably arises in the course of the dysentery. The daily exploration of the hepatic region, as well as of the course of the large intestine, will therefore in every ease be necessary, to obtain a just appreciation of all the circumstances of each case. Here depletion, both general and local, must be carried to such extent as to remove congestion of the portal system, tumidness, and pain of the liver, while by the nightly use of calomel and ipecacuanha, followed by compound powder of jalap in the early morning, and diaphoretics with diuretics during the day, we relax the skin, emulge the liver, and restore the lost balance of circula- tion. The measures here indicated must be repeated so long only as the signs of general congestion and hepatic complication are present, discontinuing the use of calomel and blood-letting imme- diately on their disappearance. In this, as in every other instance where leeches are used, I would urge on the young surgeon the necessity of applying so many leeches as may be necessary, and no more, arresting the oozing from their bites without delay, while no poultices or fomentations should be applied until all oozing shall have completely ceased. After the removal of acute symptoms, should fulness or tender- ness of the liver still continue, the occasional application of blisters 448 ACUTE DYSENTERY OF BENGAL. sliould be made over the region ; and to advance convalescence, the nitro-muriatic acid, internally and externally exhibited, will prove eminently serviceable. It is necessary in the dysenteiies of the East to have constant regard to the hepatic complication ; for it may be that, by appropriate means, we can remove inflamma- tion and consequent ulceration of the mucous membrane of the intestine ; but if disordered function, congestion, or inflammation of the liver tending to abscess be going on, the cure will be post- poned or prevented by any one of the circumstances named, or by the occurrence of dysenteric relapse — a condition to be vigilantly guarded against. In the cure as in the prevention of scorbutus we have mainly to look to the avoidance of all exliausting and depressing causes — to the removal from damp, to care in the diet, cleanliness, ventilation, cheerful occupation, and change of air; while medically, and re- ferring to the scorbutic complication in dysentery, our first indica- tion of treatment is, by appropriate medicine and regulation of the diet, to restore the health of the blood. The want of fresh meat, fresh vegetables, and milk has every- where contributed to the induction of scorljutus. In addition to the liberal use of pure lime-juice, vegetables and fruits should be abundantly supplied, and potatoes especially, as being eminently anti-scorbutic. During long voyages some re- duction in the meat portion of the ration might be advantageously made, granting a proportionate increase of vegetables and fruits ; for it is to the want of these last, even more than to the sameness of the diet and the salted meat, that the production of the scor- butic taint is referred. Scorbutus is not only a serious disease in itself, but its complication with fever and dysentery, and the greater liability of scorbutic persons to be affected with the various tropical diseases, malarious and other, render its prevention and cure a question of great importance."^ In scorbutic dysentery fresh lime-juice with opiates simply, or in the form of Dover's powder, will prove the best medicine, while a liberal allowance of fruits and vegetables should be granted, along with so much fresh animal food as the stomach will bear. When irrital)ility of stomach exists, the chlorate of potash, the carbonates of soda and potash in effervescence, lime-juice being in excess, may be given with advantage ; and when tormina and tenesmus occur, with bloody discharges from the bowels, anodynes and astringents combined, or lime-juice and opium in the form of enemata, should be employed, while the infusion of cinchona with the nitro-muriatic acid and opium are given by the stomach. * Sir Gilbert Blane states that "the first ample supply of lemon-juice to ships of war was as long ago as 1757, to the squadron under Admiral Watson, in the East Indies, at the suggestion of his surgeon, Mr. Ives, a gentleman highly educated, of great merit and modesty ; and we do not learn that he courted public notice, far less that he solicited a reward for doing what he deemed to be merely his duty." ACUTE DYSENTERY OF BENGAL. 449 When sloughs are discharged by stool along Avitli grumous blood, the scorbutic taint being manifest, the danger to life is imminent. For the removal of the oozing Avliich takes place in scorbutic dysentery from the gums and mucous membrane of the bowels, the astringent and tonic properties of the sulphate of iron, largely administered in solution by the stomach and rectum, and used as a gargle, will be foimd eminently serviceable ; with the same view the muriated tincture of iron is recommended by Annesley and otlio's, but it is not intended that either means should supersede the use of the direct antiscorbutics. The combination of iron and alum will likewise be found of great service, as will the Sand Eoek chalybeate water of the Isle of Wight. In default of lime-juice, the medical officer must seek for sub- stitutes in citric acid, and in all kinds of summer fruits. For more than a century fruits have been justly lauded by our army surgeons in the treatment of dysentery, and the physicians of Spain and Portugal, according to William Fergusson, have for ages employed the juice of lemons with good effect in the endemic and epidemic dysenteries of their respective countries. Dr. Cabbel, a talented young surgeon of the Peninsular army, used no other medicine in treating British soldiers ; when severely attacked in person by the disease in Portugal, though attended by Dr. Fergusson, he refused all remedies other than lemons and oranges, and he speedily recovered. " In Trinidad, too, when a dysentery of uncommon malignity appeared there. Dr. Lynch O'Connor found that lime- juice, administered by the mouth and in lavement, was the only remedy that could be depended upon.'' Isambert, speaking of the antiseptic powers of the chlorate of potass, says that it has been found of use in scorbutus ; and thus we find the materies returning by another route to one of the first affections the chlorate was recommended for, on the theory of deoxidizing the salt in the economy. Pringle, more than a hundred years ago, used grapes freely in the treatment of dysentery, and there have been few since his time who may be regarded as better authorities. On the subject of the Bacl fruit of Bengal, and on the use of fruits generally in the East Indies, I beg to refer the reader to what is stated respect- ing them in the article on chronic diarrhoea. Dr. Kinloch Kirk, of the Bengal army, speaking of the sickly condition of the 78th Highlanders in Sindh, in 1843-44, states that the soldiers suffered from " large livers and spleens, and were weakened by continued colliquative purging.'' In this state, and suffering from a low fever, " the men found, from their own expe- rience, more comfort and more advantage from the use of limes than from any other substance, and many gave back a portion of their rations to receive in lieu its value in limes." This intelligent officer, with an excellent power of observation and a rare practical G G 450 ACUTE DYSENTERY OF BENGAL. tact, wlien serving in tlie same country witli sepoys suffering in the same manner, made nse of the Pliijllanthus emhl'ica, or Aoula of the natives, and which is held by them in high repute. The fruit is iised in various ways, preserved in its dried state, in syrup, or pickled, and is to be found in all considerable towns throughout India. " An infusion of two ounces of aoula in twenty of water was given to ten men three times a day, in conjunction with whatever else was necessary, as bark, quinine, opium, &c. ; and I found this remedy as useful certainly as lime-juice, in cases where the spleen and liver were enlarged." Dr. Kirk found, on examination, that the fruit consisted of '^ citric acid, tannic acid, and pectin, or vegetable jelly." For years Dr. Kirk, unhappily killed in the mutinies, had been using lime-juice in the treatment of enlarged spleen, '^ with the most beneficial effect." This quotation is made from the '' Pathologia Indica" of Professor Allan Webb, of the Cal- cutta Medical College, a work of the greatest value to all who are interested in the progress of tropical medicine. In treating the complications of dysentery with fevers, remittent and intermittent, we must have regard to the type and prevailing character of the febrile movement, as well as to the paroxysms, in addition to the attention that may be demanded by the condition of the bowels. When the fever is of an ardent inflammatory, or of a severely congestive character, our antiphlogistic means must be applied with an energy proportioned to the violence of the disease ; while in the low adynamic type we must have recourse to bark, quinine, opiates, chalybeates, the vegetable and mineral acids, improved diet, and change of air. In this latter form of the disease, the morbid actions are very liable to assume a low adynamic character — sometimes degenerating, in low damp situations and crowded camps, into the hsemorrhagic and sloughing type, followed by a terrible mortality. Here opium in large doses, conjoined with quinine, will be found to constitute the best treatment. Opium has been administered in the East Indies, in such states of disease, to the amount of from twenty to thirty grains in the twenty-four hours, without inducing narcotism. A rather generous diet, with wine or ale, will likewise be found necessary to the suc- cessful treatment of these cases ; and by such course of treatm^ent the nervous and vascular functions will be supported, pain and irritation will be relieved, while time will be afforded for the reparative processes of nature. When, on the other hand, malarious dysentery is complicated with congestive or inflammatory states of the liver, the combination of calomel with quinine and opium — preceded and followed by the means already indicated — will prove of excellent effect. In short, here, as in fever, to be successful, we must hold continually in view the prevailing type and character of the disease, and adapt our measures of cure accordingly. Where, happily, convalescence has commenced, it may be both promoted and matured by the use of chlorinated solution and the nitro-muriatic acid. ACUTE DYSENTERY OF BENGAL. 451 In convalescence from dysenteries, acute and chronic, indeed and of every type, much active benefit will be derived from the external and internal use of the nitro-muriatic acid. When the spleen is found to be enlarged, whatever the stage of dysentery, and whatever the type of the fever, mercury must be carefully avoided, trusting rather to the means just named, and to all such as vivify and improve the blood. It is almost unnecessary to add likewise that the abstraction of blood, in the complication of these fevers with dysentery, should be practised only when the fever is of the acute or ardent type ; the adynamic forms, as well as the splenic cachexia, not admitting of the use either of mercury or of blood-letting. As regards the treatment of convalescence from dysentery, I would impress on the inexperienced a careful attention to all that has been urged upon that subject in the conclusion of the article on fever. There is not a word of caution there inculcated that does not apply with equal force to the management of the stage of recovery from tropical dysentery, as to that of convalescence from fever ; and too much attention cannot be paid to either case, if we would protect the seaman or soldier from the dangers of relapse. It should be a rule w'ith all medical officers to grant the seaman and soldier sufficient time to confirm convalescence and restore health, before returning him to duty. Time is necessary to the absorption of interstitial deposits, and for the cm'e of functional disorders, the results of acute disease ; and it would indeed be a mistaken notion of efficiency which should cause a half-cured man to be sent to labour, whether in peace or war, not to speak of the inhumanity of such conduct. So much having been offered on the treatment of dysentery, simple and complicated, I must once more urge upon the naval and military surgeon the value of time in dealing with such a disease. In treating fever as well as dysentery, it should again and again be remembered that time is either our most important ally, or else our most powerful enemy, just as we may use or neglect it. Time will often be tiu'ued into a dire enemy, both by the soldier and seaman, if permitted ; and in civil life the same neglect will occur through the carelessness or the vices of indi- viduals ; so that the patient comes under treatment at all stages of the morbid progress. Excepting under the pressure of actual war, when dislocations and impediments will occur, it is happily in the power of officers in command to order parades of inspection con- ducted by the surgeons ; and thus every man may be looked to on the instant of his falling sick — an incalculable advantage to the individual and to the state. THE DIET. As in fever, so in acute dysentery, the diet must be of the most G G 2 452 ACUTE DYSENTERY OE BENGAL. spare during the first few days of active treatment ; and what little is allowed should be of the most bland and unirritating natvire, and consist of farinaceous fluid preparations. Under circumstances of returning healthy milk with sago, arrowroot, or tapioca will be found an excellent addition; and, as convalescence becomes matured, soups and broths may be substituted, ending in gradual return to the accustomed and regular diet. In the scorbutic, sloughing, and hsemorrhagic forms of dysentery, on the other hand, diet constitutes from the commencement of the disease a most important part of the treatment ; and the same l^rinciple will apply when dysentery is associated with ansemic states of the system — in all these latter instances, a more or less nutrient diet, together with wine, will be found necessary to the cure, INIedicines alone will not cure such diseases ; and not to speak of the destitute condition of the troops in Burmah, I have seen, both in hospital and in private practice in India, cases of dysenteries such as are here referred to, which appeared to tei-mi- nate fatally from want of the diet proper to them. Dr. Kenneth Mackinnon, speaking of the low adynamic jail-dysentery of the natives of India, says justly — " Give me the benefits of pure air and change of diet, and I would feel inclined to exchange for them all the drugs in the pharmacopoeia.^^ If the patient is seen in the first stage, or simple inflammatory, or in the second stage, or that of exudation into the submucous tissue — Arrowroot with milk or with cream will prove the best diet. I propose now, as in the instance of remittent fever, to present a catalogue-raisonne of the treatment of dysentery in difl"erent ages and countries. This, while it exhibits the limited views of some men, establishes with authority the comprehensive measures of cure of the majority of authors : — 1623. Bontius : — Bleeding, repeated according to occasion — vomit of ipecacuanha, and a pui'ge — the extract of saffron, " the anchor of hope " — emollient enemata and fomentations — fruit diet. 1696. Sydenhain : — Early blood-letting — opiate at night — active purge in the morning, repeated every other day, and followed by a powerful opiate — an anodyne with a diaphoretic every night, or every eight hours in severe cases — emollient injections, and injec- tions containing Venice turpentine. 1760. Dr. Huck : — Blood-letting repeated according to occa- sion — purgatives — ipecacuanha and tartar- emetic, in repeated and full doses. 1768. Pringle, Sir Joseph : — Blood-letting — vomiting — mercurial purges — ipecacuanha and opium — grapes. 1773. Dr. John Clark : — Full emetic of ipecacuanha and tartar- emetic, followed by mild purgatives — ipecacuanha and opium in small and repeated doses. ACUTE DYSENTERY OF BENGAL. 453 17S2. Mr. Curtis: — Purgatives chiefly; in the advanced stage, small doses of ipecacuanha powder — astringents and tonics. 1787-9. Dr. Moseley: — Blood-letting — autimonials freely ad- ministered — revulsion. 1791. ]\Ir. Wade of Chunar : — Solution of tartar-emetic and purging salts — anodynes and sudorifics. 1791-1820. Robert Jackson: — Copious blood-letting during immersion in the warm-bath, " the sovereign remedy, without which nothing can be done with a fair prospect of benefit/' fol- lowed by an emetic and mercurial purgative ; — the alternate use of evacuants and sudorifics, " Dover's and James's powders hold- ing the first rank of the latter" — hot fomentations to the abdomen, with the local use of cold water/and " tonic applications in glyster" — warm clothing — change of air, especially a sea-voyage. 1796. Dr. Hunter : — Mercurial and saline purgatives, followed by opiates. In mild cases this constituted the sole treatment; in severe cases — draughts of infusion of bark with rhubarb— fo- mentations — blisters. 1799. Dr. Lempriere : — An emetic — warm baths and fomenta- tions — emollient injections " as a necessary preparation to a purge" — active and persistent purging by common purging salts, by calomel and rhubarb, or by calomel and jalap — diluents — farina- ceous diet. 1799. Blane, Sir Gilbert: — Blood-letting — vomit and purge at the beginning — ipecacuanha and opium — purgative salts — small doses of ipecacuanha powder. 1799. Dr. Whyte: — Profuse blood-letting — flannel roller over the abdomen — careful confinement to bed, the body being anointed with oil — no medicine. ISOl. M'Grigor, Sir James: — Blood-letting — mercury with sudorifics — flannel roller round the abdomen — aperients — opiates — nitric acid internally, and in the form of bath — enemata of lead and zinc — demulcent drinks — antiphlogistic regimen — change of air. 1811. James Johnson: — Blood-letting, repeated according to occasion — calomel in full doses — sudorifics — occasional mild pur- gatives — anodynes — cooling antiphlogistic diet — w^arm clothing — change of air. 1817. AVilliam Eergusson: — Blood-letting — small doses of calo- mel with ipecacuanha — inunction, till the gums become aff'ectcd — fomentations — warm clothing — the use of fruits — change of air. 1818. Ballingall, Sir George : — Topical bleeding — purgatives — infusion of ipecacuanha — opiates — warm baths and fomentations — enemata — blisters. 1818-22. The Dublin Physicians — Epidemic dysentery: — Blood-letting, general and local — calomel, antimony, and opium combined — emetics — enemata — counter-irritation — warm baths. 1 819. Mr. Bampfield : — Blood-letting — cathartics— diaphoretics with mercury. 454 ACUTE DYSENTERY OF BENGAL. 1822. Annesley, Sir James: — Emetic of ipecacuanha^ followed by full doses of calomel, smart purge, and warm bath — then blood- letting, general and local, according to constitution and length of re- sidence in India — calomel and opium, alternating with purgatives and enemata — ipecacuanha, or antimony, with opium as a sudorific. 1823. Dr. Latham: — After the failure of all the remedies com- mon to European practice^ including ipecacuanha — " calomel and opium became the settled practice.^' 1832. Mr. Twining : — General and local blood-letting, repeated according to occasion — simple powder of ipecacuanha with extract of gentian — purgatives. 1833. Dr. J. Smith, Edinburgh — Epidemic dysentery : — Scruple doses of calomel, given so as to fall short of salivation, " the more common measures having failed." 1833. Dr. Joseph Brown — Cyclopedia of Practical Medicine : — Blood-letting, general and local, repeated according to urgency, aided by hot baths and fomentations — gentle laxatives — mercury as a subsidiary to general and local bleeding, and combined with simple or compound ipecacuanha powder — sudorifics — opiates — enemata. 1835. Copland — Dictionary of Practical Medicine: — Blood- letting, general and local, repeated according to occasion — opiates '' after depletion" — mild aperients — cooling diaphoretics — ipeca- cuanha and opium — blisters. It is observed by Mason Good, that " the jmnaples of Syden- ham's practice it is not easy to improve upon ;" nor, indeed, have either his principles or his details of practice been much improved iipon from his day to the present — blood-letting, sudorifics, opiates, and aperients remaining still at the head of our standard remedies. There can be no doubt that the ^' putrid dysentery" of Clark, described by him as prevalent in Calcutta in 1773, was compli- cated, like the fevers of those days, with scurvy. The then pro- tracted voyages to India, the bad diet, the general sanitary neglect during the voyage, and, if possible, the greater sanitary neglects after landing in Bengal, left little hope to the British seaman or soldier when tropical disease was added to scorbutus. It is stated on the authority of the records of the Calcutta European General Hospital, that even in more recent times the mortality by dysentery was as follows : — Treated. Died. 1797. March, April, and May 37 ... 21 i June and July 58 ,, August and September 22 ,, November and December 21 1798. March, April, and May 17 ,, June, July, and August 27 ,, October, November, and December ... 25 1799. July, August, September, and October . . 31 35 IS 15 7 14 11 Total 233 ... 127 ACUTE DYSENTERY OF BENGAL. 455 111 tliosc (lays the treatment of fever and dysentery was by calomel and opium, mereurial inunctions, bark, animal food, and wine. Of the authors quoted in the above catalogue, those who speak most in favour of their success in treating tropical dysentery are — Bontius, Dr. John Clark, Dr. INIoseley, and Mr. Wade : — a brief inquiry into the merits of their respective modes of treatment may therefore prove of some interest. Bontius commenced with the abstraction of blood, and with vomits ; — then came the extract of saffron, " than which, I dare to say, a more excellent remedy was never discovered by mankind ; and I am fully persuaded that it is the most perfect antidote against this disease, even when of a malignant kind.^' Dr. Clark merely wishes "to present facts; but he must add that he has given bark to one hundred and fifty fever patients in Bengal and other places in the East Indies ; and of that number lost only one who took the medicine with perseverance." This gentleman was equally successful in the treatment of dysentery ; for out of " a number of patients" he only " lost four." Dr. Moseley abstracted blood likewise : — " Bleeding,^^ he says, " being an operation of great consequence in the flux, the cure is generally begun with it, repeating it as symptoms authorize, ob- serving only, Koii qica atm sit sed qua vires sint. After bleed- ing, a vomit of ipecacuanha is to be given, and then an opiate after its operation is necessary. This is to be followed by a care- ful and continued use of antimonial wine and laudanum combined, Avitli a view to keep up a sweat proportioned to the violence of the disease, and not in the trifling way of giving them in small doses, Avhilst the patient is exposed, and their operation neglected." The Doctor goes on to relate that the eminent success of this plan was exhibited when the soldier had been suffering from "the worst condition of the disease, with blood running from him as in a haimorrhage ;" and he adds that this demonstration of his superior success had been made before " several of the ofiicers of different regiments in the West Indies who were desirous to be spectators of a fact so interesting to the army." He concludes his triumphant narrative by exclaiming — " Such is the power of revulsion." The power of rcA^ulsion in the cure of dysentery is undoubtedly great, whether produced by agents internally or externally exhi- bited. I remember, when serving with the army in Ava, to have heard that a British merchant, while prisoner in the capital, was seized with dysentery. After days of unmitigated suffering, under circumstances of barbarous treatment, and when death appeared to him near and certain, an order arrived for the removal of the prisoners to a place of closer and still more severe confine- ment, where they were literally packed together. Here the suf- ferer was tlirown into a violent perspiration, and from that time 456 ACUTE DYSENTERY OF BENGAL. all liis symptoms left him. Sucli^ again_, is tlie x^ower of revul- sion ! Mr. Wade of Chunar claims an amount of success unbroken, except by " two cases of unfortunate termination in the treatment of about four hundred cases of fever and dysentery.'^ The treat- ment for both diseases was by a solution of purgative salts and tartar-emeticj followed by anodynes and sudorific night- draughts. Mr. Wade observes, that ^^ the medical world may draw their own comments on the cases which are submitted to their exami- nation. The person who has treated and compiled them shall defer his until the public may have formed some unbiassed opi- nion of them, he should only venture at present to vouch for their authenticity.^' This is just what has been done and said at all times by every writer of such cases, and by every pretender to ex- traordinary' cures ; but it is a curious fact, well deserving consi- deration how it happens — and happen it always does — that those who in their day claim the greatest and most exclusive success in the practice of medicine should, in after times, be the least fol- lowed in their modes of treatment. Some of the causes of error in reasoning and practice, as re- spects dysentery, are so well stated by Sir James M'^Grigor, that I cannot do better than present them in his own words : — " My op- portunities of seeing this disease have been no common ones. Rarely, I believe, has it fallen to the lot of an individual to see so very many cases of one disease in such a variety of climate and situation. In the 88th Eegiment, during more than ten years, I saw the same man the subject of this disease on the continent of Europe, in America, in both extremities of Africa, and in India. Of late, it has afforded me not a little amusement to review my notes as well as my journals of practice in this disease, in all these quarters. . . I became convinced in Alexandria that, with change of country and climate, we had a different disease. This is one proof how improper and how unsafe it is for the practitioner of one climate to set down and describe the diseases of another. They only who have studied the same disease in various opposite cli- mates can fully comprehend the extreme absurdity as well as the fallacy of this. From reasoning of any kind we are incompetent to decide on the identity of disease. Reasoning from analogy here always deceives. In many of the symptoms diseases may agree, but from thence to infer their identity is taking a very narrow view." Dr. Macpherson of Calciitta, speaking of the comparative re- sults of the treatment of dysentery by the free use of opium and other soothing means, observes with proper candour : — '^ Our ob- vious difficulty in arriving at safe conclusions is, that the disease itself varies so much in intensity in different years, as well as in different periods of the same year. Thus, her Majesty's 55th ACUTE DYSENTERY OE BENGAL. 457 Regiment lost at Sccunderabad, in 1837, one in four and a half; in IS'38, one in seven and a half; in 1839, onein ten; yet the treatment was the same, and eonducted by the same medieal officer throughout/^ If dysentery and fever were diseases of an uniform character, ha^"ing an uniform cause and seat, then perhaps they might be treated after an uniform plan ; but a very slender experience of the two diseases, as they prevail within the tropics especially, and even within the British Isles, shows that this is not the case ; for although, in the disease now under consideration, some portion of the larger bowel is universally implicated, yet, either from the ac- cession, or during the progress of the disease, for we cannot often say which, the lesser bowel, the liver, the spleen, the pancreas, and mesentery frequently become the seats of plethora and of other morbid actions, so as greatly to complicate the disease and modify its treatment. The pathology of our dysenteries, whether in southern or northern India, as described by our best authors, sufficiently es- tablishes the fact that, in this formidable disease, morbid action is not confined here, auy more than in Europe, to the course of the large intestine alone ; but that all, or most of the associated organs are found after death to be more or less deeply involved, just in proportion to the extent and severity of the symptoms during life. The truth is, that the dangerous and fatal characters of tropical dysenteries are principally due to these complications. " I have been repeatedly astonished," says Dr. Macpherson, of the General Hospital, Calcutta, " to discover after death an immense extent of stinictural change in boys, whose illness could not be ascertained to have exceeded eight or ten days.'^ It appears to me that to a want of just consideration of these inevitable pathological compli- cations must Ave refer the system of exclusive treatment, so much reprehended by every author who has had varied and extended opportunities of observation in dysentery ; these complications explain also the successive abandonment, by the surgeons of our fleets and armies, of every exclusive plan of treatment hitherto proposed, almost as soon as it has been tried. " In the treatment of no other disease, perhaps," says Dr. Copland, " has the baneful influence of exclusive medical doctrine been more fully exerted than in that of dysentery." The adhesions of the peritoneum — the pink colour, thickening and softening of the omentum, the effrised lymph, the adhesions between the diS'erent intestinal surfaces, the red and thickened state of the mesentery, with the enlargement of its glands — while they indicate the general amount and great extent of inflammatory action during life, leave the fact still demonstrated that, in causing death, the main force of the disease has been expended on the mucous surfaces.- He Avho would treat dysentery with success, w^hile he shuns 458 ACUTE DYSENTERY OF BENGAL. exclusive means and the inertia of accepted conclusions^ must assign to eacli remedy its proper value^ and neither more nor less. Blood-letting, sudorifics, and purgatives constitute the most uni- versal remedies ; in simple uncomplicated dysenteries^ of the in- flammatory and congestive characters^ and where applied early in proper subjects^ they will prove all-sufficient. But when the ab- domen is tumidj and there is pain in the liver, or in any other region, while the nature of the discharges indicates advancing in- flammation, calomel conjoined with sudorifics, and repeated to meet the occasion, will powerfully aid the curative eff'ect, through its influence on the depurative functions — on the circulation, in unloading, jointly with purgatives, the gorged vessels of the ab- dominal organs, on the blood and on secretions generally, and on the very sudorific function Avhich we so much desire to excite. This, in so many words, I believe to be the real value of calomel in the treatment of dysentery ; and the inexperienced have been led into much unnecessary doubt, and into no small amount of error, by some writers who regard calomel as a remedy of necessity, and by those who, on the other hand, would exclude its use alto- gether. It is hardly necessary to repeat that while calomel is a most powerful agent in its place, as an aid to blood-letting, the push- ing it to the extent of ptyalism is here by no means intended ; nor should mercury in any shape be used in adynamic forms of the disease, in the splenic cachexia, nor in states of ansemia — for in all these conditions of the system its actions are most injurious. Amongst the surgeons in Bengal blood-letting, general and local, takes the lead, and has done so for many years, in the treat- ment of dysentery. It is the standard remedy ; and I believe that when the subject comes early and freely under this treatment, and the case is not complicated with hepatic or other conges- tion, or with inflammation, little else than a few doses of sudorifics and aperients, as aids to general blood-letting, will be needed for the cure. But, as in most cases of this formidable disease as it appears within the tropics, the morbid action going on in the large intestine is intimately associated with general abdominal plethora and individual complications, other and important means speedily follow upon the bleeding ; and of these the first are those which act powerfully on all the secreting organs, internal and ex- ternal — such as calomel with ipecacuanha, in full doses at first, and given at bedtime ; followed by mild laxatives, sudorifics, ene- mata, warm baths and fomentations, blisters, and other minor adjuvantia. I believe this to have been for many years the course of practice in Bengal, and I have seldom seen calomel urged to the extent of producing salivation : neither do I think this degree of eff'ect at all necessary to the cure. Several experienced medical officers have assured me that antimony in combination with the ACUTE DYSENTERY OF BENGAL. 459 calomel proved^ in their hands, quite as efficacious as ipecacuanha, but in my own practice I always preferred the latter. When, after a few days, inflammatory action has been subdued by blood-letting, with the lowest diet, and intestinal irritation has been overcome by calomel, ipecacuanha, and aperients, then re- course should be'had to milder measures, as a persistence in the stronger ones is no longer either necessary or proper to tlie cure ; indeed, such persistence would prove eminently injurious. The late ]\Ir. T^vining would appear to ignore the associated diseases of the liver, and in his clinical work he advocates the use of simple ipecacuanha powder combined with bitter extract, which plan of treating dysentery he states to have been very successful. As first assistant, and as officiating surgeon to the General Hos- pital of Calcutta, during ]Mr. Twining's service in that institution, I had ample opportunity of witnessing the results of his treatment, and I am not aware that his system Avas followed at the time, or since, by any of the other medical officers of that hospital ; neither would his plan of treatment appear to be successfully imitated in the provinces throughout Bengal. Dr. Macnab, in an excellent practical report on the dysentery of the native soldiery of Hindu- stan, when serving in Bengal Proper, says, that " blue-pill with ipecacuanha and extract of gentian proved a complete failure, as has generally been the case in my trials of it. Indeed, I much suspect that ]\Ir. Twining overrated the value of his favourite re- medy, and that he may have also miscalculated the anti-emetic properties of the gentian.^' On Mr. Twining's use of drastic purging Dr. Everard says : — " Twining has certainly overpraised repeated strong purging. The Deputy Inspector-General Murray informed me that in his tour of inspection he found some cases which had heen dysenteric^ labouring under one-drachm doses of compound jalap powder given daily at noon, which got loell immediately on removing the ca2ise." Over-treatment is always a cruel infliction upon the sick, and so also is the cry to let well alone, which, in respect of disease, proves too often but the negligence which would leave ill alone. How much of close observation and of discernment do we require to ap- portion the means to the end ! how much of both, conjoined Avith experience, must we exercise even in withdrawing and withholding our means of cure ! Ipecacuanha has been a favourite remedy in the south of India for nearly a century, although Mr. Twining, like many respectable practitioners, fell into the error of supposing that what he observed was new, while in truth it was very old. Speaking of his cotem- poraries, Drs. Geddes, INIortimer, and Baikie of Madras, he con- cludes : — " In fact, ipecacuanha has been a favourite remedy with some of the medical men at the INIadras Presidency ;" and from the context it is evident that a very recent date is here meant. Dr. William Dick of Bengal says that in 1782-83 he used the 460 ACUTE DYSENTERY OF BENGAL. ipecacuanlia, in the form of infusion^ with the most excellent effects. " Though it vomited the patient the first day, it seldom had that effect afterAvards, and in general it occasioned more copious evacuations than many stronger purges. All medicines for this complaint ought to be given in a fluid state, if possible, as I find they irritate and gripe less than powders, however fine the}'^ may be ; and I am convinced of no fact more than that oily medicines are hurtful, rendering the use of emetics more necessary than the irritable state of the stomach always admits of. I believe also, that a more sparing use of purgatives, and a freer use of glysters, would in general answer better." Dr. Whitelaw Ainslie, writing in 1813, after an experience of thirty years in Madras, and an extensive practice amongst all classes of Europeans, says of this drug that '' it has no equal in simple dysentery, that is, dysentery not complicated with hepatic derangement ; in such cases, given even so as to produce daily a little vomiting, it has the happiest effects.'" This is an observation of great truth, and practical im- portance consequently, and I believe that it impresses and fixes a just discrimination in the use of ipecacuanha. In speaking from a personal experience of two-and-twenty years in the East Indies, and from an extensive range of observation of this disease as it occurred in hospitals, European and native, and in extensive pri- vate practice in Calcutta — also as it occurred amongst troops serving in the unhealthy provinces of Orissa and Gondwana, and in the fatal campaigns of Rangoon and Upper Ava, in the first Burmese war — I should say with Dr. Ainslie, that it is alone in simple uncomplicated dysentery that ipecacuanha shoAvs its best effects, administered as an aid to blood-letting and moderate purging. In hepatic dysentery — a frequent complication in Bengal, espe- cially during the cold season — calomel is absolutely necessary to the cure. I remember treating, for this form of the disease, an officer who had suffered severely from the fever of Batavia, con- tracted at the capture of Java ; he was bled generally and by leeches, the depletion being followed by sudorifics and purgatives ; but no amendment took place, and nothing was voided but mucus and blood j two full doses of calomel with antimonial powder Avere then given at bedtime, Avhich produced copious biliary discharges, folloAved by immediate relief; a few doses of blue-pill and ipecacuanha, followed by mild aperients, concluding the treatment. There existed in this case no enlargement of the liver, nor uneasiness on pressure, but there was a total absence of biliary secretion, and until that was restored, the other treatment afforded no relief. In another case of very severe hepatic dysentery, requiring remedial measures of great activity, recovery was marred on convalescence by errors in diet ; the liver became as enlarged and painful as ever, the dy- sentery recurring, and requiring a repetition of general and local blood-letting, mercury, &c., and this under circumstances of greatly reduced strength. This gentleman Avas sent to China, A\'here, six ACUTE DYSENTERY OF BENGAL. 461 months afterwards, and owing to continued errors in diet, hepatic abscess took place, from which he died. Cases of hepatic complication, treated Avithout mercury, fre- quently terminate in inflammation and abscess of that organ, even where blood-letting has been employed. It is not enough here to reduce the volume of the blood, nor yet, along with it, to diminish the force and frequency of the circulation ; we must also emulge the gland involved in disease. To such as prefer ipecacuaidia in the treatment of dysentery it might prove desirable to ascertain the following circumstances : — 1st. AAliether extract of gentian have any and what effect in preventing vomiting under the use of this drug. It is true that, after a few days' use, a comparative tolerance of medicine seems to be established, as in the case of the antimonial preparations ; but altogether, as it appeared to me, unconnected with the use or disuse of bitter extract. 2nd Whether the preparations of the Cannabis Indica may, from their sedative as well as from their powerfully anti- emetic qualities, prove serviceable in conjunction with ipecacuanha, or with antimonials. Unlike opium and its preparations, hemp does not lock up the secretions. 3rd. Whether four grains of ipecacuanha occasion as much sickness as ten grains, and if so, whether the larger dose should be preferred for the cure of dysentery. If the action of ipeca- cuanha be pm-ely revulsive, or if, according to Dr. Paris, it be to abate both the velocity and the force of the heart's action, so as to affect "the whole series of blood-vessels from their origin to their most minute ramifications," we may do wrong by being sparing of om* dose, in so formidable a disease as dysentery, if the stomach can be made to bear the larger quantity. This subject has not, I think, received the attention due to its importance, in reference to the subject here under consideration. " Ipecacuanha has long been usefully employed," says the British and Foreign Medico- CMrurgical Reviev for July, 1855, "in various morbid puerperal con- ditions. M. Legroux is said to resort to it with almost uniform suc- cess at the Hotel Dieu, in sub-inflammatory and congested states of the uterus following delivery." I would recommend the powder of nux-vomica in conjunction with the ipecacuanha, as in every way a preferable adjunct to any of the bitter tonics, and as possessing powers of its own which are of great value in dysentery. Referring to the above observations on ipecacuanha, originally pubHshcd by me in Calcutta in 1837, and to the suggestion to use large doses of ipecacuanha, I have recently been gratified by the perusal of a report of cases of acute dysentery treated at the ^lauritius by Mr. Docker, surgeon to the 7tli Royal Fusiliers. He begins generally with an emetic, but invariably with a thorough clearing of the bowels by a purgative. He then commences the following course of treatment : — A sinapism to cover the abdomen. 463 ACUTE DYSENTERY OF BENGAL. and immediately after tliis application_, a drachm dose of laudanum is exhibited. " Half an hour after^ when the irritability of the stomach has been diminished^ the ipecacuanha is administered, generally in a draught, sometimes in pill or bolus, while a semi- recumbent posture is steadily maintained/^ The doses ranged " from ten to ninety grains ; rarely less than twenty grains. The larger quantity was given in urgent cases only, the ordinary dose being a scruple or half a drachm/' Mr. Docker states that in a considerable proportion of cases the medicine was not rejected, or it was retained long enough to do its work. If necessary, it was repeated until the stomach did retain a sufficiency for the cure. It was never used in the form of enema ; and where such large doses as sixty to ninety grains were given by the stomach, an interval of ten or twelve hours was allowed before repeating the dose ; and whenever dysentery ceased, so did the use of ipecacuanha. " The action of these large doses is certain, speedy, and complete ; and truly surprising are sometimes their effects. In no siugle instance has failure attended this medicine thus em- ploy ed.^' Out of more than fifty cases thus treated, Mr. Docker " lost but one." On the authority of this gentleman, as on all grounds of justice, this simple plan of treatment ought to have, and no doubt will have, the fairest trial. But here, as in every question referring to the treatment of disease, experience has to be waited for. An extensive trial, and a successful one apparently, has been made in the Madras Presidency, under order of the Director- General there, and excellent reports have been recently published in the Madras Quarterly/ Journal of Medical Science, by Mr. Cornish and Dr. Blacklock. It appears from tables furnished by Mr. Cornish, that those treated for dysentery, by thirty-four medical officers, throughout Madras, are as follows : — Europeans 297 Natives 218 Total 515 The cases were not specially selected for experiment, but " Mr. Mee thinks that the type of the disease had become milder before the ipecacuanha treatment began." Of the whole number of Europeans suffering from acute uncom- plicated dysentery, four cases only proved fatal — giving a death- rate of 1*3 per cent, instead of 7*1 per cent., the average of seventeen years previously. In the newly-arrived 44'th Regiment, forming the garrison of Fort St. George, there were admitted into hospital 104 cases of dysentery. Of this number 68 were treated " in the ordinary way, with a mortality of six, or of 8*8 per cent. /' while of another party numbering fifty-nine, '^ treated with large doses of ipecacuanha/' all recovered. ACUTE DYSENTERY OF BENGAL. 463 "Altlioiigh the large majority of medical officers pronounce strongly in favour of this treatment only in the acute uncomplicated dysentery of Europeans, yet there can be no doubt, from the ex- perience of others, that it has had a remarkable effect in some cases where disease had passed beyond the first stage, and where deposition in the submucous tissue, or ulceration, already existed. In such cases, however, the remedj^ requires judicious management, and its operation should be carefully watched. Further experience is required before we can determine how far it should be depended upon in cases which have advanced to the second stage before coming under treatment." Dr. Blacklock says, that "ipecacuanha in full doses is undoubtedly a remedy of great value in the acute stage of sthenic dysentery, and in those sthenic intercurrent periods indicated by increased dryness and heat of skin, scanty evacuations of blood and glairy gelatinous mucus, with increased firmness and frequency of pulse, occurring from time to time in the progress of severe cases, after the first acute attack has been subdued ; but its employment must be restricted to this state of the system. If this precaution be not observed, great disappointment will be sure to follow its exhiljition on the first occurrence of an asthenic epidemic constitution, and it will quickly pass out of favour again, as it often has, since its first employment for the cure of dysentery in Paris in 1686." " Like tartar-emetic, and all other evacuants, ipecacuanha induces, when continued too long, the very state of vessels we find in in- flammation, sometimes in the bronchia, sometimes in the stomach and bowels, or in all these parts at the same time." . . " The great danger, therefore, from the large-dose treatment is, that the power of the heart may become so much impaired by its con- tinuance, that the brain may soon be too sparingly supplied Avith blood, and general unmanageable prostration ensue, while at the same time the local congestion increases with the debility. We require, for the removal of the disease, that the heart's force should be reduced to that of health, and the capillaries be moderately constricted ; but, if we permit the effects of the medicine to pass beyond these safe limits, or continue the medicine after the natural progress of the disease has materially modified the original type, Avc place the patient in an asthenic condition in which adynamic congestion of the diseased bowel will be as marked and as destruc- tive as was the dynamic congestion we sought to recover, and far more difficult to treat successfully." Although " the good and bad effects of ipecacuanha are best elucidated by carefully observing its influence on the symptoms daily recorded in cases," it is here admitted that " really acute dysentery seldom presents itself in a form to permit of its being successfully treated by any one remedy. But no single remedy, nor combination of remedies, has ever been of such signal ser\ice in the first stage of the disease as ipecacuanha, when administered 464 CHRONIC DYSENTERY. in large doses. No other medicine so soon brings the system into a condition favourable to the restoration of healthy function in the diseased intestine^ and by its employment we have the great ad- vantage of being able to dispense with blood-letting, and other means which are^ to say the leasts very unsatisfactory in their consequences/* For the following interesting table, exhibiting the prevalence and the intensity of dysentery, as indicated by the mortality in various countries^ I am indebted to Sir Alexander Tulloch : — Stations. Windward and Leeward Command Jamaica Gibraltar Malta Ionian Islands Bermudas Nova Scotia and New Brunswick Canada Westei"n Africa Cape of Good Hope St. Helena Mauritius ., Ceylon Tenasserim Provinces.. Madras Bengal Bombay Period of obser- vation. 20 years. 20 „ 19 „ 20 „ 20 „ 20 „ 20 „ 20 „ 18 „ 19 „ 9 „ 19 „ 20 ,, 10 „ 5 „ 5 „ 5 ,. Aggregate strength. 86,661 51,567 60,269 40,826 70,293 11,721 46,442 64,280 1,843 22,714 8,973 30,515 42,978 6,818 31,627 38,136 17,612 Dysentery. Attacked. 17,843 4,909 2,653 1,401 3,768 1,751 244 735 370 1,425 751 5,420 9,069 1,460 6,639 5,152 1,879 Died. 1367 184 64 94 184 36 18 36 55 44 69 285 993 137 559 411 151 Proportion of deaths to admissions. 1 in 13 1 in 26| 1 in 41i linl5 1 in 20i lin48| 1 in 131 n 201 n7 n32i nil n 19 n 9 nlOi n 12 n 124 nl2h CHEONIC DYSENTEEY. One has but to behold a soldier in hospital under chronic dysen- tery to grieve that a disease so destructive had not been cut short in its acute stage ; for truly does William Fergusson declare that the sufferer exhibits " a spectacle of distress of as pitiable a kind as can be found in the history of human misery." Let the young naval and military surgeon ponder on the spectacle before him, and determine so to master the subject and manage the treatment of acute dysentery, as that he may have the least possible amount of the chronic to deal with. He will thus by one act cure the acute, and prevent the chronic disease. DYSENTERY OF THE NATIVES OF INDIA. 405 Chronic dysentery, following upon, acute inflammatory dysen- tery, like visceral infarction consequent upon remittent and inter- mittent fevers, must be regarded, in a large proportion of instances, as the token of had practice — the measure of the insufficiency of the means employed during the acute stage of the disease. It is different when the original dysentery has been of the adynamic, malignant, or scorbutic characters ; for in such conditions there is much which the surgeon can neither anticipate nor control, his appliances often coming too late into use, and thus proving neces- sarily unavailing. The fault here is generally with governments, and with commanders. It is not intended in this place to enter into the details of chro- nic dysentery, the reader being referred to an article on that sub- ject in the second part of this work, and which describes the disease as it occurs in European invalids on their return from tropical climates. But chronic dysentery in the East Indies differs from that disease as it appears in persons on their return to Europe in this — that in India a certain amount of congestive and inflammatory action still remains, both in the mucous mem- brane of the large intestine and in the associated organs, re- quiring moderate topical blood-lettings, mercurial alteratives and blisterings ; whereas in the same disease, as it appears in England in the person of the tropical invalid, neither of the above con- ditions hold. With the important exceptions stated, the treatment of chronic dysentery should be the same in both hemispheres ; and in that of the East as of the West I would strongly urge the internal and external use of the nitro-muriatic acid, shielded by opium. It is a powerful remedy as a substitute for mercurials, powerful in ma- turing convalescence. NOTE ON DYSENTEEY IN THE NATIVES OF INDIA. A LARGE proportion of the sickness and mortality of the native troops throughout India occurs from dysenteries and diarrhoeas, originally contracted as such, or resulting from fevers remittent and intermittent ; and this holds especially in respect of the troops recruited in the plains of Hindustan, when they are transferred thence to the low marshy countries along the course of the great rivers, or into countries abounding in jungle. The late Mr. John Tytler, of the Bengal INIedical Department, in an Essay on " a most melancholy disorder," which he terms Diarrhcea Ilectica, states that " it is no exaggeration to say, that of the total deaths among the lower orders of Hindustan, three- H H 466 DYSENTERY OF THE NATIVES OF INDIA. fourths ai'e tlie eiFect of this disease, either idiopathic or as a ter- minating symptom. It is the scourge of crowded jails, and of hospitals filled with harassed and fatigued sepoys ; and it is the great avenue through which the swarms of naked and famished paupers and miserable infants that occuj)y the bazaars are con- tinually vanishing.'^ Mr. Burnard, speaking of the sufi'erings of the sepoys in Aracan, under General Morrison, says : '' Dysentery and diarrhoea were the diseases which proved most fatal, not in their acute form, but ensuing as a consequence of fever ; and their ravages, parti- cularly amongst the native troops, were very great." " The average mortality amongst natives in the Calcutta Medical College Hospital,'^ says Dr. Macpherson, " has been 16' 9, that among Europeans, 22*5. This accords with general experience, which has shown the disease in natives to be more amenable to treatment than in Europeans." The symptoms of dysentery in the Asiatic races are precisely the same as in the European, differing oidy in degree of severity and in complications ; and the same may be said as to the patho- logy of the disease. The post-mortem appearances exhibit ulcerations in the large intestine, amongst the natives of India, as with Europeans ; but the complications in the dysenteries of Asiatics are by no means so frequent nor so severe, if we except that of the spleen in mala- rious districts, in which dysentery and diarrhoea are commonly associated with the remittent and intermittent fevers of such loca- lities. Here the ulcerations of the large intestine are always of an anaemic, atonic character. Excepting in the instances of powerful and athletic sepoys, and those mostly of the better-fed Mahomedans, I seldom had re- course to general blood-letting in treating natives for this disease, leeching being in the far greater numbers quite sufficient. The same regard to measure holds good in the use of purgative and other remedial appliances, the mildest in moderate doses being effective to the cure ; and mercury in any form is seldom required^ unless it be to the more robust, especially the Mahomedan, to Avhom I had often to exhibit one_ moderate dose of calomel with ipecacuanha or antimonial powder, followed by a brisk purgative, with the view to remove jaundiced appearances of the conjunctivae, indicative of hepatic congestion. If such indications were not present, I never had recourse to mercurials in any shape. The great principle of treatment in the dysenteries and diar- rhoeas of the natives of India, in their acute stages, is what Mosely would term revulsive — sudorific ; ipecacuanha, in sufficiently full doses, being the best means, aided by gentle aperients, farinaceous diet, fomentations to the abdomen, and warm clothing. When by such means we have overcome the more acute symptoms, the Dover's powder will very fitly complete the cure ; and the assist- I I ON DISEASES OF THE LIVER. 4G7 ancc to be derived from proper diet and warm clothing should uever be overlooked. Cold aets most banef'uUy on the native constitution, and too much attention cannot, therefore, be paid to the subject of suitable covering by night and day, especially during the cold season. For maturing convalescence from the ordinary dysenteries of India, the nitric, or uitro-muriatic acid in bitter infusions will be found very efficacious; but where convalescence is retarded by continuance of liquid discharges, the acetate of lead and opium will prove greatly effective, the lead being exhibited in full doses. I had recourse to the acetate of lead in treating the native soldiery, after the more acute symptoms had passed, very early in my ser- vice in India, and afterwards very extensively in treating the dysenteries of the natives of Calcutta, while surgeon to the Native Hospital of that city. My excellent assistant at this institution, Mr. O'Brien, has for more than ten years subsequently, as sur- geon to the -ith Regiment of Native Infantry, Gwalior Contingent, carried out this plan of treatment with great success, from the very onset of the dysentery. The Native Hospital formula was acetate of lead, tincture of opium, and distilled vinegar. This treatment has continued to be very successful in the hands of Mr. O'Brien as well as in mine ; and he says that " when the liver is compli- cated, appropriate treatment is directed to that viscus ; but acetate of lead is given at the same time without at all interfering with the other remedies. I do not mean to say that I employ lead solely ; for I employ leeches, aperients, and blisters, which are very generally indispensable." The sulphate of copper and opium are also an excellent combination in the chronic stage of the dis- ease. At all stages, indeed, and under every degree of severity and of distress from this disease, we are limited, in the treatment of natives, to the use of medicines by the stomach alone, as ene- mata they will not consent to use — the very impression of death making no alteratiou in their fixed aversion to every such remedy. ON THE DISEASES OF THE LIVEE. The most cursory reference to the articles on fever and dysen- tery must satisfy the reader that, whether as original or secondary affections, inflammation, congestion, and chronic enlargements of the liver constitute in reality very frequent and very important diseases in the East Indies. Nor do the official returns, under the special heads of acute and chronic hepatitis, afford any ap- proach to the actual frequency of hepatic diseases ; for when these last occur as complications with, or as sequelae to fevers^ dysen- H H 2 468 ON DISEASES OF THE LIVER. teries, diarrhoea^ and cholera, the hepatic complication or sequel remains unnoticed in the numerical returns — the cases being classed and numbered under the primary disease, whether fever, dysentery, diarrhoea, or cholera. It thus happens that the nume- rical hospital returns do not yield anything like an approximation to a true estimate of the existing amount of hepatic disease. The same observations will, I believe, apply with equal justice to the returns of acute diseases of the West Indies, the West Coast of Africa, the stations in the Mediterranean, and the French posses- sions in Algeria, although in a less degree. Referring to diseases of the liver in the Bombay European Fusi- liers, Dr. Arnott says : — " The functional and organic diseases of the liver amounted, during the years 1846-1854, to 57^ cases, which, compared with the cases of fever, will show one case of hepatic disease to about thirteen cases of fever ; but the chance of death is greater from one case of hepatitis than from thirteen of fever.^' INCREASED SECRETION OF BILE. On the subject of the physiological influences of the climate of India on the functions of the liver, I must refer the reader to the ob- servations in the introductory chapter on Climate. It is there stated as a generally received opinion, that an increased secretion of bile is one of the ordinary results of the exposure of an European to an unnaturally high range of temperature : and this opinion I believe to be well-founded to the extent, first — that the exaltation of function is not of long duration, and is very much confined to the earlier years of residence, declining thence ; — secondly, that to a certain degree, such increase of secretion is salutary ; — and thirdly, that it is in part from the sudden suppression of secretion through cold, that congestive and inflammatory states of the liver are engendered, rather than through any serious injury from increase of secretion — a process consisting more of acclimation than of disease, and one which nature adjusts in the progress of residence in India. So much has been said by some writers on tropical diseases as to morbid increase and vitiation of bile, that they have altogether forgotten the more important but less notable defi- ciencies and suppressions of this secretion — conditions far more serious in their results than mere excess of secretion. Chemically, we have as yet ascertained nothing as to the healthy or unhealthy qualities of bile ; and, practically, all we do know is, that with certain symptoms there is a redundancy, and with others there is a deficiency of this secretion. We know also, from the scalding sensations that accompany certain forms of bilious diarrhoea, that the fluid in question is then of an acrid, irritating quality ; and that is all. Dr. Kemp, in his experiments on the functions of the mucous 1 ON DISEASES OF THE LIVER. 469 membrane of the gall-bladder, observes with respeet to the action of nnicus : — 1st. That when left in the gall-bladder in eontact with the cystic bile, it is capable of subverting the composition of the fluid, :2nd. That this change is much accelerated by even a moderately elevated temperature. 3rd. That when the contents of the gall-bladder are evaporated to a syrupy consistence, the bile, at first neutral, becomes alkaline, and broken up into several organic groups. -1th. That if the mucus of the gall-bladder be carefully re- moved by alcohol or acetic acid, and the perfectly fresh bile be then evaporated, these changes do not take place. The following generalizations appear to Dr. Kemp to be legiti- mately deduced from his researches : — " 1st. That the mucus of the gall-bladder is not merely a secre- tion destined to lubricate the interior of that organ, and protect it from the irritation of its other contents, but is an essential inte- gral portion of the cystic bile. " 2nd. That the gall-bladder is not merely a receptacle and reser- voir for the bile, but an organ highly endowed with organic functions, and that the proper secretion of the liver is converted into cystic bile mainly through the agency of its mucous mem- brane." — Proc. Hoy. Soc. Dr. Helenus Scott believed that nitro-muriatic acid exercised a solvent action on viscid and impacted bile, and, referring to para- graphs three and fom', such an opinion would seem to have some foundation. TREATMENT. If, along with an acrid and irritating bilious diarrhoea there be fulness and uneasiness in the region of the liver, so as to excite the suspicion of congestive action, a few leeches, followed by fomentations and warm baths, together with a mild mercurial and an aperient, will procure relief ; but when heat and dryness of skin exist, with irritative febrile symptoms, effervescing draughts, con- taining antimonials and diuretics, will prove both grateful and curative. In general, the disorder constituting increased biliary secretion, and those I'esulting from it, are sufficiently cured and prevented by avoiding the direct rays of the sun, by a strict attention to diet, exercise, clotliing, bathing, and by the use of demulcent and sub- acid fruits, as the bael, pomegranate, orange, grape, &c., and by the occasional use of mild aperients. "^^'ith few exceptions, and these resulting from exposure to direct solar influences, or from ill habits of life, such simple means of treatment I have always held to be both suitable and effective ; and I cannot but think much unnecessary confusion has arisen 470 ON DISEASES OF THE LIVER. from wordy descriptions of what certain writers on tropical dis- easeSj as Annesley, appear to regard as an affection demanding a complicated medical management. They talk of " bile'' as if it were a disease, and would cure it by " full doses of calomel at bed-time, generally for five or seA^en days, followed by Pil. Aloes and Myrrh alone, or with Pil. Hydrarg.'' Of such unmeasured, disproportionate, and unnecessary treatment of a mere functional disorder, it is to be hoped we have seen the last : — it is really worse than routine. The real diseases connected with bile — and very serious they are, too — are those in which bile is altogether absent, and wanting to the cure ! CONGESTION OF THE LIVER. Congestions more or less acute, according to constitution, pre- vious condition of health, and season, are very common to all countries in the East. Sudden changes of temperature, producing chills — the repeated cold stages of fevers, remittent and intermit- tent — an over-full and stimulating diet, together with the abuse of vinous and spirituous liquors — violent bodily exercises, especially those carried on in the sun, exposing the individual to the more ready influences of cold ; — those are the more ordinary causes. The organ will be found enlarged, generally in its upper convex direction, but sometimes in all directions, as in malignant inter- mitten ts — the enlargement resulting from venous and biliary con- gestion, and the latter being produced by the pressure of the over- distended veins preventing the due diminution of the smaller ducts — a condition of the liver, I repeat, frequently associated with, and following upon, remittent and intermittent fevers."^ The bulging out of the liver — the evidence of severe vascular turgescence — is rarely accompanied by more than uneasiness on exploration, or of weight on getting into the erect posture : — the respiration on the affected side will be found more or less op- pressed and impeded. These symptoms will become well-marked when, as occasionally happens, the volume of the liver is much augmented ; and when such is the case, we may fairly infer that stagnation and consequent viscidity of the bile will take place, both in the gall-bladder and ducts, so as to complicate and aggra- vate the disease. The countenance and complexion will exhibit pallor, or else a dusky, livid, sallow hue, according to the temperament of the patient, or the duration of the disease — paleness, with sense of cold and shivering, being more characteristic of the immediate result of external cold or chill. The tongue will generally be found coated — the bowels constipated — the intestinal and viscal excretions depraved — the appetite defective, with occasional * Passive congestion of the liver, and torpor of that organ, as they appear in the returned Indian, are noticed in the second part of this work. ON DISEASES OF THE LIVER. 471 nausea or even vomiting, and more or less headaehe. Tlie pulse is slow, oppressed, irregular, or quick and feeble, according to the age and constitution of the patient, and to the duration of the disease ; but the frequency of pulse will not be that of fever. Here, in short, the symptoms are obscm-e — not declared — and they must be taken in their collective characters, assemblage, and connexion, and not separately or individually. When, through any or all the causes above enumerated, con- gestion of the liver has been of long duration, permanent injury to its structure and secreting function may result : — the disease in any form must, therefore, be regarded as one of importance. The signs in this, as in other diseases of the liver, are so obscure, that of such as we actually possess a knowledge, we cannot afford to overlook the least, if we would do justice to our patients, and to our own characters. On examination after death, the liver is found to be enlarged, principally upwards into the right thoracic cavity — dark from impeded circulation, and full of blood : and, when the disease has been of any duration, its texture will be found softened. TREATMENT. "When from careful exploration, and a due consideration of all the attendant symptoms, we are satisfied that congestion of the liver does actually exist — for its existence must not be assumed — a mode- rate venesection, followed by leeches if necessary — a few doses of blue pill or calomel, with purgative extract and an antimonial, all three united — a few saline purgatives — hot fomentations to the region of the liver, and warm baths ; — these means, together with absti- nence in diet, will speedily bring about a cure. Nor must Ave be deterred — all other circumstances being duly considered — by feebleness or oppression of the pulse, from the use of such antiphlo- gistic means in these cases ; for, under judicious treatment, the pulse will rise and expand under the use of these means, and general relief will follow. Finally, convalescence will be matured, and an exemption from future attacks secured, by attention to diet, exercise, bath- ing, attention to clothing, and by avoidance of exposure to direct solar influences, as well as to chills by night. HEPATITIS. Amongst the better classes of Europeans, who are careful in their habits, this disease is not of so frequent occurrence as for- merly, when the habits of life were difterent from what they are now; and this observation has special reference to the acute inflammatory or adhesive form of the disease. The cases seen in private practice are very much confined to those of fair com- 472 ON DISEASES OF THE LIVER. plexion and lax fil)re. European females of every class are far less subject to tliis disease, and to every form of hepatic afFectioUj tlian their countrymen ; and women of the better classes are rarely affected comparatively. Out of three hundred cases of hepatic abscess occurring in India, nine cases only were in females. Amongst British soldiers, and Europeans who lead what is called a free life, and who incur exposure to the direct rays of the sun, and to the damps and chilling influences of the night, the disease, on the other hand, attacks men of all ages, and of every variety of con- stitution. It is a disease of great importance in a military sense, causing much immediate loss of life, invaliding, and ultimate in- efficiency in the European portion of the army. It would appear from various returns to which I have had access, that, of British soldiers attacked, upwards of half were lost to the service by death, by ruined health in India, and by invaliding to England. In the Madras European regiment, according to Dr. Geddes, 280 cases of hepatitis occurred in five years, out of an average strength of 570 men; and in the Bombay European Fusiliers, according to Dr. Arnott, there occurred, in eight years, out of an average strength of 957 men, Hejjatitis, acute and chronic 483 Jaundice 89 Total 572 In the Windward and Leeward Command, although hepatic diseases are by no means so frequent there as in the East Indies, they are nearly thrice as prevalent as among troops serving in the United Kingdom, and they occasion a mortality five times as high. Diseases of the liver vary considerably, both in prevalence and mortality, at the different stations of the West Indies ; for instance, at Grenada they occasion three times the mortality that results in other islands, and that without any cause as yet ascertained. The mortality during twenty years, from acute and chronic hepatitis and jaundice, as given by Sir Alex. TuUoch, was as follows : — Acute hepatitis 1 Admitted. Died. Proportion of deaths to admissions. 903 , 79 902 1 76 141 I 6 lin 11 lin 12 1 in 23 Clironic ,, Jaundice Total Annual ratio per 1000 of mean strength 1946 161 lin 12 22 1 1-8 In the Jamaica Command there occurred the following amount of hepatic disease and mortality during twenty years : — ■ ON DISEASES OF THE LIVER. 473 Admitted. Died. Proportion of deatlis to admissions. 336 109 94 27 20 4 Iinl2 1 in 5 1 in 23 Total 539 51 1 in 11 Annual ratio per 1000 ) of mean strength ) 10 1- The frequency of hepatitis amongst European soldiers in India, as compared to all the other colonies occupied by British troops, stamps the disease as essentially tropical. The proportion of admissions into hospital from hepatitis is stated by Mr. Wai'ing to be much higher throughout India, and in Madras especially, than in all the other possessions put together ; and the earlier years of residence in the East are those in which the disease is most frequent. The intemperate European appears to be twice as lialjle to hepatitis as the temperate and the absolutelj^ abstemious. The natives of India he regards as almost exempt from hepatic diseases, only five cases out of ten thousand convicts in the jails of ]\Iadras having been thus recorded. SYMPTOMS AND PROGRESS. The symptoms and progress of hepatitis vary much according as the inflammation is seated in the upper convex surface, on the ex- terior of the organ, or in its central parenchyma ; but the nature and amount of the inflammation are assuredly the first and most important considerations to be determined^ if we would successfully combat so dangerous a disease. For practical purposes hepatitis may be considered, first — as consisting in a more or less superficial and adhesive inflammation of the organ ; and secondly, in deep-seated suppurative inflam- mation of its parenchyma, of the nature termed congestive. 1. This well-marked form of the disease is ushered in by rigor, or sense of cold and constriction of the skin, followed by febrile reaction, the complexion being of a dusky, sallow hue, nausea and vomiting, lu'gent thirst, loaded tongue, occasional headache, loss of appetite, pain of the right hypoehondrium, increased by pressure or a full inspiration, and more or less acute according as the peri- toneal covering may be more or less involved ; pain occasionally of the right shoulder, cough and oppressed breathing, difficulty in lying on the left side ; such are the usual and more urgent symp- toms. They will not all be present in any case ; but so many of them will be manifested as to render diagnosis generally easy. There occurs frequently a loose state of the bowels, the matters 474 UN DISEASES OF THE LIVER. voided being pale or muddy, and watery ; at other times tlie bowels are even constipated. The surcharged state of the urine in this disease is caused by the suppression of the excretion of carbon by the liver, and perhaps by the lungs also. The urine is always scanty, high, sometimes porter- coloured, with deep yellow tinge, and depositing a reddish-yellow sediment. When vomiting is urgent, with sense of heat and burning in the epigastrium, it indi- cates an acute state of the disease, involving the ducts, duodenum, and pylorus. But with a view further to confirm and establish the accuracy of diagnosis, the surgeon must be careful to explore the region of the liver by inspection, commotion, and general pressure, and by percussion in the sitting posture, pressure being likewise carefully made over the intercostal spaces corresponding witli the liver. As the disease advances, the pulse becomes frequent and hard, the skin is hot, dry, and constricted, the pain, cough, and oppres- sion of breathing increase, there is occasional hiccup, with an anxious and desponding countenance, all indicative of advancing disease ; and if this condition be not speedily arrested by remedial means, abscess of the liver, destroying life, or permanent enlarge- ment of the liver, destroying the general health, will inevitably result. In this formidable disease we should regard the severity of the hepatic and epigastric pains, and other distressing symptoms as really invaluable indications ; for while they warn us of a pressing danger they explain everything, and thus relieve the mind from what otherwise would be a most painful state of doubt and anxiety. In the form of hepatitis which is attended with so much sufiering as is here described, the fate of the patient is comparatively secure ; for even the inexperienced will be induced to apply immediate and decisive remedies. 2. It is different in respect to the deep-seated, congestive, and suppurative inflammation of the parenchyma of the liver ; for here the danger is even greater than in the former instance, with no salutary warnings from symptoms. It is one of the most dan- gerous of diseases, because of the total absence of urgent symptoms, and consequent insidiousness ; the process which leads to destruc- tion is here silent and rapid. Of the various kinds of inflammation the suppurative is by much the most frequent, in Bengal at least. It attacks persons of both sexes, and those even of the most temperate habits; it not unfre- quently terminates the career of the old Indian. Whether occurring in the person of the older resident in Bengal, or in the new comer, this form of the disease occurs very generally in the cold season, and is caused by exposure to alternations of heat and cold, by such means, in short, as determine powerfully from the surface to the internal organs. I have seen cases wliere it resulted from the chilling thorough- draughts of the northern ON DISEASES OF THE LIVER. 475 entrances to the Calcutta lionses, on issuing from a ball-room, for instance; and other cases where it was occasioned by exposure to damp and cold before daylight for the purpose of hunting. The disease is sometimes preceded by a perceptible falling off in the general healthy indicated by emaciation, dry cough and embar- rassed respiration, loss of appetite, or the complexion gradually assimiing a muddy, sallow hue, but it more generally comes on in the midst of apparent health. We seldom indeed see the patient till inflammation has actually commenced ; when he generally com- plains of a feeling of abdominal uneasiness, but more particularly of the epigastric region and that of the liver, with some degree of fever, preceded by slight rigor or ague ; but all these may be so slight as too often to attract but little of the patient's attention. Perhaps he consults his physician on account of diarrJioea supposed to result from ei'rors in diet ; medicine affords some relief, and the patient proceeds in his ordinary occupations for days, or, Avhen the action is less acute, for weeks, though under great depression of the mental and corporeal energies, till at length his altered appearance, hacking cough, permanently dry skin, invincibly rough furred tongue, and morbid taste, all expressive of a suppressed and de- praved state of the secretions, attract some more serious notice on his own part, and that of his family, ^lie real nature of the disease may still remain a secret to both patient and physician ; and it may not be till actual tumour of the liver, a marked suc- cession of rigors, or profuse and clammy sweats announce in un- mistakeable terms the formation of abscess, that either party be- comes awake to the impending danger ; and then it is too late. A sense of uneasiness, hardly amounting to an obtuse dull pain, a sense of weight and oppression, may or may not exist in the region of the liver, according as the disease is centred more or less deeply in its substance or in its upper convex surface ; when the former exists, the symptoms are more than usually obscure and insidious ; in the latter case they are somewhat more of an acute nature. In this form of hepatitis it is seldom that we discover any pain in the shoulder. I should say, then, that a rigor, or a diarrhoea, folloAved by feverishness, the peculiar harsh state of the skin, the tongue hav- ing the roughness of a coarse file with adherent coating, together with the local uneasiness already described, cough, scanty sur- charged urine, often of a deep saffron colour, ought immediately to warn the physician of the suppurative inflammation which speedily leads to abscess. In every instance the diagnosis will receive material assistance from the external examination of the chest, especially when the upper convex surface of the liver is the seat of disease. Nor should the exploration of the abdomen be less carefully made : nothing should satisfy the medical at- tendant as to the condition of his patient short of the most painfully assiduous explorations often repeated ; for we have here 476 ON DISEASES OF THE LIVER. to deal with a disease deadly iu its nature and rapid in its pro- gress. CAUSES. The causes of hepatitis will be found in the following circum- stances : — residence in hot climates^ exposure to high ranges of temperature followed by cold and damp^ causing sudden arrests of the cuticular as well as of the internal secretions, the cold seasons of tropical climates, night exposure while imperfectly clothed, the exposure of the bivouac. These causes become very powerful Avlien fatigue is added to them, and under irregularities of diet, and in- temperance in the use of wine and ardent spirits especially. Dy- senteries and fevers, remittent and intermittent, a too rich and stimulating diet, producing gastric and duodenal irritation, these are frequent and influential causes of hepatitis ; and more remotely may be numbered previous attacks, malaria^ various forms of dyspepsia, neglect of the natural action of the bowels^ the age of puberty. When we take iuto account that " the absorption of nutritive mat- ters is not solely the work of the lacteal vessels, but that a part of the food digested in the gastro-intestinal canal is taken into the blood through the portal vems,^^ and that " the liver must be also re- garded as the organ for the assimilation of substances which have been absorbed from the intestine^^ generally, we discover at once how the abuse of highly-seasoned food, wine and spirits, with the absence of due exercise, must tend to the production of disease in this the greatest and most powerful of the glandular organs. PATHOLOGY. Were the earliest morbid change in the liver ascertainable ante- cedently to actual inflammation, I have no doubt that that condi- tion would in most cases consist in acute congestion; for, as in the well-known instance of hej)atic congestion and consequent diarrhoea, both resulting from the sudden application of the cold damp of the Himalayahs, for example, so the pale, watery, premo- nitory diarrhcEa is one of the most ordinary and immediate pre- cursors of hepatitis ; it is generally the earliest and, indeed, the only symptom which attracts the notice of the jiatient ; and it should always receive the instant and close attention of his medical attendant. In two cases of hepatitis in recently-arrived Europeans, and which terminated fatally, Mr. Twining found " the internal membrane of the hepatic veins inflamed, and puriform matter in the right ventricle of the heart." Their complaints, he says, " began as common diarrhoea of a severe description." In the case of an European soldier in Burmah, treated by Dr. Murchison, and in which inflammation terminated in abscess, " an obstinate diarrhoea had been one of the most harassing symptoms in this case ; but no ON DISEASES OF THE LIYER. 477 traces of ulceration were found either in the small or large in- testine.^' These observations on the earlier pathological changes, refer to every form of hepatitis, but more especially to the deep- seated suppurative inflammation of the parenchyma of the liver ; and he who will best ascertain them at their commencement will least be taken by surprise in the progress and terminations of this disease. In the suppurative inflammation the earliest observable lesions I believe to be redness and softening, soon to be aggravated into the formation of abscess. Mr. Twining declares that he has " never seen a case terminate in abscess without our being able, by a careful examination, to detect the disease that is in progress long before there was any reason to believe that suppviration existed. '^ This may be generally true, hut then the examination must he most rigorous and often re- peated, until we are quite satisfied as to the true nature of the case. The patient's recovery or death will depend on the care and dis- crimination with which this examination is made ; a false diagnosis is here a death-warrant, — they are indeed but convertible terms. I remember that, in the cold season of 1837 alone, in Calcutta, I was consulted in four cases of suppurated liver, in which no such condition had been previously suspected. The appearances on dissection of Europeans who have died of hepatitis will vary with the intensity and the duration of the dis- ease. Various vascular discolorations of the peritoneal covering are observed, difi'ering according to the degrees of inflammation, and the number of previous hepatic ailments— thickenings of the peritoneum, and efliisions under it, being very generally discover- able. Adhesions of the liver to the colon, stomach, and diaphragm are also common. Where inflammatory symptoms have run high, and death has ensued rapidly, there will be great enlargement of the liver, with much redness and vascularity of the organ, and depositions in the interlobular cellular tissue ; in other cases its colour will be dark, or even black — bleeding freely in both instances on section being made. In other cases the covering membrane is found of a pale hue, thickened and indurated — the structure underneath bleeding but little on being cut ; while induration, more or less extensive, with deposition of coagulable lymph, tubercles, and concretions are very general. On the concave surface of the liver, the gall-bladder is often en- larged and filled with viscid bile ; in other instances it is dimi- nished in volume, its coats thickened, and the body covered with false membranes. The observations of Rose and Henry would seem to show that the quantity of urea excreted by the kidneys is lessened in suppurative hepatitis apparently in a degree proportioned to the extent to which the secretion of the liver was destroyed l:»y the ab- scess. " If the statement be proved by future observation^" says 478 ON DISEASES OF THE LIVER. Dr. ParkeSj " it is, in my opinion, impossible to overrate its im- portance in a pathological as well as in a physiological point of view/' Since my return to England I have on several occasions tried to obtain from India information on this and on other important mat- ters connected with the chemistiy of the blood and of the secretions in tropical diseases ; but some officers said they were over-worked^ others that they were situated too far from the Presidencies, and so on. Thus I have failed in my object ; but I hope yet to succeed. TREATMENT. The maxims of De Retz that what is absolutely necessary is never dangerous, and that what looks the boldest course is generally the safest, are true in medicine as in politics ; nor is there here any real difficulty in perceiving either what is necessary to be done, or yet what is safe in the treatment of acute hepatitis ; it is like- wise very easy to comprehend what it would be dangerous to leave undone — the greatest danger in reality being found in feebleness, irresolution, and in do-nothing plans. However long the disease may have existed, and in whatever part of the liver the inflammation may be situated, provided there he no symptoms indicative of suppuration, general blood-letting, repeated as the symptoms may demand, and copious in relation to age, health, and length of residence in India, must be had recourse to ; and the sooner the better for the patient, the measure of deple- tion being, in all cases, a sense of local and general relief — tviih softening of the skin. These are the only criterions of adequate loss of blood ; and it should be always held in recollection that inflammation, suppurative especially, and of the most deadly cha- racter, is present, and that, consequently, there is not an hour to be lost. After the general blood-letting, a full dose of ten grains of calomel with five of James's powder is to be exhibited at bedtime, followed in the early morning by a strong saline purge, or a full dose of compound jalap powder ; and this course must be pursued — using leeches to the side, mercurials with antimonials, purgatives, and diaphoretics with diuretics daily, so long as they are called for by fulness or tenderness of the hepatic or epigastric region. The medical attendant must remember that the subsidence of local symptoms, together with a declared and satisfactory abatement of all the general symptoms, including that of the force and frequency of the circulation, and a permanent relaxation of the skin, with freedom in the secretions, can alone warrant the discontinuance of antiphlogistic means, including the most spare use of farinaceous food and drink. If the bowels be irritable, and anything like diarrhoea threatens to distress the patient, the Dover's powder, or ure opium, must be added to the calomel, in lieu of the antimonial. ON DISEASES OF THE LIVER. 479 As regards the constitutional influence of mercury^ the utmost that I found necessary, even in the worst cases, was the producing a gentle action on the gums, salivation being unnecessary^, and in the instances of persons of a feeble or strumous habit, naturally injurious. The precautions already insisted on against oozing from leech-bites must here be carefully regarded ; while blisters will be found useful on the entire disappearance of inflammatory action. Nor should the most strict abstinence in diet be deviated from, until, by the subsiding of all uneasiness, and tumidness of the region of the liver, and of the abdomen generally, by the cessation of all febrile movements, and by the restoration of healthy secre- tions, we feel assured, on these sufficient evidences, that convales- cence is well established : — and even then, the return to accus- tomed habits should be made very slowly, so as to afibrd time, under great abstemiousness, for the absorption of interstitial de- posits ; a reparative process which cannot take place under a full stomach. Mild saline aperients in bitter infusion, the nitro-muriatic acid in bitter infusion — the bicarbonate of soda in large doses with bitter infusion, where there is much acidity — warm baths, and gentle exercise in the open air — all tend to the maturing of conva- lescence ; and, in the cold season, great attention must be paid to the clothing. Nor should the European soldier here, any more than under fever or dysentery, be permitted to return to the bar- rack life, or to duty, before his strength has been restored : it is to the neglect of this rule that many of the serious and often fatal relapses are due. When convalescence proceeds unkindly, and there is reason to apprehend stnactural injury to the liver, a full course of the nitro- mui'iatic acid, as described in the second part of this work, will be found the surest and best remedy. Mr. Twining relied too exclusively on blood-letting in hepatic inflammation, and too little, as appears to me, upon other remedial means. There are cases where inflammation will go on notwith- standing the most copious depletions, and others in which the same will occur with a debilitated constitution and a weak pulse. What, then, is to be done ? '' What degree of depletion,'" says Dr. Billing, " will remove a node, or syphilitic iritis, without mercurial and other medicines ? What would venesection do for rheumatic pains without antimony, colchicum, opium, bark, mercury, and other medicines ? The question is not so much as to possibility, as expedition and safety to the constitution." Robert Jackson — no advocate of mercurial treatment in tropical diseases — admits that '^ mercury, after the condition has been prepared for its action, is the principal means of cure where biliary secretion is principally in fault." Mr. Twining, who was in the habit of prescribing half-scruple doses of calomel at bedtime, in hepatitis, asks the following ques- 480 ON DISEASES OF THE LIVEIt. tion respecting the action of mercury in this disease : — " We have been told that mercury is beneficial in hepatitis in the way that the breast-pipe or pump relieves inflammation of the female breast, ■when milk abscess is impending. But a legitimate parallel cannot be established in the action of the respective remedies ; the pipe relieves the inflamed breast by drawing off" the superfluous milk, without exciting increased secretion. Has the action of mercury an analogous effect on the liver ?" No : and if it had but the limited effect of the pump or pipe, it would not be the valuable remedy which physicians and surgeons have ever found it to be in so great a variety of inflammatory affections, and in the deadly inflammation of the liver in particular. It is for the very reason that calomel assists powerfully both in ^' drawing off" accumtdations, and in promoting " increased secre- tion,^^ that it proves of such value in aid of blood-letting. It is, in fact, by this very double action, of purging and increasing- secretion at the same time, that calomel relieves the loaded and inactive vessels of the diseased gland ; not to speak of the other acknowledged physiological influences of this mineral, such as — its increase of all the secretions and excretions of the body — its in- fluence on the capillary circulation — its febrifuge effect — the peculiar specific power ascribed to it by physicians and surgeons, as an antagonist to inflammations, whether general or local — its stimulant power over the absorbent functions — its power of un- loading, at the same time that it gives a new impulse to, the vascular system — its peculiar power in removing viscid and tena- cious intestinal secretions — its antiphlogistic, solvent, and alterative eff'ects on the blood ; — these are the actions and uses ascribed to mercury, when exhibited for the cure of acute disease, during a few days only, by the ablest British practitioners and authors -, and they are such as to place this remedy second only in order of importance to blood-letting in all the more acute hepatic affections of India. That mercury enters into intimate union with the elements of the blood is now an ascertained fact : it must therefore " modify its plasticity, and influence all the organic functions to which it is subservient." Mr. Tyrrell, treating of acute iritis, says : " The early stage of the disease may be arrested and subdued very readily by mercury. . . As certain as mercurial action takes place, so certain will be the arrest of the inflammation." He adds that it " appears not only to arrest the inflammation, but further to promote absorp- tion of fibrin, which is the common product of the morbid action in the iris, and which occasions changes destructive of vision." That mercury has been, and is still, abused by ill-informed and inconsiderate persons, is quite true, both at home and abroad ; but to argue hence its disuse would not be either safe or wise. In respect to remedial agents of acknowledged power, it is not just to support either means alternately and neither effectually. ON DISEASES OF THE LIVER. 4S1 Neither is it just or true to prefer a certain evil to a remote or possible danger; for such an argument might be turned against anything, hoAvever necessary. What is there in medicine Avithout some danger, either in what we do or in what we leave undone ? How great, thercfore_, should be the knowledge and discernment of the physician. It is of great practical importance that the real benefits derivable from the use of mercury be impartially set before the inexperienced tropical practitioner, and I have here endeavoured briefly to do so ; I hope, with fairness to the subject, and to persons with Avliom I may happen to differ in opinion. Mr. Twining would appear to hold the language of congratulation as to the result, and of censure as to the means. In the pride of pathological science we are sometimes induced to believe that, because we see and examine, we therefore under- stand, to the neglect of the science of pure observation so inestim- able to the physician ; and thus, I think, it happens that matters are still in doubt with us which a more chastened and correct observation ought long ago to have fixed and settled ; and that Ave are driven, or betake ourselves to solemn trifling, and to a huge German manufactory of big words, as an off'-set to research ; to the bondage of mere phrases — to hazy sounding transcendentalism. Our faith in our remedies must carry reason with it, otherwise we move in ignorance or in wilful error. "When inflammation has terminated in hepatic abscess, mercury given Avith the vicAV to its general influence, is ahvays highly in- jurious : — it aggravates the irritative fever and general distress, while its specific influence — so hopeful in the prcAdous stage — noAV but aggravates the danger by increasing the suppuratiA^e process and the general debility, so as to retard or altogether to obviate the curative efforts of nature. Shortly before I left Calcutta, a case came under my care, in the month of August, in Avhicli slight hepatic tenderness existed in complication Avith severe dysentery. From both diseases the patient speedily recovered ; and to restore his strength, I advised a short voyage to sea, where, having exceeded in diet, the liver became tender and enlarged, there being no recurrence of dysentery. A second time he recovered, but being of a weakly habit, and now much reduced by disease and treatment, I sent him on a longer voyage to Pinang. Here again, despite the most careful Avritten instructions, he took to excesses in eating and in the use of wine : — the result Avas that, in three months from his leaving Calcutta, an hepatic abscess formed, and discharged itself through the stomach by vomiting, soon after which he died. I mention this case as aff"ording an illustration of the necessity for abstinence in diet, and to shoAv that, even when the hepatic disease is but secon- dary, it may, and very often does, prove the ultimate cause of death by the formation of abscess. I I 482 ON DISEASES OF THE LIVER. In 1837, a young staff officer consulted me on account of cougli and emaciation, wiiicli he considered to indicate tubercular con- sumption, as some relatives of liis had died of this disease in England. His respiration and pulse were very rapid, and he had profuse night-sweats ; in short, 1 found that he was dying of sup- purated liver. The history he gave me was to the effect that, six weeks previously, he drove in an open gig from a ball-room in Calcutta to Barrackpore, and that, on getting to his quarters, he was seized with shivering, followed by feverishness and diarrhoea ; he continued to perform the duties of his office up to the day on which he consulted me, and the real nature of his disease had not till then been so much as suspected. He died in a fortnight, and the entire substance of the liver was found to be converted into a huge cyst filled with pus. Well might Curtis, writing in 1781, speak of hanging up cases such as these " in terrorem, against the attacks of this insidious disease ;'' or rather, he mii^ht have added, as warnings against the crimes of heedlessness and inattention in cases of so pressing a duty. I will now present a case the converse of the above : — In the cold season of 18;i6, a professional friend called on me to consult respecting the case of a patient of his ; and just as he was taking leave, he said, as if by accident, that he had " a jmin in Jiis hack like Imnbago.'' Being an able, experienced surgeon, I might Avell have said, ''go home and take care of yourself;" but there was a something in his expression of countenance which excited a suspicion of disease, and so I made a careful examination. The result was the discovery of deep-seated inflammation of the liver, and that it had existed for three days, during which he had been living as usual, and using the cold bath every morning. All the patient had noticed was a slight shivering three nights previously, followed by feverishness and pain in the back ; but he considered his symptoms of so little moment that he felt a doubt as to the accuracy of the diagnosis. 1 then referred him to our common friend, Mr. Nicolson of Calcutta, who concurred with me com- pletely as to the nature of the disease. The patient was young and of robust habit, so that with the loss of about eighty ounces of blood in the first twenty -four hours, followed by calomel and antimony gently to affect the gums, strong pm'gatives, and total deprivation of food, he rapidly recovered ; but I think he recovered with difficulty ; a few more hours lost to the treatment, and it would have been too late. The above case is interesting and important, as showing how very obscure and insidious are the symptoms, and how little they possess of urgency to cause a salutary alarm, even to the mind of a professional person. But it is always thus when the inflamma- tion is centred in the parenchyma of the liver; and hence the absence of that acute pain and those urgent symptoms which ON DISEASES OF THE LIVER, 4S3 characterize inflammatory states of tlie peritoneal covering of the gland, and which generally give ample warning. HEPATIC ABSCESS. From a table of 216 cases of fatal hepatic abscess, presented by Mr. "Waring of Madras, it appears that the maximum both of ad- missions and deaths occurred in the cold months. The diseases which immediately preceded, or in the progress of which hepatic abscess supervened, were as follows : — Hepatitis, acute and chronic 43 per cent. Dysentery, acute and chronic 27 ,, with liepatic complication ... 4 Fever, continued fomi 4 ,, remittent 1 „ intermittent 1 ,, intermittent with diarrhoea .... 2 Other diseases are here omitted, as are fractions; but eight per cent, of the deaths from hepatic abscess resulted from fevers. ]\Ir. Waring concludes that the proportion of cases of hepatic abscess occurring after or during the progress of hepatitis, dysen- tery, and fever, is not only larger than that of any other disease, but of all diseases put together. The formation of abscess in the liver, as already stated, is generally announced by irritative fever, increased towards night — rigors or shudderings, followed by pro- fuse cold sAveats — a tenaciously furred rough tongue — scanty and high-coloured urine, &c. &c. ; when the abscess is large, by a per- ceptible tumour of the right hypochondrium — the mind being anxious and depressed. Jaundice is by no means a general occur- rence in conjunction with hepatic abscess. These symptoms vary in degree according to the extent of the abscess ; and when that is extensive there is much oppression of the respiration, with restlessness. When, on the other hand, the abscess is small, the symptoms are displayed in a very obscure manner and degree ; — so that it is from a careful consideration of all the circumstances already detailed that the judgment must be formed. It is probable that in some persons mere congestion with softening of the textures will terminate in a kind of chronic abscess. I remember hearing of the case of a trooper of her Majesty's llth dragoons, who fell from his horse on parade at Cawnpore, and was killed on the spot by fracture of the skull and laceration of the brain. On po^t-mortem examination, an abscess was found in the liver ; and this, although the man had never expressed any feeling of indisposition, and had not for months been an hour absent from duty. Soon after I went to India, I was requested by my friend Mr. Nicolson, and bv Dr. William Russell, to assist at the examination I I % 484 ON DISEASES OF THE LIVER. of tlie body of a deceased magistrate of Calcutta. He had but a week previously returned from a hog-hunting party, feeling then slightly indisposed. There had been no fever, nor any symptom to indicate danger ; — so that his sudden death took his friends by surprise. The appearance of the body exteriorly was that of a powerful and healthy man ; but in the liver were found seven abscesses, distinct and separate, and varying from the size of a common nut to that of an orange. I was then very young, and this case left a deep impression on my mind as to the concealed dangers of such cases. Mr. Twining fancied that '^ a greater degree of tension of the riglit reef as abdominis muscle than of the left,^^ formed " one of the most undeviating symptoms of congestion with incipient deposit into the texture of the liver, which commonly goes to deep-seated abscess. ^^ The truth I believe to be, that the right rectus abdo- minis, like any other muscle in the body, will contract more or less, according as any organ beneath its fibres is in a state of suffering or of pain — no matter whether that pain be from inflam- mation, congestion, or other cause; — but that the mere tension or partial contraction of a muscle could prove an " undeviating symptom'^ of congestion, of suppuration, or, indeed, of any one special or peculiar morbid change in a gland beneath it, cannot be admitted in any case ; neither have I ever seen it confined to inflammatory or congestive states only : — on the contrary, I have known many persons in whom it was a well-marked accompani- ment of hepatalgia, as well as of the painful aff'ection of the bowels described by the late Dr. James Johnson, and in whom it con- tinued so for many years. The same symptom was noticed by Dr. Budd, in a case of jaundice from a closure of the common duct, and in a case where a cancerous ulcer of the stomach had eaten into the adherent liver ; and by Dr. Graves, in an inflamed gall-bladder. Dr. Parkes, again, has seen this state of tension very prominent in a case of phthisical diarrhoea, in which there was extensive alteration in that part of the ileum situated imme- diately under the muscle ; while partial contractions of the abdo- minal muscles over a suffering part, are justly stated by Mr. Holmes Coote and by Dr. Kirkes to be frequent in jaundice and other affections of the abdominal organs. We may therefore conclude with Dr. Watson, that this sym- pathetic affection is but one instance among many of that kind of protective instinct whereby a tender part is in some measure shielded against the infliction of pain by pressure. TREATMENT. It is little indeed that we can do for the unhappy sufferer from hepatic abscess. When the abscess is small, we may favour the efforts of nature at absorption by care in diet and clothing — gesta- ON DISEASES OF THE LIVER. 4S5 tion ill the open air, and change of air — the use of the nitro- miiriatic acid with hitter tonics, &c. When the ahscess has hap- pily discharged its contents into the stomach or bowels, or ex- ternally, a more nutritions diet will be proper, with the vicAV to support the strength of the patient, and even a little wine may now be allowed. But nothing should be done which may unduly excite the nervous or vascular functions ; and mercury in every form is to be carefully avoided, and even the mildest aperients should only be exhibited under necessity. When hepatic abscess has once formed, its treatment is to be conducted on the same general principles as irritative fever induced by purulent forma- tions in any other region of the body. Of the instances of recovery within my personal knowledge, the majority were amongst such as had discharged the pus by the bowels ; and one married lady I remember to have recovered health rapidly, after vomiting the contents of an enormous abscess. I also saw several instances of recovery where the abscess had opened into the bronchi — the direction which the most extended observation in all countries points to as comparatively favourable. Of those in whom the pus was discharged through the external integument, the majority have within my knowledge died. But by much the greater proportion of the instances of hepatic abscess end fatally — either before the bursting of the abscess, or within a few hours from its discharge into the peritoneal or thoracic cavity : — and this brings me to the consideration of the propriety of making an opening for the discharge of such abscesses through the external integument. I have often seen this operation performed in India, and I have myself performed it ; but in no instance that I remember did the operation appear to me to result in eventual good. I therefore agree with Dr. Biadd, that " it is generally best, when an abscess of the liver projects at the side, to allow it to open itself. Nature performs the operation better than the sur- geon. When the abscess opens of itself, it is usually by a very small apertui'e, like those of worm-eaten wood, which never closes ; and the matter gradually oozes out as the sac contracts. No air gets mixed with the matter of the abscess, and no violence is done to its walls ; and, consequently, no fresh inflammation is set up. The discharge is very gradual, and as small in quantity as it can be. There is less shock to the system, and less drain from it than when the abscess is opened by the knife. The prominent part should be poulticed, and the matter allowed to escape in the poultice, but should not be squeezed or pressed out." These observations accord altogether with my own experience in India, where, too often, young medical officers are urged, by the pressing dangers of the case, and by the importunity of friends, to " do something. '^ Dr. Budd is deserving of attention on another question con- nected with this subject. " In opening an abscess in the sub- 4S6 ON DISEASES OE THE LIVER. stance of the liver/' he says, ''^ there is another, and greater, and more unavoidable source of danger, which has not been noticed by the writers to whom I have referred. It is, that the solid hepatic tissue cannot readily collapse, so as to close the cavity when the abscess is opened. When, then, a free opening is made even into a recent abscess, air almost necessarily enters into the cavity, and from the sudden removal of pressure, or, it may be, from the manipulation emjiloyed to empty the cavity, violence is done to the walls of the abscess, and there is often some degree of liaemorrhage from them. Air and blood thus become mixed with t!ie pus in the abscess, decomposition takes place, and the air, or the decomposed pus, sets up fresh inflammation of the inner surface of the sac. This causes, of course, a fresh accession of fever, and of other constitutional disturbance, and if the abscess be large, a profuse, and foetid, and continuous discharge, which may soon exhaust the strength of the patient. The secondary inflammation thus excited by the presence of air, or by the decomposed pvis, may even lead to gangrene, and speedily destroy life ; and this happened in one of the cases that fell under my care at the Dreadnought. A similar case is noticed by Cruveilhier.'^ Of fifty-seven cases of hepatic abscess, real or supposed, re- corded in the 31edical Journal of Madras for 1844, the following were the terminations : — Recovery took place in 17 cases. Of these the trocar entered the abscess . . n in 8 ,, No pus obtained I in 3 ,, Pus obtained on the 6th, 7th, and 11th days / in 3 ,, No pus mentioned ) in 3 ,, Death occurred in 40 ,, The proportion of recoveries to deaths in eighty-one cases of hepatic abscess, recorded by Mr. Waring, of the Madras array, and in which their contents were evacuated by operation, was as follows : — Eecoveries 15, or 18'519 per cent. Deaths 66, or 81*481 ,, 81 100-000 „ Referring to 300 fatal cases of hepatic abscess, of which the details are given by Mr. Waring, in the first part of his work, he considers that operation might have been applicable in the follow- ing proportions : — Total number of cases 300 There was a plurality of abscesses in 108 192 Of 177 cases in which abscess was solitary, there was more ) or less extensive ulceration of the large intestines in . . j 76 116 ON DISEASES OF THE LIVER. 4S7 Thus it appears tliat " the jiroportlon of cases of hepatic abscess which hold out a reasonahle hope of cure by the performance of an operation for evacuating the contents, is much smaller than most persons are aware of/' . . Out of the whole number aljove recorded, "only in 116, or little more than one in three, could the operation have been undertaken with any reasonable pro- bability of success ; and this number wovild, of course, be still further diminished by taking into account the cases in which abscess, though solitary, communicated with the lung, colon, or some other \dscera, and those in which other organic disease existed." The best surgery here is what Trousseau terms " armed medi- cine, neither more nor less" — the arms, however, being held in reservation for very special and appropriate cases only. M. Kouis, Surgeon-Major of the First Class to the Military Hospital of Strasbourg, has published an excellent monograph, en- titled "Recherches sur les Suppurations Endemiques duFoie (Paris, I860)," giWng the results of eleven years' experience in the climate of Algeria. The subject is considered under the various heads of pathological anatomy, symptoms and progress, modes of termina- tion, duration, convalescence, complications, prognosis, diagnosis, causes, and treatment. An analysis is given of 203 cases of hepatic abscess which came under the author's own observation, and the history of 10 of the cases is recorded in detail. Of the 203 cases, 162 proved fatal, 2 made an imperfect recovery, and 39 recovered completely. From this it would appear that four out of every five cases died. In 179 cases, or about nine-tenths of the entire number, the abscess in the liver was preceded or accompanied by dysentery. Of the 203 cases, the pus escaped from the liver in various directions in 50 ; and of these 50 cases, the abscess burst into the bronchi in fifteen, into the peritoneum in fourteen, eleven times into the right pleura, five times into the stomach, three times into the transverse colon, once into the duodenum, once into the pericardium, once into the gall-bladder, and once into the bile- ducts. A circumstance which, however, has been noticed before, was, that of the cases where the abscess burst into the bronchi, almost as many recovered as died. Bursting of an hepatic abscess into a bronchus is, therefore, comparatively, a favourable occur- rence. The pathology of hepatic abscess is discussed with great minuteness and ability. The pus contained in the abscess is de- scribed as being usually of a yellowish-white colour, like that from an ordinary phlegmon ; but in some cases it presented a claret or chocolate colour, owing to the admixture of blood-globules or the debris of the hepatic tissue. In the case of old abscesses, it often exhaled a peculiarly foetid odour." 4SS ON DISEASES OF THE LIVER. JAUNDICE. This disease occurs in India, as elsewhere^ as an acute affection, and as a distinct and separate disease — often unconnected with hepatitis, fever, or dysentery. But there is observed not unfre- quently a congested state of the hver, which, with the morbid con- ditions of the duodenum and gall-bladder, demand a very careful examination. To prescribe for the yellow skin, as is too often done, is to dispense with the care and justice necessary to the occasion, and to bring discredit on the prescriber. In jaundice, as in every disease affecting the liver, the exploration of the region should be made carefully and repeatedly, until we become satisfied whether the organ be enlarged, inflamed, or congested ; circum- stances which may always be determined by a careful percussion — as may likewise enlargement and distension of the gall-bladder. Jaundice is usually attended by mental depression and physical lassitude — dyspepsia with loss of appetite, nausea, a yellow furred tongue, and flatulence. In some persons there exist fulness and uneasiness on pressure of the epigastric region and that of the liver ; while the amount of sallowness of the conjunctivae, skin, and urine, together with the degrees of paleness and of absence of bile in the alvine discharges, will depend on the intensity of the cause of the jaundice. The characters of the disease will vary also with the age, constitution, habits, and length of residence in India — age and length of residence being circumstances that are certain to operate to the disadvantage of the patient, especially if visceral disease, or an anaemic state of the system, be present at the same time. The existence of gall-stones obstructing the ducts may be in- ferred from the following symptoms : — A sudden seizure of violent fits of pain in the epigastric and right hypochondriac regions, ac- companied by irregular transient shiverings, and severe fits of vomiting — the pain at times being excruciating. Feverishness of the irritative character now makes its apj)earaRce ; and within twenty-four or more hours, sallowness over the forehead, extend- ing rapidly to the trunk and extremities, becomes evident, while on the appearance of the jaundice pain usually subsides. It is well to note here, that the pain attending the passage of gall- stones far exceeds that even of peritoneal inflammation, and that the fever, when such is present, is of a subdued character, unlike the endemic fevers of India — diagnostic circumstances worthy the attention of the inexperienced. In the East Indies, and as it generally appears amongst Euro- peans there, the progress of the disease, under appropriate treat- ment, is very generally of a favourable tendency — the cause being in most cases of a congestive or inflammatory nature, susceptible of easy removal : and we find that as convalescence proceeds, the mine gradually loses its icteric, saffron hue, while the skin also ON DISEASES OF THE LIVER. 489 becomes fairer by slow degrees. More rarely, tliougb tlie jaundice is plainly seen, so as to require no other diagnosis than is furnished by the complexion, the causes of this complaint are nevertheless very difficult to trace. CAUSES. Whatever causes may produce hepatitis, or more especially con- gestion of the liver, will give rise to jaundice : — so biliary gravel, folIo^ved by hepatic colic, is a frequent and familiar cause of jaundice. Certain affections of the brain have been known to excite this disease, as the extremes of despondency, and sudden bursts of passion ; but by far the more ordinary causes are — cold applied to the surface of the body, or cold applied suddenly to the stomach in the form of iced drinks, when the body has been heated by exercise or other exertion. In an analysis of seventy-two cases of icterus typhoides, by Professor Lebert, one-third of all the cases occurred in November and December, or in two only out of the cold months. Previous attacks predispose powerfully to jaundice. Formerly, when extreme courses of mercury were used in the treatment of venereal diseases, Avliat with the action of mercury on tlie hepatic function, and with the influence of external cold on the skin, jaundice was a frequent disease in our hospitals at home. In every case of javmdice that I have seen in England amongst the returned Indians, cold has been the immediate cause of the disease. Jaundice, according to Dr. Budd, may be produced in two ways : — first, by some impediment to the flow of bile into the duodenum, and consequent absorption of the retained bile ; and, secondly, by defective secretion on the part of the liver, so that the principles of the bile are not separated from the blood. It is probable, he adds, that jaundice which follows closure of the common duct, does not result merely from absorption of retained bile, but also, in part, from the secretion of the liver being less active, so that the principles of bile are retained in the blood. " But in many cases of jaundice, perhaps in the greater number, there is no impediment to the flow of bile through the ducts. In fatal cases, it happens not unfrequently that the gall-bladder and gall-ducts are found empty, and their mucous membrane is un- usually pale, showing that no bile was secreted. The jaundice results solely from suppressed or deficient secretion.^' I think it right to place before the reader the views of this able writer, as to the causes of jaundice; adding, however, that in India the more general causes are congestion and inflammatory aO'ections, involving the gall-ducts more or less directly. In jaundice the presence of bile in the serum of the blood is mani- fest, while the absence of the hepatic secretion from the alvine dis- charges is caused by the bile not finding its way into the duodenum. 490 ON DISEASES OF THE LIVER. Catarrhal inflammation, with temporary obstruction of the ducts, may be inferred as a frequent cause of jaundice, as may, also, an impaired condition of the secreting structure. Jaundice in its more ordinary form results from obstruction to the excretion of bile ; in other words, from the absorption into the blood of bile already secreted, but which is prevented by some me- chanical impediment from escaping by the natural channels. The actual suppression of the secreting function of the liver is a rare cause of jaundice in any climate. Frerichs states that we have become acquainted with three causes of jaundice : — " 1 . Obstruction to the escape of bile. " 2. Diminished circulation of the blood in the liver, and conse- quent abnormal diffusion. Both these conditions give rise to an increased imbibition of bile into the blood, and in both cases the liver is more or less directly implicated. '' 3. Obstructed metamorphosis, or a diminished consumption of bile in the blood. This cause is independent of the liver, and, so far as we yet know the matter, is chiefly influenced by the composi- tion of the blood, and by everything which essentially limits or modifies the processes of metamorphosis within the vascular system/^ PATHOLOGY. As few persons die in India of uncomplicated jaundice, the op- portunities for the examination of the liver and its appendages in such cases can only occur by accident, as when a sufferer from jaundice dies of another acute disease. Such occasions, however, have been sufficiently numerous to establish, on examination after death, the following appearances : — These consist in inflammatory states of the liver and of the gall-ducts ; congestions of the liver ; deposition of coagulable lymph within the capsule of Glisson, with enlargement, more or less considerable, of its absorbent glands ; effusion of lymph into the areolar tissue about the gall-ducts ; and the presence of gall-stones impacting the common duct. Morbid affections of the duodenum are also found to be associated with jaundice. Dr. Henry Kennedy of Dublin, after narrating some cases of rapidly fatal greenish-yellow jaundice, in which the ducts were found quite pervious, and in which the discharges from the bowels, " though probably of a lighter colour than Avhat is natural, were by no means free from bile,'^ suggests that " a much deteriorated bile, the absorption of which would cause serious consequences,'^ may have here caused death. Dr. Cathcart Lees, of the same city, has been led by the examination of the urine of jaundiced patients " to entertain the opinion that the absence of any symptoms re- ferable to the nervous system in many cases of jaundice might be accounted for by the presence cholic acid in the ui'ine, and its con- I ON DISEASES OF THE LIVER. 491 sequent absence from tlie blood/' . . . "If the supposition be correct, I think the detection of cholic acid or its conjugates in the urine, may prove a very important element of prognosis in every ease of jaundice, as assuring us against the supervention of cerebral symptoms in cases where it is present ; while, if absent, it may put us on our guard, and possibly enable us to adopt a pro- phylactic treatment/' In a fatal case of jaundice reported by Dr. Lees, in March, 1856, the presence of the biliary acids in the blood which flowed from the cranial cavity was satisfactorily determined ; while, in the liver, the hepatic cells were greatly diminished in size, and there was fatty degeneration. The case was one of acute yellow atrophy, iu which terrible affection jaundice is caused by non-elimination of bile. The patient died in a state of delirium and convulsion on the third day of his admission into the INIeath Hospital, In the urine voided after the development of the first cerebral symptoms, not a trace of biliary acids could be found, but albumen was present, and the amount of urea was very greatly diminished, while urea was found in the blood and serum taken from the brain. Dr. Budd suggests that in these fatal cases a kind of decomposi- tion may go on in the liver, with absorption of the poisonous pro- ducts thereof into the blood. TREATMENT. Before proceeding to treat this disease, we must weigh carefully the symptoms, and be well satisfied as to the probable natui'e of the morbid action producing the jaundice. Where we find tumid- ness and tenderness of the epigastric region, extending into that of the liver, with a harsh dry skin, feverisliness, and a furred tongue^ the constitution being sound, one general blood-letting, followed by leeches and fomentations, will generally relieve the more acute symptoms ; after which a few doses of calomel, of active purgatives, saline diaphoretics, with diuretics and warm baths, will in a few days bring about a solution of the disease, the diet consisting of farinaceous articles, fruits, and diluents, soda-water being about the best drink. Convalescence will be matured in such cases by the continuous use of warm baths, a moderately low diet, and by the daily use of saline aperients in some bitter infusion. In treat- ing the jaundice of the returned Indian at home, I have found no remedy in the early stage of the disease more serviceable than the warm bath used at bedtime. In treating the calculous form of jaundice we must commence with the use of such means as allay pain and relieve the hepatic colic, as ethereal anodynes, ehlorodyne, &e., followed by hot fo- mentations to the affected region, and both measures should be repeated until relief shall be obtained. By such means the violence 492 ON DISEASES OF THE LIVER. of pain and spasm will generally be overcome, while a hot bath used to faintuessj and followed by a dose of calomel and a strong saline purge, will conduce greatly to the relief of the patient, and prepare for the stage of convalescence. Chloroform conjoined to the liquor potassse, in doses of twenty minims each, has proved eminently efficacious in jaundice resulting from gall-stones — relax- ing the spasm, relieving pain, and gi^^ing freedom to the discharge of calculi. This combination may be repeated every hour until relief is obtained. In a case of gall-stones accompanied by violent spasmodic and remitting pains— hepatic colic — Dr. Charles Kidd exhibited chloroform internally in ten-drop doses every half-hour. The pain subsided after the third dose, and a speedy restoration to health followed. When hepatic gravel and colic ar^ proved to be the cause of jaundice, alkaline drugs should be administered, and green vege- tables and fruits, as solvents, and as calculated to obviate the forma- tion of fatty substances, should be freely used ; while exercise, by which their combustion is promoted, should be regularly and sys- tematically practised. I have during many years, in India and at home, been in the habit of prescribing freely the extract of taraxacum with alkalies, in hepatic gravel, jaundice, and all the functional disorders of the liver ; and these means persevered in, along with a spare diet, exercise, and warm baths, very generally conduce to a true recovery. Such means are believed to saponify fat, render it soluble, and promote its combustion, Avhile they eliminate the ducts and promote a healthy biliary secretion. I have also found the greatest benefit from the alternate use of the alkalies and the nitro-hydrochloric acids, these last acting as tonics and eliminants. Should congestive or inflammatory symptoms supervene, the appropriate antiphlogistic means already indicated will become necessary, including nauseating doses of emetic tartar. When, on the other hand, the patient is ansemic, or long resi- dent in India, with a flat abdomen and evidences of enfeebled health, neither blood-letting nor mercurials will avail to any good, but indeed the contrary. We must here be content with saline purgatives, bitter tonics, diaphoretics, and the persistent use of the warm bath at bed- time. Should drowsiness or tendency to coma appear, very active purgatives perseveringly used, sinapisms to the epigastric region, and blisters to the nape of the neck will prove eflective, even in cases wearing an alarming aspect. Death occurs not unfrequently from blood-poisoning or cholaemic intoxi- cation, and from retention of the constituents of the urine. When jaundice, whether simple or complicated, becomes chronic, I know of no means to be compared in effect to the persevering use of the nitro-muriatic acid bath applied to the whole body, iinder the influence of which I have seen cases of the most obdurate nature recover, both in India and at home ; cases which had the ON DISEASES OF THE LIVER. 493 characters of disorganization of the secreting structures. As stated elsewhere, this powerful ageut was first used in the treatment of hepatic diseases by the late Dr. Helenus Scott of the Bombay army, avIio, according to Mason Good, '^plunged the Duke of AYellington in a bath up to the chin for a severe hepatic affection he was then labouring under, and thus restored him to health in a short time.^' It was through this means that General Wellesley was enabled to return to his command, and to fight what, in pro- portion to the numbers engaged, was the most bloody of his victories, the battle of Assaye, and thus to lay the foundation of his future greatness. In all acuteformsof jaundice of the congestive and inflammatory characters, severe irritation of the duodenum is an inevitable asso- ciation. Here refrigerants and saline aperients, with leeches and fomentations to the affected region, will be found to procure the most speedy relief from duodenal disturbance and portal dis- tension. During the actual paroxysm of hepatic colic, so generally followed by jaundice, the means already indicated will usually prove sufficient ; but it is proper to state that some pi-actitioners rely ex- clusively on minute doses of morphia, as one-sixth of a grain every half- hour until relief is obtained. Dr. du Parcque, on the other hand, found remarkable benefit to follow the exhibition of the following preparation, given in tea-spoonfuls, well mixed, every half- hour : — Athens sulpliurici 5j' 01. Eiciiii, Syrupi Aurant., ana 5j- CHRONIC ENLARGEMENT AND INDURATION OF THE LIVER. Although the subject of this article is fully detailed in the second part of this work, I am desirous very briefly to notice this form of hepatic disease as it appears in Bengal. It is presented as the result of previous inflammation of the liver, more or less acute, of congestions of the organ, or as the sequel to fevers, remittent and intermittent, and to dysentery. The liver is enlarged, rising above the fifth intercostal space, and descending below the margin of the false ribs, it is sometimes indu- rated in a perceptible manner, and its function is. greatly impaired, the biliary secretion being scanty and depi'aved ; that of the kidneys being similarly aftected. There is frequently a hacking dry cough, dyspepsia in various forms, a despondent state of the mind, and much general ill healtli, a generally cachectic state, with a sallow pasty complexion and emaciation ; more rarely we find dropsical eflusion into the great cavities. In this form of hepatic disease we occasionally find, also, an embarrassed state of the circulation in the form of excitement of the heart's action, or an intermittent pulse — these symptoms being prominent in proportion as the liver 494 ON DISEASES OF THE LIVER. is more or less indurated. In both instances tlie disturbance would seem to arise principally from the impediment to a free circulation offered by an indurated liver. Whenever^ therefore, I hear men- tion of an excited or intermittent state of the heart's action, I make a careful and searching examination of the hepatic region, the only kind of examination that is of any value. The perfunctory per- formance of this great duty is a real crime in the surgeon.* There is a morbid condition of the stomach and bowels described by the late Dr. James Johnson, which is very often mistaken, both in India and in England, for hepatic enlargement or other diseases ; it is a mistake of consequence, inasmuch as the disorder is one of frequent occurrence, and the treatment usually employed, on the supposition of its hepatic origin, is very injurious to health. In both cases there is tenderness of the right side and epigas- trium, increased by pressure, but here the resemblance ceases. There are, in the affection described by Dr. Johnson, none of the other symptoms characteristic of hepatic disease, and the tumid- ness, besides the difl'erence in anatomical position and somatic relations to other organs, wants both the appearance and solid character of the real hepatic enlargement. Abdominal tumors, such as morbid growths of the omentum or peritoneum, and faecal accumulations in the caecum or colon, are occasional sources of mistake ; but the situation and fleeting character of such tumours, together with the occasional and spasmodic nature of the attendant pain will, in general, point to the true nature of the case. In this state of the stomach and bowels there will generally be found a red, inflamed, or excoriated state of the tongue, gums, and fauces, indicating a highly irritable condition of the mucous digestive surface, the nervous system being much excited. There is occa- sionally, also, a continuous acceleration of the pulse, while at other times irregular attacks of feverishness occur, preceded by rigors, and followed by irritable dyspepsy. Purgatives are borne with great distress, especially when of an acrid nature; and calomel, so often resorted to for the cure of the supposed liver disease, is but rasping the already inflamed or irri- tated mucoTis membrane of the stomach and bowels, so as fre- quently to produce discharges of blood and mucus, with great ag- gravation of all the symptoms. Grievous, then, as are the errors of omission noticed in the article on hepatitis, where acute disease of the most dangerous nature is allowed to proceed undetected, and fruitful as they are in calamity, they are not surpassed in result by the errors of com- mission in chronic affections, where mercury, bleeding, and drastic * Gentlemen who think that tliey may hurry tlirough so important an examination, would do well to recal to memory the following very elementary facts : — 1. The superior limit of the liver should in health correspond with the line of the fifth rib (some say below the sixth), or about two inches below the right nipple. 2. The inferior border of the liver should correspond with the margin of the ribs. ON DISEASES OF THE LIVER. 493 purgatives are q\iite as injurious to liealth as they are necessary to save life iu the first-mentioned instance ; in fact_, there are no mistakes more detrimental, nor any against which the inexpe- rienced should be more on his guard, than the two here mentioned. In my experience, however, such errors in diagnosis do not arise so much from want of knowledge as from a careless and hasty manner of examining the patient — an unpardonable negligence in exploration. The treatment of this disease is not well understood. Mercury I believe to be improper : it injures the stomach and bowels, already but too often over-drugged, without exciting any secretion from the organ chiefly affected, and on which this mineral, from repeated use, has lost its influence ; indeed, in the great majority of instances, the system is in a cachectic state, so as to render mercury on any account inadmissible. Purgatives of an irritating or drastic nature are especially injurious; in fact, it is often an unmanageable disease, not readily amenable to treatment or change of climate. It must be borne in mind that I am here treating only of simple chronic enlargement of the liver unaccom- panied by plethora, general or local, or by inflammation of the gland. AVhere such tendencies exist, or where general or local ab- dominal congestion is present, antiphlogistic means must be used, followed by the persevering application of the nitro-muriatic acid bath. This bath is the plan of cure that I have had recourse to for many years past, both in India and at home. Like mercury, it seems to act powerfully on both the excretory and absorbent systems ; and in the cases here under review, it acts with a power and efficiency superior to any other remedy that I have used, or that I have ever seen used. If we admit absorption by the capillary veins and the absor- bents, and their conveyance of substances rejected by the lacteals directly into the vena portse, to be transmitted to the liver, there to " undergo a true and proper digestion, a hepatic digestion which is as real as that efifected in the stomach and duodenum," we shall be at no loss to account for the powerful influence of medicinal agents exhibited in the manner of the acid bath. When from morbid dryness of skin the acid is not readily taken up, I direct the occasional use of the vapour bath, or the warm- er ater bath, with powerful friction to the whole surface, in order to restore the exhaling and absorbing actions, always suspended or suppressed in this disease, and, generally, with a view to stimulate all the functions of the skin. Out of many cases treated by me with success while in India, I will select one of the earliest and worst. It was that of a gentle- man of the Civil Service who had resided ten years in India, and who liad suffered three years previous to the illness now described from a dangerous attack of remittent fever. The details are in the 496 ON DISEASES OF THE LIVER. words of the patient, a preferable mode "when the sufferer is a person of education ; because we daily observe, with Gooch, that " such is the nature of the human mind that cases for a precon- ceived opinion are retained easier than those against it." Were the example of Sir A. Cooper and others followed in this particular, medical cases would stand better, and carry more weight with the profession as authentic evidence. "In November, 1829, I arrived in Calcutta, suffering from a jungle fcA^er contracted at Chittagong; my liver and spleen were perceptibly enlarged, my limbs were much swollen, and so stiff that I could with difficulty walk, and the least exertion occasioned vomiting. Before my arrival at the Presidency, I had for many months taken medicine. This plan was altered, and I was put through a course of the nitric acid bath, taking a vapour bath every other night for the first week. The nitric acid bath acted in a few days very powerfully immediately on using it, and in about three weeks both the liver and spleen could no longer be felt, nor did pressure give me much uneasiness ; the stiffness, too, disappeared, and my skin became less tense and dry. I took an aperient draught twice a week, and nothing else but the bath. I left Calcutta in the end of December for Simla, and had little or no occasion for medicine for two years afterwards, my general health being completely restored." This was a case of extreme and urgent danger : — there was enormous enlargement of both liver and spleen ; so much so that, on using any drink, if the patient walked across the room the move- ment caused the fluid to pour from his mouth. There were ascites and universal anasarca ; and, altogether, the case was regarded as of a very hopeless nature. In the cold season of 1838, this same gentleman again visited Calcutta in a peculiar state of disease. There was an unnatural dryness or suspended function of the surface of the body and of the mucous intestinal membrane, with a doughy enlargement of the abdomen, swelling of the hands and feet, and obstinate consti- pation, his excretions from the bowels being deficient in bile, pasty, and peculiarly dry. He brought the following report from the surgeon of his station : — "Arrived at this station in January, 1836, in tolerable health. During the cold season the digestive organs were much deranged, with loss of appetite, obstinate constipation, distension, and hard- ness of the epigastrium, particularly after meals, acidity, and flatu- lence. The complexion was sallow and pale, and occasionally he complained of a dull heavy pain in the right hypocliondrium. These symptoms continued till the cold season of 1837, when some improvement took place ; but on the return of the hot season all the former symptoms recurred with increased violence, accom- panied by excruciating headache, which for the time utterly inca- pacitated him from attending to the important duties of his office. ON DISEASES OP THE LIVER. 497 Towards the termination of the rains^ the hands and feet hegan to assume a dropsical appearance ; and for many months he was compelled to take drastic purgatives almost every day, without which no movement of the bowels could he effected/^ Regarding the case now, as one of well-marked and extreme torpor of the liver, I directed the patient to go through a course of the nitro-muriatic acid bath, and vapour bath, as before, adminis- tering mild saline aperients. Presently the sldn began to soften, the tumidness of the abdomen to subside ; and with these symp- toms, a more ready action of the bowels, so that, in about a month, a fourth part of his original dose acted as an aperient ; and before he left Calcutta for the Cape of Good Hope, the bowels were for the first time during two years moved without purgatives, the dis- charges having become copious, dark, and pitchy ; — in other words, the first outpourings of a long pent-up liver. This was a case of peculiar interest from its severity, " calomel, alternate courses of blue-pill, combined with purgatives and ipecacuanha, and strong irritating medicines,'^ having, in the language of the surgeon^s re- port, '^ utterly failed of doing any good." In the chronic enlargement of the liver, change of air and of climate should never be omitted in the treatment. We have, in the protracted stages of tropical diseases, indeed, no adequate substitute for change of air. " In India," says Sir James M'Gri- gor, " when patients, whose condition of life permits them to take a voyage to Europe, are in this state of disease, they never fail to take it, and most commonly are recovered by it ; but there is no hope for the poor soldier or sailor." It is so likewise in the latter stages of fevers and dysenteries ; and Dr. James Johnson, speaking of the sufierers from the latter disease, in our fleets and armies, says : " they waste away and die for want of the only remedy that possibly could arrest the hand of death — change of climate." The distinction so feelingly pointed to by the eminent men just named, as between the seaman and soldier and his officer, has been partially removed in respect of the British soldier serving in the East Indies. The distinction, I repeat, is unjustifiable in prin- ciple, as it is cruel and barbarous in results ; and I trust the day may not be distant which shall see both classes treated alike in their diseases. On any medical, moral, or just financial grounds, the distinction is, I think, unwarrantable. The natural afiections — the desire to return home to see once more their families and friends — to recount to them their sufferings and escapes — to share in honours and rewards — these feelings are as strong with the peasant as the peer. As in the articles on fever and dysentery, I conclude the present one with a table exhibiting the geography of hepatic diseases, fui'- nished me by Sir Alexander Tulloch. It shows that though diseases of the liver sire somewhat more frequent in the south of India, K K 498 ON DISEASES OF THE LIVER. they are more fatal in Bengal. It is remarkable in tlie geography of this disease that^ though there exists so great an apparent simila- rity between the climates of the eastern and western hemispheres, there should yet be so great a dissimilarity of result in the com- parative influence on the European constitution : — in the East Indies generally, Annesley states that thirteen per cent, of the effective strength of British regiments are attacked with hepatic disease, while, according to Sir Alexander Tulloch's reports, but 2^ per cent, of the effective strength in the Windward and Lee- ward Command, and one per cent, only in Jamaica, are similarly affected. Stations. Windwai'd and Leeward ? Command j Jamaica Gibraltar Malta Ionian Islands Bermudas Nova Scotia and New ) Brunswick j Canada Western Africa Cape of Good Hope St. Helena Mauriti us Ceylon Tenasserim Provinces Madras Bengal Bombay Period of observation. 20 20 19 20 20 20 20 20 18 19 9 19 20 10 5 5 5 years. Aggregate strength. 86,661 51,567 60,269 40,826 70,293 11,721 46,442 64,280 1,843 22,714 8,973 30,515 42,978 6,818 31,627 38,136 17,612 Inflammation of the liver and jaund ce. Proportion Attacked. Died. of deaths to admissions. 1946 161 1 in 12 539 51 1 in 11 759 22 1 in 34 857 47 1 in 18 1168 58 1 in 20 168 6 1 in 38 384 10 1 in 38§ 488 12 1 in 40| 150 11 linl4 496 25 1 in 20 171 24 lin 7 2508 122 1 in 20i 4382 213 1 in 11 488 29 lin 17 3372 190 1 in 17| 2412 174 1 in 14 1084 62 1 in 17i There died in London, according to the reports of the Registrar- General, during the fifteen years, 1840-1854, of the specified he- patic diseases as follow, and doubtless a goodly proportion of them had their origin in the influences of tropical climates : — Hepatitis. 2270 . Jaundice. . 2091 . Disease of liver. . 7914 Total 12,275. 499 ON THE ENDEMIC CONGESTION OF THE SPLEEN. Considering the frequency and fatality of splenic affections, amongst soldiers especially, both European and native, and amongst tlie European inhabitants of our intertropical possessions, it has always been matter of surprise that so little attention has been bestowed by the profession on the consideration of diseases of the spleen. But when we look to our imperfect knowledge of the anatomy and physiology of this organ, we shall cease to wonder that naval and military surgeons have refrained from disquisitions on what could only result, at the best, but in unprofitable speculation, and con- fined their attention more particularly to the cognate aflections of the liver. Mr. Gray, of St. George's Hospital, the most recent and most successful investigator of the structure and uses of the spleen, con- siders that the organ " serves to balance alike the qiiantiti/ and the qi(aHt/j of the blood, and is especially adapted for this function by its connexion with that part of the vascular system which is concerned in the introduction of new material into the circulation. '^^ Mr. Gray, from numerous experiments, has come to the conclu- sion '' that the weight of the spleen increases conslclerahlij during the time when the digestive process is near to its completion, at the time when the new material is about to be, or has become, converted into blood ; and that it decreases considerahJy in weight at varying periods after that process has been finally completed." This conclusion, says Dr. Carpenter, is confirmed by the results of experiments upon highly-fed and upon insufficiently-fed animals of the same species ; for the increase during digestion was carried in the former to an unusual degree, so as to give the organ more than twice its former weight, whilst in the latter no increase after feeding was observable. The distinguished reviewer concludes : — '' We are inclined to believe that the office of the colovrless parenchyma of the spleen is not only to serve as a storehouse for the surplus albumen that finds its way into the circulation on the completion of the digestive pro- cess, but also to exert an assimilating action upon it, whereby it is rendered more fit for the nutrition of the tissues ; and of this assimilating action we deem the generation of fibrine to be one of the results. And if it be true, as we have elsewhere suggested, that one special function of red corpuscles is to assimilate or prepare that peculiar combination of materials which is required for the nutrition of the nervo-muscular apparatus, the disintegration of these corpuscles, in the splenic parenchyma may answer the two- * Review by Dr. Carpenter, "Brit, and For. Med.-Chir. Rev." for January, 1855. K K ^ 500 ON THE ENDEMIC CONGESTION OF THE SPLEEN. fold purpose of regulating their total proportion in the mass of the bloodj and of diffusing through the liquor-sanguinis the materials which the nervous and muscular tissues are to draw from it for their own development/^ If such be the functions of the spleen, we can readily perceive how diseases of that organ may, and actually do, spoil the blood, and produce a state of general cachexia. The tumid or turgid spleen — the congestive enlargement — as it appears in Europeans who have resided in low marshy districts in Bengal, or as it comes under observation in hospital among the children of indigent Europeans, and as seen in British soldiers who have campaigned in unhealthy countries, appears to consist in passive congestion, or hypersemia of that organ, and is found in its most severe forms during the cold season. It may, and does, occur as a primary disease, the result of mere residence in mala- rious localities, but far more generally congestion of the spleen is found, in India at least, as a complication of, and a sequel to fevers, remittent and intermittent, and especially in their adynamic types, as on the West Coast of Africa, Walcheren, parts of Italy, Aracan, and other malarious countries in the East. When complicated with endemic fevers, it may be regarded as in its more acute stage ; but with the subsidence of the primary disease, this condition gives place to that of passive congestion, or simple hypertrophy. Why the worse term " engorgement" was preferred by Mr. Twining to the more truly expressive and old one, congestion, does not appear ; but certain it is that the altered form of expression has in no way added to, or improved, our knowledge of the obscure pathology of congestion, whether of the spleen or of any other organ. In the medical, as in other sciences, terms ought not to be changed, unless they express relations established as certain which have not been determined before; whereas here we have but a distinction in words without any difference in fact. A German phraseology, now too much in use at home, threatens to become a fashion with us, overlaying our terse and manly language, while it is^ but ill calculated to fill up the voids in our knowledge. The Germans have reduced the art of talking about disease to a system. In the fevers of the West Indies, Robert Jackson found that the spleen was " generally distended, sometimes even to rupture." Hyperemia and a softening of the spleen are found also to be very general complications in the congestive typhoid fevers of our own country, and of those of the continent of Europe — the fact being demonstrated in the most extensive post-mortem examina- tions, SYMPTOMS. In the more acute form of the disease we have present some febrile action — a sense of dull pain in the left hypochondrium, ex- tending to the shoulder of that side, accompanied by fulness and ON THE ENDEMIC CONGESTION OF THE SPLEEN. 501 increased uneasiness on pressure — all indicative of something more tlian mere vascular engorgement — the disturbance of the abdominal functions being referrible to congestive fever, and to its splenic complication. The symptoms of splenic diseases, whether acute or subacute, are ahvays more or less negative in character. Whether this form of splenic enlargement be the result of fever, or the- more gradual influence of malaria, it is a very important affection, owing to the unfavourable state of the constitution Avhich invariably accompanies it. As a complication with fever, too, it is unfavour- able in itself, and as putting an instant bar to the use of mercury, however desirable the exhibition of that mineral might prove, as a means of equalizing the circulation — of eliciting increased secre- tions — or of relieving local congestions in other organs. To the practised eye, the very countenance of the sufferer be- speaks his condition. The expression is dull, the mind apathetic ; the complexion is of a dirty lemon-colour, the integument being puffed up and bloated, the eye pale, and of a pecvdiar clearness, the lips, tongue, and fauces blanched and bloodless ; in short, we have here a concentration of cachexia of systematic writers — the very type and essence of ansemia. A wound or trifling abrasion, which at another time would escape notice, now becomes a foul and sloughing ulcer, owing to the depraved state of the blood, and the generally diseased state of the system : — hsemorrhages arise from slight causes — sometimes spontaneously ; and so altered is the character of the blood — from want of red globules apparently — that when performing surgical operations of immediate necessity, at the Native Hospital of Calcutta, I always became aware of the presence of splenic disease on making my first incision — the hue of the blood being demonstrative of the fact. In addition to the depravation of the fluids, we have excessive muscular debility, bodily inertness, and mental despondency — the whole morbid assemlDlage tending to impair the functions of respiration, assimilation, and secretion. It can be matter of no surprise, therefore, that when fatal terminations occur, they should be preceded by dropsies, haemorrhages, or gangrenous ulcers of the cheeks and gums — conditions to which persons suf- fering from splenic disease are peculiarly liable. CAUSES. Of all tHe known causes of splenic disease, the most influential is malaria. The long-continued application of the ordinary endemic influences, without causing acute disease of any kind, will, as already observed, produce ansemia, enlargement of the liver, of the spleen, and of the mesenteric glands. But the most ordinary cause of splenic congestion, whether active or passive, will always be found in the malarious fevers of the East — remittent and inter- mittent — which, for longer or shorter periods, and by the recur- 502 ON THE ENDEMIC CONGESTION OF THE SPLEEN. rences of their cold or congestive stages, for months or years together — disturb, or eventually destroy, the balance of the abdo- minal circulation, and with it the integrity of the abdominal functions. When to these morbid conditions we add destitution — the absence of comfort in food and clothing — the residence in low, cold, and damp localities — mental depression — those causes, in short, which contaminate the blood, and determine its flow into the alidominal organs ; all these causes will powerfully tend to the production of splenic disease. Previous inflammation and acute congestion are often found in India to terminate in chronic enlargement of the spleen. PATHOLOGY. '' Dr. Henoch of Berlin recognises two forms of chronic enlarge- ment of the spleen. The most common form is a true Ii/jpertrojj/if/, a mere increase of the natural elements of the organ. In a large num- her of cases, however, he considers the enlargement is due to exces- sive interstitial exudation of plasma, probably of a character unfit for healthy nutrition, and he consequently regards this kind of tumour as the result of chronic splenitis. -"^"^ The appearances on dissection vary from the firm and friable condition — congestion with fibrous hypertrophy — to the indurated and banded texture approaching to scirrhus — the degree of enlarge- ment varying according to the intensity of the malarious and other external influences, and to the duration of the disease. The substance of the spleen is often found of a dark purple on being cut into, and composed chiefly of granular matter. Dr. Sievekiug found crystals interposed among the granular matter, which were soluble in acetic acid ; also yellow spots with tuberculous-like deposits. In the softened spleen we find its substance reduced to the con- dition of a grumous mass, indicating a diseased state of the con- stituents of the blood. Thickening of the investment and adhe- sions of it to that of the surrounding parts, are more generally found in the native than in the European subject. There is reason to conclude that endocarditis is a frequent and serious concomitant of the more active diseases of the spleen, in- flammation of the interior lining membrane of the heart, together with vegetations on the aorta and valves, coagula, and other ap- pearances demonstrative alike of endocarditis and of a diseased condition of the blood, being often observable after* death. I have no doubt that the numerous sudden deaths of both Europeans and natives of the army of Aracau, in the first Burmese war, during apparent convalescence, arose from the causes just noticed; the fever which destroyed the army ha^dng been a malignant adyna- mic intermittent. Sudden deaths from the same causes are found to occur in yellow fever. ♦ Dr, Ballurd, "Brit, and For. Rev." for July, 1855. ON THE ENDEMIC CONGESTION OF THE SPLEEN. 503 Infarctions of tlie spleen occnr much more frequently as the results of intermittent than of remittent fevers, and in the latter than in typhus. According to Dr. Tebault of Virginia, the pre- sence of enlarged spleen gives to typhoid fever a paroxysmal character. TREATMENT. In splenic congestion of recent occurrence, where the system is sound, and exhibits an inflammatory action, or an acute state of congestion, whether of the abdominal vessels generally, or of those of the spleen, a moderate blood-letting, general or local, repeated according to occasion, and followed by brisk cathartics and sudo- rifics, will conduce powerfully towards convalescence. On the cure of the fever, indeed, we shall generally find that the splenic complication will subside; but if tumidness of that organ still remain, by the continued exhibition of quinine and brisk purga- tives, followed by chalybeates and change of air, congestions, both general and local, will be removed. But, on the other hand, if the type of the fever be adynamic, and the state of the general health anaemic, opposite and tonic remedies must be used ; every indication of cure resting on the two radical conditions — the local or endemic influence existing at the time, and the sanitary condi- tion of the individual. Within a few years of my arrival in India, I suffered severely from the dangerous remittent fever of Gondwana, followed by ma- lignant, adynamic intermittent. For the recovery of my health, I was sent to Calcutta, where, notwithstanding the best ad\T.ce and care, ague recurred twice or thrice every month during a year and a half, Avlien I was ordered to sea. There was then enlargement of the spleen with cedema of the lower extremities. I made a voyage to sea, and was absent but eight months from Bengal ; and although I used not one grain of medicine, all my ailments dis- appeared. The truth is, that there are fevers, dysenteries, and chronic forms of hepatic and splenic disease, of malarious origin, which no amount of medicine can cure, but which change of air ■ic'dl cui*e with some degree of certainty. When the more acute local symptoms have subsided, and the disease has become a simple chronic enlargement, we still find that no corresponding improvement takes place in the health ; and in general, according to the duration of the disease and the size of the spleen, so do we find a complicated parabysma and the consequent cachectic state to prevail; softening and relaxation being prevalent in the nervous, vascular, and glandular structures. Again, we occasionally see cases where enormous spleens, occupy- ing two-thirds of the abdominal cavity, cause but surprisingly little disturbance pf the health apparently — the patient complaining only of sense of weight in the left hypochondrium ; but this state of passive toleration does not last long, the general health being 504 ON THE ENi)EMIC CONGESTION OF THE SPLEEN. sure to suffer in the end ; -while in otiier cases, and with varying degrees,, we have all the unfavourable disorders of the system already described as concomitants of the more acute stages of splenic disease. When the disease seizes upon the children of indigent Europeans, who are unable to command change of air or removal to Europe, we find every function in life — the develop- ment of the mental faculties — the building up of the corporeal frame — every constituent part stunted and retarded in growth ; and without any precocity in youth, there is an actual precocity of old age. In the chronic enlargement of the spleen, measures of depletion can but very seldom be required ; and even those of a local nature should be used but sparingly. The general practice in Bengal is a steady use of the tonic aperient of Mr. Shulbred, formerly sur- geon to the Native Hospital of Calcutta, aiding its operation by quinine, chalybeates, stimulant and rubefacient liniments to the affected region, and change of air. The formula of Mr. Shulbred, and the watery imitation of it by Mr. Twining, are as given below : — Me. Shdlbked. Mr. Twining. Pulveris Jalapse, Pulveris Jalapse, „ Rhei, ,, Rhei, ,, Calumbse, ,, Calumbse, ,, Scammonise, ,, Zingiberis, Potassae Bitartrat. aa 3j. Potassee Bitartrat. aa 5j. Ferri Sulphatis, 3ss. Ferri Sulphatis, ^j. Tinct. Sennce, 5iv. Aq. Menth. Sativse, oX- Of Mr. Shulbred's powder a sufficiency is given to move the bowels twice or thrice daily. It has for half a century been a favourite remedy in Bengal ; and Mr. Twining's formula is given to those who prefer the fluid manner of exhibition. He recom- mends a chalybeate with purgative extract overnight, followed in the morning by powder of myrobalan and the black salt of the bazaar ; — this as a change of treatment. The kala-nimuk, or black salt of the bazaars throughout India, is composed of the following ingredients in one ounce : — Muriate of soda 444 grains. Sulphur 14 ,, Muriate of lime 12 ,, Black oxide of iron 6 „ The natives have long been aware of the beneficial effects of acids as well as of chalybeates and bitters in the treatment of the com- mon tumid spleen, for which the bazaar doctors prescribe the undi- luted sulphuric acid in doses of one drop at a time placed on a bit of plantain, or more generally five drops in cold water night and morning. Another native plan of treatment is by a mixture of aloes, vinegar, and garlic with a small portion of the bazaar sulphate of iron, " kuzees :" — this latter formula is said to be very successful. The decoction of the seed of the Carum nigrum, with ON THE ENDEMIC CONGESTION OF THE SPLEEN. 505 tlie addition of acetic acid or lime-juice^ is also used by the natives, and it is said with a marked benefit. I found, in treating both Europeans and natives, that severe irri- tation of the mucous digestive surface was often present, attended by a loAv irritative form of fever. Here the spleen medicines in ordinary use were altogether inadmissible, as causing increase of irritation or dangerous diarrhoea. In such cases, and they were of frequent occurrence, after svibduing intestinal irritation, I had recourse to pure chalybeates, as the saccharated carbonate of iron, the muriated tincture of iron with tincture of iodine, frictions with croton oil, warm baths, &c. In this manner cases having a very unpromising appearance recovered; and the largest spleen I ever saw was cured by the iodide of lead internally administered. It was that of an European boy in poor circumstances. His health had been much reduced by an eruptive fever, when he was seized with ague, for neither of Avhich diseases had he any treatment : the consequence was enormous enlargement of the spleen, and for which the iodide of lead alone was used, internally and ex- ternally. The treatment was continued mildly for four months, when the spleen was no longer to be felt ; and dui'ing the whole process of cure he never took so much as one aperient. The en- largement in this case had come on very suddenly, but when I first saw the patient it had existed during several months. In the case of a gentleman from Demerara, treated by me in consultation with Mr. Henry James Johnson of London, and in whose management we had to contend with extreme cachexia and sloughing ulceration of the penis, the iodide of lead was persisted in for two months, to the extent, indeed, of producing lead colic, when the spleen, previously of enormous bulk, was reduced to the natural size. Iodide of potassium, warm baths, gestation in the open air, stimulating frictions to the afiected region, are all bene- ficial ; but in the chronic enlargement of the spleen, with cacliectic states of the system, blisters are apt to slough ; and as to leeches and mercurials in such instances, they are most destructive — gene- rally certain death. In Europeans the liver is very often involved in disease along with the spleen, and then there is no remedy which, in my ex- perience, can at all be compared in power and efficacy to the per- severing use of the nitro-muriatic acid bath, using the combined acids internally at the same time with bitter infusions, and keeping the bowels freely open. Here, owing to the hepatic complication, quinine and chalybeates prove ineffective to the cure of the splenic, while they injure the hepatic disease. At pages i95-6 will be seen a remarkable instance of rapid cure, by the acid bath, of enor- mous disease in both liver and spleen associated with universal dropsy. It was. one of the earliest cases treated by me after this manner, and I regard it as one of much interest and im- portance. 506 ON THE ENDEMIC CONGESTION OF THE SPLEEN. A practical fact of some importance, and which I found to take place in India as in this country, is this — that the acid bath acts more speedily and with far greater power in the hotter than in the colder months. Following out the suggestion afforded hy this fact, I always directed the use of a warm-water or vapour hath twice or thrice a week at the commencement of the treat- ment in the winter months, with the view to open and purify the pores of the skin, and to increase its absorbent and exhaling func- tions. It is almost unnecessary to urge the necessity of attention to the diet in every stage of this disease. So long as heat of skin or any febrile movement exists, the diet must be of the lightest and easiest of digestion, being limited to articles of a farinaceous nature ; and even in the chronic stage animal food should be used but once in the twenty-four hours. Some eminent French physicians have vised large doses of quinine for the cure of enlarged spleen, exhibiting the salt to the extent of from forty to eighty grains in the twenty -four hours, the quantity of the drug used being in direct ratio to the extent of the disease. When the stomach did not retain the large doses exhibited, the Continental doctors administered the quinine in the form of enemata carefully retained in the bowel. Dr. Elliotson, in his lectures, recommends a similar plan of treatment ; but I am not aware that this mode of cure has been anywhere established on the foundations of success. From all I have personally ob- served and studied I am disposed to look mainly to the emulgent plan by nitro-muriatic acid, internally and externally applied, for the cure of splenic diseases, aided and followed by purgatives, quinine, and chalybeates. This important subject is recom- mended to the careful attention of our intertropical practitioners ; recollecting that " some of the greatest improvements in medi- cine have resulted from researches made in hot climates, and that there is not a single fact observed or a single disease investi- gated on the banks of the Ganges or the Mississippi that does not bring its quota of utility to the practice of medicine in our own country. ^^ The following table but ill represents the prevalence of splenic diseases in any of the military commands specified, such affections being too often ^' lumped under the head of other diseases." I have been unable to procure any returns for the three Presiden- cies of India ; and in the naval force in the East Indies, forming an aggregate strength, from 1830-43, of 40,512 men, only thirty- nine cases are returned under the head of splenitis. We may nowhere hope to find any record of the splenic com- plications of fever and dysentery, although these last form to- gether by far the most prevalent forms of the disease. ON THE ENDEMIC CONGESTION OF THE SPLEEN. 507 Stations. Period of observation (inclusively.) Aggregate strength. Number admitted into hospital. Number died. Proportion of deaths to admissions. Windward and Leeward 1 Command J Jamaica Bahamas Honduras United Kingdom (Dra- ) goon Gds. & Dragoons ) Gibraltar Malta Ionian Islands Bermudas Nova Scotia and New ^ Brunswick ) Canadas Western Africa St. Helena •] Cape of Good Hope ) (Cape District) j Cape of Good Hope (Eastern Frontier) ... Mau ritius Ceylon 1817—36 1817—36 1817—36 1822—36 1830—36 1818—36 1817—38 1817—36 1817—36 1817—36 1817—36 1819—36 1818—21 1836—37 (6 yrs.) 1818—36 1822—34 1818—36 1817-36 86,661 51,567 535 320 44,611 60,269 40,826 70,293 11,721 46,442 64,280 1,843 5,908 22,714 6,630 30,515 42,978 104 59 5 21 21 133 2 19 25 166 49 17 60 1 in 34 in 59 Oin 5 Oin 5 Oin 21 1 in lOi 1 in 33J Oin 2 Oin 19 Oin 25 1 in 23| in 1 Oin 49 in 5 Oin 17 in 50 In the very able report of a committee assembled by order of tlie Governor- General of India, to ascertain whether the Great Ganges Canal^ which now unites the Ganges and the Jumna^ would tend to increase disease, and thus prove not a blessing but a curse to the inhabitants, we find a test proposed by my friend, Mr. T. E. Dempster, which seems to yield positive and satisfactory conclu- sions, and the value of which appears to have been fully established. ]\Ir. Dempster examined the spleen in a certain number of indi\'i- duals, and by the presence or absence of an enlargement, he de- termined whether or not the resident in a certain locality had l)reviously suffered from endemic fever. The following table con- tains a summary of the whole inquiry.^ It will be observed that in each subdivision of the table, the smallest number of spleens and the corresponding small number of previous fever cases, occur in the inverse ratio of the proximity to the river or the canal. 'Brit, and For. Med.-Chir. Rev." for October, 1855, pp. 353-54. 503 ON THE ENDEMIC CONGESTION OE TPIE SPLEEN. ,..0 t^l^ (M ;-*-* (MCN © fl 0^ iX) ^ 3 o a o^?1 ■s ° 2 ;: C B Ph m W -^ C ai ■T3 g a J, 85° ). ,. 85° >j >> 83 81 82 82° 79° 74° 91 M 66° '•2. •8. Dry. Rain. '•0. = •4. . r T5" Dry. Dry. Rain. '■1. Rain. •8. Rain. •0. Rain. •8. Rain •2. •6. Dry. Dry. Dry. EPIDEMIC CHOLERA. i59 In tlie jails of Bengal, according to Dr. Kcnnetli Mackinnon, there died of cholera, dnring ten years, in the months of March, April, ^Nlay, Jnne, and July, 243 1 prisoners ; Avhile in the remain- ing seven months of the same years the casualties amongst the prisoners amounted to hut 1046. It thus appears that while the proportion between the Hindu and Mahomedan inhabitants of Calcutta is but 2^ to 1, the ratio of mortality amongst the former is to that of the latter, as 5^ to 1. This great difference in favour of the Mahomedans can only be ascribed to their better habits of life — to their better diet, clothing, ha*bitations — comparatively. The influence of the highest temperature of the year on epi- demic cholera is exhibited in a still more striking manner on the sickness and mortality of Europeans ; for, by the following table, it appears that for the twelve quarters ending 30th June, there were admitted into the General Hospital of Calcutta, 492 cases of this disease, of whom 220 died ; while, for the remaining 36 quarters, there were but 311 admissions and 152 deaths. This is a remarkable fact. Table of Admissions and Deaths of Europeans from Cholera into the General Hospital of Calcutta, for each Month during Tivelce Years : — Kange of observation. In 12 Januarys... 12 Februarys 12 Marclies ... 12 Aprils 12 Mays 12 Junes 12 Julys 12 Augusts ... 12 Septembers 12 Octobers ... 12 Novembers 12 Decembers Grand total 803 Total Total admissions. deaths. 28 11 8 5 56 34 86 57 268 125 138 38 32 6 37 18 10 5 49 27 59 32 32 14 372 It should be observed that the patients admitted into the Euro- pean General Hospital of Calcutta are — soldiers belonging to de- tachments, invalid soldiers from the Upper Provinces, soldiers forming the garrison of Fort William, European townsmen, and men belonging to the shipping in the river. With exception of soldiers on duty in garrison, all the Europeans sent into the General Hospital are exempted from that salutary regulation and discipline which prescribes that every man shall come under me- dical control the instant he falls sick ; and hence, doubtless, a great increase of deaths from cholera, as well as from all other acute diseases within this institution. 560 EPIDEMIC CHOLERA. The results of an extensive series of observations,, ranging over twenty years, show that, in the Presidency of Bengal, the annual mortality of European soldiers from epidemic cholera is about 1*15 per cent., while of the Bengal sepoy army it is but 0'22. This remaricable difference, so opposite to the popular belief, is worthy our careful investigation. Here we perceive that the boasted strength of the European does not serve him. On the contrary, in his power to resist this terrible scourge he stands vastly below his comparatively feeble native comrade. Why is this ? We can only refer it to the habits of life of the British soldier, to his ha- bitual indulgence in an over-full animal diet, and to his abuse of ardent spirits, thus keeping the digestive, nervous, and vascular systems in a constant state of over-excitement. He is thus ren- dered more prone to collapse of the vital powers ; for, whatever lowers these last, reduces the general nervous energy, deteriorates the blood, or interferes with the processes of digestion and nutri- tioUj Avill dispose to attacks of cholera. PREDISPOSING CAUSES. Some of the predisposing causes, as already stated, have been ascertained with some degree of accuracy, but not yet the exist- ing cause. Here, despite our science, all is mystery, alike in the fleet on the ocean, or in the army on the march — all is inscrutable. W^hy does the epidemic come in one year and at one season, and not for years or seasons thereafter ? These and such questions no one can answer. The number of instances which I observed in Calcutta of Ep- som or Seidlitz salts leading to profuse serous diarrhoea, and subsequent fatal cholera, is a circumstance worthy of notice. The dose was always taken in the early morning, and the patient had gone through his ordinary avocations throughout the day, mistaking for the operation of a saline aperient what was in reality the induction of choleraic diarrhoea, true cholera, and deadly collapse. In the end of March, 1833, I was requested to visit the head partner of a large house of business — a healthy and powerful man. The note, wliich was not expressed with any urgency, was delivered to me at 5 p.m., near to the house of the patient, so that I was with him within a few minutes of its being written. I found the gentleman at his desk, at work. His countenance and voice at once expressed fatal collapse, and he died at eight o'clock that evening. He stated that at five o'clock that morn- ing he had taken a dose of Seidlitz, his health previously having been quite good. PRECURSORY DIARRHOEA. I have never attended a case of cholera in which precursory diarrhoea, of longer or shorter duration, had not been plainly mani- EPIDEMIC CHOLERA. 5G1 fest; but I have seen people — villagers and camp followers — struck clown with sudden deatli on the line of march during April and May, in the deadly jungles of Gondwana, and there the relatives and attendants declared emphatically that there had been no ante- cedent purging or vomiting whatever. All I observed personally was, that the persons lay dead by the road-side, and that there were no evidences about them of there having been any diarrhoea or vomiting. The cholera was raging at the time in our moving camp, of which I had charge. A gentleman of the civil service, describing to me the fatal out- break of cholera which visited Calcutta in 1843, says : — " It some time in March took quite a new character, — those attacked had not the usual purging and vomiting, but it came on with a sort of faint sinking — the strength was, without ovitward effort or apparent cause, totally prostrated, and the patient died without suffering, as if labouriug under the effect of poison/^ In the terrible epidemic which seized on Her Majesty^s 86th Regiment, at Kurrachee, in June, 18-i6, and which destroyed within sixteen days 23S men out of 399 who were attacked, it was noted that " the peculiarity in many cases was, that there was neither vomiting nor purging, and in the latter cases, by no means profuse. Also, among some of the first cases, before the natural hue had been replaced by the livid look so characteristic of the disease, the pulse at the wrist was almost imperceptible, the eyes turned up, and the voice hollow and feeble. In an hour after, such cases were dead.^^ Others are described as attacked of a sudden, " and the collapse preceding the vomiting and purging of serous fluid." Dr. Lindsay, of Perth, declares that ''cases of cholera undoubtedly occur without any rice-water evacuations : nay, it does not appear essential to cholera that there should be intestinal evacuations of any kind." In the onset ,of- many epidemics we learn that sudden deaths occur, apparently from the concentration of the poison : men are thus struck down at the outbreak of yellow fever and plague, as well as in cholera. Dm-ing the onset of epidemic plague, almost all who are at- tacked with it perish — death occurring in from twenty-four to forty- eight hours; while, after a little time, death is deferred to the fourth, sixth, fourteenth, and even to the twentieth day — many cases recover- ing health: at length the pestilence loses its malignity altogether. It has been held that in a practical sense diarrhoea cannot be held to be premonitory unless it have been of such duration as to allow time for the action of remedies ; for where vomiting, purging, and collapse have followed each other in rapid succession, neither the vomiting nor the purging can be justly said to liave been " premonitory." There is here no premonition; for persons have died of collapse without any marked symptoms, in whom the intestines were found filled with serous fluid. There is in recent discussions on premonitory diarrhoea in cholera, much of what our forefathers termed word-catching. o 562 EPIDEMIC CHOLERA. In the onset of tlie cholera epidemic whicli afflicted our army in Bulgaria many men were^ according to Dr. Hume, " death-struck 3" and Dr. Williams observed that in those worst cases " there was no premonitory diarrhoea. ^^ The truth is, that we must regard the painless and colourless diarrhoea as the most characteristic and important symptom of commencing cholera ; as the first stage of the disease, in fact, and as that which is easy of cure in the average of cases. PATHOLOGY. The first circumstance that will strike the observer in cholera is the astonishing and fatuous prostration of the mental sensi- bilities, on all questions relating to the disease, and to the condition of individual danger belonging to it. The person who, before the seizure, was all anxiety, alacrity, and alertness on the subject of cholera, both as affecting himself and others, is now fatally apathetic; the feelings of hope, sympathy, and fear having vanished, and that of self-preservation even being deadened by the morbid impression of the poison on the nervous system. With all this, the faculties of the mind are in perfect integrity for the arrangement of business and the disposal of property— the patient making his will with a cold indifferent justice — the mind being as benumbed and pros- trated as the body. The first impression of the morbific cause would appear to be made on the system of the organic nerves and their functions ; for almost immediately we have the vital actions of circulation, respi- ration, the generation of heat, secretion and absorption, conspi- cuously depressed; and that probably, amongst other causes, through some unknown changes in the proportion of oxygen, or in the electric condition of the atmosphere. We have here, to use the language of John Hunter, the death of the blood. This condition of the circulating fluid produces torpor of the brain : the voice is veiled, as when great hremorrhages occur, and very soon cyanosis becomes complete, the complexion assuming a lavender hue. To the prostration of the nervous system, and to the death and vis- cidity of the blood, we may refer the rapid destruction of life in cholera. Fevers, both symptomatic and idiopathic, are referred by Dr. Billing to the loss of the functions of the nervous centres — the citadel of life, as they have been termed — and subsequently to that of the organs depending on them. In all the severer visitations of this epidemic, we have symp- toms at the very onset of the disease which, as it appears to me, can be referred to no other circumstance than this primary influ- ence of the poison of cholera on the great nervous centres — giving the death-blow to the organic functions. All the secretions are suppressed, and in their place we have a general and exhausting transudation from the bowels and skin. In short, all the great EPIDEMIC CHOLERA. 5G3 functions of life are first altered and perverted, and tlien com- pletely and fatally arrested. The very stomach and bowels seem dead-drained of their serum sanguinis; — all now tends, in fact, to death. It is a common saying Avith the European soldiers in India, when they have felt the sun's power, " it has taken me in the pit of the stomach ;" and there, in seasons of the epidemic, the symp- toms of cholera make their immediate appearance. The shock to the nervous system, paralysing its functions, causes the blood to be detained also in the great trunks, and thus the functions of secretion and excretion become additionally supi)ressed — the power of generating heat to be lost — and eventually the death of the blood, as John Hunter termed it. The livid hue on the surface of the body is due to the non-arterialization of the blood in the process of respiration. TREATMENT. In respect of plague, yellow fever, and cholera, we shall do well to study their natural history, with a view to the discovery of the most efficient means for their prevention; for as to their cure, we may not, in our time at least, hope for a knowledge such as can lead directly to so desirable a result. The instances are without number, in the East Indies and other countries, in which the prompt use of alterative mercurials with opium and spices have arrested precursory diarrhoea, and thus prevented cholera ; but in the stage of maturity, and in tliat of collapse, who amongst us can conscien- tiously count his cures ? It is indeed impossible to say anything satisfactory on the treat- ment of a disease which would seem every year to become a subject of greater difficulty to medicine. Like the pestilence of the fifth century before the Christian era, described by Arnold, this epidemic has in a manner travelled up and down over the habitable world, unafiPected by human endeavours, returning often to the same place after a certain interval ; pausing sometimes in its fury, and appear- ing to stop, but again breaking out on some point or other within its rangCj till, at the end of its appointed period^ it disappears — we dare not say — altogether. Dr. EUiotson declares that " if, as respects this country, all the patients had been left alone, the mortality would have been much the same as it has been. We are not in the least more advanced as to the proper remedies than we were when the first case of cholera occurred." Certainly, every year makes us more and more familiar with the phenomena of the disease ; but this circumstance has in no way improved our acquaintance with the means of checking its progress in the human frame, or of effecting its cure. It is indeed in the 2ireveittioii, rather than in the cure of cholera, as of j)lague and common typhus^ that medical science will at all times prove most o o 2 564 EPIDEMIC CHOLERA. conspicuously beneficial in this disease. If measures of cure be in a large proportion of instances beyond the reach of the sufferers, or of but little avail when applied, we should devote our energies with redoubled force to the prevention of cholera ; for here it is ascertained that our power of beneficial action is great. In the stage of collapse, the disease has too often proved to physicians what traumatic tetanus is to surgeons — a disease, according to Hennen, which, once fully formed, tended more to show him what he could not trust to, than what he could place the smallest reliance on. But we have every day presented to us, in every form and variety, what are termed new views of the causes, pathology, and treatment of cholera ; yet of each and all of them how small a portion, if any, is really true. It is better to argue from cause to effect, than from effects to infer causes ; and if we are to arrive at any just pathology, or successful treatment of this disease, it will probably be through such course of investigation. Certainly, the search after specifics does not appear to be a promising course. Reasoning, for instance, would lead us to expect some aid against the desperate stage of collapse from the conjoined iise of the oxj'geuated gases and galvanism ; but it does not appear that any persevering trials have been made of them. In 1827, at the General Hospital of Calcutta, I ordered the in- halation of pure oxygen gas in the case of a robust European soldier who was dying in the stage of collapse. The eff'ect for a time appeared very promising, the skin becoming warm and the pulse being restored at the Avrist ; but, from defective means, I was unable to pursue the experiment."^ To decarbonize the surcharged blood globules, and rouse the capillary circulation. Dr. A. C. Macrae of Calcutta had recourse to the nitro-muriatic acid bath ; and the results were so interesting, when used by him in the Howrali Seaman's Hospital in 1851, that further trial of this powerful agent is anxiously looked to. " The patient when in the worst stage of collapse, with cold, blue, shrivelled skin, pulseless and voiceless, moribund, was stripped and wrapped iip in a sheet taken from a vessel containing the bath prepared according to your formula, occasionally made a little stronger. Over this was placed a blanket, and the attendant was instructed to wet the sheet every few minutes by means of a sponge, taking care to replace it carefully when thrown oft' by the restlessness of the patient. He was instructed to continue this treatment until reaction decidedly set in, the period of which varied from one to six or eight hours : the signs of it were first seen in the conjunctiva, which, changing from the dull leaden hue so characteristic of cholera collapse, became of a brilliant red, simu- * Oxygen gas may easily be produced by intimately mixing chlorate of potash with one-sixth of its weight of black oxide of manganese, and throwing the mixture on an iron shovel heated to dull redness. EPIDEMIC CHOLERA. 563 lathig acute ophthalmia. The same chanj^e, though in a less marked degree, took place in the skin, the blue colour giving place to a general erythcmatic blush. With these signs of improvement, otliers speedily were manifested^ as cessation of cramp, of incessant thirst and general restlessness^ until reaction fairly set in, and so far the patient was saved. ^^ This able officer treated twenty of the Avorst cases after the manner here described ; " and the result was most encouraging, the proportion of recoveries being greatly in excess of that from any other mode of treatment. ^^ When first I entered on military practice in Bengal, the disease had some marked points of difference in character, and in the means used to combat them, from those of more recent visitations of the epidemic. Formerly simple mucous congestion of the most aggravated nature appeared to form the more essential feature of the disease ; and the consequent spasm, which was of a clonic character, could be referred to the oppression of the nervous energy following on concentrated cerebral and spinal congestion. It is on the supposition that this condition formed the leading feature of the disease in its earlier visitations, and of the organic ner\ous function being there less involved, that I would account for the efficacy of blood-letting during the first six years of our acquaintance with cholera ; for, latterly, there seems to prevail a depression of the vital actions which has greatly embarrassed our treatment, and deprived us almost altogether of our former great resource, general blood-letting. The first European whom I treated was a stout young soldier of Her Majesty's 59th regiment stationed in Fort William. There was incessant vomiting and purging of a watery fluid, with spasms so violent that four men were required to hold the patient in his cot. I bled him largely, and in a few hours he recovered health. What a simple matter did the treatment of cholera then appear to my sanguine and youthful inexperience, and in how few years had I to think and act differently ! The efficacy of blood-letting, even on the approach of the stage of collapse, we constantly observed; and we practised it as if under direction of the great physician of congestive disease — Robert Jackson. In 1822, when serving in the Governor-General's body- guard, I found the European farrier-major of the corps apparently dying of cholera. During the night he had voided enormous quantities of fluid by vomit and stool, and when I saw him in the early morning his appearance was surprisingly altered. He was cold and livid, his countenance shrunk and shrivelled, his voice veiled, the circulation flagging in the extremities. I opened a vein in each arm, but it was long ere, through the aid of diffusible stimuli, frictions, &c., I could obtain but a trickling of dark treacly matter; at length the blood flowed, and by degrees its darkness was exchanged for the more florid hue of nature. The 566 EPIDEMIC CHOLERA. ' farrier was not of robust habit, and had resided long in India ; but nevertheless, I bled him copiously, when he, whom but a moment before I regarded as a dying man, stood up and exclaimed, " Sir, you have made a new man of me.'' The changes in the course of disease here spoken of are another example of that depressing influence operating on the nervous system, which has beeu observed in many countries where, through epidemic constitutions of the air, or other causes, epidemics have engrafted themselves on the endemics, as on the parent stock of the soil. Here, for instance, we have, to appearance, the same symptoms in the same order, but these signs are fallacious ; and the treatment which proved most successful on the first appearance of cholera no man will now venture to put in practice. It would appear that in the more recent visitations of the epidemic in Bengal, we have, from the very onset of the attack, a greater de- pression of the organic nervous function, and a more rapid loss of vitality in the blood, than was observable in its earlier history. It is in the manner here indicated that dysenteries, fevers, and other endemic diseases come, in the progress of years, to alter these characters. After what has just been stated, it may appear almost beneath the dignity of medicine to speak of cures in such a disease ; yet I believe the thing is to be done, with some degree of success, too, if only undertaken in time. Cholera being the most acute of all acute diseases, medicine, to have any chance of success, must be applied at the earliest moment of its invasion. If the first impression of the morbid cause be to depress the in- nervation of the ganglionic nerves, and thus to paralyse all the great functions of life, the indication of treatment should be to excite and restore the healthy powers of the nervous centres. In my own expeiience, this indication has best been fulfilled by the exhibition, at the very onset of the disease, of large doses of calomel and opium; and where, nevertheless, the disease stiU proceeded, the repeated use of smaller doses of calomel with highly diffusible stimulants was persevered in, so as to rouse the nervous and vas- cular actions. It seems admitted in actual practice, in all portions of the British Empire, and by the great body of the medical profession, that during the premonitory stage, or that of simple diarrhoea, opium is the sheet anchor of reliance. Some give this remedy alone — some with chalk and aromatics — some with calomel ; but all give opium in some form or combination, thus following still the original prac- tice in India. Opium thus used acts at once as a cure of diarrhoea and of the earlier stage of cholera, and as a prevention of the coming and fatal collapse. After all our experience, in all parts of the world, the treatment by calomel and opium at the commencement of the disease^ and EPIDEMIC CHOLERA. 5G7 calomel with difiFasible stimulants in its subsequent stages, as originally practised in the East^ is that treatment Avhich has been the most steadily and the longest approved by the profession. In the Report on the results of different methods of treatment pursued in Epidemic Cholera, and addressed to the President of the General Board of Health by the Treatment Committee of the Medical Council, we find the following summary : — " The evidence of these tables condemns the eliminant treat- ment altogether as a principle of practice. " It testifies against the stimulant principle, excepting as a re- source in extreme cases. " It displays a decided advantage in the alterative principle, especially as carried out by calomel and opium; and it shows a still superior advantage in the astringent principle as applied through the means of chalk and opium — the general per-centage of deaths following each plan of treatment being — Of eliminants 71"7 per cent. ,, stimulants 54* ,, ,, alteratives, calomel and opium . . . 36'2 ,, ,, astringents, chalk and opium .... 20*3 ,, In order to judge correctly of the value of this evidence, it is necessary to examine, as far as may be possible, the degree of severity of the cases brought beneath this test. The only means at our command (on the present occasion, at least) to make this examination, is to consider the relative proportion which the cases of collapse bear to the number of deaths of their own classes respectively. Examining, therefore, the collapse cases with the number of deaths, we find that calomel and opium stands highest in the scale of success, and the order of preference appears as follows : — Calomel and opium 59 "2 per cent. Calomel (larger doses) 60 "9 Salines 62-9 Chalk and opium 63 "2 Calomel (small doses) ...... 73 '9 Castor oil 77 "6 Sulphuric acid 7 8 '9 According to this result, the superior success of calomel and opium in severer cases appears a distinct fact elicited by the present in- quiry. It is accompanied by other facts — viz., the relative ad- vantages of those other modes of treatment which follow in thsir order of success. This order marks the use of calomel in small doses, of castor oil, and of sulphuric acid, as actually to be depre- cated in severe cases. " Chalk and opium, as shown above, stands at the head of the list, in the general per-centages, both in hospitals and in private practice ; but in the comparison of the collapse cases with the number of deaths^ the average declines to the fourth rank." 568 EPIDEMIC CHOLERA. The names appended to the report, of which the above is an extract, are : — John Ayrton Paris, President of the College of Physicians ; James Alderson ; Benjamin Guy Babington ; Alex. Tweedie ; Nathaniel Bagshaw Ward ; all Fellows of the said Col- lege. In the " Report on the Treatment of Epidemic Cholera in the Provinces thronghout England and Scotland, in 1854, being Supplementary to the Metropolitan Report, addressed to the Pre- sident of the General Board of Health by the Treatment Com- mittee," all the above facts are substantially corroborated. I have only to state, in conclusion, that in cholera, in common with the last stages of violent fevers and dysenteries — as, in fact, in all diseases of great exhaustion — the patient will always owe much to the horizontal position, and to careful and unremitting nursing. The most careful nursing, and the most attentive watch- ing of the patient, are both of the utmost importance in this disease ; and so easily is the balance of circulation fatally overtiu'ned, that a strict attention to the recumbent posture is absolutely necessary to success. In no other diseases are these simple matters of so great importance to be attended to ; and in the disease under special notice, I have seen many a life apparently lost from inat- tention to them. For the following Tables I am indebted to my friend Dr. Bal- four, of the War Office. They exhibit the average sickness and mortality from cholera in certain of our foreign possessions ; and show by how much more fatal epidemic cholera has proved in the country of its birth than in any other. EPIDEMIC CHOLERA. 5G9 pq ■d "P •«J< 00 -* 00 rH O »0 ip 'p CO o 1< CO ■* t~ OJiUooo010 i^ looSSH,— iioSSSSS^oooj • • • a 1-1 ^o,^^^o,ooj|^^j|°c^^ : . . -a 'SJ <" . "S-a o O00-5f(lO00C0'j5'*tr- t^00C0>000C0Ob-d '^'3) CO OOiOS-Hl^^CO'+l'tC COO'iJti-lt^COQOCOr-l t! a Oi 'U* en Tf OS CO d l-~ CO IT l005COlOC3iOCOOiGf t-T CO~ '^'^ oT cc " T-l" io~ r-T o' of t-T oo" o" r-T taoS 05 OjtOCqiM -*10<>]00»0 C0->*r-(00»0O | -< <" I-I I-I 1-1 °l ^ ^o to ^ o ^ «o ■ o CO t— t~ >o t- c a t" 3 S 3 1 ^ c c3 3 a ;-< 1 3 .3 o < ) t 3 en > c c PC c 0-2 a "f o 1— ( 0-*^lOi— i»o ooooooooooooooooooo ■^ 0 1— I : >n>oiaT-i*(M>o^eo-*oia50Cit~.-icoio«o(Mi-ioo'* 1— iCOJNtZJiMlO'OOr-llOCilO^HlOCO-^T— 1-"^-^ r-1 00--^05rH0500?0'MmeOOOOOc3i?0 eOCOCOCOC0C<300COC0COC0»Oi— l Aquas 5viij.* But opium, given early and largely, with the view to overstep the stage of excitement, and thus forcibly to induce sleep, is unsafe. It should be given as suggested, in aid of the tendency of nature, in as moderate doses as may be, consistently with the assuring of sleep. To obtain repose for the brain by any means is the first indication of cure ; and this cardinal object has been attempted by opiates — by opiates with antimony — by chloroform — by chloroform with opium — by chloroform by inhalation — by the Indian hemp — by heroic doses of digitalis — by the expectant or placebo system. Delirium tremens is doubtless, to a certain extent, of " the class of self-limited disorders," and the fact ought not to be lost sight of in its treatment ; but he who has to deal with this disease in India must put a guarded limit to his expectations of the curative powers of nature, and be careful to come to her assistance in time ; otherAvise the limit may be that of death. Doubtless the alcohol is eliminated * Tlie question whether ipecacuanha may not in most cases be substituted for the emetic tartar is well worthy of consideration, the former being far less depressing in its actions. 620 DELIRIUM TREMENS. in due time from the blood and secretions, but with tlie limit of this process, as to time, we are unacquainted. Meanwhile, we must have special regard to the condition of the nervous system, and to the nature and extent of the complications in each individual case. When the symptoms, as here supposed, are the direct and im- mediate results of a fit of drinking — no inflammatory action being present within the cerebral cavity — the course of treatment sug- gested will generally prove of speedy efiFect. In the true delirium tremens, however, or that resulting from the withdrawal of an ac- customed stimulus, with exhaustion of the nervous and vascular systems, the treatment becomes at once more complex and difficult. Here, as in the former instance, ive should commence by the exhibition of a full dose of calomel and opium, followed by a powerful aromatic and stimulating cathartic, with a view to remove retained and vitiated intestinal accumulations, and to act as an energetic cholagogue. After the free operation of the cathartic, opium in moderate doses, conjoined, in healthy subjects, with antimony, and in old or ansemic subjects with camphor or am- monia, should be given every two hours, until evidence of abated nervous irritability and nervous exhaustion be made apparent, in a tranquil sleep. For the purpose of allaying nervous agitation and sleeplessness, very large and very unwarrantable doses of opium have been exhibited ; but it should at all times be the object of the attentive physician to obtain his objects by a moderate use of direct narcotics ; and happily, in the use of chloroform, internally exhibited, we possess a powerful and harmless means of command- ing nervous perturbation and depression. Chloroform, in very severe cases, may be conjoined with small doses of laudanum, and so as to command sleep. Chloroform is thus valuable in itself, and as enabling us to dispense with large and repeated doses of opium. As stated in the article on fever. Doctors Corrigan and Gordon, of Dublin, have, for some time past been in the habit of using chloroform in delirium tremens. One drachm is given by the stomach at first, and it is often increased to two drachms, or even larger doses. The dose is repeated every two or three hours, until sleep results ; and, unlike opium, this medicine does not lock up the secretions. The moderate use of chloi'ofoi'm by inhalation has likewise been had recourse to with marked benefit in cases of extreme violence, the patient awaking refreshed and restored after several hours of sound sleep. In America the Indian hemp has been exhibited in large doses every hour, it is said, with similar results. Heroic doses of tincture of digitalis — half an ounce re- peated in four hours, and in rare instances a third dose of two drachms — have been exhibited by various practitioners, in different times and places, and very recently by Mr. Jones, of Jersey ; while he declares that smaller doses, in the earlier stages of the disease, are inefficient, if not injurious. DELIRIUM TREMENS. 621 On tlie effects of half-oimce doses of tincture of digitalis in delirium tremens we may conclude with Dr. Peacock, of St. Thomases Hospital — '' 1st. That the drug, when exhibited in full doses, does not by any means produce the amount of depression which our previous experience of its action in small and frequently repeated doses would have led us to expect ; and, 2nd. That the remedy, in conjunction with other means, may probably be more usefully employed in the treatment of certain cases of the disease, and especially when it occurs in young and robust persons, whose strength has not been broken doAvn by prolonged habits of intem- perance ; and particularly when it arises as the immediate result of excessive spirit- drinking. Delirium tremens, like other acute diseases, occui's uuder varied and opposite conditions, and it would be alike opposed to sound theory and practice to extend the same treatment to all cases of the disease." But to aid the actions of narcotics or calmatives, the use of active cholagogue purgatives, of warm baths, of spiced negus, and of well-made soups, will materially advance the solution of the symptoms ; by such means we may emulge the depurative organs, while we support the depressed nervous energy. Articles of diet at once nutritious, light, and easy of digestion, should be carefully exhibited, in order to guard against exhaustion. Wine and porter I have always given in preference to alcoholic drinks, and these have been allowed only with soups or solid articles of diet. Personal restraint and coercive measures are seldom called for, and should not be used without a necessity. The disposition of the patient is generally harmless ; and by careful and constant atten- tion on the part of the attendants, and by judicious management, he can be induced to comply with all the requisite orders of the hospital. In the hands of exclusive practitioners, I have often seen means, apparently opposite in their nature and influences, followed by successful results : — for instance, a late friend of mine, a surgeon of the Bengal army, and one of the most able men whom I have ever known, entertained a positive dislike of opium, from its well- known quality of locking up the secretions. He treated delirium tremens with very large doses of calomel, followed by purgatives ; and his success was, according to his impression, equal to that of his brother officers. But this instance only proves how much the use of cholagogue purgatives has to do with the treatment of this disease, and how necessary it is that they should always consti- tute a prominent part in its treatment. It is here, as in other complicated diseases ; it is not by one favom'ite remedy, or fancied specific, that disease is to be over- come, but by the proper application of all the known remedies. To conclude : — For the just treatment of delirium tremens, then, there must be sundry means adapted to the various conditions of so formidable a disease; — cholagogues and purgatives, diuretics 62^ DELIRIUM TREMENS. and suclorifics, to elicit secretion and to discharge vitiated matters — opiates to calm and promote sleep — diffusible stimulants to main- tain the nervousj vascular, and respiratory forces, and suitable means of nutrition. Narcotics alone will not fulfil the true indi- cations. The following Table exhibits the Relative Prevalence and Mortality from Deliriiom Tremens ammigst the European Troops of Her Majestfs Army in the several Commands mentioned : — Delirium Tremens. Aggregate strength. Admitted. Died. Proportion of deaths to admissions. 86,661 61,567 22,714 30,515 42,978 11,721 46,442 64,280 60,269 40,826 70,293 44,611 36,286 31,267 18,073 7,000 1426 191 13 514 35 102 207 296 44 38 192 27 672 496 113 34 175 42 3 50 7 9 18 18 5 5 30 4 14 21 15 5 1 in 8 lin 41 lin 4i 1 in 10| lin 5 1 in 11 1 in 12 1 in 16 1 in 9 1 in 8 lin 61 lin 62 1 in 48 1 in 24 lin 71 1 in 7 Jamaica Cape of Good Hope Mauritius Ceylon Nova Scotia and New Bruns- ) wick ) Upper and Lower Canada Gibraltar Malta Ionian Islands United Kingdom Bengal, 1836 to 1840 Madras, 1832 to 1836 Bombay, 1836 to 1840 Tenasserim Provinces, 1836-37 The above table suggests many inquiries, but which cannot be answered without entering into a variety of circumstances affecting the moral and physical condition of the soldier. Why the mortality by delirium tremens in Madras should be double that of Bengal, for instance, and why that of Tenasserim and of Bombay should so very far exceed that of both the sister presidencies, are points of much interest. Again, so far as ordi- nary tropical infiuences are concerned, the colonies of the Cape of Good Hope, Mauritius, and the provinces of Tenasserim, enjoy a remarkable exemption, the deaths by fever, dysentery, and hepa- titis being few in these colonies, as compared to the other British possessions ; yet in these most favoured climates, delirium tremens proves most fatal. Even within the British islands, we find that, though delirium tremens is comparatively a more mild and rare disease, the ratio of deaths to cases treated is nearly eight times as great as in the unhealthy countries under the Bengal presidency. It may be that, as in the instance of mercury, a certain amount I DELIRIUM TREMENS. ' 623 of injury is prevented by so much of the alcohol being removed from the system by the copious perspirations prevalent throughout India generally, and in Bengal especially, during so many mouths out of every year. That the excessive transudations which occur in the hot and rainy seasons have such a tendency, appears to me more than probable ; for, in the instance of mercury, we have a demonstration of the fact. Through the same channel of the skin, but by means of active exercise in the open air, the " three-bottle-men/' the fox-hunting squires of old, " carried off" their port wine. The hunting during three days of every week kept the depurative functions in acti-^^ty, and thus they lived on to a lusty old age, while, without such active habits, they must have died in youth and middle life from visceral disease and delirium tremens — the inevitable fate of the sedentary sot. PART IV. CIEONIC DISEASES OF EUEOPEANS EETUEN FEOM TKOPICAL CLIMATES, AND THEIE CUEE. Note, — In the following attempt to explain the physiological influences under which the balance of European health is disturbed in hot climates, as well as the counter effects of the climate of Europe, there are certain inevitable repetitions of matters which have already been set forth in the chapter on medical climate. But many per- sons will peruse this fourth part of the present work to whom the other parts will not possess the same interest ; — and it is better to repeat than to be misunderstood. INTEODUCTOEY CHAPTEE. In the foregoing portion of this work, I have endeavoured to ex- plain the origin of those formidable diseases which, under tropical influences, affect the stranger European, and to trace them to the altered physiological actions induced by an unnaturally high range of temperature and other causes which, during a residence generally protracted, disturb the various functions on whose just balance health must everywhere depend. I purpose now to examine the converse of all this — the reverse of everything that holds under tropical influences — to describe the flow and ebb of excitement — the inertia, approaching to a collapse of the various functions of the body, which follows as a necessary consequence of the previous tumultuous action — and to describe both the condition and the treatment of the tropical invalid on his return to his native climate. I design, in short, to trace the pecu- liar physiological circumstances that have led to the state of ill- health common to tropical invalids, and also to explain the real or essential nature of their diseases ; and, finally, I shall detail the special conditions to be regarded in their treatment. As in the previous portion of this work, I venture with much diffidence to approach the subject by the high but difficult road of phy- siology. INTRODUCTORY CHAPTER. 62 5 The courses of investigatiou liere spoken of are surrounded with the diffieultics inherent in everything that relates to climate as a science ; bnt fully impressed with these great disadvantages, I am nevertheless more and more persuaded^ by every-day expe- rience, of the necessity of prosecuting such inquiries in the manner here proposed. I believe it to promise a superior usefulness in result, whether we regard the advancement of the preventive or the curative departments of our profession. A familiar acquaintance with the most concentrated forms of disease, as they prevail in tropical climates, assists materially to- wards a just appreciation of those that lie between, or of minor degrees of disease, as they prevail in more temperate regions. Observation of the nature and power of external causes in the production of disease Avithin the tropics assists us also to form a more just estimate of the power of other and different circum- stances of climate, whether morbific or sanative, in our native country. In other words — the antecedent circumstances being known, the consequents become more easy of being appreciated. This counter-experience, acquired in the observation of invalids on their return to Europe from hot climates, ought to be of much value by extending the circle of our acquaintance with the conditions of health resulting from the influences of tropical climates. Without a knowledge of the antecedent circumstances Avhich, under tropical heats, disturbed the functions of the stranger Euro- pean, as well as a knowledge of the converse present conditions which, under the cold and damp of Europe, disturb his functions in a different and opposite manner, it is impossible to obtain a just or comprehensive view of the history of his health, to appre- ciate his actual condition, or to regulate his medical management. " To know the cause of disease,^' says Dr. Watson, " is sometimes to be able to care, often to be able to prevent it.^' The subject is of great and of increasing importance also, seeing that the numbers are annually increasing, who, from choice or necessity, betake themselves to the intertropical possessions of this empire. This consideration, as well as the great difficulties above alluded to, render it a matter of serious regret to me, that in such an under- taking I am not aided by the experience and observations of other and more competent authorities. With the exception of the admirable " Observations" of my late friend. Dr. James Johnson, the subject as here proposed to be treated is almost, if not altogether new. It is incumbent on me, therefore, to explain the grounds on which I pretend to undertake the discussion of it. During a residence of tAvo-and-twenty years in various parts of India, and in some of its worst climates, I had extended oppor- tunities, in peace and in war, during seasons of prosperity and adversity, in hospital and in private practice, of witnessing the in- fluences that affect the health of both Europeans and natives. For s s 626 INTRODUCTORY CHAPTER. many years I was a severe sufferer from fevers, remittent and intermittent : in Gondwana, in Upper Ava, and in Calcutta, I nearly fell under tlie violence of malignant remittents. I have seen how the masses and how individuals were affected, how they lived and prospered, how they sickened, recovered, or died ; — the habits of life and the causes of death, in short, of the Asiatic and European races. I have had the further advantage of witnessing the influences that tend to produce like results in the native climate of the European on his return home ; and it is this last circumstance that specially encourages me to make the present attempt, trusting that, ere long, I may be followed by other expe- rienced and more competent observers from amongst my brother officers of the medical departments of the Indian army. In proceeding to treat an European invalid just returned from India, it will be found that a consideration of all the antecedents, vrithin the tropics, is quite as necessary to a just appreciation of his condition, as that of the present influences of an English climate. Both circumstances of climate have, in fact, so strict a relation one to the other, that a consideration of either, examined apart, must fail to lead to a thorough understanding of those im- portant agencies and changes which modify and stamp the habit and constitution of the individual, so as to render him a special and peculiar subject of medical care. These truths, which can admit of no denial, will, it is hoped, be received in excuse of the following details. And let no one consider these subjects tedious or unimportant, but rather that the manner of their exposition may be so.* It is necessary to hold in recollection, in reference to the sub- ject-matter of the following Section, that of the sufferers from the diseases treated of, a large proportion always consists of young officers belonging to every branch of the Indian services, civil, military, and naval. They generally present in their persons, on their arrival in Europe, examples of the severer ravages of acute tropical disease, or of those which, from their original violence, from their frequent recurrence, or from the consequence of active treatment, have baffled alike the endeavours at immediate cure, and those intended to promote convalescence by recourse to the many changes of climate attainable by a removal to the Hill Ranges and the Seas of the East. None of the servants of the Government are sent home but such as have resisted all the known means of cure ; for none can, iinder existing regulations, obtain sick leave but through the most strict medical scrutiny, and through a succession of different checks ; there must be exhi- * The object of these cursory remarks is to point out the injurious results following upon exposure to extremes of climate. Were it proposed here to speak of the remedial powers of climate, I should quote Largely from the valuable work of Sir James Clark on "The Sanative Influence of Climate," — a work deserving the careful consideration of all classes of the community. INTRODUCTORY CHAPTER. C27 bited in every case a proved and certified necessity for so pro- tracted an absence from duty as is involved in a return to Eng-^ land. Of the other class of suiFerers, or those who have retired from the public services of India, in middle or more advanced life, it may be said generally that, from their longer residence in India, and from their comparatively increased years, their ailments are of a more chronic character. The peculiar circumstances here mentioned render it evident that, in treating persons of either class in England, the duties and cares of the physician are increased and complicated in no ordinary degree. The return of the tropical sojourner to the land of his fathers, strange as it may seem, is not unaccompanied by serious risks to his health, and by many moral considerations of a painful and dis- tressing character. Since the day when, as a mere youth, he bade adieu to his sor- rowing relatives, quitted the protection of the paternal roof, and his native climate, he has undergone changes in his moral and physical nature but little considered or understood by his kinsmen and countrymen in general, amongst whom he now finds himself, in middle or more advanced life, differing in habits, associations, and pursuits from those around him — his nearest relatives departed, and he an invalid and a stranger in the land of his birth. This is a great and sad revolution in life, whether we regard it in a moral or a physical sense, and the medical officer who has observed its violently acute causes abroad, and its chronic and protracted consequences at home, can bear testimony to severe and compli- cated sufferings on the part of a highly intellectual portion of our community. The youth, on his arrival in India, is at once placed in a society wherein the social affections and the domestic habits of our native country are cherished and cultivated with a luxuriance character- istic of the climate, and of which no other country, perhaps, has offered so distinguished an example. At a distance of twelve thousand miles from the British shores, and separated for more than half our lives from all those who, in our early yoiith, were most cherished, it is but natural that in India we should cling together the closer that all feel in common — the old Indian and the new comer — the utter uncertainty of again revisiting the homes of our youth. Such is the state of feeling in the East ; and tliroughout the whole period of an Indian^s career, whatever his line of service, he lives in a society whose generous kindness in prosperity, and whose soothing attentions in adversity or in sickness, are unequalled in any other quarter of the world ; and it may be said with truth that no one who deserved its consideration was ever otherwise treated by the community of the Indian presidencies. If we look to the physical condition of the youth, it is at first, s s 2 G28 INTRODUCTORY CHAPTER. under favourable circumstances, no less cheering. All the func- tions of life receive an impulse from tlie agency of heat, while the susceptibility to impressions is increased in the like proportion. The comforts, and even luxuries of life, are within his reach if he will be but prudent ; for want of any kind in India is unknown, except to the heedless or the profligate. Disease, tropical disease, too, is as yet a stranger to him ; and should he be in the army, and not have campaigned, or served in unhealthy countries, or during the most unhealthy seasons, the equable determination to the surface of the body, produced by an elevated range of tempe- rature, tends, along with the increased excitability of the nervous and vascular systems, to raise the animal spirits, and impart a feel- ing of invigoration and health delightfid to the senses. But time passes on, and even if, through the contingencies of service in various regions, or through his own imprudence, disease has not ensued, the lengthened application of these operations of climate, which at first appeared beneficial, are sure to impair the health, and that, too often, with a termination so suddenly dangerous or fatal, as at once to shock and terrify all who behold it. Loss of time in the climates of the East implies loss of opportunity to save life ; for an omission or a mistake in the treatment admits of no future correction or remedy. As an example of the amount of disease which may occur in India within a brief space of time, I will quote the report on Ensign F., of the Bengal Army : — " Has been in India only three years and a few months, and has already had four separate attacks of hepatitis, two of dysentery, one of con- tinued fever, and two severe tertian intermittent fevers, besides numerous other illnesses. ^^ This officer bore the marks of his stormy career of disease, being greatly shattered ; but he was young, and he recovered his health. In tropical climates the attentive observation of the early stages of disease is of the utmost impor- tance, for then we can both prevent and cure with ease ; we now can cure by mild remedies, while by such simple and easily applied means of cure, we prevent severe ill-consequences. In the East, diseases of every kind, when once established, proceed with a tumultuously rapid course to the destruction of certain organs ; and exactly as may be the judgment and power with which remedies are applied, so will the result j)rove a complete cure, with speedy restoration of vigour, or a partial and imperfect cure, ending in chronic disease. The distinctive value of the two courses here indicated, is most important to the welfare of fleets and armies ; for by early and just measures of cure, the men are restored to service, while by feeble and inert courses, they are consigned to the hospitals, there to linger and die, as I have mentioned, of chronic disease. It will now be proper to look in some detail to the operation of those causes which tend, by their protracted application, to dete- riorate or destroy the best of European constitutions ; because a INTRODUCTORY CHATTER. G,:29 practical acquaintance with these causes, and Avitli tlicir modes of operation, is absolutely necessary to a right understanding of their effects. In India Ave find that no amount of talent, or of general and professional knowledge, can compensate for the absence of local experience in the treatment of its diseases ; and it is hardly necessaiy to say that the same kind of experience is quite as neces- sary to the just management of their sequelce in Europe. A care- ful consideration of all the influential circumstances, moral and physical, under which the European lived within the tropics, ("Whilst he did climate tliere,^' as Shakspeare expresses it), will go fai', however, to supply the want here mentioned ; and it is in the hope of contributing in some degree to this end that I venture to submit the following observations. The most immediate of the tropical influences on European con- stitutions are evidenced in the excited conditions of the nervous and vascular systems, interfering as they do with the rhythmical action of the heart, more or less according to the term of exposure ; while the most important are those afl'eeting the functions of the skin, liver, lungs, and kidneys ; and owing to the extraordinarily high range and rapid changes in the temperature, humidity, and other qualities of the atmosphere, all these important influences are exemplified in extreme degrees. The transmission of the nervous influence, according to Eck- hard, is more rapid when the temperature is higher. During the hot and rainy seasons, which in Bengal extend from the beginning of ]March to the end of October, the determination of the fluids generally is to the sm^faee, accompanied by an increase of the nervous excitability and animal heat ; by an acceleration of pulse, and a prodigious increase of the pulmonary and cutaneous exhalations, the latter amounting, in the rainy season, to an ex- hausting discharge, as if the very serum of the blood were exuded. At this latter season, through the saturation of the atmosphere, its vivifying properties are diminished, while the excessive decomposi- tion of animal and vegetable matter gives to the air in some of the most imhealthy localities the properties of a tainted vapour bath. The perspiration is not carried oft' by evaporation, while the transuda- tion is enormously increased — thus, heat accumulates in the body, and the local action of cold produces serious consequences, rendering the system susceptible of the least impression from cold or ma- larious influences, with a strong tendency to congestion in all the abdominal organs. "When the atmosphere is saturated with moisture, there can be no cooling relief to the body by evaporation. The air, according to Professor Smith, of Edinburgh, expanding with the heat, while the lungs remain of the same capacity, they must take in a smaller quantity by iceight, though the same by measure, of oxygen, the supporter of life". This, he adds, is one of the reasons of the lassi- tude felt in warm climates : " but if, in addition to the air being 630 INTRODUCTORY CHAPTER. rarefied, it be also still further distended by tlie vapour of water being mixed with it, it is evident that a certain number of cubic inches by measure, or lungsful, will contain a less Aveight of oxy- gen than ever ; so little, indeed, that life can hardly be supported, and we need not wonder at persons lying down almost powerless in the hot and damp atmosphere, and gasping for breath/' It has been supposed by some observers, indeed, that in hot climates both the volume and the weight of the lungs are diminished as com- pared to those properties in Europe. The natives of India, of the higher classes, avoid all exertion during the rainy season ; while the working classes, at all seasons, are sparing of extra labour, and when compatible with the work in hand, sitting is ever the postiire of the artisan in the East. The excessive watery discharge from the skin during the rainy season must of necessity have the effect of rendering the venous blood unnaturally dense, and of thus causing the European to be more liable to congestive forms of disease. Dr. C. Williams refers the disposition to liver complaints, dysentery, and cholera, to the stimulating properties of the blood, deprived, as we have seen, of more than its usual amount of water, and of less of its hydro- carbon. Such, briefly, are the hot and rainy seasons of tropical climates, and such are some of the reasons for their proverbial unheal thiness. The mind even seems to partake in the general relaxation and lassitude, being unfitted for vigorous or sustained eflforts of any kind. During the eight months here under consideration, the sleep is seriously disturbed — a circumstance in itself sufficient to account for many of the attendant evils. The " cutaneo-hepatic sympathy " of Dr. James Johnson is well known, and so is the theory which considers that, while respiration is less perfectly carried on, owing to the rarefaction of the air, a Adcarious decarbonization of the blood is established by a great • increase of the biliary secretion. If, as supposed by Liebig, the function of the bile is " to support respiration and produce animal heat, by presenting carbon and hydrogen in a very subtile form to the oxj^gen of arterial blood," how greatly must the condition of the vital functions — respiration, the generation of heat, circulation, and secretion — be influenced by the palpably increased secretion of bile in tropical climates, followed as that excited action of the hot and rainy season is by a proportionately diminished action and consequent tendency to congestive disease in the cold season ? Indeed, we are everywhere, in hot climates, thrown back on the observation of that acute and accurate pathological observer. Dr. John Clark, that of all the viscera in the human body the liver is the most subject to disease. The condition of the atmosphere during the hot and rainy season prodxices in reality many of the results of an insufficient supply of air, or of air despoiled of a portion of its oxygen. The INTRODUCTORY CHAPTER. 631 heated and rarefied states of the air produee a double result ; for the introduction into the blood through respiration of a limited supply of vivifying property, impedes and retards the disengage- ment of putrescent eiSuvia from the lungs and skin ; and thus the imperfect oxidation of the blood causes not only a correspondingly imperfect elimination of eft'ete matters from the circulating fluids, but also the return of poisonous matters into the blood — all which circumstances predispose the system to the reception of malarious and epidemic poisons, and to their consequences. All these cir- cumstances, however difficult of proof, are of vast importance to be well considered ; and there seems at length some reason to hope that the vicarious nature of the relations existing between the de- purative functions of the liver, kidneys, mucous surfaces, skin, and lungs, may receive demonstration from chemistry. The blood being less arterialized in proportion to the elevation of temperature, it is evident that in tropical climates, according to Dr. Reid, the systemic circulation becomes decidedly venous and consequently unfit for carrying on the process of nutrition, and that it passes less freely through the capillaries into the veins. The lungs, too, are, in hot climates, relieved from some of the labour performed by them in temperate or cold regions ; and thus it hap- pens that many persons enjoy good health in hot climates, who, from tendency to pectoral disease, could not have lived in Europe ; indeed, many persons in the curable stage of consumption — that is, labouring under the preceding stage, or that of " tuberculous cachexia," regain their health and survive their relatives at home. Those, on the other hand, who go to India with softened tubercles, or even in the stage approaching it, are only hurried into their graves. Mr. Curtis states that in his time, 1782-8-3, "diseases of the thoracic viscera were exceedingly rare, or rather never appeared at all in India, under an idiopathic form. Pulmonary consumption was wholly unknown." The correctness of these observations is confirmed by modern statistics. In the instance of Europeans desiring to proceed to India, or in those of officers wishing to return to their duties there, I always rest the question of their fitness to encounter the climate on the existence or otherwise of organic disease in any of the three cavi- ties. Where, on careful examination, none such is discoverable, I determine at once that such person may proceed to a tropical climate with an average probability of enjoying health. When any considerable degree of functional disturbance is apparent, within the cerebral or abdominal cavities especially, I call for delay, and await its removal. As a general rule also, no one, whether ill or well, should be sent to a hot climate who bears the heats of European countries badly. On the other hand, where there exists a hereditary or other disposition to morbid affections of the chest, I recommend such persons to proceed to India, as offering the best prospect of escape 632 INTRODUCTORY CHAPTER. from a condition of disease whicli^ in England, terminates too freqnently in hopeless pulmonary consumption. Such, in a few words, are the principles on which I have been in the habit of re iting this important question. During the hot and rainy seasons here referred to, the function of the kidneys is always diminished, while at the same time the urine is surcharged with saline and other impregnations. Unnatural and over-excited in all his functions as the European subject has hitherto been viewed, we soon find him, under the influence of the cold seasons, affected in a manner completely the reverse. The blood, owing to the larger proportion of oxygen used in respiration, now becomes more arterialized, while its consistence is rendered more viscid. In the cold season, a larger quantity of oxygen is consumed in maintaining the temperature of the body. The now altered balance of the circulation and nervous function ; the entire drying-np of the sm'face, and the corresponding conges- tion of all the viscera ; the consequent diminution of the biliary, and the enormous increase of the renal secretions ; the oppressed state of the cerebral, thoracic, and abdominal functions, leading to the most formidable and complicated diseases, and to the suppres- sion of chronic eruptions in a previous state of development ; all these circumstances render the cold season of Bengal the reverse of healthy, except to those of sound constitution, or the newly- arrived European, or such as have not suffered from the previous unhealthy seasons. The fevers of this season, nnlike those of the hot weather and rains, approach gradually, insidiously, but not less dangerously, than those more ardent and concentrated types of fever last named. It will be seen that congestion has repeatedly been mentioned as participating in the most dangerous of our diseases. That climate has a principal share in producing this unfavourable state there can be no doubt ; but admitting this, we must consider also that the absence of all exhilarating exercises of mind and body, with their animating, varied, and healthful influences, on all the func- tions, predisposes much, when aided by a too full and stimulating diet, to this end ; unhappily, too, the European resident in tropical climates has no sufficient remedy against the evils of this double inaction, except moderation in diet, which many will not adopt ; for during the hot and rainy seasons, the amount of exercise neces- sary to health in temperate regions would here be impossible, and would be hurtful even if possible. Those who would preserve their health, therefore, must be temperate — use such bodily exer- cise as each season admits of, and relieve their minds from the monotony of routine official duty by the inexhaustible resources of European literatm^e, science, and elegant accomplishments. It is only thus that health, happiness, and reputation can be insured under the accumulated disadvantages of our position in India^ where too commonly the whole time is given up to business. INTRODUCTORY CHAPTER. 633 I shall now enumerate tlie diseases peculiar to each season, pre- mising that it is to a long continuance of exposure to the various causes stated, more than to their intensity, that we must refer the greater portion of the injurious influences of tropical climate on European constitutions. It has been seen that in hot climates the lungs are relieved of a portion of carbonic acid through the increased acti^dty of the cutaneous exhalations, while the kidneys and mucous surfaces are similarly relieved of uric acid, urea, salts, and water. This state of activity, which holds during eight montlis of every year, will ex- plain how it is that in such climates diseases of the air-passages, lungs, and kidneys are of but rare occurrence, while, on returning to Europe, dangerous diseases of these organs are liable to occur. In many persons, on their retiuni home, the disturbed balance of function between the skin and kidneys gives much trouble, and requires an attentive medical care ; for owing to the more or less partial arrest of the cuticular discharge, during the English winter and spring seasons especially, the urea and other salts, carried off in part through the skin in India, can only pass off through the kidneys in our native climate. The processes of accommodation and adjustment, under the cold of Europe, are of much difficulty to some constitutions, requiring alterative and sudorific medica- ments, aperients, Avarm baths, and warm clothing for their even- tual accomplishment. Fever is by far the most common result of the high temperature of our hot season in the East, complicated with disturbance of the nervous centres and occasional determination to the liver. This fever is generally of the continued, occasionally of the remittent form, and of an ardent character. It demands experience and care in the treatment. Cholera is most prevalent and fatal in the hot months of April, May, and June. In the succeeding rainy months, fever assumes a remittent cha- racter, with diminished vital action generally, and a dangerous abdominal congestion. In place of the burning dry skin and racking headache of the fever of the hot season, we have here a moist, cool surface, indicating a want of action in the sudatory vessels, an oppressed pvilse, and a tendency to the most formidable collapse. As the season advances, dysenteries as well as fevers become more frequent, severe, and complicated, the former impli- cating the whole of the abdominal organs. The diseases peculiar to the cold season are, congestive fever, of the continued form ; intermittents, with the sequelse of tumid or indurated spleen or liver ; insidious, subacute, hepatic inflamma- tion, terminating rapidly in abscess ; dysenteries, frequently com- plicated with hepatic disease, — all more or less acute, according to indiA-idual habit or length of service in India. Apoplexies of the most fatal fofm known in India occur at this season, as do the paralytic affections so commonly associated with them. Chronic 634 INTRODUCTORY CHAPTER. eruptions^ in active development during the two previous seasons, are now suddenly repelled, and are followed by congestion of some of the viscera. Having exhibited in the rapid manner here sketched, the diseases to which the European stranger is liable in the East, and the powerfully deteriorating influences to which he is exposed during each year of residence, we shall now suppose him, after a sojourn of from twenty-five to forty years, returned to his native country. Here he enters at once, and without preparation, on a season of eight months' cold and moisture, in exchange for the same period of excessive tropical heat, and excessive moisture con- joined. I am here speaking of the English season from the be- ginning of October to the end of May. This is a great revolution in climate, and it at once induces a corresponding physiological change in the system, stamping the individual with a peculiar physical character. The exhalent organs of the skin, which for so long a succession of years had been called into the most violent action, now become sealed, as if with a coating of varnish ; from the extreme of transudation he comes at once, under the rigour and vicissitude of an English winter, to constriction and dryness of the entire surface of the body. The result of such changes it is easy to perceive. From the previous extensive, equable, and sometimes violent de- termination to the surface of the body, he is suddenly subjected to an opposite action — an extreme dryness of the surface, amount- ing, occasionally, to a furfuraceous desquamation of the cuticle, and at other times to a miliary eruption, accompanied by deter- mination of the entire mass of the blood inwards ; a loaded condi- tion of the great venous trunks of the abdominal, thoracic, and cerebral cavities, with diminished power in the heart and arteries. This is by far the most common result of exposure to the cold of an European winter and spring ; but we occasionally find its oppo- site — a relaxation of the surface, inducing a copious and clammy sweat on the least exertion, accompanied by extreme languor of the circulation, with cold, damp extremities. This state, which is generally confined to persons of leucophlegraatic habit, is only to be removed by a complete restoration to health. The nervous function, highly exalted during the earlier period of residence in the East, becomes now proportionately obtunded, depressed, and, in extreme cases, exhausted. These are great changes, and it is next to impossible that any man shall go through them with impunity ; indeecl, the first inspection of the Indian on his return home proves that he has been subjected to changes foreign to his original nature. He has now to undergo others which, through long acquired habit, have become almost equally foreign to him. The effects of a long- continued application of heat, by promoting both the undue extrication and expenditure of the nervous ener- INTRODUCTORY CHAPTER. 035 gies^ as e^'iIlced in the primary increase and subsequent diminution of their actions^ must eventually disturb and debilitate the functions of the cerebro-spinal and organic systems, so as, sooner or later, to affect the integrity of every function of the body. The children, again, of the upper classes of Europeans in India, and who remain there during the first five or six years of infancy only, exhibit a restlessness and mobility of the nervous system — a busy idleness — beyond their age, as compared to the habits of children of the same ages born and bred in England. This ex- cited state of the nervous function is associated with a comparative incapacity for long-continued application to study, or for sustained effort of any kind ; but this disadvantage, complained of to me by many schoolmasters in and around London, gradually yields to time and a temperate climate, until it finally disappears, between the ages of fourteen and eighteen. There is likewise a marked disposition to muscular relaxation, and to a loose relaxed state of the joints in such children, and to consequent lateral curvature of the spine, especially amongst girls; but I have seen several cases of the same nature even in boys. An acquaintance with these facts is of much importance, as bearing on the moral and intel- lectual training of such children. Passive congestion is the condition most prevalent, under the circumstances of European cold ; and no matter what his previous disease in India, the morbid condition now superadded proves a serious difliiculty to the invalid. If the patient suffered from tro- pical dysentery, his distresses are greatly aggravated during the long English winter and spring. The sufferers from fever, hepatic or splenic disease, are similarly distressed by severe abdominal congestion ; and if the tendency, through plethora or other cause, be towards the cerebral cavity, apoplexy is produced by exposure, or the absence of care, during the season of cold and damp in Europe. When the liver becomes the seat of congestion, this morbid condition may be confined to the venous trunks, or to the whole secreting parenchyma ; or it may extend to both. In either case it is a serious state of disease. I have seen many persons also, whose relatives at home were weak- chested and consumptive, become subject to severe chest diseases from the same cause. In short, if the sufferings were great under the long-continued exposure to the tropical heats, they are neither small nor unimportant under its opposite in Europe — especially under exposure to damp cold, which exercises a pecu- liarly baneful influence. ]\Iy experience here in the last twenty years would lead me to conclude that, if there really be any such immunity from cold during the first year of residence in England as we hear spoken of so generally in India, it is enjoyed only by the healthy, the youthful, and the robust. Numberless examples have satisfied me as to the truth of this observation. A dry, or even frosty cold is well borne, comparatively, even by the enfeebled 636 INTRODUCTORY CHAPTER. tropical invalid; but the clawp cold produces sensations of inde- scribable distress and depression in persons possessed of consider- able powers of resistance. Many invalids^ again, arriving in Eng- land in an enfeebled state, seek what they call " the bracing air^^ of Brighton and other such places during the winter and spring months, in forgetfulness, or in ignorance, that without a previous restoration to health, this said bracing is impossible of attainment. Many valuable lives are annually sacrificed in this vain endeavour. The truth is, that in general, the cold which a tropical invalid can bear without injury for a year or two after his return to Europe, is not of a low degree ; and in extreme cases of disease, the in-door temperature, carefully regulated during the winter and spring seasons, is that alone which is safe to him. He must now be treated with a climate very different from such as may in a year or two, and when health is restored, be suitable to him. Common sense points out that the delicate and the sick must be prepared for invigoration, and not forced into it. "We cannot '^ comfort " such a person '' with cold,^' as the Americans do their English customers with ice. In truth, the newly returned Indian invalid cannot bear exposure to cold, and he cannot bear exposure to heat. It depends, in fact, on the state of the health and constitution at the time whether cold is to prove salutary or injurious. Certain moist winter and spring seasons are followed in tem- perate climates by increase of sickness and mortality in summer. " The proverb, ' a green yule makes a fat churchyard,^ " says Dr. Earr, " probably expresses a scientific fact, notwithstanding the evident fatality of cold ; and we may hope that the population will escape some of the epidemics which germinate in mild winters, and burst out suddenly in summer.^' Referring, however, to the dangers arising from cold, the authority quoted adds, that ^'^ as age increases, the system rapidly loses the power of producing internal heat; and the resulting fatality by reduction of temperature is doubled every nine years after the age of twenty to forty .^' In India all our numerous and excellent appliances are directed towards the counteracting of heat, while here, in England, they ought to be directed, especially in the case of the tropical invalid, so as to defy cold. The applications of the former to health and comfort are well known in the East ; but amongst the returned Indians, the necessity for the last is not so generally nor so well understood. More unfounded still is the prevalent notion amongst inexpe- rienced and thoughtless lay persons, that on returning to England from hot climates they are to take leave of all their ailments, at the same time that they need take no care whatever as to their habits. This is only another out of many examples of the facility with which the mass of men receive mere opinions as established facts. It is but the " It is true, they say it" of the Spaniards, and that is enough for the unreflecting many, who see only with their cars. INTRODUCTORY CHAPTER. C37 "A moderate acquaintance with mankind," says Dr. James John- son, " is sufficient to stamp the truth of the remark, that expe- rience seldom instructs the mass," This is quite as true as the observation of the older doctor of the same name, the moralist and lexicographer — \\z., that there are some men who are incapable of acquiring experience. In nothing are both remarks so just as in all that popularly relates to health, whether private or public, per- sonal or general. A gentleman of the civil service came home after twenty years' residence in India, on private leave, not being considered sick. He arrived in October, and early in the following month he made a journey of four hours on a railway, with the window open. The lung next the window became that night completely engorged ; and owing to the impoverished condition of the blood, and to the deficient powers of the system, the substance of the lung rapidly filled with serum. He died in a few days. Engorgement of the lungs of a fatal character is no infrequent result of exposure to cold, in feeble and anfemic persons, on their arrival from hot climates, during the English winter especially, and three such instances have lately come under my observation — all modes of treatment proving vain. " It is really lamentable," says James Johnson, ^^to see men returned from a tropical climate, walking about the streets of London, or going to places of amuse- ment, in the cold raw evenings of winter, while the hacking cough, emaciated figure, and variegated countenance, proclaim a condi/- tion of the lungs which ill comports with this exposure to the vicis- situdes of a northern climate." Sir James Clark justly observes of the natives of tropical climates, and of children in this country, that owing to their habit of body being disposed to tuberculous aff'ections — the most nearly allied to tuberculous cachexy — pulmo- nary diseases are prevalent and rapid with them in our " cold and humid atmosphere." The same may be said with truth of the tro- pical invalid in general, but of the anaemic class more especially. Catarrhal affections, more or less severe, are almost universal with tropical invalids on first coming to England ; and many become thus affected on their passage through Egypt and the Mediterra- nean, weeks before their arrival at home. A captain of cavalry, while in ludia, had discharged a large hepatic abscess through the bowels. He consulted me on account of aphthous diarrhoea, from which after a few weeks he seemed to recover rapidly. A drive through the streets of London on a cold, foggy November afternoon, in an open carriage, brought back the diarrhoea with great violence, and he died at Guernsey in a month. Major arrived in England in October, worn to the bones by diarrhoea of ten months' duration. By the end of November his health had greatly improved ; but on the 27th of that month he went out in a hard frost. The result was remarkable. He passed some hours of the night deprived of the powers of speech and of 638 INTRODUCTORY CHAPTER. swallowing ; and thougli tlie surface of the body and tlie extremi- ties were warm, he felt all night ''as if his inside had been filled with ice." A dangerous recurrence of diarrhoea was the result. It is needless to multiply instances. If the temperature of the cold season of Bengal be such as to prove unfavourable to the European invalid and to the old Indian — to all, indeed, excepting the newly-arrived and the robust of constitution — how careful ought all who have resided long in warm latitudes to be on coming at once from a climate in which they are annually exposed to eight months of great heat, to an- other where they are subjected to eight months of comparatively great cold, in which the conjoined humidity is most injurious by its more rapid abstraction of animal heat. Such persons should recollect that, though the compensating powers of nature are great, they have their limits. Referring to the unpleasant impression produced by the cold season of Bengal on the skin of the older residents, I would here mention that a dislike or horror of this season I invariably observed to form the first indication that the individual was " climate-struck ;" in other words, that the general powers had become enfeebled, while the nervous and vascular systems had become morbidly sensitive to all the changes of season, but most so to the damp cold of the night. Truly has it been observed that cold and damp together are noxiously sedative. Cold indeed, as a chill, or night exposure after the day's heat, or after fatigue, constitutes the most frequent cause of some of the most formidable of our acute diseases within the tropics. The medium temperature of the English summer and autumn is favourable to the health of the general population, and it is espe- cially so to that of persons arriving from tropical climates ; for, even amongst resident Englishmen, the winter and spring seasons cause a rapid increase of sickness and mortality from those diseases which contribute most to the ordinary annual mortality of the climate — congestive and inflammatory diseases being most preva- lent also in the seasons last mentioned. These are obvious circum- stances, but I see them continually disregarded by invalids from India. A gentleman in the second year of his residence in Calcutta suffered from acute inflammation of the liver, but came home soon afterwards in what he deemed perfect health. On getting into the English Channel he was exposed to a cold easterly wind, which caused violent congestion of the liver and right lung, from which he nearly lost his life. A friend of mine who had resided twenty-six years in India, on being asked how he got through the winter and spring seasons at home, replied : — " A tight band drawn round the head, and another rou.nd the belly, with indescribable sensations in the skin of the whole body, represent my feelings during the cold weather." There is another influence, though seldom of a serious nature, INTRODUCTORY CHAPTER. 639 wliicli often proves injurious to the returned Indian ; I mean over- exertion of the muscular powers. ]\Ien who for years used no other exercise in India than an evening and morning ride of a few milesj at a gentle pace, will, under the counter-influence of cold, make great and prolonged exertions at home in riding and walk- ing. The exhaustion of the nervous and muscular energies, resulting from such imprudence, is very injurious, and Aveakly per- sons do not recover from it for months subsequently. I have seen permanent disturbance of the hearths action follow upon such over- exertion. An Indian officer of a stout habit, but of previously good health, ran, he said, for a quarter of a mile only, to o^'ertake a railway train. From the time of making this exertion he never enjoyed an hour's comfort, both the circulation and respiration being now permanently disturbed. His death, which took place two years afterwards, was one of unusual suffering. We have seen that in hot climates the lungs are relieved of a portion of carbonic acid through the increased activity of the cuta- neous exhalations, while the kidneys and mucous surfaces are in like manner relieved of uric acid, urea, salts, and water. These condi- tions, which hold during eight months, or more, of every year in Bengal, will explain how it is that, in such climates, diseases of the lungs, aii'-passages, and kidneys are of but rare occurrence ; and how, on returning to Europe when the complete converse of all the above-named physiological actions is taking place, or has been established, dangerous diseases of the lungs, bronchi, liver, kidneys, and mucous surfaces generally, are so liable to occur. It is but natural to conclude, also, that both in India and in Europe material and opposite changes take place in the chemical constituents of the blood, as well as in those of all the excreted fluids. I entertain no doubt on this head, but we must look to animal chemistry for the demonstration of the facts. If in hot climates the animal heat rises from 2°' 7 to 3°' 6 above that of temperate climates : if for years the functions of the system are adapted to this increased temperature, what disorder must be produced when circumstances render the stimulus of this tempera- ture impossible — when the tropical invalid, or the old Indian, returns to his native climate ? The process of respiration under the tropical rarefaction of the air, and under the condensing cold of an English Avinter and spring, must also be materially aff'ected, so as to cause correspond- ing changes in the amount of oxygen absorbed, and in that of carbonic acid expired. The increase of the animal temperature in hot climates is dependent, to a certain extent, on the more rapid circulation and metamorphosis of the blood, for less oxygen is inspired in hot than in temperate regions, owing to the rarefied state of the air in" the former. The relation between the functions of the lungs and liver, un- 640 INTRODUCTORY CHAPTER. naturally disturbed in hot climates, becomes again on a sudden disturbed in a direction towards the restoration of the balance of health, on our return to temperate climates. This is a difficult process to the tropical invalid, and one that is attended with risk to both health and life. In addition to these hazardous circum- stances, the dangers from excesses in diet, from close and over- heated rooms, and from subsequent exposure to night-cold, are not to be overlooked. Anaemia is common to a very large proportion of tropical invalids on their return to Europe. In this morbid state, the paucity of blood corpuscles causes a diminished absorption of oxygen, a quicker circulation, and consequently a diminished animal heat. I have no doubt, that by long- continued exposure to tropical heats and to malaria, the nervous and muscular systems of the heart and uterus are relaxed and weakened, becoming thus irritable, and defective in contractile power. I believe that to these circum- stances we must, in a great measure, refer the diminished power of the forces that circulate the blood, and the intermitting character of the pulse so common to old Indians ; also the frequency of uterine haemorrhage in females who have been long in India. We have now viewed the European from his arrival in India, during his career of active service in the tropics, to the termina- tion of his public life and his retiu^n home. How vast the range of the physical and moral influences to which he has been ex- posed, and how changed does he find himself on his return, which is, in fact, his first settlement in life ; how altered are those of his nearest relatives who remain to greet him, and how many more of them have been gathered to their fathers ! The depressing influence of the great and long-continued flux and reflux of the functions — of all the causes, in short, just enu- merated — will go far to account for the hypochondriasis and other disorders, not to speak of the graver ills to which our countrymen are prone on their return to Europe. If the returned Indian be the father of a family, he has seen his children removed from the care of a mother and his own control, at the tender age of five years or earlier, their education, moral and intellectual, being consigned to relatives in England, perhaps to utter strangers ; and thus we occasionally find that the children of the absent grow up without that deep instinct of filial reverence, those family afi'ec- tions, and that self-respect, Avhich are so necessary to preserve youth in the trying passages and ordeals of life. He has again seen these children return to India, the land of their birth, at the age of eighteen, knowing their parents only by name, their natural atfections being fixed on those at home who had the care of them, the domestic ties having been broken in infancy, never to be re- paired. Truly has the Hindu poet said, " There is no remedy for a soul Vv'ounded by the sharp sword of separation.^' The sons have been rendered strangers in the house of their father, the INTRODUCTORY CHAPTER. C41 daughters have never known the care of a mother ; and it may so happen^ that before either has been allowed time to cultivate the acquaintance even of their children, they are again doomed to separate, the father being driven home to repair the shattered con- stitution, while the sons and married daughters remain in India. No wonder that, under such unnatural cii'cumstances, the home of his youth should be to him cheerless. It has been seen that all the conditions of life, in the instance of the European resident in tropical climates, tend to ultimate depression of the constitutional powers, whether we regard the intluences of an unnatural climate, aggravated by an unsuitable regimen, or the moral circumstances. In warm regions, moreover, there is a precoce development and maturation of the European constitution, while, unhappily, the tendency to decay is, in pro- portion, unnaturally and prematurely accelerated. Curtis says that " persons returning from either India often bring home Avith them a constitution wasted and debilitated by the diseases of those climates, from which they recover with difficulty, or not at all :'' — in other Avords, those Europeans who have been injured in constitution by heat and malaria are, for a longer or shorter time, rendered incapable of resisting the rigour of an English winter and spring ; and the disabilities are greatly increased when visceral disease is superadded. In truth, the great majority of those who come home from India on account of ill health adopt a course of conduct directly at variance with justice to themselves. They " trust to climate,'^ as they call it, without adapting their habits to the altered circumstances of their healths and constitutions; and after jiassing some twelve or eighteen months in doing nothing, or very little, towards the restoration of health, they apply to a physician for relief, only when within foui' or six months of the expiration of their leave, when they are expected to be on the Avay to the East. What ought to be done in all cases is — to pro- ceed to the removal of organic disease, or to the restoration of disordered function, immediately on arrival from India — so that the remaining, latter, time may be advantageously made use of, to mature and confirm the health in the pure atmosphere of the country, under proper regulation as to diet and exercise. It is not enough to cure the disease — a margin being in every case necessary to the assuring of health. Let it not be supposed that I here present an exaggerated view of those disorders and diseases, or of the social and moral disad- vantages to which an European is subject, during a residence, more or less protracted, in a tropical climate ; nor yet of such as may visit him at home. I do not relate a mere description ; for I have personally, largely, and repeatedly shared in the suli'erings I detail — both in India and in this country. Mine is not a picture drawn from the iinagination. It must be recollected that I am not speaking of the healthy old T T 642 INTRODUCTORY CHAPTER. Indian — a select life in any country — nor of the youtliful and healthy officer on furlough ; for to both the cold of an English winter may prove tonic and agreeable. Such men may control, through their superior power of resistance and of accommodation, the influences of one law of nature by the operations of another. These observations refer to such only as have suffered from pro- tracted residence in hot countries, and to those who have laboured under the diseases incident thereto. And here I must bear testi- mony to the manly fortitude and cheerful resignation of the Indian officer under sufl'ering. We find in him no peevish, fretful, or presumptuous intolerance of sickness. He does not expect an instant cure of all his diseases : and failing of this, he does not flee in ignorant fancy to the empiric. He has generally seen and suffered so much as to render him considerate at once of what is rightly due to himself and to others. He is therefore, and under all circumstances, an object of interest to his physician and sm'geon. The highest surgical authority in this country has often spoken to me emphatically on this remarkable characteristic of the Indian officer, and on this account, as well as on that of the great intelligence of the Indian officers generally, he designated them a " PECULIAR CLASS.^^ The Highland chief who said — " Doctor, I want to be cured immediately'^ — gave expression to a natural feeling ; but thus speedily to realize the expectations, in the sequelae to tropical diseases, is rarely indeed practicable. I know not a better test of good sense, or of a well-regulated mind, than that furnished by our conduct in sickness. Under suf- fering are exhibited in the most marked manner the results of a sound education, religious, moral, and intellectual. The practised physician detects at once the sensible, firm, and Avell-trained mind ; and with the same speed he discovers the senseless, frivolous, and ill-regulated tendencies of his patient's disposition. I have every- where observed that the same absence of principle which leads weak minds into extravagances in religion, renders the same persons also prone to follow quackeries of every other kind, moral and medical, as aycII as religious. We come now, in conclusion, to the practical issue as to the medical treatment of the European in the Eastern and Western hemispheres. In the first, we have had to overcome, by the most powerful remedial means known in medicine, the most acute and dangerous forms of disease, and that under the continuous disad- vantages of a high range of temperature, and other injurious in- fluences ; while in the latter instance, we have to deal with the sequelae of these formidable diseases, in a temperate climate, and under the sedative influence of cold. It is obvious that under these opposite circumstances of climate and of disease, our means of cure must have corresponding dif- ferences. Inasmuch, however, as the injurious influences of tro- pical climateS; in the great majority of instances, have an exact INTRODUCTORY CHAPTER. 643 relation to tlieir duration, so also do those favourable operations of temperate climates require time for the demonstration of their results. The sick furlough, which allows of but two years' actual residence in Europe, is not sufficient to numbers of those who seek reliet from it ; and I have strong reason for concluding that the remarkable proportion of casualties amongst officers on their return to the East and AA est Indies, is not referable so much to their second process of acclimation, as to the circumstance that many are forced to retm-n too soon, and before their diseases have been effectually removed. If we could be furnished with the statistical results of lengthened residences in the West Indies, under the old rules, and with the then difficulties of obtaining leave of absence, as compared to the now existing short residence, with faciHties for procuring leave, we should have, I am sure, a demonstration of the justice of the observation here offered. It must be ob\dous, that with a large proportion of invalids from the East Indies, nothing but care in diet, clothing, and in all the habits of life, along with a judicious use of medicines cal- culated to restore the healthy balance of function, and thus to as- sist the influence of their native climate, can avail to theii- re- covery. ^ With all these aids, too, the object in view must be a work of time. I seldom see those who have suffered much restored to health under the two years of furlough ; and I have in many in- stances been constrained to postpone the return to India to the utmost limit ; but such cases have been examples of extraordinary suffering and danger. It is an old observation in the British Army that the " East Indies takes more out of a man than the West ■/' but the observation is true only because of the long residence of tlie European m the former countries. In the olden times even, European regiments were seldom kept in the West Indian Islands above half the time they served on the Indian continent : and of late the time of service in the former countries has been fui'ther shortened ; hence the real cause of the difference in the compa- rative injury to constitution in the two hemispheres. When British regiments are ordered home from the East Indies, those soldiers who have served above seven or eight years, gene- rally volunteer to other corps serving in India, in the hope of com- pleting their time there. They have become domesticated in the East and prefer the ease and comfort of their position in that country, and the luxury of having native servants, to the rough chances of ser^qce m Europe, or in our other colonies. Comparatively few retm-n with regiments except those who have only been exposed for a short period to the cUmate, or men who are what is termed, m military language, '^ worn out," haWng com- pletccl the usual, period of service exacted from soldiers. Yet even amongst the youngest of these subjects, there is an excess of mor- tality over that of soldiers servnng in the United Kingdom, of thi^ee T T 2 644 INTRODUCTORY CHAPTER. per thousand annually during the first three years after their re- turn from India ! If this be so "with the youthful and compara- tively healtliy soldier^ what must be the influence of the variable climate of England on the exhausted and more aged invalid during what may be termed his probationary residence in it^ and how in- sufficient must be the ordinary sick furlough of two years for the restoration of health in all cases of tropical diseases, and how dan- gerous must be the cold of our winter and spring to the broken- down troj)ical invalid ? British soldiers who have served in India entertain an extreme aversion to home service, especially during the winter and spring seasons ; and pensioners who have served in hot climates volunteer cheerfully to settle in the Australian possessions. The very deprivation of the accustomed sensations derivable from heat, will account for many of the discomforts and personal sufferings complained of by every healtliy European during their proba- tionary acclimation on return to their native climate ; but the In- dian invalid finds in the homeward voyage round the Cape of Good Hope, and nowhere else, that equable temperature, to quote the words of Lord Halifax, between " the climate in which men are roasted and the climate in which they are frozen,^' which is alike agreeable and necessary to him. Among the older soldiers who return home, the excess of morta- lity beyond that of the same class in the United Kingdom of the same age, does not much exceed three or four per thousand an- nually, notwithstanding their longer service in the East ; but they are the survivors of hundreds who have sunk under the same course of service, and must obviously have possessed uncommon vigour of constitution originally, to have stood the trial of tropical service for the greater part of twenty-one years. Referring finally to the influence of protracted residence in tropical climates, it has always been remarked in the East Indies that Europeans are frequently carried ofi^ in what is there termed — "the one year more^^ — the last year of residence; after the stamina has begun to give way, and, too often, after the ties which bound them to home are broken. It is a peculiarly melancholy event ; for the deceased has all but completed his term of years, and all but accomplished the object of his hopes and of his long- cherished ambition. With a view to insure comfort at home, he remains a year or two longer in India ; and with the goal in sight, he is cut ofl", and all his fond anticipations end but in death. All statistical evidence goes to prove the increase both of sickness and mortality in relation to length of residence ; yet with these proofs before them, we see in India that every season brings with it in- stances of Europeans, broken down by long residence, and who fall victims to the unnatural struggle against the fatal " one year more." The Dutch, who are not given to jesting, appear, nevertheless. INTRODUCTORY CHAPTER. 645 to have been aAvare of the uncertainties and dangers of deferring the departure from the East till '^ next year •/' for in one of their older settlements there was found an inscription over the grave of a Dutchman to the following eifect ; — " Here lies Minheer, Who was to have gone home next year." In Mr. Neison's Report on the Bengal Military Fund, and referring to the mortality of retired officers of the Indian army, as given by ]Mr. Christie, it appears, that as compared to the mortality of England, that of retired officers is uniformly in excess, age for age, being for the ages of forty-eight and under sixty about one- third more. After the age of sixty, the mortality of both retired officers and soldiers but little exceeds that which prevails even in civil life amongst persons of the same age, who have never left this country. But while the mortality amongst retired officers is proved to be as stated, that of the widows of deceased officers, on their return to Eui'ope, is found to differ so little from the mortality of females of like ages in England and Wales as to be hardly appreciable. This fact can, as I conceive, only be attributed to the circumstances, that — firstly, the European female is not sub- jected to the hardships and direct solar and other exposures to which military offiQ,ers are liable ; and secondly, to the perfectly temperate habits of ladies in India, which save them from many of those formidable diseases which there deteriorate the health and destroy the lives of their husbands. Thus the widows of our officers come to England in the enjoyment of health, and they live as well and as long as those who have never been absent from their native country."^ I would urge, in conclusion, one other important consideration, which should be held in recollection, before entering on the medical treatment of the retired Indian — viz., that though not old in years, or, least of all, in mental character or habit, he has become prematurely aged in his physical constitution. The general principles of medical management must therefore be care- fully modified and specially adapted to this condition of the system. Under no circumstances of disease can such a man be treated with the \igour that may be safe, or even proper, in persons of the same age, but who have passed their lives in England. Indeed, no contrasts can be greater than such as are exhibited in the moral and physical constitution of the European newly arrived within the tropics, and in the same person on his return to his native climate after an absence of thirty years. In the first case we have a youth, buoyant with health and * For these interesting and important statistical facts in corroboration of my views, I am indebted to Major-General Sir A. Tulloch and Mr. Neison. They were obtained long after this article was written. 046 INTRODUCTOEY CHAPTER. animal spirits^ with all his functions exalted through the stimulus of heatj and with the mind eager for employment and for distinc- tion j while in the last we perceive but too often premature age^ with obtunded sensibilities and depressed functions^ coupled with profound mental depression^ amounting in some cases to the most severe form of hypochondriasis — all resulting from the oppo- site states of the nervous, vascular, hepatic, and other excretory functions, brought about at first by an unnaturally high and con- tinued range of temperature, and now by the sudden application and sedative influence of cold. It is true that the Indian, coming home at the middle or more advanced stage of life, approaches the land of his fathers with hopes and expectations quite as exalted, though by no means pos- sessing the same glow of enthusiasm and buoyancy, as when a mere youth he quitted the paternal roof — " And from the dregs of life hopes to receive What the first sprightly ruuning could uot give." Lord Clive, though but forty-two years of age on his final retire- ment from India, writes to his friends whom he left in the East : — ^' I have sufi'ered so much ever since my arrival in England, that I have not been able to interfere so much with public affairs as I could wish. Parliamentary concerns have embiT)iled me more than is good for my health, and I really begin to grow tired of them.^^ He then exhorts his friends to be satisfied with a moderate com- petency, and return to England while they have youth to enjoy it, rather than by staying longer lose that youth, and sacrifice that constitution which no riches can possibly compensate for. Clive's disease is spoken of by his biographer. Sir John Malcolm, as '' a severe bilious complaint, attended with spasms from gall-stones, loss of appetite, and indigestion; a continuation or consequence of that derangement of the liver from which he has already suffered so much in Bengal.^^ This great commander, in a letter to his friend George Granville, describes his personal sufi'erings as " very distressing to the mind and to the body ;'' and on hearing of Gran- ville's death, he expresses '' his indifference, not only to the world's politics, but to the world in general.'^ To give a more concentrated view of the physical circumstances above related, it may be said, that in hot climates, the air being expanded, less oxygen is taken in at each inspiration. The necessity for hydrocarbonaceous food is therefore lessened. Less of the " elements of respiration" ought to be taken in the food than would be taken in colder climates. In consequence of the external increase of temperature, less internal heat is required. Exercise increases the heat of the body by increasing the rate of circulation and respiration. In a very hot climate, all increase of heat is undesirable. Moreover, the excessive heat renders INTRODUCTORY CHAPTER. 647 muscular action impossible, because the circulation is chiefly directed (in consequence of the activity of the skin) to the surface, in order that fliiid may be furnished for evaporation, to keep down the heat of the body, and to prevent the parching of the surface which must otherwise ensue. In consequence of the lessened muscular action, less of the albmninous constituents of the food are required to supply the waste of the muscles. Hence, in hot climates, less of both kinds of food should be taken, and Nature points this out in the absence of appetite ; to force an appetite, stimulants are taken, and then the system is loaded with nourishment. The excessive perspira- tion requires an excess of liquids; but instead of water alone, sugar and spirit, the elements of respiration, are taken with the water, in the form of beer, and the spirit, by its stimulating pro- perties, is doubly injianous. The excessive flow of blood to the surface — the consequence of the high temperature — no doubt prevents, for a time, the e^dls resulting from an excess of the two kinds of food. The chemical changes and evaporation going on in the skin draw the circulation to the surface of the body, just as the flame of the lamp draws the oil up the wick. Whilst the high temperature lasts, this increased action of a flow to the surface is kept up. It is probable that the action of the heart is thereby made feeble by the excessive suction of the skin, as we see it frequently is, temporarily, by the perspi- ration bath. As soon as the temperature falls the blood ceases to flow in excess through the skin. According to the degree of cold, it is almost driven from the surface. It accumulates within, and congestions and inflammations are produced. Free action on the inner or outer surface of the body for a time relieves the conges- tions and enables the circulation to proceed. After such alternations for years, the resident in the hot climate returns to a far colder home. There no heat leads the blood to the surface ; it accumulates in the vessels and capillaries of the internal -viscera. The outward appearance is that of anaemia, whilst in reality an internal plethora frequently exists. The more frequent and severe the temporarj'^ congestions of the viscera have been whilst in the hot climate, the more permanent does the internal congestion become when the surface is con- stantly exposed to cold. Though the face and extremities may look void of blood, the capillaries of the liver and spleen will often be full, and the engorgement of the venous trunks, which was the effect of previous congestion for years, becomes permanent when the coldness of the atmosphere leaves the blood to be circulated by the enfeebled heart alone. If the nervous influence be the power which regulates the con- traction and relaxation of the capillaries, how much must this important pari of the circulation be affected — first^ by the long- 648 INTRODUCTORY CHAPTER. continued heat of tlie tropics — and secondly^ by tlie cold and damp of the climate of Europe, so as, under both agencies, to distui'b alternately, and conversely, this great function ? Tropical heat has had the effect of exalting for a time, and then diminishing the nervous energy, and thus of eventually relaxing and diminishing the circulating power of the capillaries; while cold, on coming to England, will have the contrary effect of con- stringing the capillaries, and thus of determining the great mass of the circulating fluid upon the internal organs : — such power, acting on the enfeebled European on his return from tropical climates, must prove of extremely injurious effects. Dr. Billing concludes his admirable " Principles of Medicine ^^ by stating that they '' have been deduced from physiology ; and for the explanation of the pathological phenomena he has referred to the action of the capillaries and nerves — nerves and capillaries together, not artificially separated, but as they exist in nature — • ramifying and supporting each other throughout; for by their combined action upon the blood sent to them by the heart, tliey produce the phenomena of health — in their deranged actions they originate disease." Dr. James Johnson justly observes, that " The powers of the constitution, however plastic, cannot immediately accommodate themselves to great and sudden changes of climate, even when the translation is from a bad to a good one ; and the tropical invalid requires full as much caution and prudence in approaching the shores of England, as he did in landing at the former period on the banks of the Ganges. "" Speaking of tlie beneficial influences of the voyage home round the Cape of Good Hope, the same autho- rity states, that " When the European has become much debili- tated by liver affection, dysentery, or fever, and its consequences, the main hope of recovery rests on change of climate, and, under such circumstances, the sea-voyage often effects a cure. Indeed, the instances are not few Avhere more benefit is obtained by the voyage home than by the subsequent residence in England." But this voyage, with its uniformity and salubrity of the sea air, aided by the mental exhilaration of a hotne anticijjation, producing as it often does, " surprising effects on the animal economy," is not now nearly so much resorted to as it ought to be. The overland journey, as it is termed, subjects the invalid to numerous discomforts, both by sea and land — often to insufficient accommodation, always to a more or less hurried meal — to a. hurried and uncomfortable journey through Egypt ; and if, un- happily, he arrives in England in the winter or spring, he has to encounter their rigours within six weeks, with very imperfect, or with no preparation, instead of the four months' voyage round the Cape of Good Hope, with its rest, ease, and comforts, and with its unequalled climate. The clothing with which invalids are supplied in India is alto- INTRODUCTORY CHAPTER. G-19 gcthcr insufficient to protect tliem against tlie cold of an easterly Aviud in the English Channel ; and hence the frequency of chest affections, diarrhoea, and abdominal congestions, even before they set foot on shore. In a moral and physical point of view, and more through the agency of moral and physical influences of an extraneous character tlian through age, no two persons could present contrasts greater tlian may every day be recognised in the very individual under our consideration, as compared to the youth of five-and-twenty years back. The average age at which the Indian, whether civil or military, retires, may be taken at fifty to fifty-five years. A certain propor- tion of those who thus return home are, to all public purposes, worn-out men ; and but few of those even who are equal to the exertion make any effort to enter upon public duties in England — duties for which their official aptitude, their administrative expe- rience, and their varied abilities so eminently qualify many of them. Of old men there are none in India — the members of the civil service averaging thirty-five years of residence, on the average, with fifty-five years of age — the general of forty years^ service being but a year or two older. I may here mention that, of all the mental occupations, the mathematical have proved, in my experience, the most injurious to the mental faculties ; engineer officers, accountants, and persons devoted to statistical pursuits, having, in course of my observation and practice, broken up in mind to a most remarkable extent. Some have lived for years in a state of nervous distress and inca- pacity, while others have lingered in insensibility on the water- bed, the \dctims of overwrought nervous system, and eventual softening of the nervous masses. Several causes present themselves as efficient to such morbid rcsidts, as the necessary intensity of the mental application in all matters of calculation, the severe sameness of the pursuit, the sedentary habit, and the absence of that salutary variation in mental labour and employment which seems as necessary to mental in- tegrity as variety in diet to the bodily health. It has been nobly said by Cowper that — " A want of occupation is not rest, A mind quite vacant is a mind distressed." I would now refer to a question of great importance, and one in which I have often had to interfere. Officers of all classes frequently leave India in such a state of ill -health and exhaustion as to feel hopeless of recovery within the time allowed by regula- tion for ordinary leave of absence. In this state of moral and physical depression, despairing of health, they often express their purpose to retire from public service and enter into private life. The advice I have almost invariably given in such cases has been 650 INTRODUCTORY CHAPTER. to the following effect : — " You have at least two years' absolute leave^ at the expiration of which come to me and I will then tell you what you had better do. At present, borne down by mental and bodily suffering, you are altogether unequal to the determin- ing of any important question in life ; and, for the rest, your case IS not so hopeless as you suppose/^ Often have I been warmly thanked in aftertimes for this counsel, and that not seldom before the expiration of the two years ; many declaring with much feeling that " I had saved them from ruin/' However desperate the case may appear, provided there is youth on the side of the patient, we ought not to despair — a circumstance which I would strenuously urge on the attention of all medical officers throughout India, as well as on that of the profession at home when dealing with this description of patients, designations, under the circumstances mentioned, ought seldom to obtain the sanction of the physician, whether civil or military. The series of converse actions and reactions is thus far com- pleted. We have seen that up to a certain stage, for a limited period, and under temperate habits, the functions of the body, as w^ell as the mental energies of the stranger European, are exalted in the intertropical heats, to be again seriously depressed by dis- ease, or by a protracted exposure to the same influences which at first proved stimulating. But on his return to his native climate all the functions, mental and corporeal, of the tropical invalid are about to be subjected to new trials — to depressing moral influences, and to the sedative influences of cold ; and this state of double depression continues to atttict him, until, through the restoration of health, this same cold shall become to him a powerful tonic, bracing the mind and the body — proving a source alike of vigour and of enjoyment. Such, in brief, are the widely-extended successions of changes and of profound impressions of which but a sketch is here pre- sented. That so happy a termination as health — that to accom- modate the system to the last of its numerous changes — that to restore the long-lost balance of the functions — should, for its consummation, require time, much care and management, must be sufficiently evident. In truth, a more important subject, whether regarded in a physiological, pathological, or therapeutic sense, can hardly engage the attention of the physician. 651 Of all tlie conditions incident to tropical invalids, tliat morbid decrease of tlie blood Avliich we term anaemia is the most general. It presents the sequel most common to fevers, whether remittent, intermittent, or continued ; indeed, whatever may have been the nature of his prcA'ious acute disease — whether it was fever, dysentery, diarrhoea, hepatitis, or cholera — we are pretty sure to find, in the tropical invalid, that ill state of the general habit termed cachexia. All the diseasesjust mentioned tend, directly or indirectly, to spoil the blood. "Where organic lesions are present, as the results of previously acute disease, or of a long residence in hot climates, they Avill generally be found associated with an ansemic condition of the system, so as seriously to complicate the case, and add to the difficulties of treatment. These considerations have induced me to select AN.EMIA as the first suliject for attention ; for the cachectic state now referred to must be very generally kept in view in the treatment of the European invalid on his return from tropical climates. It has an important bearing on much that relates to the history, nature, and treatment of most of his disorders and diseases. The depraved state of the blood in diseases of the spleen has been noticed in the first part of this work, and there the subject has received a separate and special consideration. Ansemia is frequently produced by long residence in the mala- rious districts and stations of tropical climates, even in persons who have not been sufferers from other actual disease, acute or chronic, such as the fevers and fluxes of their more unhealthy localities. This is what may be termed the cachexia loci — etiolation ; or more properly, paludal cachexia. It is, in truth, a chronic marsh poisoning in a large proportion of persons. European females of the better class, though far less subject to the more formidable of the tropical diseases than males, are yet, through long- continued disturbance of the nervous, vascular, and secreting functions, very liable to become ansemic. The excessive perspiration will of itself produce anaemia in weakly constitutions. The very treatment necessary to the cure of acute disease, especially blood-letting, mercury, and drastic purgatives, along with the most rigid abstinence, tends powerfully, even in young persons, to produce a deficiency of red particles ; while the same course of treatment in persons of more advanced age, along with their more protracted exposure to malarious influences, are sure to diminish the old blood-globules, and to prevent the formation of new. The " debility'' spoken of by all writers who have noticed the condition of tropical invalids, as one of theii' main characteristics, will be found, in the great majority of cases, to be none other than the debility of the cachectic habit — of anaemia, in fact. 652 ANEMIA. Owing to this impoverished state of the circulating fluid^ all the functions of the body ai'e enfeebled^ all the secretions defective, diluted,, and depraved; the patient is wanting in the power to repair any serious injui'y. I often find severe and protracted ansemia to result from the unguarded application of leeches. Three hundred leeches, and in one instance five hundred, were men- tioned to me as having been applied to the abdomen in remittent fevers, attended with gastric or hepatic complications, and in dysenteries. Mr. E , then a youth of sixteen, fell into the hold of a ship upon his loins. He writes : — " I was bled three times ; hot fomentations were used for ten days, and I had seventeen dozen leeches on (204), and was bled once more.^^ Lieutenant S says : — " 1 had three different times sixty leeches applied, and I think twenty more afterwards, making in all two hundred in less than ten days.^^ This officer was tall, slender, and of delicate frame, and only nineteen years of age. If, as gene- rally believed, the Indian leech abstracts an ounce of blood — nay, if it be allowed to abstract but half the quantity, how large must be the aggregate amount of depletion in these cases ? Annesley ascertained that the Indian leech abstracts, on the average, one ounce and a quarter, " besides what flows from the bites. ^^ This simple fact should prove a warning not to apply leeches in the careless or indiscriminate manner witnessed by me in its results, a few more examples of which I will adduce. Mr. , a mercantile gentleman from one of the Indian Pre- sidencies, states, January 3rd, 1855, that after a fall from his horse he had twenty-two dozen of leeches applied at once, by order of Dr. , Avhile Lieutenant states, that in the course of two months he had thirty-six dozen of leeches applied to the abdomen while suffering from fever. Lieutenant was seized in August, 1849, with diarrhoea, followed by intermittent fever and enlargement of both liver and spleen. By order of his regimental surgeon '^ he was bled to twenty ounces, and about a hundred leeches were applied during the subsequent five days." This officer is described in the Medical Report of his surgeon as " of weak constitution." The patient went to another station, where another surgeon states that he subjected him to " depletion, keeping up a drain from the organ" (the liver), and occasionally a large number of leeches have been ajjplied, as indicated by symptoms. Lieutenant concludes : — " I had altogether applied to my side, from December, 1849, to January, 1851, fully one thousand two hundred, at the very least" But all wonders must cease regarding the leechings of lay per- sons, when we come to the following case of a medical officer : — " When I went to India, my constitution was excellent, and I was able to withstand any amount of fatigue j but within three months ANEMIA. C53 of my arrival, I suffered from an attack of Bengal remittent fever, "with great determination to the liver and colon, accompanied by- spasms of the stomach and gall-duct; and the treatment of the early stages of the disease having been inactive and inert, it was the opinion of the late Mr, Twining that I would remain a martyr to the ill effects of the climate of Bengal for life. This opinion has been fully verified — disorders of the liver, spleen, mucous digestive surface and bronchial tubes being the result. Early in my illness, organized lymph tubes were voided from the bowels ; and this state being regarded as purely inflammatory, leeches were applied in vast numbers. Occasionally fifty leeches were applied in the twenty-four hours; and for weeks in succession the number of leeches expended amounted to upwards of one hundred and fifty per week. Great exhaustion folloAved, with a high degree of anasarca of the body and limbs. I came home on sick leave, and I was told by Dr. Marshall Hall, and your friend, the late Dr. James Johnson, to wliom, under the providence of God, I owe my life, that there was not on record a case of such extreme depletion — an opinion in which Dr. Abercrombie, of Edinburgh, fully concurred. I rather resembled a model of wax than a being endued with life. On summing up the extent of local depletion which was employed in my case, to the best of my judgment and belief, I am under the mark when I state that the number of leeches which were applied within the space of six years amounted to three thousand. ^^ It is almost unnecessary to say that this excellent officer was constrained to abandon the service early in life. INIr. Twining, speaking of the congestive fever of the cold season in Bengal, observes : — " The altered appearance of the blood, in many of those fevers which arise from exposure to the malaria of the jungles, is very remarkable, and merits careful investigation. Connected with this morbid condition of the blood there appears, occasionally, some corresponding disorder of the solids, and par- ticularly of the vascular system, which favours prolonged and pro- fuse oozing of blood from leech-bites.^' The condition of the blood here mentioned is the anaemic ; and without stopping to inquire as to the author's meaning on the other points of pathology here only hinted at, it may be questioned whether, in such a con- dition of the system, blood-letting ought at all to be practised. Certainly no one can doubt the unhappy consequences of the " pro- longed and profuse oozing of blood from leech-bites" in such cases. Some men never recover from the effects produced on the blood, and on all the functions, nervous and vascular. The anaemic patient generally presents a pale, sallow, or dingy, bloated, and exsanguine complexion,, the eye being of a morlnd, pearly whiteness, the pupil relaxed, irritable, and often much dilated ; the expression dull and inert ; the mind being irresolute, feeble, and despondent, the memory impaired; in extreme cases. 654 ANEMIA. tlie mind is fatuous, but more generally we perceive a peculiar and cliaracteristic peevishness. The abdomen is tumid^ inelastic, and congested ; the skin harsh and constricted to the touch, and of a temperature generally below the natural standard. The digestion is feeble and depraved ; the processes of depu- ration are imperfectly performed; the feet swell. In ansemic patients, I have found the temperature in the mouth to be generally below the natural standard. The mean of eighteen observations, by insertion of the thermometer in the mouth of an anajmic patient, during the months of November and December, afforded a temperature of 90°. On four days the temperature was taken before he left home, and after his return from a walk ; the mean temperature was 85° before going out, and 88° on his return. After a journey to Scotland, the temperature remained at 98° for two days, on the two following days it fell, and was observed at 97°. The patient was an officer of engineers, a man of high scien- tific and practical attainments. How and to what extent an anaemic condition of the brain, spinal cord, and nervous central ganglia may affect the functions of the nervous system generally, the present state of our know- ledge does not enable us to determine ; but that such a condition of the blood must have an extensive influence no one can doubt. I have seen an instance of what could only be termed nervous apoplexy from anaemia of the brain. Neuralgic pains of the abdomen are very commonly to be found on exploration of that cavity ; and when they are present in the epigastric, or in either or both the hypochondriac regions, there is a risk of their deceiving the inexperienced as to their cause ; thus leading to very grave errors in treatment. The pains here spoken of, when of a neuralgic character, will always be found to disappear on the return of health ; and I would seriously urge the necessity of care in explorations, lest the pains in question be mistaken for those produced by organic disease in either liver or spleen. These abdominal neuralgic pains are common to chlorotic females in all countries, and they seem to depend on a morbid sensibility of the nervous system induced by depravation of the blood, Avhich in its normal condition is the natural support of the nervous system. Here, in Europe, the patient presents the complete reverse of the order of his original acute state of disease under the sun of the tropics — to the acute distur])ance of all the functions of life, torpor and feebleness of corresponding extent have succeeded. There is now a general cachexia, with atony of all the vital functions. The motions of the heart, along with those of respira- tion, are feeble and perturbed on the least exertion, and a blowing murmur in the direction of the pulmonary artery, and frequently a loud venous murmur in the neck, can be discovered. Palpitations and throbbings in the head are common, accompanied by giddi- ANiEMIA. 655 ness and fivn'itn.s aiiriinn. The voluntary raiiscles are attennated, feeble, and relaxed, and there is a disinelination from all exertion. The excretory functions are imperfectly performed ; the bowels are torpid, the tongue being coated and exsanguine. It is CNident that here, owing principally to an altered condition of the organic constituents of the blood, a corresponding alteration has taken place in the nutrition of the various tissues of the body. We find, in short, that the functions of the stomach, bowels, kidneys, liver, lungs, organic nerves, and brain, are seriously disordered, through deficiency of blood, or through blood of a depraved quality, or both. I have frequently seen a temporary fatuity to result from an?emia, general and cerebral ; but it occurs more generally in that form of the disease which follows upon malignant fevers, remittent and intermittent. The fevers of the Indian tarais, of the provinces of Aracan and Gondwana, and of the Crimea, have been observed to terminate in mental enfeeblement, which looks as if the malarious influences had much to do with the nervous depression, as well as with the an?emic condition, ' ' We're not ourselves When Nature, being opprest, commands the mind To suffer with the body." Ansemic patients, especially if advanced in life, are prone to haemorrhages and to passive congestions of a serious natm-e in the abdominal or thoracic cavities, according to individually acquired or to hereditary tendencies. The state of disease here under con- sideration demands much care in the treatment. The heroic remedies, originally required to save life, are no longer possible to the cui'e. In their place must now come those agents calculated to restore enfeebled functions to a healthy ^dgour, and then we have to rebuild the sunken and shattered frame. We have to impart tone to the organs of supply, by attention to diet, air, exercise, the various habits of life, and by the proper use of medi- cines, while we have a due regard, by these various means, to the regulation of the excretory functions of the skin, liver, bowels, and kidneys. Such are the conditions that hold in the instances of vast numbers of persons arri"\dng from our intertropical possessions, and such I conceive to be the indications, which, for a longer or shorter period, according to the duration and severity of symptoms, should be followed in their treatment. Without such care, the climate of England will do but little for them. When a young man presents the conditions here mentioned, I am never satisfied with merely prescribing medicines for him. I advise his passing as much of his time as possible in the open air, nnder the most gentle exercise, and far from the temptations and from the atmo- sphere of our great towns, I recommend " the best of tonics, relaxation of mind, with exercise in good air" — that is to say, not a London life. The patient must be taught that time is as essential to his cure as medical treatment, and that the attempt to forestall 656 ANEMIA. the one is to lose the other^ and thus sacrifice the health which it is our endeavour to restore. There are many considerations which will suggest themselves to the medical observer why invalids should not be kept within the atmosphere of great cities. Everything within them tends to retard convalescence ; and there are even districts in England which appear unfavourable to the restoration to health of tropical invalids — especially those whose atmosphere is humid. " The health of different parts of the country differs widely," says Dr. Farr, " and the difference is greatest in summer. In the summers of 1841-50, the mortality in 506 districts, comprising, when the census was taken, 10,126,886 people, was at the rate of 18' 15 in a thousand annually ; while in 117 districts, comprising the chief towns, and 7,795,882 people, the mortality was at the rate of 25 in a thousand annually. Thus at least 7 in every 25 deaths Avhich occur in towns are the result of artificial causes.^' Ever since my return from India, I have remarked that the most rapid, as well as effective restoratives to health, have resulted from a visit to the Highlands of Scotland. Doubtless the moorland exercises of walking and riding, with the cheering accompaniment of sport, and the general prevalence of temperance in diet, have, in this instance, contributed largely to the benefits derivable from inspiring pure air. But the peculiar local properties of the air have appeared to me to aid likewise in the beneficial results ; — I mean the union of the ocean air to that of the mountains, such as we everywhere find it in the Highlands. A pure mountain air we appreciate in many countries ; but the proximity of the Atlantic and German Oceans to the mov^ntains of Scotland cannot fail to constitute a powerful and peculiar accessory. Those who have to remark on the difficult and tedious convales- cence of invalids in certain unfavourable localities, will require no arguments as to the importance of this subject ; " but few have a clear conception," says Liebig, ^' of the influence of air and tem- perature on the health of the human frame." I seriously impress on the ansemic patient the necessity of avoiding all occasion for the use of mercury. If benefit does not accrue within a given time, I recommend travel, and it is surprising what an impetus this simple measure gives to the flagging functions, and to the restora- tion of the blood. With no class of invalids is the medicina mentis of more importance than here — the benefits to be derived from a well-regulated course of "dietetics of the mind" being second only to a proper adjustment of the ordinary medical appliances. " A journey," says Sir James Clark, " may indeed be regarded as a continuous change of climate, as well as of scene, and constitutes a remedy of unequalled power in some of those morbid states of the system in which the mind suffers as well as the body." For the morbid business-imagination — for yourworn-out, steady, moping business-man — the old heathen poet's remedy was wine : the ANJilMIA. 657 Christian poet's remedy is a more moral and pliilosopliic one — a resolute mental holiday — " a wise vacancy/' "With the aids to be derived from a temperate climate, the medical management of these cases is generally easy : that is, when the patient is not advanced in life, and the anaemic condition is not complicated with organic disease. The various salts of iron may almost deserve to be termed specifics : this is so much the case, that we can hardly go wrong in prescribing the citrate of iron, the citrate of iron and quinine, the compound iron mixture, the prot- oxide and sesquioxide of iron, the old wine of iron, with or without the addition of tincture of the sesquichloride, the ammonio-citrate of iron, &c., while the regulation of the bowels may be effectively promoted by the use of the aloetic pill with myrrh, or aloes with iron. By these means we promote the development of the blood. To obviate the tendencies to headache, and to excitement of the heart's action, often arising from the use of chalybeates, I am in the habit of ordering the sesquioxide of iron in the first instance, and as a preparation for the other stronger salts. When carefully prepared, it is an admirable tonic and sedative. A few cases will best illustrate this portion of the subject. Case 1. — Capt. T , aged thirty-two, originally of plethoric habit, has resided fourteen years in the Presidency of Bengal. Four years ago he had a severe attack of remittent fever, followed ever since by annually recurring attacks of intermittent fever. During the first illness he was bled from the arm, and by leeches to the temples and the epigastric region ; he used calomel to slight salivation, with a continuous course of powerful purgatives, the diet consisting of sago and arrowroot. From this violent seizure he recovered but sloAvly, and only after a residence of six months in the mountain ranges of the Himalayahs On his return to his corps in the plains, however, he soon became subject to tertian ague. For this last disease. Captain T took mild mercurials, purgatives, and quinine. He was occasionally, and for months together, able to perform his duty ; but in the rainy and cold seasons his fever recurred, and he was at length, and after much suffering and emaciation, ordered home. He is now in a state of complete anaemia, with a pale, bloated, and lemon complexion ; and mossy, dry, and scanty hair. There is no enlargement of the spleen or liver ; the abdomen is doughy and inelastic ; the skin harsh, dry, and constricted ; the pulse feeble and slow ; the tongue pale and flaccid ; the bowels are constipated. His appetite is good, but he feels distressingly inflated after meals, and he is unable to bear the slightest pressure on the abdomen after food. There is great debility and emaciation. He was ordered to take two pills of watery extract of aloes, with sulphate of quinine and iron, every night. These had the effect of regulating the bowels, and of im- parting tone to the digestive organs, while, as a general tonic, he u u 658 ANJSMIA. used tlie old wine of iron with the tincture of the sesquichloride three times a day. He was allowed a light hut generous diet, with bitter ale at dinner. He was directed to use warm baths at 96°, three times a week, just before going to bed, and to use friction to the skin night and morning, when dressing and undressing. He improved rapidly in health even while in London ; and by com- munications from him I learned that, in the country, he became so much improved in health that in eight months he was enabled to discontinue all medicine. During eighteen months that I was in occasional communication with this officer, he continued to report favourably of his health and strength ; and at the end of two years he returned to India. Eeiiiarks. — This is an example of simple uncomplicated ansemia, resulting from remittent and intermittent fevers, and their neces- sary treatment by blood-letting, mercury, purgatives, and low diet. The patient had been under able and experienced medical manage- ment, but the malarious influences proved too powerful to be resisted even by his robust European constitution. By a careful attention to his habits of life, and to the simple rules of medical treatment mentioned, Capt. T left England in perfect health. Case II. — Lieut. M , aged twenty-six, of vigorous frame, served nine years in India, and latterly in Sindli, where he con- tracted severe intermittent fever. He was leeched largely and repeatedly, and took calomel, purgatives, and quinine. After ten months^ residence in this unhealthy province he became so en- feebled by repeated accessions of fever, that a return to Europe was at length considered necessary to his recovery. He is now in the pale and bloated state characteristic of the diseased condition of the blood under consideration, being in what may be termed an acute state of anaemia. The pulse is hurried and feeble ; the abdomen hard, full, and tense ; but I cannot discover, on the most careful exploration, that there exists any enlargement of either liver or spleen. He had two attacks of ague on the way home — one in Egypt and the other at Southampton. The complexion is very pale and bloodless ; the mind feeble and desponding ; the appetite is wanting, and the bowels constipated ; the entire surface is harsh, dry, and heated. He is a cigar-smoker, and I attribute much of the disturbance of the heart's action to this circumstance, having observed the same result in hundreds of instances in India. To regulate the bowels, he was directed to take, every morning, a solution of the sulphate of magnesia and quinine, with dilute sul- phuric acid ; and as a general tonic he took, twice a day, tAvo ounces of a mixture containing the sulphates of quinine and iron, with dilute sulphuric acid. When by these means the tendency to fever had been subdued, the frequency of the circulation mode- rated, and the bowels brought into regularity, the more simple chalybeates were employed. He was then ordered a light diet, ON THE TREATMENT OF INVALIDS. C59 ■witli a little wine^ or hitter ale, and no cigars. He used \^arm baths, with powerful friction to the entire surface of the body night and morning. In a few weeks he was able to proceed into the country. 7?ei//(/rh\ — This officer recovered but slowly, being subject to aguish attacks whenever exposed to cold or damp. He owed much to his own good sense, for he carefully avoided everything that he perceived to be injurious. By persisting in the use of chalybeates, by travelling, and by regulated exercise, he at length completely recovered his health, and was enabled to return to his duty in India at the expiration of his furlough. OX THE TEEATMENT OF INVALIDS SUFFER- IlSGr FROM THE SEQUELAE TO THE FEVERS OF TROPICAL CLIMATES. Fevers, remittent, intermittent, and continued, are the diseases most frequently seen amongst Europeans in India. Next to fevers stand the formidable bowel complaints, as dysentery, diarrhoea, and cholera. These, together with diseases of the liver, form the chief scourges of our Indian armies, European and Native. There is not a district, station, or cantonment, in the vast extent of Hin- dustan and the dependencies to the eastward, or in Ceylon, in which malarious fever in some form, dependent as to type and in- tensity on local circumstances, will not be found to prevail, either as an occasional epidemic, or as the endemic of the soil. Of the better classes of Europeans, many escape attacks of dysentery, diarrhoea, cholera, and hepatitis during even a long residence in the East Indies ; but there are very few who do not at some time suffer from some form or other of fever. Out of an aggregate European force of 25,431 men of Her Majesty's array serving in periods of eight and ten years respec- tively, between 1823 and 1836, in the stations of Calcutta, Chin- surah, and Berhampore, for instance, all in Bengal Proper, there occurred, according to Colonel Tulloch, 13,596 cases of fever; and though the climate of Lower Bengal is very inimical to European health, comparatively to that of many parts of India, and though the years included within this return were subsequent to the first Burmese wai', still the proportion of fever cases is enormous, making every allowance for such unfavourable and contingent influences during one or two years of the period under consideration. It must not be forgotten, that of the soldiers engaged in the Burmese war, seventy-three -per cent, perished at Rangoon and Upper Ava, and that in Arakan '' three-fifths of the whole perished in the course of eight months ;" so that, of the few survivors, the admis- 660 ON THE TREATMENT OF INVALIDS sions into the hospitals of the three named stations could not materially aftect the results. In the Mysore division of the Madras native army alone^ out of an aggregate force of 194,170 men serving there during twenty-foiu* years, there occurred 63,810 cases of fever ; and out of an aggregate British force of 82,342, serving in the Presidency of Madras generally, from 1842 to 1848, there occurred 22,923 cases of fever. Amongst officers and the better classes of Europeans, who, from their better habits of life, are not so subject to hepatitis and dysentery as soldiers, it will very generally be found that fever in some form has been the first dis- turbing cause of illness, and that to recurrences of fever are to be referred many of their subsequent more local diseases on their return to Europe, whether these last be seated in the liver or in the bowels. The experience of the West Indies confirms the statistics of fevers in the Eastern hemisphere. Out of that portion of the inhabitants of George Town, Demerara, who are likely to resort to public institutions — the total population of the town amounting only to 20,000 — there were admitted into the colonial hospital, from June, 1846, to June, 1847, 2938 cases of remittent and inter- mittent fever ; and the annual consumption of quinine in Deme- rara and Essiquibo — countries somewhat resembling Lower Bengal in medical topography and climate — averages 3000 ounces ! If we look to the embouchures of the Mississippi, we shall find a state of public health, and a prevalence of fever especially, not less remarkable. The New Orleans Charity Hospital is one of the most extensive fever hospitals in the world. It appears from the records that, in a period of nine years, from the 1st of January, 1841, to the 1st of January, 1850, there were admitted into this hospital 73,216 patients ; of which number were admitted, for all the difi:erent forms of fever, 33,381 ; and among these last, for intermittent fevers, 17,217. Great as are the advantages possessed in India by the officer over the common soldier as to habits of life, accommodation, &c., it is still matter of every-day observation, that even amongst the better classes of Europeans there, civil and military, the se- quelae to malarious fevers are both severe and frequent. Some of these I have already noticed ; but here I shall confine my obser- vations to the slighter forms of organic diseases, and to the func- tional disturbances and ill-health which follow on tropical fevers, remittent, intermittent, and continued : those conditions, in fact, which are common to the three types, and which are most fre- quently observed in England as the results of tropical fevers. It should be held in recollection, also, in reference to the subject of this article, that most of our tropical remittent fevers are in a great degree, and very generally, of a gastric character, one of the prominent conditions consisting in acute congestion of the mucous digestive surface; so much so as to cause Robert Jackson to SUFFERING FROM THE SEQUEL/E TO FEVERS. G61 designate the bilious remittent fevers of the West Indian Islands by the term " gastrie^ or bilious remittent fever/^ This profound observer considers the fevers of all countries to be more or less of this nature ; and practically, although the thoracic and cerebral Aiscera are occasionally affected in a serious degree, and although the cerebral and spinal systems are always disturbed in their func- tions, still we find, in tropical fevers at least, that almost all the symptoms exhibited during life, and almost all the lesions dis- coverable after death, are to be referred to, and centre in, the organs of the abdominal cavity. The importance of a constant and due regard to these considerations, as bearing on the condi- tion of persons who have suffered from the fevers of the East and West Indies, must be manifest. The liability to the recurrence of fever on exposure to slight causes, is also an important and very distressing consideration. I have known many young officers, originally of strong constitution, so harassed with fever, recurring again and again, that after coming to England two or three times for the recovery of health, they have, on repeated and desperate trials of Indian climate, been compelled to resign the sernce. Some of them have never regained sound health at home, and of those who strive on, many fall a sacrifice to relapses on their return to the tropics. Patients who come to England for the recovery of health, after having sufi'ered from tropical fevers, present morbid appearances varying according to form and constitution of body, or as the fevers may have been of long continuance, and more or less con- centrated, and according to the severity of treatment. Some are puffed and bloated, having a leaden, yellow, or copper-yellow complexion, while others are emaciated and lemon-coloured ; pre- senting the very type of the marsh cachexy. ]\Iany present the purely anaemic condition described in the last article. In fact, the distressing state of broken health which follows on protracted tropical fevers, appears under separate and distinct specification, according to the special organs affected, and to the degree of antemia which may be present. But whatever the configuration or complexion may be, we are sure to find the pathological condi- tion centred in the abdominal organs, so as sometimes to involve their structure, but at all times to disturb their functions. When the patient has been a sufferer from intermittent fever, we find that, owing to the repeated and violent congestions attendant on the frequent recurrences of ague, with its severe and protracted cold stages, the vessels of the abdomen, but especially the venous trunks, become dilated, and the blood, already spoiled by use, is detained in them, so as to be still further deteriorated. The vital energy and vascular tone of all the abdominal viscera are more or less impaired in cases of this nature, according as the previous fever has been of longer or shorter duration ; in other words, the nervous centres, and all the organs depending on them, share in C62 ON THE TREATMENT OF INVALIDS the general injury and depression. The obstructed and depraved state of the bloody and consequent depravation of all the secretions and excretions, and of assimilation also, must not be overlooked.^ We sometimes find the heart impaired in its functions^ through long-continued and often-repeated engorgements of the great venous trunks during the cold or congestive stages of remittent and inter- mittent fevers, and from the violence of the subsequent bounding reactions. Through the operation of these causes, associated, as they often are, with an anaemic condition of the system, the heart is occasionally found to be flaccid in its texture, and dilated in its cavities, while its action is feeble and irregular. In every form of malai'ious fever, but more especially in " the tremendous remittents of hot climates,'^ it is manifest that the sensibility and energy of the entire nervous system are blunted and enfeebled, and that the muscular system, voluntary and involuntary, is relaxed and enfeebled also, in consequence both of the lesion of the nervous system and of the altered condition of the blood, so common to tropical fevers, and as resulting from their treatment. These disturbances, repeated during years, in a climate more- over which, of itself, and without the intervention of actual dis- ease, disturbs greatly the functions of the nervous, vascular, and muscular systems, will go far, I think, to account for the inter- mittlng state of the heart's action, so often noticed in these essays as characteristic of a large proportion of returned Indians. A long residence in the East, without the intervention of fever, may alone induce the irregular state of the pulse now under considera- tion ; but a lengthened stay in India, together with repeated fevers, is almost certain to cause it. From many of the symptoms indicative of disturbed function of the hearths action, witnessed in malarious countries, and from the periodical nature of some of them, I have long entertained no doubt that they often have their origin in the efficient cause of fevers, remittent and intermittent. A cause which operates so seriously to the disturbance of the nervous and vascvdar functions generally, which induces paroxysmal fcA^ers of the most deadly nature, visceral congestions, and neuralgic affections ; a cause which produces most serious disturbances of the cerebral and organic nervous functions, may well be believed to aid at least, along with the general enervation and muscular relaxation, in oc- casioning the feeble and intermitting states of the heart's action, the epigastric pulsation, and the other nervous and vascular dis- turbances so frequently observable in the persons of retm'ned Indians. Sufficient attention has not been given to the lesions discover- * To such as would inquire more at large into the causes and consequences of tro- pical fevers, I would recommend the perusal of the admirable articles in Dr. Copland's " Dictionary of Medicine," — a great work that should be placed, by authority, in the bauds of all ijaval and military surgeons, SUFFERING FROM THE SEQUELS TO FEVERS. 603 able ill the heart and great vessels in persons who have died of the concentrated fevers of hot climates. The observations of INIaillot, of Antonini, and JNIonard woukl show that softening of the heart is a frequent accompaniment and sequel of algid fevers^ and the j}ost-mo)-feiJ/ examinations of the French surgeons in Algeria tend to the same conclusion as to the result of malarious fevers there. The importance of the subject demands a more careful attention than it has hitherto obtained. Dr. Barlow states (Guy's Hospital Reports) that a very feeble state of the ventricular parietes may, by causing delay in the cir- culation, give rise to irregular or intermittent pulse; also that dyspepsia and other diseases associated with irritation or with lesions of the brain and upper part of the spinal cord, will ma- terially affect the action of the heart, so as to render that action feeble or irregular. The conditions requisite for the regularity of the pulse he describes to be — a regular supply of blood to the left ventricle, and a due supply of nervous influence ; and, on the other hand, the chief, if not the only cause of intermittent pulse is a want of due supply of blood to the left ventricle. I have all my life been familiar with this disturbance of the cir- culation, and suffered very severely from it in person, as the re- sult of numerous malarious fevers, and of overwrought nervous system dimng my residence in Calcutta. One of the first in- stances that came under my notice, on my return to England, was that of an aged general officer of the Bengal army. On remarking to him that his pulse intermitted very much, he said, " Yes, I know it does, and it has done so for about fifty years." This gentleman died at the age of ninety -three. Another officer of plethoric habit, who had resided long in India, and in whom a distressing irregularity of pulse existed, was largely bled at his country residence on account of cerebral congestion ; and from that day, 1840, to the present time, the intermissions have entirely disappeared, and his health has in all respects been, good. Complicated with all these morbid conditions, alterations in the structure and functions of the mucous digestive surfaces are fre- quently observable, with their train of irritable dyspepsias and constipations. In the great majority of persons suffering from the sequelfe of tropical fevers, we find that the whole abdomen is tumid, doughy, and inelastic, with e\ident venous congestion of all its viscera, while the action of the heart and arteries is feeble. There is, in fact, such a stagnation of the venous blood as to weaken the func- tions and spoil the secretions of the stomach, liver, bowels, and functions of the spleen, while the general circulation, and the functions of the skin in particular, are oppressed and enfeebled. All these conditions become aggravated when the sufferer from tropical fever arrives in England iu the winter or spring seasons. 664! ON THE TREATMENT OF INVALIDS In other instances we find congestive enlargement, Avitli the com- mencement of interstitial deposits, more or less chronic, of the liver, spleen, and mesentery, accompanied, as in the former case of simple abdominal congestion, by torpor of the digestive powers, depravation of all the secretions, a feeble and oppressed circulation, and morbid derangement of the cuticular functions. In both instances there is great sensitiveness to the impression of cold ; the regular periodicity of malarious countries now giving place to the smouldering, dumb, or bastard forms of remittent and inter- mittent fevers, resulting from the change to the climate of England. The medical management of such cases, whether functionally or structurally affected, is always a matter requiring care, and the cure may occasionally, in persons greatly debilitated by fever, or by long residence in India, be protracted. We have to emulge with one hand, while we impart tone with the other. We have to maintain a gentle but persistent action in all the depurative organs, at the same time that by medicine, proper diet, free exposure to the air, and by exercise, we improve the quality and augment the quantity of the blood. Case I. — A gentleman of robust frame and short stature, aged thirty-eight, had resided sixteen years in India as an iudigo planter, and during that time he had been continually, and in all seasons, much exposed to direct solar heats, to excessive rains, and to cold. His habits of life had been moderate, and for fourteen years his health had been excellent. Two years ago, while exposed to cold and damp weather, he was seized with severe in- termittent fever, the stage of rigor lasting frequently for three hours. Medical aid was obtained from a distance, and but irre- gularly. Calomel and antimony, followed by brisk purgatives and by quinine, overcame the immediate violence of the fever, but he has ever since been out of health. The least exposure to the sun, to damp or cold — circumstances never considered when in health — now excited him to fever, especially if such exposure occurred about the full and change of the moon. His fever by degrees, and under the influence of quinine, lost the severity of the rigor, until that symptom entirely ceased, and on the accession of the cold season it assumed the continued form. At length he became worn out by repeated irregular attacks of fever. His mus- cular system, which had been powerful, fell away, while the ab- domen became large, full, and tense. In this state he was recom- mended to return to England, where he arrived in the month of March. He now presents the true physconia, or parabysma, of systematic writers, in the sense of " morbid congestion. ^^ Among the causes of this state of stagnation. Dr. Mason Good justly considers the absence of valves in the abdominal veins as prominent, owing to that want of support to the returning column SUFFERING FROM THE SEQUELiE TO FEVERS. C65 of blood -wliicli belongs to tlie veins distributed to more superficial parts. That the cold stage of severe intermittent fever, or the stage of congestion, must, when often repeated, tend poAverfully to produce, and to maintain, stagnation in the abdominal venous trunks, seems evident. It proved so in this case. The abdomen is now full, hard, and round as a barrel, but percussion affords no evidence of enlargement of either liver or spleen. The complexion is of a copper-yellow hue. The skin is harsh, dry, and cool, and when the integument is pressed between the finger and thumb, the marks are long in regaining the colour of the surrounding parts, owing to the feebleness of the capillary circulation. The sublingual and conjunctival surfaces look pale, and exhibit a defi- ciency of red particles in the blood ; there seems to be an entire suspension of the exhalent and absorbing functions ; the pulse is feeble, slow, and oppressed ; the respiration hurried on the least exertion, and impeded by the fulness and tension of the abdomen. Abdominal congestion would seem to be the sole cause of his weakness and his sufferings. The bowels never act without the aid of medicine; the intestinal secretions are pale and scanty; the urine natural in appearance. The muscular frame is so en- feebled that he cannot Avalk a hundred yards without fatigue. His sleep is broken, uneasy, and unrefreshing. The patient was directed to take a tablespoonful of the following mixture every morning in a small tumbler of cold water, or so much as should produce two evacuations daily : — Saturated solution of sulphate of magnesia, seven ounces and a half; dilute sulphuric acid, half an ounce ; sulphate of iron, sulphate of quinine, of each a drachm. He was directed at the same time to use two doses daily of a mixture composed of fluid extract of taraxacum with bitartrate of potash. These medicines after a time acted freely on the bowels and kidneys, while the functions of the skin were pro- moted by warm baths twice a week, immediately before going to bed. Frictions to the surface were prescribed ; and horse exercise advised. The diet was ordered to be light and spare ; and as all food produced a sense of weight and oppression, he was allowed to take a small tumbler of weak brandy-and water at dinner. On this plan the patient improved steadily, though slowly, during six weeks, when he wrote to me from the country that he could walk for an hour Avithout fatigue or hurried respiration, his waist being now reduced by seven inches. The biliary secretion became abundant, and the appetite and digestion had greatly improved. The taraxacum was now exchanged for a pure chalybeate, and the purgative was directed to be used every other day only. When the weather became warm in May, the convalescence was rapid ; and in the following month he proceeded on a tour to the conti- nent. He used the waters of Homburg ; but in his own opinion the change of air and the continued exercise were of most effect. He returned to England in September^ in perfect health. QQ6 ON THE TREATMENT OF INVALIDS Hemarh. — This was a case of excessive abdominal congestion resulting from fever^ accompanied by ansemia. This state of the blood was doubtless maintained by the stagnation of so large a portion of the circulating fluid in the abdominal venous trunks. The whole machinery of life was clogged. By the removal of intense abdominal congestion the general circulation was liberated, the quality of the blood improved, while the nervous system was thereby invigorated. Perspiration, digestion, and secretion were also set free towards the restoration of the general health. Youth, a robust constitution, and temperate habits of life, favoured the patient and aided his recovery. His treatment was simple but efiective. In a case such as this, a persistent course of tonic pur- gatives is always necessary ; and I believe that purgative medi- cines, when conjoined with tonics and chalybeates, as in the present instance, do not injure the functions of the colon, as they are too apt to do when given singly in large or repeated doses, or where given with or after calomel. When this gentleman arrived in England, it was supposed by his medical attendant in the country, that effusion had taken place within the abdominal cavity ; but this I was unable to verify, owing to the extreme fulness and tension of the entire region. Certainly the case wore a very unfavourable aspect, and dropsy, general or local, might well have been apprehended. Case II. — Major , of the Indian army, aged forty, had served twenty-two years in India. For the first sixteen years his health had been good; but during the last six years he was em- ployed in field-surveying, the duties of which necessarily exposed him to great variations in temperature and humidity, as well as to the malarious influences. His constitution, originally delicate, appeared indeed to have been improved and invigorated during the first ten years of residence in India. After that his health remained stationary till six years ago, when he was seized, in the month of May, with the ardent remittent fever of the hot dry season. Violent determination to the head, with tumidness and pain of the right hypochondrivim, took place immediately, accom- panied by delirium. He was freely bled, generally and locally, and took calomel, sudorifics, and purgatives in large doses. His re- covery was rapid, and apparently complete. By the month of August he had regained his usual health, when acute bilious diarrhoea came on, rendering mild mercurials, with ipecacuanha, laxatives, and low diet necessary. Again he recovered rapidly, and in the end of October proceeded on his duties of surveying. The country was jungly, and the soil remained moist and marshy from the previous annual rain. His public establishment and pri- vate servants contracted intermittent fevers, but by the aid of small doses of quinine, and by selecting elevated grounds of encamp- ment, Major hoped to escape. He did escape until the SUFFERING FROM THE SEQUEL.E TO FEVERS. 6G7 end of January, when he was attacked with severe fever of the continued form, accompanied by jaundice. He was again bled moderately, and used calomel, antimony, purgatives, and low diet ; but his recovery was slow. From this time to the jsresent he has never been in good health. Every year he has been more or less harassed by fevers, sometimes continued in type, at others inter- mittent^ and his health and strength have been gradually reduced. He was urged to go to sea, or to return to Europe, but circum- stances of a private nature prevented his doing either. At length, and after years of distress and suffering, he came home in the month of February, worn out with fever. He Avas now greatly ex- hausted in all the functions of the body and mind, and in a state of great emaciation. The abdomen was hard and flattened, the abdominal muscles being in a state of extreme tension all over, and this state, owing to neuralgic pains, was rather increased by tactile examination and percussion. All seemed hard beneath, but I could not perceive that any one region was more indurated than another, and there was no tumidness in either hypochon- drium. The pulse and respiration were slow and feeble, the heart flaccid, and sluggish in its movements ; there was a frequent hacking, dry cough. The complexion was of a dingy parchment hue, the skin being extremely harsh and dry to the touch ; the hair was of a mossy dryness, its growtli being imperceptibly slow; the nails were exfoliated and crumbling off" — all indicating that nutrition Avas at the lowest ebb. The intestinal secretions Avere scanty, pale, and foetid ; the urine of a natural appearance, occa- sionally limpid. For years the bowels had not acted without the aid of medicine. He had no appetite, and experienced great op- pression, with sense of distension, after the smallest meal. The sleep Avas disturbed and unrefreshing ; the general habit Avas anaemic, and the mind greatly depressed. To promote the functions of depuration, and to impart tone to the digestive organs. Major was directed to use the nitro- muriatic acid bath three times a week, just before going to bed, Avhile a combination of the nitro-muriatic acid Avith tincture of sesquichloride of iron was taken in water, three times a day. The gentle action of the boAvels was promoted by the jnlida aloes et ferri of the Edinburgh Pharmacopoeia. Animal food was used but sparingly, Avhile fruits and vegetables were allowed ; also weak brandy-and-water at dinner. He took gentle exercise on horse- back daily, or whenever the weather admitted ; but the cold easterly winds of March he could not face. Such days were passed, huddled up in coats and blankets, by the fireside. Yet, Avith care and attention, his health amended, though very slowly, so that by the end of June he was able to ride ten miles on end, the appetite and poAver of digestion having greatly improved. By tliis time he -had gained eleven pounds in Aveight, Avhile his miud had become cheerful and hopeful. ThQ medical treatment 668 ON THE TREATMENT OF INVALIDS was contiimed till tlie end of August, by whicli time the major ac- quired seventeen pounds in weight, along with considerable increase of vigour in all his functions. ■ The bowels now acted without medicine, the biliary secretion being abundant. By the middle of September he proceeded to the Highlands of Scotland, where, with the aid of a pony, he was enabled to ascend the mountains, and enjoy grouse shooting ; but he was incapable of any sustained muscular exertion. With little further aid from medicine. Major continued to regain health and strength during two years that I was in occasional communication with him, and he returned to India at the end of three years " as well as ever he was.'' Remarks. — A torpid discharge of all the functions of the body was the character of Major 's case on his arrival in England. To the previous excitation, within the tropics, of the various functions, and to the tumult and disturbance of tropical fever, had then succeeded a torpor and impaired tonicity of the circulation, respiration, and of the nervous functions, with interrupted and depraved secretion and excretion. The gastric and intestinal di- gestion appeared paralysed, with characteristic dryness of the mucous surfaces, and atony of the muscular layer of the stomach and bowels. He did not appear to labour under any organic disease of the liver or spleen, nor could I discover through exploration, or through the symptoms, that any anatomical changes existed in the other abdominal viscera. Major was so exhausted on his first arrival at home, that, viewing his recovery as hopeless within the time allowed by the regulations of the Indian army, he desired to resign his com- mission and retire into private life. I objected to this resolution, urging that his mind Avas enfeebled, and that he was consequently not in a fitting frame for coming to the determination of that or of any other important step in life. He yielded to my reasoning, and thus a valuable appointment, useful to himself and his family, has been preserved. By similar advice, given in India and at home, to officers both civil and military, I have saved many a valuable public servant from the commission of a hasty and irre- trievable mistake. The cases just related furnish fair examples of the average re- sults of tropical fevers. The first presented pure abdominal con- gestion of the passive form, and the last a general torpor and loss of power in all the abdominal functions. Many more examples might be added ; but those now furnished appear to me, together with the two cases about to be briefly noticed^ sufficient to illus- trate the subject under consideration. Case III. — While writing this article, the following cases came under my care ; and as they represent a state of disease not in- frequent, oAving to the present rapid transit to Europe from India, I here present them. SUFFERING FROM THE SEQUEL.E TO FEVERS. C69 " Lieutenant , ]Maclras cavalry, aged twenty-tlireCj had served four years in India, during which he enjoyed good health, with the exception of occasional headache and an irregular state of the bowels. Towards the end of November, 1850, he obtained a year's leave of absence to visit his family in England, and marched to Bombay for that purpose. When half way, he was seized with jungle (remittent) fever. In nine days, though feeble and ex- hausted, he was enabled to resume his march, and arrived in Bombay in the end of December. Here he was attacked with tertian intermittent fever, the cold stages being severe and long- continued, and followed by an imperfect reaction. As in the first seizure^ Lieutenant was treated with calomel, purgatives, and quinine. On board the steamer, both in the Red Sea and Mediterranean, he suffered from repeated attacks of ague, and when the day was in the least degree cool, he was obliged to take to his bed. He is now (February 9th) in London, in an extremely emaciated and enfeebled state, and though five feet ten inches in height, he weighs but nine stone and three pounds. The liver and spleen are greatly engorged and tumid, their regions bulging out perceptibly, and feeling tender on the least pressure. The complexion is of a dull leaden yellow; pulse, 112; bowels con- stipated ; urine madder-colom-ed ; tongue clean ; skin warm, moist, and relaxed. The little food he is able to take causes great op- pression and distension at the stomach, and he is unable to bear the pressure of his dress over the abdomen. The cold is most distressing to his feelings, and he shivers whenever he quits the fireside. There is complete and general antemia, and the circula- tion is distressingly hurried in ascending the stairs. He was ordered to take of the satuiated solution of sulphate of magnesia, combined with dilute sulphuric acid, the sulphates of quinine and ii'on, so much every morning as should procui-e two free evacuations from the bowels; while he used two doses in the day of the sulphates of iron and quinine, with dilute sulphui'ic acid, as a tonic and febrifuge. His diet to be carefully regulated, using animal food to dinner, but sparingly ; no wine or fermented liquor allowed. Warm baths were dii-ected to be used twice a week at bedtime. Feb. 15th. — Great improvement has already taken place; the bowels and kidneys act freely, and he is not so much distressed by the cold nor by gastric oppression ; pulse 94. 2Gth. — Bowels violently moved in the night, when enormous quantities of frothy, foetid matter were voided. This discharge has afforded great abdominal relief, and his waist is reduced four inches. Urine copious and less charged, the complexion clearing, while the shiverings have nearly disappeared. Hitherto the. bowels have acted but twice a day, under the influence of the tonic pui-gative, and the present discharge is 670 ON THE TREATMENT OP INVALIDS viewed as the liberation of pent-up bile rather than an ordinary- purgative effect. The medicines and diet as before. 28th. — Continues to improve in all respects^ and is able to walk a little in the open air on dry days; pulse 78. The appetite is becoming keen, and requires restraint. Urine copious, and nearly natural ; bowels freely moved twice a day. Treatment continued. March 4th. — Has acquired nine pounds in weigh t_, while the tumidness of the abdomen is greatly reduced. Pulse 76 ; urine copious and natural in appearance. The bowels continue to act freely twice a day. 12. — Getting well; complexion nearly natural and the waist of the usual dimensions. He is now able to wear his former clothes, buttoned, with ease. He takes long walks in the open air and increases daily in strength. The tonic aperient to be taken every other day, then every third and fourth day, so as to be gra- dually discontinued, while a pure chalybeate is substituted for the quinine and iron mixture. Bemarks. — The case just related affords an example of the acute and immediate consequences of malarious fever. The rapid tran- sition to Europe, by steam, brought the sufferer home with his tropical ills fresh upon him, with the addition that his fever had now assumed a low continued form. " Visceral disease," says Dr. Billing, " converts ague into continued pyrexia ;" and in further illustration of this principle, the same authority adduces the hectic fever of pulmonary consumption, and the irritative fever of surgical cases, which latter he considers " a mixture of morbid sensibility and pyrexia from inflammation." It has appeared to me both in India and England, that quinine, when given in large doses, and for a continuance, has occasionally had this same effect — namely, the conversion of ague into continued fever. Blood-letting in the cold stage of intermittent fever has been found to produce a like result. This young officer had been altogether ill but little more than two months, yet the poAvers of the constitution were completely subdued by malarious fever and abdominal congestion. But the duration of his illness having been but brief, his recovery was rapid. No mercury was exhibited in this case, the general anseraia and splenic engorgement prohibiting the use of that mineral. Case IV. — Lieutenant , of the Bombay army, aged twenty- nine, had served eight years in India. The medical report of his case by the surgeon of his corps represents him to be " of a naturally delicate constitution, with a predisposition to liver com- plaint." In November, 1849, after two years of " bad health, suflFering constantly from fever and hepatic derangement," in Guzerat, Scinde, and Moultan, he quitted the latter station for Kurrachee. '' Deriving no benefit at this place, he was sent to Bombay, and eventually to Mahabaleshwar," a mountain station sufferi;ng from the sequelae to fevers. C71 for sick and convalescents. " lie rejoined Lis regiment at in Fel)ruary, 1850, apparently in improved health; but soon after he suffered another attack of fever, which has since returned re- gularly at the spring tides, and been invariably attended with con- gestions of the liver and incessant bilious vomitings." Calomel and opium, saline purgatives, quinine, and tonics procured relief " for a few days," but " the obstinacy with which the complaint returns has greatly debilitated the constitution." " The in- fluence of the moon, too, is very remarkable." In another state- ment, dated in JNIay, Lieut. is reported to be continually harassed with fever, while " quinine has lost its power." He was then ordered to return to Europe for the recovery of his health, and arrived in England in July, 1850. Feb. 2Gth, 1851. — The patient states that ever since his arrival he has resided in the north of England, but that his health has in no way improved ; fever, accompanied by a dull heavy pain in both hypochondria, having recurred aljout the full and change of the moon every month since July last. There is now pain and some slight fulness of both liver and spleen, with a hard tumid state of the whole abdomen ; the bowels are constipated, and the urine generally high-coloured ; the i)ulse is feeble and slow ; the surface relaxed, cool, and damp to the touch ; the tongue is loaded with a thick white fur. He is much distressed by aguish feelings in cold and damp days. The general condition is anremic. On the plan of treatment prescribed in the last case this officer recovered rapidly ; and from the time when the bowels were made to act freely, his disposition to fever daily subsided. In a month he returned to the country, greatly improved in health and strength, using only the tonic and febrifuge treatment. Remarks. — In both the cases just described the tendency to fever disappeared in remarkable coincidence with the subsidence of abdominal congestion, through the use of gentle but persistent evacuants, combined with tonics. That a temperate climate and the absence of malaria may have materially aided in these results, I entertain no doubt, although in the last recorded very obstinate instance, climate alone proved insufficient ; and so it proved also in the case of a gentleman from the south of Spain, whom I lately treated, and who was much distressed by ague, until brought under the infiuence of the emulgent treatment here described. He had taken enormous quantities of quinine without effect. Every one has seen intermittents, on the other hand, which re- sisted the influence of ordinary purgatives, and of every anti- periodic remedy, until mercurial purgatives were exhibited ; in other words, until the necessary degree of freedom was given to the abdominal circulation, through powerfully emulgent means. In Zeeland, the biliary functions are said to suffer so much during the intermittents of the country, that they are called by the in- habitants gall-fevers. 672 CHRONIC DIAERH(EA. I frequently find, in the instances of persons returning home from hot climates, that the bastard or dumb ague resists the in- fluence of quinine and all forms and varieties of tonics and anti- periodics, even when the use of these last have been preceded by emulgents ; while the same difficulties are encountered in the cure of the neuralgic affections which are so often associated with, or which follow upon intermittents. In such cases, the preliminary depuration through the channel of the kidneys, mentioned in pages 192-3, followed by a ten or twelve days^ course of the arsenical solution, will often produce surprising results. I see cases of this nature in which I have reason to believe that the inertness of quinine has been the result of over-dosing with it, and of undue persistence in the use of it. That the partial stagnation of the venous and arterial circulation in the liver, spleen, and other abdominal viscera tends, by the detention of the blood, to unfit it for the purposes of the general circulation, and to dispose also to attacks of intermittent fever, would appear highly probable. Dr. Proud goes so far as to de- clare that the blood in the portal system is deprived of a portion of its vitality. A condition of the blood exists in the cases here under consideration similar to that in varicose veins ; and it has been observed by Mr. Bransby Cooper that the discharge of such blood by puncture of the diseased vessels " does not produce any constitutional effect, the blood contained within the varicose veins, being to a certain extent thrown out of the general mass of the circulation, and retained in a half-stagnant state within them.^' CHEONIC DIAERHCEA. The late Dr. Matthew Baillie, who had seen much of the diseases of tropical invalids, describes a diarrhoea, of an " almost constantly fatal" character, in persons of a sallow complexion, '' who have resided for a considerable time in warm climates." It consists " of an evacuation of a matter resembling in its appearance a mixture of water and lime, which is generally frothy on its surface. When this kind of purging lias once taken place, it is hardly ever radically removed, although it may for some time be occasionally suspended." Dr. Baillie, who Avas rather of a despairing disposi- tion, as a physician had " no opportunity of examining the con- dition of the liver and bowels in such patients after death ;" and his treatment consisted of very small doses of mercury, with astrin- gents and bitters, and great care in diet. My object in the present paper is to exhibit the pathology and set forth the treatment of this complicated and dangerous disease. In tropical invalids, suffering, on their return to Europe, from CHRONIC DIARRHCEA. 673 clironic diarrhoea, we perceive, along with the cachexia so generally- characteristic of the class, an excessive irritability of the mind and body, an anxious countenance, and a blanched condition of the entire surfiice, conveying an impression that the patients have been drained of all their fluids, and thus become dried up and attenuated. Tiie vis vit(^ appears in such cases to be absolutely washed out of the body. The abdomen is generally tumid, but occasionally, in common with the muscles and integuments of the entire frame, it is shrunk and shrivelled. Pain, other than neuralgia, I have seldom been able to trace in this cavity, on the most careful exploration of its various regions by tactile examination and percussion. The skin will generally be found dry, cool, and sometimes harsh to the touch ; occasionally of a soft, velvety character ; all indicat- ing a diminished vitality — diminished exhaling and absorbing power — the secreting function being suspended through dryness. The state of the system, as already stated, is usually anaemic. There is much restlessness, the little sleep that is obtained being unrefreshing. The intestinal secretions are sometimes of the appearance and consistence of pea-soup, and at others serous or watery, or, as some patients describe them, like soap-and-water, or semi-fluid and yeast-like, with little or no colouring matter. The evacuations are generally voided without any pain. They are always copious and exhausting, especially dimng the night or in the early morning. The disease occurs occasionally in paroxysms, and is sometimes preceded by distinct feverishness — the paroxysms of diarrhoea and of fever recurring once or twice a month. The urine, in all the in- stances in which I have examined it, contained oxalate of lime in greater or less quantity. The appetite is sometimes voracious, at others defective and capricious. The secondary or chronic diarrhoeas of Europeans who have resided long in hot climates are always difficult of cure ; and when of long standing, they constitute a class of disease dangerous and intractable beyond most others. \Yhether the disease under consideration presents itself in the* form of diarrhoea originally contracted as such in India, or as one of the sequelae to acute tropical dysentery, as the result of hepatic disease, fevers, cholera, malaria, the abuse of mercury and purga- tives, or from errors in diet and habits of life, we seldom find the disease simple in its pathological nature — that is, confined to the mucous digestive surface alone. On the contrary, a careful explo- ration of the abdominal regions, coupled with an attentive consi- deration of all the antecedent and attendant circumstances, will generally show that diarrhoea, in a large proportion of instances, is complicated with, if not mainly dependent on, chronic disorders and diseases of the liver. And here it is worthy of remark, that in India diarrhoea is a frequent and immediate evidence of dangerous X X 674 CHRONIC DIARRHCEA. congestion^ or of inflammation of the parenchyma of the liver, and sometimes it results both in India and in Europe from abscess of that organ. The first approach of congestion or of inflammation of the liver suspends its secreting power^ and diarrhoea is the result. An entire suspension^ or its converse^ an excessive flow of the biliary excretion^ will generally produce diarrhoea."^ That there are in India, on the other hand, diarrhoeas of a simple and uncom- plicated nature, is a fact well known ; but they are mostly acute and comparatively easy of cure, the subjects of them recovering on the spot ; so that in eficct none are sent home but the most severe, protracted, and complicated cases. Although chronic diarrhoea generally follows on previous tropical disease, I have seen it affect persons on their return to England, who, during their residence in India, had never suffered from any of the diseases of that country. The health of such patients, how- ever, had been enfeebled, and they were thus rendered susceptible to the influence of cold or damp, or to what is always more inju- rious to the retvxrned Indian — to both conjoined. The returning Indian is often seized with diarrhoea fi'om exposure to cold on board ship, especially if exposed to the spring easterly winds. The cold of the English winter and spring proves very adverse to the cure of this disease, and I have constantly to send patients suffer- ing from it to the sheltered places on the coast, as Hastings, Bournemouth, Ventnor, &c. Fatigue is almost as injurious as cold. An officer whom I sent to Bournemouth missed his way home, and had to walk beyond his powers. The result was a re- lapse which nearly proved fatal. Diarrhoeas of course vary in their nature with their causes, and these last constitute the most necessary points for primary consi- deration in practice. One will depend on disorder or disease of the liver ; another will result from fever ; a third from dysentery ; a fourth has for its cause a hyperemia of the mucous digesti\e surfaces ; while a fifth is associated with anremia of the same tex- tures, as well as of all the abdominal organs. I have seen cases in which the abuse of purgative medicines appeared to produce chronic diarrhoea, and others in which the same effect seemed to result from the large or the protracted use of calomel. A morbid state of the biliary secretion, and its injurious influ- ence in producing and maintaining the chronic bowel complaint here noticed, have been mentioned emphatically by some vvriters on the diseases of tropical climates, as a fact of most frequent oc- currence ; and so also, with more justice, has the total absence of hepatic secretion, constituting what is termed the iv/iite Jinx. This latter form of diarrhoea, whether associated with intermittent * Dr. James Lind, describing hepatitis in Calcutta in 1762, says — "The cure of infianunation of the liver proved uncertain and tedious, as it was frequently followed by colliquative diarrhoea, which speedily put an end to the patient's life ;" so that, whether hepatic disease may be more immediately or more remotely antecedent, diar- rhcEa is frequently found to be its result. CHRONIC DIARRIICEA. 675 fever or not, often recurs in paroxysms, more or less distant. On such occasions it is common to find the tongue assume a more or less red, abraded, or even idcerated state ; but it is worthy of careful remark that, on the restoration of the hepatic function, all these indications of mucous-intestinal irritation gradually suljside. The intermittent fever, so generally the antecedent of chronic diarrhcea, would appear to stamp its character of periodicity and of paroxysm upon its consequent, and tlius to render it more or less paroxysmal or periodical, according to the severity of the original ague ; in other words, according to the intensity of the primary malaria. A periodical excoriation, or else an aphthous state, of the mouth, tongue, and fauces is also a frequent occur- rence in this disease ; and when either of these morbid states is present, there is usually, and for the time, a mitigation of diarrhoea. But when the aliraded or ulcerated mucous surface heals, then the disorder of the bowels recurs with more or less severity. Those who have visited Simla, and some of the stations near it on the hill ranges of the Himalayas, have ver}'^ generally observed a change to a pale, colourless state of the intestinal secretions soon after their ascent into those regions, resulting, it is presumed, from the comparative cold and damp of the mountain air. Diarrhcea is^ in fact, a frequent result of this change of climate ; so much so, indeed, as to have received from the British residents there the name of " the hill trot.^' Exposure upon active field service, or during the night and the early morning marches in India, especially during the cold season, often produces the same result. Both the conditions here mentioned, the pale secretion and the diarrhcea, would appear to result from hepatic congestion, the consequence of the sudden application of cold and damp to the surface of the body, previously relaxed by the heat of the plains. The result is, a diminished or suspended secretion of bile, and a consequent dis- order in the entire process of digestion, the matters voided from the bowels being colourless, acrid, and irritating.'^ Officers of the Bengal army who marched from Sindh, where the thermometer rose to 135°, to Cabul, Avhere it fell below 75°, have stated to me that, soon after exposm-e to this relative cold, they all became more or less jaundiced : some were seized with diarrhoea, but all were jaundiced. By some very observant patients, I have been told, on the other hand, that in their instances diarrhoea com- menced in India by enormous and long- continued " discharges of pure bile," which would appear to have exhausted the functions of the liver : then came the " white flux," with its complete suspension of tlic nutritive processes; the ansemia of all the organs and * In that excellent periodical, "The Indian Annals of Medical Science," will be found (vol. i.) admirable Remariis on Hill Diarrhoea and Dysentery, by Mr. Alexander Grant, of tlie Bengal ai-my, to which I would refer the reader who desires to be informed on this subject, and on the influence of the climates of the "Himalayan ."Sanataria" generally. X X 2 C70 CHRONIC DIARRIICEA. tissues of tlie body ; the aupcmic ulcerations (cLronic aplitlise) of the mucous digestive surface ; and all the attendant difficulties and dangers, so as to call into trying exercise the toilsome and difficult requirements of the physician. In his admirable "Remarks/' Mr. Grant characterizes the Hill Diarrhoea and Dysentery as "peculiar and often inveterate" forms of disease; and he does not hesitate to pronounce them " endemic of the group of Hill Sanataria that includes Kussoula, Sim] ah, Sabathoo, and the new station of Dugshai." Mr. Grant states that it is this " peculiar class of diseases which occasions nearly all the mortality, and has, in some instances, been a serious source of inefficiency and loss to regiments for years after their return to the plains.'^ He adds, however, as deserving of particular notice, that "no healthy corps has as yet been sent to any of the Hill Sta- tions : on the contrary, almost all the regiments were in an in- efficient condition — the constitutions of the men being more or less broken down, or tainted with malaria, and numbers of them suffering from intermittent fever and its sequelae, enlarged liver and spleen." These facts corroborate in the strongest manner my early observations on the climates of the mountain stations hitherto occupied by British troops in the East Indies; — namely, that they may be made of the utmost and most extended value in peeservikg THE soLBiER-'s HEALTH, but that for the cure of his diseases, con- tracted in the hot and pestilential plains^ they are of very subordi- nate value. As an example of diarrhoea very formidable in its nature, and of very frequent occurrence, I adduce the following : — Colonel , aged sixty-three, served forty-three years in India, where during many years he enjoyed an average share of good health. In 1840 he came home intending to resign the service, being possessed of a competent fortune ; but the call made by the Indian government in 1842, on all military officers then on furlough to return to their duty in India in consequence of the disaster at Cabul, induced Col. , out of pure military zeal, to proceed to join his corps, despite of a certificate from myself, and from the late Mr. Turner, to the effect that he was not fit to serve in India. An accomplished and distinguished officer, he was soon placed in positions of varied and important trust, and he served in the campaigns of the Sutlej in 1845-46, and in that of the Tunjab in 1849. Colonel had pre\dously been twice on sick leave to Eng- land, and by the recent exposures and exertions he began again to feel the exhausting influences of severe and unremitting duty, as well as those of climate, when, in January, 1850, he was unfor- tunately induced to accept a mission into a malarious district. Here he was seized with an acute attack of intermittent fever, from which he recovered but slowly, and he arrived in Calcutta from the M CHRONIC DIARRTTCEA. 677 N. "W. provinces in April, 1850, weak and exhausted. The season and the opportunities for departure to England being considered unfavourable. Colonel was induced to remain in Bengal, making an occasional trip to sea; but the climate still proved inimical. In August, that being the height of the rainy season, he was seized witli a wasting diarrhoea, which harassed him even after his embarkation for England, by the Cape route, in the end of January, 1851. During a four months' voyage no improvement took place, not- withstanding the most prudent care in diet. He was, on the average, purged eight times every twenty-four hours after leaving Calcutta; and on reaching lat. 30° north, a great aggravation of purging, accompanied by vomiting, took place. The cold to whicli he had looked as a friendly and bracing agent, " penetrated into his bowels," as he described it, and he landed in the middle of May, 1851, at Torquay, in a state of great exhaustion. Repassed a night at Exeter, during which he Avas purged twelve times, and from Clifton he wrote me : — " jNIy nerves are dreadfully shattered ; indeed, at this instant, I am a sad wreck." ^Slay 24] A MANUAL FOR HOSPITAL NURSES and others engaged in Attending on the Sick by Edwaed J. Domtille, L.R.C.P., M.E.C.S. Crown Svo, 2s. 6d. [1872] CANCER: its varieties, their Histology and Diagnosis. By Henry Arnott, F.E.C.S,, Assistant- Surgeon to, and Lecturer on Pathology at, St. Thomas's Hospital. Svo, with 5 Lithographic Plates and 22 Wood Engravings, 5s. 6d. a872] ON DISEASES OF THE LIVER : Lettsomian Lectures for 1872 by S. 0. Habershon, M.D.,E.E.C.P., Physician to Guy's Hospital. Post Svo, 3s. (id. [I872] ON SOME AFFECTIONS OF THE LIVER and Intestinal Canal; with Eemarks on Ague and its Sequelae, Scurvy, Purpura, &c., by Stephen H. Ward, M.D. Lond., E.E.C.P., Physician to the Seamen's Hospital, Greenwich. Svo, 7s. [i872] ON GEREBRIA and other Diseases of the Brain by Charles Elam,M.D., E.E.C.P., Assistant-Physician to the National Hospital for Paralysis and Epilepsy. Svo, 63. [1872] HANDBOOK OF LAW AND LUNACY; or, the Medical Practitioner's Complete Guide in all Matters relating to Lunacy Practice, by J. T. Sabben, M.D., and J. H. Balfoub Browne. Svo, 5s, [I872] CATALOGUE OF RECENT WORKS FOURTEEN COLOURED PHOTOGRAPHS OF LEPROSY as met with in the Straits Settlements, with Explanatory Notes by A. F. Andersok, M.D., Acting Colonial Surgeon, Singapore. 4to, £1 lis. 6d. [1873] LECTURES ON WINTER COUGH (Catarrh, Bronchitis, Emphysema, Asthma) by Hoeace Dobell, M.D., Senior Physician to the Eoyal Hospital for Diseases of the Chest. Second Edition, with Coloured Plates, 8vo, 8s. 6d. [1872] BT THE SAME AUTHOE, TRUE FIRST STAGE OF CONSUMPTION (Lectures on the). Crown 8vo, 3s. 6d. pseTj A HANDBOOK OF UTERINE THERAPEUTICS and of Diseases of Women by E. J. Tilt, M.D., M.E.C.P. Third Edition, post 8vo, 10s. [ises] BY THE SAME AXJTHOE, THE CHANGE OF LIFE in Health and Disease : a Practical Treatise on the Nervous and other Affections incidental to Women at the Decline of Life. Third Edition, Svo, 10s. 6d. [I870] THE ORIGIN OF CANCER considered with Eeference to the Treatment of the Disease by Campbell de Morgan, F.E.S., F.R.C.S., Surgeon to the Middlesex Hospital. Crown Svo, 3s. 6d. [I872] THE ANATOMICAL REMEMBRANCER; or, Complete Pocket Anatomist. Seventh Edition, carefully Re- vised, 32tno, 3s. 6d. [1872] ZYMOTIC DISEASES : their Correlation and Causation. By A. Wolef, E.E.C.S. Post Svo, 5s. [;1872] PUBLISHED BY J. AND A. CHURCHILL THE URINE AND ITS DERANGEMENTS (Lectures ou), with the Application of Physiological Chemistry to the Diagnosis and Treatment of Constitutional as well as Local Diseases by George Haklet, M.D., F.R.S., F.R.C.P., formerly Professor in "University College. Post 8vo, 9s. [1872] ADVICE TO A MOTHER on the Management of her Children, by Pye H. Ciiavasse, F.R.C.S. Eleventh Edition, fcap 8vo, 23. 6d. [I872] BY THE SAME AUTHOB, COUNSEL TO A MOTHER: being a Continuation and the Completion of ' Advice to a Mother.' Second Edition, fcap 8vo, 2s. 6d. [I872] ALSO, ADVICE TO A WIFE on the Management of her own Health. With an Introductory Chapter, especially addressed to a Young Wife. Tenth Edition, fcap Svo, 2s. 6d. psys] ALSO, MENTAL CULTURE AND TRAINING OF A CHILD (Aphorisms on the), and on various other Subjects relating to Health and Happiness. Fcap. Svo, 2s. 6d. [I872] WORMS: a Series of Lectures delivered at the Middlesex Hospital on Practical Helminthology by T. Spexcee Cobbold, M.D., F.E.S. Post Svo, 5s. [1872] CANCEROUS AND OTHER INTRA-THORACIC Growths, their Natural History and Diagnosis. By J. RisDOU" Bejtnett, M.D.,F.E.C.P,, Member of the General Medical Council. Post Svo, with Plates, 8s. psys] FRACTURES OF THE LIMBS (On the Treatment of) by J. Sampson Gamgee, Surgeon to the Queen's Hospital, Birmingham. Svo, with Plates, 10s. 6d. [I871] CATALOGUE OP RECENT WORKS WINTER AND SPRING on the Shores of the Mediterranean ; or, the Eiviera, Mentone, Italy, Corsica, Sicily, Algeria, Spain, and Biarritz, as Winter Climates. By Henet Bennet, M.D. Fourth Edition, post 8vo, with numerous Plates, Maps, and "Wood Engravings, 12s. [isegj BY THE SAME AUTHOE, TREATMENT OF PULMONARY CONSUMPTION (On the) by Hygiene, Climate, and Medicine. Second Edition, enlarged, 8vo, 5s. [I871] CLINICAL USES OF ELECTRICITY (Lectures on the) delivered at University College Hospital by J. EussELL Eetnolds, M.D. Lond., E.E.C.P., F.E.S., Professor of Medicine in University College. Second Edition, post 8vo, 3s. 6d. [1873] THE SCIENCE AND PRACTICE OF SURGERY: a complete System and Textbook by E. J. Gtant, F.E.C.S., Surgeon to the Eoyal Free Hospital. Svo, with 470 Engravings, £1 4s. [isyij BY THE SAME AUTHOE, THE IRRITABLE BLADDER: its Causes and Treatment. Third Edition, crown Svo, with En- gravings, 6s. [1872] THE LAWS AFFECTING MEDICAL MEN (A Manual of) by Eobeet Gr. Glenn, LL.B., Barrister-at-Law; with a Chapter on Medical Etiquette by Dr. A. Caepenter. Svo, 14s. [I871] THE MEDICAL JURISPRUDENCE OF INSANITY. By J. H. Balfotje Beowne, Barrister-at-Law. Svo, 10s. 6d. [I871] OBSTETRIC APHORISMS for the Use of Students commencing Midwifery Practice by J. Gr. Swatne, M.D., Physician-Accoucheur to the Bristol General Hospital. Fifth Edition, fcap Svo, with Engravings on Wood, 8s. 6d. [1871] PUBLISHED BY J. AND A. CHURCHILL GROWTHS IN THE LARYNX, with Eeports and an Analysis of 100 consecutive Cases treated since the Invention of the Laryngoscope by Moeell Mackenzie, M.D. Lond., M.K.C.P., Physician to the Hospital for Diseases of the Throat. 8vo, with Coloured Plates, 12s. 6d. [i87i] BY THE SAME AUTHOE, HOARSENESS, LOSS OF VOICE, and Stridulous Breathing in relation to Nervo-Muscular Affections of the Larynx. Second Edition, 8vo, fully Illustrated, 3s. 6d. [isss] THROAT HOSPITAL PHARMACOPEIA, containing upwards of 150 Formulae. Second Edition, fcap 8vo, 2s. 6d. [1873 A MANUAL OF PRACTICAL THERAPEUTICS by E. J. Waring, M.D., E.R.C.P. Lond. Third Edition, fcap Svo, 12s. 6d. [1871] DISCOURSES ON PRACTICAL PHYSIC by B. W. EicHAUDSON, M.D., E.R.C.P., F.R.S. 8vo, 5s. [i87n THE SURGERY OF THE RECTUM: Lettsomian Lectures by Henet Smith, E.E.C.S., Surgeon to King's College Hospital. Third Edition, fcap 8vo, Ss. 6d. [i87i] HANDBOOK OF DENTAL ANATOMY and Surgery for the Use of Students and Practitioners by John Smith, M.D., F.E,.S. Edin., Surgeon-Dentist to the Queen in Scotland. Second Edition, fcap 8vo, 4s. 6d. [i87i] ORGANIC STRICTURE OF THE URETHRA (An Analysis of 140 Cases of), by John D. Hill, F.E.C.S., Surgeon to the Royal Free Hospital. 8vo, 3s. [I871] § 10 CATALOGUE OF EECENT WOEKS THE REPRODUCTIVE ORGANS in Childhood, "Youth, Adult Age,and Advanced Life (The Functions and Disorders of), considered in their Physiological, Social, and Moral Eelations, by William Acton, M.E.C.S. Fifth Edition, 8vo, 12s. [1871] BT THE SAME AUTHOE, PROSTITUTION: Considered in its Moral, Social, and Sanitary Aspects. Second Edition, enlarged, 8vo, 12s. [1869] NOTES AND RECOLLECTIONS of an Ambulance Surgeon, being an Account of Work done under the Eed Cross during the Campaign of 1870, by William MacCormac, F.E.C.S., M.E.I.A., Surgeon to St. Thomas's Hospital. 8vo, with 8 Plates, 7s. 6d. [i87i] A TREATISE ON GOUT, RHEUMATISM and the Allied Affections by P. Hood, M.D. Crown 8vo, lOs. 6d. [1871] LECTURES ON OBSTETRIC OPERATIONS, including the Treatment of Haemorrhage, and forming a Guide to the Management of DifBcult Labour, by Eobeet Barnes, M.D., F.E.C.P., Obstetric Physician to, and Lecturer on Midwifery at, St. Thomas's Hospital. Second Edition, 8vo, with 113 Engravings, 15s. [1871] PRACTICAL MIDWIFERY AND OBSTETRICS, including Anaesthetics. By John Tanner, M.D., M.E.C.P. Edin. Fcap 8vo, with numerous Engravings, 6s. 6d. [1871] A TRANSLATION OF DR. DILLNBERGER'S Handy-Book of the Treatment of Women's and Children's Diseases according to the Vienna Medical School, with Prescriptions, by Patrick Nicol, M.B. Fcap Bvo, 5s. [1871] PUBLISHED BY J. AND A. CHUKCHILL 11 OPERATIVE SURGERY by C. F. Maunder, F.E.C.S., Surgeon to the London Hospital, formerly Demonstrator of Anatomy at Guy's Hospital. Second Edition, post 8vo, with 164 Wood Engravings, Gs. [I872] ON DEFORMITIES OF THE HUMAN BODY: a System of Orthopaedic Surgery, by Bernard E. Brodhurst, E.R.C.S., Orthopisdic Surgeon to St. George's Hospital. 8vo, with Engravings, lOs. 6d. [I871] A COMPENDIUM OF DOMESTIC MEDICINE and Companion to the Medicine Chest ; intended as a Source of Easy Eeference for Clergymen, and for Families residing at a Distance from Professional Assistance by John Savory, M.S. A. Eighth Edition, 12mo, Ss. [I871] SYPHILITIC DISEASES (The Modern Treatment of), both Primary and Secondary ; com- prising the Treatment of Constitutional and Confirmed Syphilis, by a safe and successful Method, by Langston Parker, F.E.C.S. Fifth Edition, 8vo, 10s. 6d. [I871] METHOD AND MEDICINE: an Essay on the Past, Present, and Future of Medicine by Balthazar AV. Foster, M.D., Professor of Physic in Queen's CoUege, Bir- mingham. Svo, 2s. 6d. [18703 THE TREATMENT OF SURGICAL INFLAMMATIONS by a New Method, which greatly shortens their Duration, by FuRNEArx Jordan, F.R.C.S., Professor of Surgery in Queen's College, Birmingham. Svo, with Plates, 78. 6d. [1870] ATLAS OF OPHTHALMOSCOPY: representing the Normal and Pathological Conditions of the Fundus Oculi as seen with the Ophthalmoscope : composed of 12 Chromo- lithographic Plates (containing 59 Figures), accompanied by an Explanatory Text by E. Liebrbich, Ophthalmic Surgeon to St. Thomas's Hospital. Translated into English by H. Eosborough SwANZT, M.B. Dub. Second Edition, Enlarged and Eevised, 4to, £1 10s. ■ [1870] 12 CATALOGUE OF EECENT WORKS THE PRINCIPLES AND PRACTICE OF SURGERY by "William Pieeie, P.E.S.E., Professor of Surgery in the University of Aberdeen. Third Edition, 8vo, with 490 Engravings, 2Ss. [I873] A SYSTEM OF PRACTICAL SURGERY by Sir "William Feegusson, Bart., E.E.C.S., E.E.S., Serjeant- Surgeon to the Queen. Fifth Edition, 8vo, with 463 Illustrations on "Wood, 21s. [WO] OPERATIVE SURGERY OF THE FOOT AND ANKLE (The) by Henry Hancock, President of the Eoyal College of Surgeons of England. 8vo, 15s. [i873] ON DISEASES OF THE SKIN: a System of Cutaneous Medicine by Erasmus Wilson, F.R.C.S., E.E.S. Sixth Edition, Svo, IBs, with Coloured Plates, 36s. BY THE SAME ATTTHOE, THE ANATOMIST'S VADE-MECUM: a System of Human Anatomy, Ninth Edition, by Dr. G. Buchanan, Professor of Anatomy in Anderson's "University, Glasgow. Crown, Svo, with 371 Engravings on "Wood, 14s. [ists] ALSO, LECTURES ON EKZEMA and Ekzematous • Affections ; with an Introduction on the General Pathology of the Skin, and an Appendix of Essays and Cases. Svo, 10s. 6d. [1870] ALSO, LECTURES ON DERMATOLOGY delivered at the Eoyal College of Surgeons, 1870, 6s. ; 1871-3, 10s. 6d. CLINICAL AND PATHOLOGICAL OBSERVATIONS in India by J. Fayrer, C.S.I., M.D., F.E.S.E., Fellow of the Eoyal College of Physicians of London, Honorary Physician to the Queen. Svo, with Engravings on Wood, 20s. [I873] PUBLISHED BY J. AND A. CHURCHILL 13 A TREATISE ON RHEUMATIC GOUT, or Chronic Rheumatic Arthritis ' all the Joints, by Eobeet Adams, M.D., M.E.I.A., Surgeon . H.M. the Queen in Ireland, Eegius Professor of Surgery in the University of Dublin. Second Edition, 8vo, with Atlas of Plates, 2l3. [is:-;] THE SURGERY, SURGICAL PATHOLOGY, and Surgical Anatomy of the Female Pelvic Organs, in a Series of Coloured Plates taken from Nature : with Commentaries, Notes, and Cases by Henry Savage, M.D. Lond., F.E.C.S., Consulting Physician to the Samaritan Eree Hospital. Second Edition, greatly Enlarged, 4to, £1 lis. 6d. (;i870] ON HERNIAL AND OTHER TUMOURS of the Groin and its Neighbourhood with some Practical Eemarks on the Radical Cure of Ruptures by C. Holthouse, E.R.C.S., Surgeon to the "Westminster Hospital. 8vo, 63. 6d. [I870J PRACTICAL PATHOLOGY: third Edition, in 2 Vols., containing Lectures on Suppurative Fever, Diseases of the Yeins, Hsemorrhoidal Tumours, Diseases of the Rectum, Syphilis, Gonorrhoeal Ophthalmia, &c., by Heney Lee, F.E.C.S., Surgeon to St. George's Hospital. 8vo, 10s. each vol. qsto] RENAL DISEASES; a Clinical Guide to their Diagnosis and Treatment by W. R. Basham, ]\LD., E.R.C.P., Senior Physician to the "Westminster Hospital. Post Svo, 7s. JI870] ALSO, THE DIAGNOSIS OF DISEASES OF THE KIDNEYS (Aids to). Svo, with 10 Plates, 5s. fi872] ON DISEASES AND INJURIES OF THE EAR by "W. B. Daley, F.R.C.S., M.B., Aural Surgeon and Lecturer on Aural Surgery at St. George's Hospital. Crown Svo, with 21 Engravings, 6s. Gd, [1873] 14 CATALOGUE OF EECENT WOEKS ON THE PRESENT STATE OF THERAPEUTICS ; with some Suggestions for placing it on a more scientific basis by James Rogers, M.D. 8vo, 68. 6d. [-1870] STUDIES ON FUNCTIONAL NERVOUS DISORDERS by C. Handfield Jones, M.B., P.E.C.P., F.R.S., Physician to St. Mary's Hospital. Second Edition, much enlarged, 8vo, 18s. [I870] PRINCIPLES OF SURGICAL DIAGNOSIS (Lectures on the) especially in Relation to Shock and Visceral Lesions, delivered at the Royal College of Surgeons by F. Le Geos Clark, F.R.C.S., Senior Surgeon to, and Lecturer on Surgery at, St. Thomas's Hospital. 8vo, 10s. 6d. [I870] IMPERFECT DIGESTION : its Causes and Treatment. By Arthur Lbared, M.D., F.R.C.P., Senior Physician to the Great Northern Hospital. Fifth Edition, fcap 8vo, 4s. 6d. Q870] STRICTURE OF THE URETHRA and Urinary Fistul^e ; their Pathology and Treatment : Jacksonian Prize Essay by Sir Henry Thompson, F.R.C.S., Surgeon-Extra- ordinary to the King of the Belgians. Third Edition, Svo, with Plates, lOs. [1869} BY THE SAME AUTHOE, PRACTICAL LITHOTOMY AND LITHOTRITY; or, An Inquiry into the best Modes of removing Stone from the Bladder. Second Edition, Svo, with numerous Engravings, 10s. [1371] ALSO, DISEASES OF THE URINARY ORGANS. (Clinical Lectures on). Third Edition, crown Svo, with En- gravings, 6s. [1872] THE DISEASES OF THE PROSTATE : their Pathology and Treatment. Fourth Edition, Svo, with nume- rous Plates, 10s. PUBLISHED BY J. AND A. CHURCHILL 15 MENTAL DISEASES (The Pathology and Therapeutics of). By J. L. C. Scheoeder Van DEK KoLK. Translated by Mr. EuDALLjF.E.C.S. 8vo, 7a. Gd. [iseg] THE CLIMATE AND RESOURCES OF MADEIRA, as regarding chiefly the Necessities of Consumption and the Welfare of Invalids. By Michael C. Q-babham, M.D., M.E.C.P. Crown 8vo, witk Map and Engravings, 5s. [isegj A MANUAL OF THE DISEASES OF THE EYE by C. MACKAiiAEA, Surgeon to the Calcutta Ophthalmic Hospital. Second Edition, fcap 8vo, with Coloured Plates, 12s. 6d. ^372] CLUBFOOT: its Causes, Patbology, and Treatment ; being the Jacksonian Prize Essay by Wm. Adams, E.E.C.S., Surgeon to the Great Northern Hospital. Second Edition, Svo, with 106 Wood Engravings and 6 Lithographic Plates, 15s. ^873] PHTHISIS AND THE STETHOSCOPE; or, the Physical Signs of Consumption. By E. P. Cottox, M.D., E.E.C.P., Senior Physician to the Hospital for Consumption, Brompton. Fourth Edition, fcap Svo, 3s. 6d. (^1869] PRACTICAL ANATOMY: a Manual of Dissections by Cheistophee Heath, E.E.C.S., Surgeon to University College Hospital. Second Edition, fcap Svo, with 226 Engravings, 128. 6d. [isegj BT THE SAME AUTHOE, MINOR SURGERY AND BANDAGING (A Manual of) for the Use of House-Surgeons, Dressers, and Junior Practitioners. Fourth Edition, fcap Svo, with 74 Engravings, 5s. 6d. [1870] ALSO, INJURIES AND DISEASES OF THE JAWS : Jacksonian Peize Essay. Second Edition, Svo, with 164 En- gravings, 128. " L1872 16 CATALOGUE OP RECENT WORKS ON MEGRIM, SICK-HEADACHE, and some Allied Disorders : a Contribution to the Pathology of Nerve-Storms by Edward Liveing, M.D. Cantab., Hon. Fellow of King's College, London. 8vo, with Coloured Plate, I5s. [I873] HUMAN OSTEOLOGY: with Plates, showing the Attachments of the Muscles. By Lutheb HoLDEN, F.E.C.S., Surgeon to St. Bartholomew's Hospital. Fourth Edition, 8vo, 16s. [i869] BY THE SAME AUTHOR, THE DISSECTION OF THE HUMAN BODY (A Manual of). Third Edition, 8vo, with Engravings on "Wood, 16s. [1868] MANUAL OF THE DISEASES OF CHILDREN (A Practical), with a Formulary, by Edwaed Ellis, M.D., Physician to the Victoria Hospital for Children. Second Edition, crown Svo, 7s. [1873] INJURIES AND DISEASES OF THE KNEE-JOINT and their Treatment by Amputation and Excision Contrasted : Jacksonian Prize Essay by W. P. Swain, F.E.C.S., Surgeon to the E^^yal Albert Hospital, Devonport. Svo, with 36 Engravings, 9s. [1869] A TREATISE ON SYPHILIS by Walter J. Coulson, F.E.C.S., Surgeon to the Lock Hospital. Svo, 10s. [1869] BY THE SAME ATTTHOE, STONE IN THE BLADDER: Its Prevention, Early Symptoms, and Treatment by Lithotrity. 8V0, 6s. [1868] PRINCIPLES OF HUMAN PHYSIOLOGY. By W. B. Caepentee, M.D., F.E.S. Seventh Edition by Mr. Henet Powee, Svo, with nearly 300 Illustrations on Steel and Wood, 28s. £1869] PUBLISHED BY J. AND A. CHURCHILL 17 A MANUAL OF PRACTICAL HYGIENE by E. A. Paekes, M.D., F.E.C.R, F.R.S., Professor of Hygiene in the Army Medical School. Fourth Edition, Svo, with Plates and "Woodcuts, 16s. [1873] ON KIDNEY DISEASES, URINARY DEPOSITS and Calculous Disorders by Lionel S. Beale, M.B., E.E-.S., F.R.C.P., Physician to King's College Hospital. Third Edition, much Enlarged, Svo, with 70 Plates, 25s. [ises] BY THE SAME AUTHOR, DISEASE GERMS; and on the Treatment of the Feverish State. Second Edition, crown Svo, with 28 Plates, 12s. 6d. [I872] PHYSIOLOGICAL LABORATORY (Handbook for the). By E. Klein, M.D., formerly Privat-Docent in Histology in the University of Yienna, Assistant Professor in the Pathological Laboratory of the Brown Institution, London ; J. Buedon-Sanderson, M.D., F.R.S., Professor of Practical Physiology in University College, London ; Michael Fosxee, M.D., F.R.S., Fellow of, and Praelector of Physiology in, Trinity College, Cam- bridge ; and T. Lauder Brunton, M.D., D.Sc, Lecturer on Materia Medica in the Medical College of Bartholomew's Hospital ; edited by J. Btjrdon-Sanderson. Svo, with 123 Plates, 24s. [I873] THE SURGEON'S VADE-MECUM by Egbert Druitt. Tenth Edition, fcap Svo, with numerous Engravings on Wood, 12s. 6d. [I870] HOOPER'S PHYSICIAN'S VADE-MECUM: or. Manual of the Principles and Practice of Physic, Ninth Edition by W. A. Guy, M.B., F.R.S., and John Harlet, M.D., F.E.C.P. Fcap Svo, with Engravings. 12s. 6d. [1874] THE APPLICATIONS OF CHEMISTRY and Mechanics to Pathology and Therapeutics (Lectures on some of) by H. Benge Jones, M.'d., F.R.C.P., D.C.L., F.R.S. Svo, 128. [1867] 18 CATALOGUE OP EECENT WORKS MEDICAL ANATOMY. By Francis Sibsok, M.D., F.E.C.P., F.E.S., Consulting Physician to St. Mary's Hospital. Imp. folio, with 21 coloured Plates, cloth, £2 2s. ; half-morocco, £2 lOs. [Completed in 1869] LECTURES ON MADNESS in its Medical, Legal, and Social Aspects by Edgar Sheppaed, M.D., M.E.C.P., Professor of Psychological Medicine in King's College; one of the Medical Superintendents of the Colney Hatch Lunatic Asylum. 8vo, Gs. 6d. [i873] TEMPERATURE OBSERVATIONS containing (1) Temperature Variations in the Diseases of Children, (2) Puerperal Temperatures, (3) Infantile Temperatures in Health and Disease, by Wm. Squibe, M.E.C.P. Lond. 8vo, 5a. [i87ij A DICTIONARY OF MATERIA MEDIC A and Therapeutics by Adolphe "Wahltuch, M.D. 8vo, 15s. [ises DIABETES: Eesearches on its Nature and Treatment by F. "W. Pavt, M.D., F.E.S., F.E.C.P., Physician to Guy's Hospital. Second Edition, 8vo, with Engravings, lOs. [1868] BY THE SAME AUTHOR, DIGESTION: its Disorders and their Treatment. Second Edition, 8vo, 8s. 6d. [1869] A MEDICAL VOCABULARY; or, an Explanation of all Names, Synonymes, Terms, and Phrases used in Medicine and the relative branches of Medical Science by E. &. Mayne, M.D., LL.D. Third Edition, fcap 8vo, 8s. 6d. [18681 IRRITATIVE DYSPEPSIA and its Important Connection with Irritative Congestion of the Windpipe and with the Origin and Progress of Consumption. By C, B. Gaeeett, M.D. Crown 8vo, 2s. 6d. [1868] PUBLISHED BY J. AND A. CHURCHILL 19 MEDICAL JURISPRUDENCE (The Principles and Practice of) by Alfeed S. Taylor, M.D., F.E.C.P., F.E.S. Second Edition, 2 vols., 8vo, with 189 Wood Engravings, £1 lis. 6d. psTS] SCHROEDER'S MANUAL OF MIDWIFERY, including the Pathology of Pregnancy and the Puerperal State. Translated by Chaeles H. Caetee, B.A., M.D. 8vo, with Engrav- ings, 12s. 6d. [1873] THE PARASITIC AFFECTIONS OF THE SKIN. By McCall AjfDERSoN, M.D., F.F.P.S., Professor of the Practice of Medicine in Anderson's University, Glasgow. Second Edition, 8vo, with Engravings, 7s. 6d. [ises] STRICTURE OF THE URETHRA (On the Immediate Treatment of) by Baenaed Holt, E.E.C.S., Consulting Surgeon to the Westminster Hospital. Third Edition, SVO, 6s. U868] OXYGEN: its Action, Use, and Yalue in the Treatment of various Diseases otherwise Incurable or very Intractable. By S. B. Biech, M.D., M.E.C.P. Second Edition, post 8vo, 3s. 6d. [ises] BT THE SAME ATTHOE, CONSTIPATED BOWELS : the Various Causes and the DifiFerent Means of Cure. Third Edition, post Bvo, 3s. 6d. [ises] OBSCURE DISEASES OF THE BRAIN AND MIND. By Forbes Winslow, M.D., D.C.L. Oxon. Fourth Edition, post 8vo, 10s. 6d. C186&1 ULCERS AND CUTANEOUS DISEASES (A Manual of the Pathology and Treatment of) of the Lower Limbs by J. K. Spekdek, M.D. Lond. 8vo,4s. [i86&] 20 CATALOGUE OF EECENT WORKS A COMPENDIUM OF PRACTICAL MEDICINE and Morbid Anatomy by William Dale, M.D. Lokd. 12mo, with Plates, 7s. [ises] GERMINAL MATTER AND THE CONTACT THEORY: an Essay on the Morbid Poisons by James Morris, M.D. Lond. Second Edition, crown 8vo, 4s. (id. [1867] BY THE SAME AUTHOR, IRRITABILITY : Popular and Practical Sketches of Common Morbid States and Conditions bordering on Disease ; with Hints for Management, Alleviation, and Cure. Crown 8vo, 4s. 6d. [ises] A MANUAL OF MATERIA MEDICA by J. P. EoTLE, M.D., F.E.S., and F. W. Headland, M.D., P.R.C.P. Fifth Edition, fcap 8vo, with numerous Engravings on "Wood, 12s. 6d. [1868] DISEASES OF THE CHEST: Contributions to their Clinical History, Pathology and Treatment by A. T. H. Waters, M.D., F.E.C.P., Physician to the Liverpool Eoyal Infirmary. 8vo, with Plates, 12s. 6d. [1868] NEURALGIA AND KINDRED DISEASES of the Nervous System : their Nature, Causes, and Treatment, with a series of Cases, by John Chapman, M.D., M.E-.C.P., Assistant- Physician to the Metropolitan Free Hospital. 8vo, 143. [i873] THE STOMACH AND DUODENUM (The Morbid States of) and their Relations to the Diseases of oth Organs. By Samuel Fenwick, M.D., F.E.C.P,, Assistant-Physi- cian to the London Hospital, 8vo, with 10 Plates, 12s. [1868] BY THE SAME AUTHOR, THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. Third Edition, fcap 8vo, with 87 Engravings, 6s. 6d. £i873j I PTJBLTSHED BY J. AND A. CHURCHILL 21 REVIEW OF THE HISTORY OF MEDICINE among Asiatic JS'ations by T. A. Wise, M.D., F.R.C.P. Edin. Two Vols,, 8V0, 16s. [;i8C8] DISEASES OF THE EYE (Illustrations of some of the Principal), with an Account of their Symptoms, Pathology, and Treatment, by Henet Powee, F.E.C.S., ]\r.B. Lend., Ophthalmic Surgeon to St. Bartholomew's Hospital. 8?o, with twelve Coloured Plates, 20s. [isev] HANDBOOK OF MEDICAL ELECTRICITY by Heebeet Tibbits, M.D., L.R.C.P.L., Medical Superintendent of the JSTational Hospital for the Paralysed and Epileptic. 8vo, with 64 "Wood Engravings, 6s. [isys] OBSTETRIC MEDICINE AND SURGERY (The Principles and Practice of). By E. H. Eamsbotham, M.D., F.R.C.P.. Fifth Edition, Svo, with One Hundred and Twenty Plates on Steel and Wood, 22s. age;] DISEASES OF THE EYE (A Treatise on the) by J. Soelbeeq Wells, F.R.C.S., Ophthalmic Surgeon to King's College Hospital and Surgeon to the Royal London Ophthalmic Hospital. Third Edition, 8yo, with Coloured Plates and Wood Engravings, 25s. [I873] THE INDIGESTIONS or Diseases of the Digestive Organs Functionally Treated, by T. K. Chambees, M.D., F.R.C.P., Lecturer on Medicine at St. Mary's Hospital. Second Edition, 8vo, 10s. 6d. [isbt] THE LUNGS AND AIR PASSAGES (On Diseases of) by W. H. Fullee, ]M.D., F.R.C.P., Senior Physician to St. George's Hospital. Second Edition, 8vo, 12s. 6d. [1867] THE MEDICAL REMEMBRANCER; or. Book of Emergencies. Fifth Edition by Jonathan Hutchinson, F.R.C.S., Senior Surgeon to the London Hospital. 32mo, 2s. 6d. [1887J 22 CATALOGUE OP RECENT WORKS ESSAYS ON THE DISEASES OF CHILDREN by William Henky Day, M.D., Physician to the Samaritan Hos- pital for Diseases of Women and Children. Fcap. 8vo, 5s. [I873] A HANDBOOK OF HYGIENE for the Use of Sanitary Authorities and Health Officers by Geoege Wilson, M.D. Edin., Medical Officer of Health for the Warwick Union of Sanitary Authorities. Second Edition, crown 8vo, with Engravings, 8s. 6d. [I873] ON THE ACTION OF MEDICINES in the System by P. W. Headland, M.D., F.E.C.P., Professor of Medicine in Charing Cross Medical College. Fourth Edition, 8vo, 14s. [1866] A MANUAL OF MEDICAL DIAGNOSIS by A. W. Barclay, M.D., F.R.C.P., Physician to, and Lecturer on Medicine at, St. George's Hospital. Third Edition, fcap. 8vo, 10s, 6d. [1870] EPIDEMIOLOGY; or, the Remote Cause of Epidemic Disease in the Animal and in the Vegetable Creation, by John Pabkin, M.D., F.R.C.S. Part I, 8V0, 5s. [1873] THE ACTION AND SOUNDS OF THE HEART (Researches on). By Geoege Paton, M.D., author of numerous papers published in the British and American Medical Journals. 8vo, 3s. 6d. [1873] MICROSCOPIC STRUCTURE OF URINARY CALCULI (On the) by H. V. Caetee, M.D., Surgeon-Major, H.M.'s Bombay Army. 8vo, with Four Plates, 5s. [I873] HANDBOOK FOR NURSES FOR THE SICK by Miss Veitch. Crown 8vo, 2s. 6d. [1870] PUBLISHED BY J. AND A. CHURCHILL 28 ON THE WASTING DISEASES OF CHILDREN by Eustace Smith, M.D. Lond., Physician to the King of the Belgians, Physician to the East London Hospital for Children. Second Edition, post 8vo, 7s. 6d. [I870] A SYSTEM OF DENTAL SURGERY by John Tomes, P.R.S., and Chaeles S. Tomes, M.A., Lecturer on Dental Anatomy and Physiology, and Assistant Dental Surgeon to the Dental Hospital of London. Second Edition, fcap. 8vo, with 268 Engravings, 148. [I873] A MANUAL OF DENTAL MECHANICS, with an Account of the Materials and Appliances used in Mechanical Dentistry, by Oaelet Coles, L.D.S.E.C.S., Surgeon-Dentist to the Hospital for Diseases of the Throat. Crown 8vo, with 140 Wood Engravings, 7s. 6d. [I873] NOTES ON ASTHMA; its Forms and Treatment, by John C. Thoeowgood, M.D. Lond., Physician to the Hospital for Diseases of the Chest, Victoria Park. Second Edition, Eevised and Enlarged, crown Svo, 4s. 6d. q873] ENGLISH MIDWIVES: Their History and Prospects, by J. H. Avelizs^g, M.D., Physician to the Chelsea Hospital for Women, Examiner of Midwives for the Obstetrical Society of London. Crown Svo, os. [1872] A TOXICOLOGICAL CHART, Exhibiting at one View the Symptoms, Treatment, and mode of Detecting the various Poisons — Mineral, Vegetable, and Animal : with Concise Directions for the Treatment of Suspended Anima- tion, by William Stowe, M.E.C.S.E, Thirteenth Edition, 2s. ; on roller, 5s. [I872] DICTIONARY OF PRACTICAL SURGERY and Encyclopaedia of Surgical Science, by Samuel Coopee. New Edition, brought down to the present Time by Samuel A. Lane, Consulting Surgeon to St. Mary's and to the Lock Hospitals ; assisted by various Eminent Surgeons. 2 vols. Svo, SOs. [I86I and I872] The following Catalogues issued by Messrs Chuechill will be forwarded post free on application : 1. Messrs GhurchilVs General List of 400 works on Medicine, Surgery, Midivifenj, Materia Medica, Hygiene, Anatomy, Physiology, Chemistry, S^'c, Sfc. 2. Selection from Messrs ChurchiWs General List, com- prising all recent Worhs published by them on the Art and Science of Medicine. 3. A descriptive List of Messrs GhurchilVs Worhs on 'Chemistry, Pharmacy, Botany, Photography, and other branches of Science. 4. Messrs GhurchilVs Bed-Letter List, giving the Titles of forthcoming New Worhs and Neiv Editions. [Published every October.] 5. The Medical Intelligencer, an Annual List of New Worhs and New Editions published by Messrs J. ^ A. Churchill, together ivith Particulars of the Periodicals issued from their House. [Sent in January of each year to every Medical Practitioner in the United Kingdom whose name and address can be ascertained. A large number are also sent to the United States of America, Continental Europe, India, and the Colonies.] Messes CHUECHILL have concluded a special arrangement with Messes LINDSAY & BLAKISTON, of Philadelphia, in accord- ance with which that Firm will act as their Agents for the United States of America, either keeping in Stock most of Messrs Chtjechill's Books, or reprinting them on Terms advantageous to Authors. Many of the Works in this Catalogue may therefore be easily obtained in America. PKINTED BY J. E. ADLAED, BARTHOLOMEW CLOSE. 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