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DISEASE IN INDIA

LONDON

PHINTED BT SPOTTISWOODE AND CO.

NEW-STEKET BQUABB

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CLINICAL RESEARCHES

DISEASE IN INDIA

CHAELES MOREHEAD, M.D.

FELLOW OF THE ROYAL COLLEGE OF PHYSICIAKS : TKINCIPAL OF GEAKT MEDICAL COLLEGE : PEOFESSOR OF THE

PRINCIPLES AND PRACTICE OF MEDICINE AND OF CLINICAL MEDICTNE : SURGEON TO THE JAMSETJEE

JEJEEBHOY HOSPITAL, AND FORMERLY ASSISTANT-SURGEON TO THE EUROPEAN

GENERAL HOSPITAL, AT BOMBAY

SECOND EDITION

^/i^'^

'%i

LONDON
LONGMAN, GEEEN, LONGMAN, AND EOBEETS

1860

JOHN M<^LENNAN, M.D.

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS. LATE PHYSICIAN-GENERAL

OF THE ARMY, AND MEMBER OF THE BOARD OF EDUCATION,

OF THE PRESIDENCY OF BOMBAY,

CONSPICtrOUS THEOTJGHOUT A LENGTHENED PEBIOD OF PUBLIC SEEVICE

rOE PEOFESSIONAL ATTAINMENTS, ADMINISTEATIVE ABILITY,

AND GENEEOUS PHILANTHEOPY,

COMMEMOEATED, ON HIS DEPAETIJEE FEOM INDIA,

BY THE UNITED TESTIMONY OP THE GOVERNMENT AND ALL CLASSES OP

THE COMMUNITY,

THIS WORK IS DEDICATED,

WITH THE ADMIEATION AND EEGAED WHICH LONG PEIENDSHIP
HAS INSPIEED.

PREFACE

THE SECOND EDITION.

The haste inseparable from the circumstances in which this work
was originally prepared and published, led to numerous defects of
arrangement and execution, which I have endeavoured to amend
in the present edition. While the size of the book has been
much reduced by the adoption of a smaller type, a more careful
selection of cases, and a thorough revision of the text, — full use has
been made of three years' additional experience in India, partly as
Professor of Clinical Medicine, and partly as Superintending
Surgeon of the Poena division of the Bombay army.

My matured opinions on the therapeutic value of quinine and
of arsenic, and on the best methods of using these medicines in
malarious fevers, have been explained. The occasional occurrence
of Typhoid — Enteric — fever in India has been acknowledged ; and
chapters on Sun-Stroke and on the Hill Sanitaria of the Deccan
have been added.

London, August, 1860.

PllEFACE

THE FIKST EDITION.

The desire which I have long entertained of contributing to the
resources of practical medicine in India, has been realised at the
present time, in obedience to the wishes of the Honourable Court
of Directors of the East India Company, originating in the following
minute, which was submitted on the 15th May, 1854, by Dr. Mc-
Lennan, Physician-Greneral of the Bombay Army, to his colleagues
in the Board of Education, approved by them and by the Govern-
ment of Bombay : —

MINUTE.

" I now beg to submit to my colleagues the proposition to which I lately adverted,
when treating of the approaching departure of Dr. Morehead on sick leave. My own
impression was, that in all probability eighteen months would be necessary for the
purpose of recruiting his health ; but in consideration of the special nature of the leave
applied for, the Medical Board restricted their recommendation to a period about which
there could be no doubt, and, therefore, mentioned twelve months only as the time
deemed requisite for his restoration to health and efficiency.

" I would now submit, that the Board of Education make a suggestion to Govern-
ment, in view to its transmission to the Honourable Court of Directors, that at the
end of that period Dr. Morehead be requested to occupy himself in advancing tlie
cause of Indian Medical Education by the preparation of a work on the Diseases of
India, calculated, not only for the Students educated in Indian Medical Colleges and
for Indian Graduates, but also for Medical Commissioned Officers of the Honourable
Company's Service on first arrival in India, and till such time as they have acquired
that experience which years of service alone supply. The period necessary to
bring out such a work, with the materials already accumulated by Dr. Morehead,
would probably not exceed another year, and thus the whole term of absence, both on
account of health and duty, would not exceed that for which leave within the limits
on the old Furlough Kules has hitherto been given.

"It may be well that I should say something of the grounds on which I venture to

X TllEFACE TO FIKST EDITION.

make this recommendation, and here I would say that Dr. Morchcad's experience
has been varied and extensive. On first arrival in India ho sen'ed for two years with
European, and for as many years with native troops, at different stations. He was
then for two years in charge of the sanatory station of Mahableshwur ; — thereafter,
for more than six years, resident Assistant Surgeon of the European General Hospital,
Bombay — an institution in which the inmates are of very varied circumstances as to
habits, position in life, nature of duties, and length of residence in India, &c. In that
hospital are accommodated the newly arrived European and the old servant of many
years' Indian residence — the seamen of the Royal, Indian, and Mercantile navies —
the soldiers of all arms and both services, Queen's and Company's — the townsman —
mechanic — clerk — male and female — adult and child — from most classes of life,
and many stations in the interior. The opportunity for seeing variety of disease,
therefore, under great diversity of circumstance, is considerable,

"Dr. Morehead was likewise for six years Surgeon of the BycuUa Schools. In parts
of 1843 and 1844 he was in Sinde, and had an opportunity of observing the state of
health of Europeans and Natives after the sickly season of 1843.

" He has been for nearly nine years Surgeon of the Jamsetjee Jejeebhoy Hospital,
and for six years has been engaged in teaching Medicine and Clinical Medicine in the
Grant Medical CoUege ; and the records of the Clinical Wards have been carufully
preserved during the whole of this period.

" He has been twelve years Secretary to the Medical and Physical Society, during
which time there has been afforded him by the Medical Board the opportunity of
becoming acquainted with the tenor of the medical reports and cases from all parts
of the Presidency.

"In 1833, and again in 1853, Dr. Morehead had the opportunity of observing some
of the hospitals and medical institutions in Madras, Calcutta, Colombo, &c. &c.

"Very numerous papers on Dysentery — Dracunculus — Diseases of the Abdominal
Viscera — Intermittent and Eemittent Fevers — Delirium Tremens — Diseases of the
Brain — Hepatitis and Cholera — Measles in the Byculla Schools, &c. &c., have been
inserted by him in the Edinburgh Medical and Sui'gical Journal, Transactions of the
Medical and Physical Society of Calcutta, and Transactions of the Medical and Physi-
cal Society of Bombay.

" In the last work, too, at a comparatively recent date, five papers, based on obser-
vations chiefly made in the Clinical "Wards of the Jamsetjee Jejeebhoy Hospital, on
the important subjects of Smallpox — Bright's Disease of the Kidney — Diseases of
the Heart — Pneumonia — and Beriberi — have been contributed, and there are
records from which to make the same kind of observations in respect to other im-
portant diseases treated in the same wards, such as Hepatic Abscess — Dysentery —
Fevers — Phthisis Pulmonalis — Paralytic Affections, &c. &c.

" Having thus detailed the sources from which Dr. Morehead's experience and fit-
ness for the task which I have ventured to saiggest have been derived, I may now add
a few words as to the nature of that want which I propose he should supply ; and here
I honestly give it as my opinion, that till some work of the kind I suggest be brought
forth, the efforts of Indian Governments and their servants in medical education will
be incomplete. At present, Graduates and Students of Indian Medical Colleges are
without any book on practice in Indian Disease, as now generally followed, or as
requiring modifications to meet peculiarities of native habit and constitution.

" The duties of the Clinical Wards in the Grant Medical College have been so
carried on, and so recorded, as to constitute an important collection of facts and prac-
tice, which may be brought to bear on this want. The labour of collecting, digest-
ing, and condensing for such a work will be considerable, and, as it is valuable
for Indian purposes, it should (it seems to me) receive support and encourageinent

PREFACE TO FIRST EDITION. XI

from the Indian Government, which Dr. Morehead has so zealously and usefully-
served.

" I, therefore, trust my colleagues will support my proposition, and recommend, that
after the expiration of the leave lately granted, Dr. Morehead may have, for the above
purpose, another year in England on Indian allowances, and to count as service, with
the right of returning to that place in the Grant Medical College, over which he has
so beneficially presided." *

In performing this duty I have endeavoured to embody my
experience in a connected form, and to illustrate my opinions by
cases which have passed under my immediate observationf and care ;
while, at the same time, I have not been inattentive to the views of
other inquirers.

My clinical researches have been directed to disease, as occurring
both in Europeans and in the Natives of India. I have aimed not
merely to increase practical knowledge of the diseases usually
termed tropical, as malarious fever, hepatitis, dysentery; but, also
to show that affections — pneumonia, phthisis pulmonalis, peri-
carditis, Bright's disease — familiar to European observers, are
sufficiently common in India, more particularly in some classes of
the native community.

Cases have been introduced chiefly with the object of elucidating
the Symptomatology and Pathology of disease. They have been
used freely in the form of summaries, which have in every instance
been carefully prepared by myself. The graduates of the Indian
Medical Colleges, for whose benefit I have chiefly written, may
often, for many years yet to come, be placed in positions remote
from their professional brethren, and in circumstances ill adapted
for the prosecution of pathological research. The recollection of
this fact has removed any hesitation which I might otherwise have
felt relative to the expediency of inserting so many illustrative
details. But, at the same time, I have been careful so to arrange
the text of the work, that it may be readily perused independent of
the cases ; and so to. classify and indicate the cases, that they may
be referred to without difficulty by those who may be engaged in
the close investigation of the diseases to which they relate.

* Report of the Board of Education, Bombay, from May 1, 1854, to April 30, 1855,
p. 144.

t The few cases not observed by myself which have been inserted, are indicated by
an asterisk.

XU PREFACE TO FIRST EDITION.

In my remarks on the treatment of disease I have invariably
endeavoured to explain fully the principles, and to state the means
by which they may be best applied. Cases illustrative of treatment
have been sparingly used by me, because practical conclusions
arrived at, after a lengthened course of experience, are grounded
partly on cases successfully treated, partly on those which have
proved fatal, and partly on the observation of different methods in
the hands of others. Therefore the physician, on looking back to
the records of his practice through a long series of years, is not
likely to meet with many cases calculated to illustrate at all points
his matured therapeutic opinions.

Making exception, then, of the few cases which have been
detailed in explanation of treatment, I would request the reader to
refer exclusively to the text for my views on this important pitrt of
my subject. Doubtless the principles inculcated by me will be
found applied in the management of many of the cases which have
been narrated with a different object; but, on the other hand, I am
very sensible that some of them may be fairly open to criticism.

It was my desire to have concluded this work with a chapter on
the Diseases of Females and of Children, but the time at my com-
mand has come to a close. In respect to some of the diseases of
which I have treated, reference has been made to their occurrence
in females, and in the early periods of life ; and a little reflection
will readily suggest the modifications of the pathological and thera-
peutic principles, which I have endeavoured to enforce, to the cir-
cumstances of difference of sex and of age. Still, the subject is of
much interest and importance, and I would indulge the hope that
I may be permitted, at some future time, to supply the omission
which at present I have been unable to avoid.

London, May, 1856.

CONTENTS.

PAOR

Preface to Second Edition . . . . . . . rii

Preface to First Edition ....... ix

CHAPTEK I.

Introduction. — General Remarks on the Causes, Pathology, and Treat-
ment OF Disease in Indla . . . . . . .1

CHAPTER II.

Remarks on the Statistics of the European General Hospital, and of the
Jamsetjee Jejeebhoy Hospital at Bombay . . . . .11

CHAPTER III.
General Remarks on Fevers in India . . . . . .16

CHAPTER IV.
ON intermittent fever.

Section I. — Different Types of Intermittent Fever

Section II. — Simple Intermittent Fever. — Symptoms, Pathology, and Treat-
ment .........

Section III. — Intermittent Fever complicated with Enlargement of the Spleen
— Symptoms. — Pathology. — Treatment ....

Section IV. — Intermittent Fever with Hepatic Complication. — Symptoms. —
Pathology. — Treatment ......

Section V. — Intermittent Fever complicated with Jaundice, or Affections of the
Stomach or Bowels ........

Section VI. — Intermittent Fever complicated with Cerebral Affection

Section VII. — Intermittent Fever complicated with Bronchitis, Pneumonia,
Rheumatism, Scorbutus, Pericarditis, Asthma

47
49

XIV CONTENTS.

CHAPTER V.

ON REMITTENT FEVEE.

Section I. — The Diagnosis of Remittent Fever, from Intermittent Fever and
ardent Continued Fever. — Division into Simple and Complicated . . 66

Section II. — Symptoms of Remittent Fever. — Ordinary, Inflammatory, Ady-
namic, Congestive, Badly developed, with unexpected Collapse, with peculiar
Features. — Also complicated with Cerebral AiFection, Irritability of Stomach,
Jaundice, Bronchitis, Pneumonia. — Diagnosis from Hectic and Symptomatic
Fever .......... 58

Section III. — Pathology. — Mortality from Remittent Fever. — Relation of
Type to Diathesis and previously existing Structural Lesions. — Complication
with Cerebral Affection and Consideration of the Pathological Import of
Cranial Serous Effusion. — Complication with Gastric Irritability, Affection of
the Bowels. — Hepatitis, Jaundice, Parotitis, and Pneumonia . . 75

Section IV. — Treatment. — Contrast of the Principles of Treatment of Malari-
ous Remittent Fever, and the Zymotic Continued Fevers of Cold Climates. —
Treatment of Ordinary, Inflammatory, Congestive, Adynamic, and Irregular
Types of Remittent Fever. — Then of those complicated with Cerebral Affec-
tion, Gastric Irritability, Jaundice, Hepatitis . . . . 106

Section V. — Treatment further considered in Remarks on Blood-letting, Mer-
cury, Cold Afiusion and Wet Sheet Packing, Purgatives, Emetics, Blisters,
Opiates, Quinine, Diet, and Change of Air . . . . .122

CHAPTER VI.
On Certain Obscure Phenomena, probably Related to Malaria . . 153

CHAPTER VII.
On Adynamic Remittent Fever of Suspected Infectious Character . 155

CHAPTER VIII.
On Typhoid Fever ........ 160

CHAPTER IX.

ON COMMON CONTINUED FEVER FEBRICULA AND ARDENT CONTINUED FEVER.

Section I. — General Remarks . . . . . . . 162

Section II. — Common Continued Fever — Febricula . . . .162

Section III. — Ardent Continued Fever . . . . .164

CHAPTER X.

On the Febrile Affections of Children in India. — Febricula. — iNTERikor-

TENT AND REMITTENT FeVER . . . . . . .168

CHAPTER XL

STATISTICS OF FEVER IN THE EUROPEAN GENERAL HOSPITAL, THE JAMSETJEE JEJEBBHOY
HOSPITAL, AND BYCULLA SCHOOLS, AT BOMBAY.

Section I. — European General Hospital. — Total Fevers . . .170

Section 11. — European General Hospital Intermittent Fever . .172

CONTENTS. XV

PAOK

175
176
177
179
181

Section III. — Jamsetjee Jejeebhoy Hospital. — Total Eevers .
Section IV. — Jamsetjee Jejeebhoy Hospital. — Intermittent Fever
Section V. — European General Hospital. — Kemittent Fever ..
Section VI. — Jamsetjee Jejeebhoy Hospital — Remittent Fever
Section VII. — Byculla Schools Intermittent and Remittent Fever

CHAPTER XII.

on eruptive fevers.

Section I. — Prevalence in the Native Army . . . . .182

Section II. — Small-pox, as observed in Bombay. — Prevalence. — Prevention

by Vaccination . . . . . . . .182

Section III. — On Measles in Bombay and the Deccan . . .194

Section IV. — Scarlatina, — Erysipelas. — Varicella. — Hooping Cough. —

Cynanche Parotidea . . . . . . • .199

CHAPTER XIII.

ON EPIDEMIC CHOLERA.

Section I. — Remarks on the Seasons of Prevalence and on the Causes of
Cholera 202

Section II. — Symptoms considered in reference to their degrees of severity.
— Diagnosis from Bilious Cholera, Irritant Poisoning, and Collapse of Remit-
tent Fever .......•• 208

Section III. — The General Rate of Mortality. — Its Relation to Age, Period
of Epidemic, and Duration before Admission considered. — General Pathology
shortly noticed. — Morbid Anatomy described . . . .215

Section IV. — Treatment in the different degrees and stages of the disease. —
Recapitulation . . . . . ■ • ,221

Section V. — Statistical Tables relative to Epidemic Cholera in European
General Hospital, the Jamsetjee Jejeebhoy Hospital and the Byculla Schools
at Bombay ♦......•• 233

CHAPTER XIV.

ON DYSENTERY.

Section I. — The Importance of Dysentery in India. — Order in which the subject
will be treated ........ 236

Section IL— Pathology.— Detailed Statement of the Morbid Anatomy . 237

Section III. — Etiology of Dysentery. — Importance of distinguishing exciting
and predisposing Causes. — Exciting Caiises. — Cold, Food. — Predisposing
Causes. — Cachectic States. — Action of Malaria discussed . . • 273

Section IV. — Symptoms of Dysentery ...... 280

Section V. — Treatment. — General Principles and Indications. — Detailed
Remarks on Blood-letting, general and local, Calomel, Mercurial Influence,
Ipecacuanha, Purgatives, Diaphoretics, Opium, Chloroform, Astringents,
Tonics, Fomentations, Blisters, Enemata, Diet, and Change of Climate . 288

XVI

CONTENTS.

Section VI. — Dysentery in Children in India . r . .

Section "VII. — On Gastro-Enteritis .....

Section VIII. — On Diarrhoea ......

Section IX. — Statistics of Dysentery in the European Hospital, and of Dysen
tery and Diarrhoja in the Jamsetjee Jejeebhoy Hospital and Byeulla Schools
at Bombay . . • • • . .

PAGE

314

316
31G

318

CHAPTER XV.

ON HEPATITIS.

Section I. — Comparative Prevalence of Hepatitis ....

Section II. — Preliminary Remarks on the nature of the Symptoms of Hepatic
Disease. — Arrangement of the Subject . . .

Section III. — Pathology. — Preliminary Remarks on the General Pathology of
Hepatitis. — Morbid Anatomy of Stage of Vascular Turgescence, of Exudation
of Lymph, and Formation of Abscess explained. — The several Courses and
Situations of Rupture of Hepatic Abscess. — Abscess Absorption. — Secondary
Peritonitis and Formation of circumscribed Purulent Sacs. — Secondary
Pleuritis, circumscribed and general Empyema. — Secondary Pericarditis. —
General Secondary Peritonitis,— Colour of Pus in Hepatic Abscess

Section IV. — Etiology of Hepatitis. — Exciting Causes. — External Cold, elevated
Temperature, Intemperance, Mechanical Causes. — Importance of Predisposing
Causes stated. — The Complication of Hepatic Abscess and Dysentery consi-
dered in reference to the Pycemic Theory of the Causation of Hepatic Abscess

Section V. — Symptoms of Hepatitis. — Early Stages. — Pain, Respiratory Move-
ments. — Physical Signs. — Altered Secretion, Jaundice. — Constitutional
Disturbance. — Suppuration. — Course of Hepatic Abscess

Section VI. — Treatment of Early Stages. — Blood-letting, general and local. —
Mercurial and other Purgatives. — Mercurial Influence. — Blisters. — Treat-
ment when Abscess is forming and is perfected. — Question of Puncture
considered. — Change of Climate ......

Section VII. — Hepatitis in Females and in Children ....

Section VIII. — Occasional Difficulties and Errors of Diagnosis

Section IX. — Statistics of Hepatitis in the European General Hospital and the
Jamsetjee Jejeebhoy Hospital, at Bombay .....

321

323

325

361

370

384
415
416

417

CHAPTER XVI.

ON CIBBHOSIS, congestion, LARDACEOUS AND FATTY ENLABGEMENT, CANCER AND

hydatid of the liver. AFFECTIONS OF THE BILIARY DUCTS AND GALL-BLADDER.

BILIARY CALCULI. — JAUNDICE. — INCREASED AND DEFECTIVE SECRETION OF BILE.

Treatment. — Complication

Section I. — Cirrhosis. — Pathology. — Symptoms.

with Hepatic Abscess . . . . . . . .421

Section II. — Congestion of the Liver. — CEdema .... 426

Section III — Lardaceous and Fatty Liver. — Cancer, and Hydatid Formations 428

Section IV. — Inflammation of the GaR-Bladder and Biliary Ducts. — Distention
of the Gail-Bladder.— Biliary CalcuH . . . . . .431

Section V. — Jaundice. — Pathology. — Causes. — Treatment . . . 433

Section VI. — On Increased and Defective Secretion of Bile . . . 440

CONTENTS. XVll

CHAPTER XVII.

ON PERITONITIS, ILEUS AND COLIC.

PAGE

Section I. — Peritonitis. — Pathology. — Plastic and sero-pimform Exudations
related to Diathesis.— Chronic Tubercular. — Chronic not Tubercular, and not
Consecutive on Acute. — Treatment ...... 443

Section II.— Ileus and Colic ....... 463

CHAPTER XVIII.

AFFECTIONS OF THE STOMACH.

Section I. — Gastritis, Acute and Chronic . . . . • 458

Section II. — Glossitis . . . . . . . .461

Section III. — Dyspepsia. — General reflections on Pathology and Principles of
Treatment ......... 463

CHAPTER XIX.

ON BEIGHt's disease OF THE KIDNEY AND ALBUMINOUS UBINE.

Section I. — Prevalence of Bright' s Disease in the Hospital-frequenting classes
of the Natives of India ....... 465

Section II. — The Relation of Bright's Disease to Albuminous Urine stated. —
The Morbid Anatomy and Pathology of the Fluids. — Pathology of the Secon-
dary Affections. — The Uroemic Theory. — The Proximate Cause of Albumen
in the Urine . . . . . . . . .466

Section III. — Etiology. — Scarlatina not influential in India. — Relation to Caste,
Age, Occupation, Habits, Season. — Cold an exciting Cause sometimes of the
Kidney Disease, generally of the Secondary Afifections . . . 487

Section IV. — Symptoms. — ^Referable to the Kidney. — Condition of the Urine. —
Treatment. — Of the Kidney Disease. — Of the Secondary Affections, chiefly the
Dropsical Effusions . . . . . . . .491

CHAPTER XX.

ON ABNORMAL STATES OF THE UBINE.

Section I. — PreHminary Pathological Remark. — A want of Information in
respect to the Normal Condition of the Urine in India . . . 497

Section II. — Chylo-serous Urine. — Short Notice of its Pathology and Treatment 498

Section III. — Saccharine Diabetes. — Infrequent in India. — Diuresis . . 502

Section IV.— Uric, Oxalic, and Phosphatic Diathesis . . . .505

CHAPTER XXI.

ON PNEUMONIA.

Section I. — Pneumonia. — Rare in Europeans in Bombay. — Asthenic Form
common in Natives ........ 508

Section II. — Etiology. — Relation to Sex, Age, Caste, Habits, Constitution, and
Season ......... 509

XVlll CONTENTS.

PAGE

Section III. — Pathology.— Preliminary Question relative to the Affected Capil-
laries.—Rate of Mortality. — Duration of Illness before Admission. — Stage of
the Disease. — Which Lung most frequently Affected. — Period of Residence in
Hospital. — State of the Lung on Discharge. — Morbid Anatomy . . 512

Section IV. — Symptoms.— Fever, Pain, Dyspnoea, Cough, Delirium, Character
of the Sputa. — Physical Signs ...... 527

Section V. — Treatment. — General and Local Blood-letting, Tartar Emetic,
Mercury, Blisters, Quinine, Liquor Potassae, Stimulants. — Concluding
Remarks ......... 534

Section VI. — Statistics of Pneumonia . . . . .547

CHAPTER XXII.

ON PLEUBITIS, BRONCHITIS, A.ND ASTHMA.

Section I. — Pleuritis. — Symptoms, Causes, Pathology, Treatment . , 548

Section II. — Bronchitis. — Asthma . . . . . . 552

Section III. — Statistics of Bronchitis . . ... . 553

». -♦-*» CHAPTER XXIII.

ON PHTHISIS PULMONALIS.

Section I. — Causes, Symptoms, Pathology, and Treatment . . . 554

Section II. — Statistics of Phthisis Pulmonalis .... 560

CHAPTER XXIV.

ON PERICABDITIS AND ENDOCABDITIS.

Section I. — Introductory Remarks . . . . . .561

Section II. — Causes, Symptoms, and Treatment .... 562

CHAPTER XXV.

ON ORGANIC DISEASE OF THE HEART AND AORTA.

Section I. — In Natives of India . . . . , .581

Section II. — In Europeans in India ...... 600

CHAPTER XXVI.
On Sun-stroke ........ 603

CHAPTER XXVII.

ON delirium tremens.

Section I. — On the Symptoms and Treatment of Delirium Tremens in the

European General Hospital at Bombay ..... 624

Section II. — On the Pathology, the Principles of Treatment, and Diagnosis . 641

Section III. — Delirium Tremens in the Natives of India . . . 645

Section IV. - Statistics of Delirium Tremens ..... 646

CONTENTS. XIX

CHAPTER XXVIII.

ON CEREBRAL DISEASE AND PARALYSIS.

PAOB

Section I. — Greneral Preliminary Remarks on the Pathology and Treatment of
Cerebral Disease ........ 648

Section II. — Apoplexy. — Meningitis. — Acute and Chronic Hydrocephalus. —
Morbid Growths within the Cranium. — Paroxysmal Headache . . 650

Section III. — Paralysis. — Hemiplegia. — Myelitis. — Paraplegia. — Paralysis
from Arsenic. — Facial Palsy ....... 658

Section IV. Statistics of Paralysis . . . . . .671

CHAPTER XXIX.

ON TETANUS.

Section I.— The prevalence of Tetanus in certain classes of the community in
India .......... 672

Section II.— Pathology. — Nature of the Deranged Action with reference to the
Physiology of the Spinal Cord. — Division into Idiopathic and Traumatic,
Acute and Chronic. — Morbid Anatomy ..... 673

Section III. — Etiology. — Diathesis, Cold, Entozoa? — External Injuries . 678

Section IV. — Symptoms. — Muscular Rigidity and Spasms. — Respiration. —
Pulse. — Febrile Disturbance, &c. ...... 680

Section V. — Treatment of Tetanus ...... 683

Section VI. — Statistics of Tetanus ...... 688

CHAPTER XXX.

ON HYDROPHOBIA.

Section I. — Short allusion to Symptoms and Pathology. — Illustrative Cases
detailed . . . . . . . . .689

CHAPTER XXXI.

ON BLOOD DISEASES.

Section I. — Object of the Chapter explained ..... 692

Section II. — Pyoemia. — Short notice of Symptoms and Pathology. — Illustrative
Cases. ......... 692

Section III. — Leprosy. — Tubercular and Anaesthetic. " — Short account of the
Symptoms and Pathology ....... 695

Section IV. — Elephantiasis. — Symptoms. — Pathology. — Causes. — Treatment . 698
Section V. — Scurvy. — Prevalence in India. — Short Practical Remarks . . 701
Section VI. — Greneral Dropsy. — Beriberi. — Symptoms. — Pathology. — Treat-
ment.— Illustrative Cases ....... 704

vSection VII. — Rheumatism. — Prevalence in India . . . .715

Section VIII.— On Snake Bite . , . . . .716

CONTENTS.

CHAPTER XXXII.

ON DBACUNCULUS,

PAGE

Section I. — Prevalence of, in Bombay Presidency. — Relation to Season. —
Allusion to Theories respecting its mode of origin. — Short notice of Symp-
toms and Treatment ........ 720

Section II. — Statistics of Dracunculus ..... 725

CHAPTER XXXIII.
On the Hill Sanitaria of the Deccan

728

APPENDIX.

A. — On the Meteorology of Bombay

B. — Sanitarium at Poorundhur

List of Cases .....
List of Statistical and Meteorological Tables
Index . . .

741
747
753
765
7G9

DISEASE IN INDIA

CHAPTER I.

INTRODUCTION. GENERAL REMARKS ON THE CAUSES, PATHOLOGY, AND

TREATMENT OF DISEASE IN INDIA.

Clinical research is the study of Pathology and Therapeutics,
by careful observation and comparison of numerous instances of
disease ; and in conducting it, the truth soon becomes evident that
the course and treatment of all forms of disease are modified
by previously existing habits of the body, congenital, or acquired
in one of the three following ways: —

1. By the neglect of a right condition of the agencies termed
vital stimuli, which are as essential to the physiological perform-
ance of function as organic integrity : they are food, water, atmo-
spheric air, heat, light, electricity, exercise and repose of body
and mind. 2. By undue discharges from the blood. 3. By the
reception into the blood of external injurious agencies — poisons;
or by the retention of excretions.

Under these heads may be classed — (a) States unduly plethoric or
sthenic ; (6) Asthenia and cachexia, from insufficient food, struma,
scarvy, vitiated atmosphere, elevated temperature, etiolation, de-
pressing mental affections, bodily fatigue, prolonged lactation,
haemorrhages, exhausting medical treatment — excessive in degree or
too long continued, malaria, syphilis, carcinoma, mercury, arsenic,
lead, alcohol, albuminuria, rheumatism, &c. Though in these
cachexise there may be peculiarities special to each, still there are
features common to all. The vital actions of the system are
defective, the nutrition of the blood and of the tissues is impaired.

2 GENERAL KEMARKS.

secretion is diminished and deranged, nervous influence and mus-
cular irritability are imperfect, and the generation of animal lieat
is lowered in degree.

In my clinical remarks on the different forms of disease,
frequent reference will be made to these states under the
terms Asthenic and Cachectic : by the first is meant only a low
degree of function ; but by the second, a defect in quality as well
as in degree.

It is very probable that an essential condition of all cachectic
states is an altered quality of the blood, and that our present
ignorance of the alterations peculiar to each may be removed by
future pathological research.

In directing medical treatment, the physician is constantly
reminded of the obstacles which asthenic or cachectic states in-
terpose to the success of his remedies, and of the necessity which
exists of making the removal of these states a leading indication in
the management of all forms of disease. Thus two important
practical lessons are enforced : —

1. Though the details of sanitary science and art are not
within the province of clinical instruction, yet the great import-
ance to the public health, and to the successful treatment of
disease, of a well-organised sanitary system, is a prominent in-
ference from clinical research.

2. The advantage derived in practice by the removal of the sick
from the influence of the causes productive of cachexise serves to
substantiate this truth : that a rational system of medicine is one
which includes a careful adjustment of the vital stimuli and the
removal of laedentia, as well as the use of medicines ; and that when
the cachectic condition is very marked, then the two first thera-
peutic principles are the most essential.

These doctrines will be frequently adverted to in my remarks
on different diseases.

The necessity of carefully considering the general condition of
the body, in the treatment of disease, is universally true; but
when investigation has reference to a particular country, then the
preliminary question arises whether, a-s regards this field of obser-
vation, there are special causes exercising an influence on the
constitution of man.

In applying this rule to India, it may be stated that, on com-
paring tropical with temperate climates, we find, 1st, that the heat
of the summer season of the former readily acts as the exciting
cause of serious forms of disease in the recently arrived plethoric

CAUSES OF DISEASE HEAT. 3

and sthenic natives of the latter ; 2nd, that in tropical countries,
not much elevated above the level of the sea, there are two special
causes of asthenia and cachexia, more or less prevailing — the
influence of long-continued and frequently repeated high tem-
perature, and the action of malaria.

The effect of elevated temperature on the European constitution,
in increasing and deranging the biliary secretion, has been a con-
stant theme with a succession of able writers on the diseases of
Europeans in tropical climates. Though the observations made on
the recently arrived, on which these opinions mainly rest, are
correct, still they are erroneous when applied to the far more
numerous class of established residents ; in them the secretion of
bile is not habitually increased.

One consequence of high atmospheric temperature on the animal
system is a diminished necessity for animal heat : hence there is
less demand for food, less metamorphosis of tissue, and less
excretion. This truth is made manifest by the asthenic condition
of the residents in warm climates, compared with the sthenic
state of the inhabitants of colder latitudes.

The European soldier or sailor, on arrival in India, does not
appreciate, and therefore does not readily adopt, the alteration in
habits of life necessary to the maintenance of health under the
circumstances of a warmer climate ; consequently the excesses,
which in the cold climate might be imattended by disorder, are,
under the predisposition caused by the action of increased heat,
followed by derangement. Ardent continued fever or febricula,
bilious cholera or diarrhoea, are under these circumstances very apt
to occur. The increased metamorphosis of tissue, or of constituents
of the blood, related to diathesis, or consequent on food taken in
excess of the normal requirements of animal heat, may in part
explain the proclivity to these forms of febrile disease. The theory
usually conceived of the biliary derangements may be correct :
viz. that the decreased elimination of hydro-carbon by the lungs,
resulting from the less demand for animal heat, is liable to lead to
the office of eliminating the excess of these elements present in the
system, being transferred to the liver. But it by no means follows,
that when there is the just relation between the quantity and
kind of food consumed and excretion, which is implied in the
habits of every prudent resident in a hot climate, there exists a
greater degree of action of the liver vicarious of that of the lungs
in the one climate than in the other.

Questions relative to the proportion of ingesta? to excreta, and of

B 2

4 GENEllAL IIEMAIUCS.

the various excreta to each other, under varying circumstances of
the animal system, can only be satisfactorily determined by careful
observation and experiment. Inquiry of this kind, on an extensive
scale, is still amongst the desiderata of physiological science; and,
in the absence of the requisite data, all that can be safely affirmed
in reference to India and other tropical countries is, that in the
normal state of the system, all the solid* excreta are considerably
less in amount than in the colder climates of Europe. The
evidence that the biliary excretion is not increased, rests on the
fact, that in the natives of India, and in Europeans whose habits
of living have become adapted to the climate, derangement of this
kind is very rarely observed.f

Malaria is the exciting cause of the intermittent and remittent
types of fever. It also induces cachexia, either in consequence of
frequent febrile recurrences, or by the exercise of a slov and
gradual influence, irrespective of distinct paroxysms of fever.
To the terrestrial miasm, whatever it may be, which is believed
to produce these and other allied effects, the term Malaria will
be restricted throughout this work, and will never be used in that
more general sense, not unfrequently adopted by modern writers,
and which it may be feared is leading to needless confusion, and
obscurity in our views on the causes of disease.

The subject of Malaria is well and fully discussed by our best
systematic writers, and it will therefore be sufficient to state, very
shortly, the leading facts which are generally accepted relative to
the generation and action of this morbific cause.

1. The presence of malaria is determined by the occurrence of
certain derangements of health attributed to its influence, for as
yet all other means of investigation have failed in detecting it.

2. A certain degree of heat acting on the earth's surface,
previously soaked wdth water, is essential to the production of

* I use the tenn solid, to exclude that water which has been receired and
eliminated without resolution into its elements.

t When this statement was written in the first edition of this work, I was not
aware that a similar opinion had been expressed by Dr. Henry Marshall, in his work
on the diseases of Ceylon. Confirmed by the previous observation of this distin-
guished medical officer, it is now repeated with assured confidence. Dr. Marshall
thus writes : — -"It is, I believe, a very common opinion, that an excessive secretion
of bile is general in warm climates. Upon what foundation is this opinion assumed ?
With regard to Europeans in health, I have not been able to observe any remarkable
difference between the secretory functions of the liver in a tropical climate from that
of the same organ in high latitudes ; and with respect to the indigenous inhabitants
of inter-tropical regions, I am not convinced that the biliary secretion is unusually
copious." — Notes on the Medical Tojpography and Prevailing Diseases of Ceylon, p. 145.

CAUSES OF DISEASE — MALARIA. 5

malaria. It is more certainly generated while the process of
drying is going on — when aeriform emanations exist, in degree
proportionate to the rapidity with which the desiccation is
effected. Hence malaria is most abundant in marshy grounds
after the quantity of water has been reduced by evaporation to
that condition when the drying of the surface of the ground
begins, and while the atmospheric temperature is still high. It
is then, after the heats of summer have passed, and the autumnal
season has set in, — the months September and October, — that
in marshy countries malarious fevers chiefly prevail.

3. In those tropical regions, in which there are periodical
rains associated with elevated temperature, the generation of
malaria coexists with the periods when the heavy falls have ceased
and the drying of the earth's surface is going on. Consequent on
the rains of the south-west monsoon, which commence about May
and terminate in September, malarious fevers are prevalent some-
times in July, but generally riiost extensively in October. But
there may be variations in respect to the particular months
in different years. The necessary conditions are such relation
between the rain-fall and the temperature as shall cause the
rapid drying of a surface previously soaked with moisture.

4. There are districts of countries, chiefly in the warmer
climates, subject to the periodical inundation of large rivers;
and, should the subsidence of the waters coexist with elevated
temperature, then the generation of malaria, as evidenced by
the prevalence of intermittent and remittent fever, takes place.
The Granges, the Indus, the Euphrates, and the Nile, are rivers
of this kind. Consequent on the melting of the snows in the
mountain regions, at the sources of these rivers, the supply of
water is increased. They begin to rise about the month of March,
and attain their greatest elevation, overflowing their banks and
covering extensive tracts of country, in the month of September.
Then they gradually fall ; and, as the surface of the inundated
tracts becomes exposed, rapid drying commences. It is under
these circumstances that malarious fevers appear in these dis-
tricts in their most aggravated form.

It would seem that, whether in tracts habitually swampy,
or regions wetted by periodical rains, or the overflow of large
rivers, still the autumnal season is that in which malarious fevers
are most prevalent.

5. Malaria seems to show a preference for low levels, and

B 3

6 GENEBAL KEMAItKS.

the surface of the ground, compared with elevated sites and
higher atmospheric strata.

6. It often coexists with decaying vegetation, but not nnfre-
quently occurs, independent of it, in situations where the surface
is sandy, dry, and bare, and where the drying — that essential
condition in the generation of malaria — must be going on in the
damp subsoil.

7. Its influence on the system is more surely experienced at
night, and near to the surface of the ground.

8. Malaria may be wafted by currents of air from the spot
where it has been produced, and thus infect adjacent localities;
or by the same power, combined with the tendency to remain
near the surface of the earth, it may be carried up the slope
of a mountain, just as fogs are.

9. Malaria is believed to lose its noxious properties by passing
over a surface of water even of small extent. It is attracted
by the foliage of trees, and thus accumulates around them, and
between them and the surface of the ground, rendering jungly
tracts in tropical countries very dangerous at the malarious
season of the year. This property of the foliage of trees, however,
may be made subservient to the protection of tracts of country,
when belts of wood are interposed between them and malarious
localities.

10. Malaria is lessened by cultivation and adequate population,
but becomes rapidly increased when lands have been deserted and
allowed to run waste.*

* Such general statements as these, relative to the generation and action of malaria,
rest upon evidence which may be found in the Medical Statistical Eeports of the
British Army, and in the medical histories of military or naval expeditions to the
coasts of Africa and Arracan, to Burmah, Java, the peninsula of Spain, and to other
countries. They are, moreover, amply confirmed by obsen^ations made in my own
field of research, or in districts adjacent to it. The fevers which occur in the months
of September and October in the provinces of Guzerat, Candeish, and Scinde, illus-
trate the relation of malaria to elevated temperature and rapid drying of the
earth's surface. In the Deccan, and at Hursole, in Guzerat, there is evidence of
malaria without vegetable decomposition; while at Deesa they have occurred in
association together. The history of a fever which prevailed among the marines
of her Majesty's frigate "Endymion," in the dockyard at Bombay (to be more
particularly alluded to in the Chapter on Remittent Fever), aiFords a striking proof of
the greater infiuence of malaria by night than by day. At Tatta and at Hyderabad,
in Scinde, the malaria generated in the adjacent lowlands was carried by the prevail-
ing winds up the hill slopes on which the troops were stationed. That malaria is
attracted by, and accimiulates about, trees has been in too many instances painfully
proved by the history of detachments of troops injudiciously marched, at unseasonable
periods, through the extensive tracts of jungle which intei^ene between the provinces
of Candeish and Guzerat. In the fallen condition of the city of Ahmedabad, and in

EXCITING CAUSES OF DISEASE. 7

Exciting Causes of Disease. — Reference has been made to
asthenic and cachectic states as predisposing to disease of all kinds,
and the importance of a right appreciation of their influence in
causing and modifying disease in India will be frequently incul-
cated in various parts of this work. Malaria has also been regarded
as a predisposing and exciting cause, and the other ordinary
exciting causes of disease in India must now be shortly alluded to.
Of these, external cold is the most common. In judging of the
facility with which the temperature of the surface of the body be-
comes reduced in India, we must bear in mind the diminished
power of generating animal heat characteristic of warm climates
and asthenic states ; and that consequently, in these circumstances,
the surface of the body may become lowered in temperature by an
amount of external cold inadequate to produce this effect in colder
climates or stronger constitutions.

In order to form a just estimate of this exciting cause of disease,
it is very necessary to study carefully, in respect to the sphere in
which we practise, the physical features of the country, and the
characters of the different seasons of the year ; more particularly
those conditions of the atmosphere which favour the abstraction of
heat, such as absolute lowness of temperature, diurnal range, mois-
ture, direction, duration, and force of the winds.* It is further of
importance to consider these atmospheric states in reference to the
presence or not of pre-existing causes of asthenia or cachexia,
as malaria, scarcity, elevated temperature, syphilis, &c. For it
is well known that cold, as well as other exciting causes of disease,
acts very readily on debilitated persons ; and if this fundamental
doctrine in etiology — the influence of predisposition — be neg-
lected, we shall often be unable satisfactorily to explain the
prevalence of disease, — as types of fever, diarrhoea, dysentery,
rheumatism, perhaps cholera, — in localities usually healthy, and

the state of health of the troops at Hyderabad immediately after the battle of
Meanee and the capture of Seiiide, we have illustrations of the statement that the
production of malaria is favoured when districts are deserted, and previously culti-
vated lands are left waste. The references made to the dockyard in Bombay, and to
Tatta and Hyderabad, in Scinde, rest on my own observation and inquiry; those
relative to Guzerat, the Deccan, and Candeish, on two very instructive and interesting
descriptions of the provinces of Guzerat and the Deccan, by Mr. Gibson, published in
the first and second numbers of the " Transactions of the Medical and Physical Society
of Bombay ; " also a " Eeport on Candeish Fever," by Dr. Graham, in the fourth
luimber; and one by Dr. Brown, on the "Diseases of the Horse Artillery at Deesa,"
in the first number of the " Transactions" of the same Society,
* See Appendix. #

B 4

8 GENERAL REMARKS.

further be unable to account for the want of success attending our
treatment.

Though the elevated temperature of an Indian climate is chiefly
influential as a predisposing cause of disease, yet it is not to be
doubted that heat sometimes acts as an exciting cause in some
forms of fever, in some affections of the nervous system, and per-
haps in hepatitis, as will be explained more fully when these
diseases are treated of.

The exclusive observation of disease in unacclimatised sthenic
Europeans by a succession of writers on tropical diseases, and the
rapid course sometimes followed by bad forms of malarious fever
and of dysentery in such subjects, have created an impression that
inflammatory disease in India, compared with colder climates, is
characterised by speedy progress and excessive vascular action.
When, however, investigation is extended beyond the limited
circle of this class, we find that this opinion is erroneous. It has
been already stated that the common type of disease in India, both
in Europeans and natives, is asthenic; and the law in respect to
this type, verified in other countries, may be also safely affirmed of
disease in India, viz. that inflammations in asthenic and cachectic
habits are generally distinguished by an obscurity of symptoms
and a slowness of progress, in proportion to the degree of asthenia
or cachexia.

These features of asthenic disease often lead in India to nesrlect
of application for relief till disorganization of structure has well
advanced ; and they, moreover, sometimes tend to mislead the
practitioner in respect to the stage, and thus create the erro-
neous impression that the morbid changes have been rapidly
effected.

This belief in the severity of inflammatory disease in India,
originating in the manner just explained, naturally gave rise to
the opinion that disease in India generally required to be met
by a freer use of active antiphlogistic remedies. But, if the state-
ment made relative to the frequency of asthenic forms of disease
be correct, then it follows that blood-letting, mercury, purga-
tives, and all other depressing antiphlogistic remedies, should as a
general rule be used with greater caution, not with more freedom,
in India than in colder climates.

The pathological doctrines now generally current on blood-
diseases, and on various forms of degeneration of tissue consequent
on defective or perverted nutrition, are very valuable in the study
of disease in India, and demand the careful attention of patholo-

PATHOLOGY AND THERAPEUTICS.

gists in that country.* They, moreover, serve to enforce addi-
tional caution in respect to the abuse of antiphlogistic remedies, to

* Since this passage was written, a paper lias been published by Mr. Macnamara, in
the third volume of the "Indian Annals of Medical Science," the object of which is to
show that fatty degeneration of the liver and other organs is the chief cause of the
high rate of mortality among European troops in Bengal. The arguments are —
1. The statement that in twenty-four post-mortem examinations of men of the
1st European Bengal Fusiliers, made by the author, fatty degeneration existed in all,
with one exception, in the liver, the kidneys, the heart, and coats of the large blood-
vessels. 2nd. The diet ration is excessive, as regards both nitrogenous and car-
bonaceous principles. 3rd. The elevated temperature, close barracks, and indolent
habits of the soldier in India, are unfavourable to the pulmonary elimination of
hydro-carbon ; and as these elements are rarely deposited in India in the form of
adipose tissue, their only remaining outlet is by fatty degeneration, — hence the
great frequency of this structui'al change supposed by Mr. Macnamara to exist in
India. The statements and the reasoning are not convincing, because, — 1st, A
succinct cKnieal history and description of the post-mortem appearances of not
one of the cases is given ; therefore, though they may satisfy the observer himself, it
does not follow that they will convince others ; 2nd. Though the ration may be
excesssive,— though there may be instances of gluttony and great indolence in the
barrack-room as well as elsewhere, — it does not follow that all the food placed on
a barrack mess-table is uniformly eaten, any more than it is at the officers' mess-
table ; 3rd. That in the hot season of India the soldier is little disposed for active
exercise in the heat of the day, and that there is great necessity for enlargement
of barrack-rooms, and covered workshops and buildings for in-door recreation, is very
true ; still this is not the habit of the European soldier in the cold season in India,
or when active exercise is likely to be beneficial; 4. It does not accord with my
observation to say that the formation of adipose tissue is rare in India. Fat
Europeans and natives are common enough.

I still believe that, as a rule, there is no increase of elimination of hydro-carbon
by the liver to substitute a supposed deficiency of that by the lungs, because the
appetite soon brings about the just harmony between assimilation and general
excretion, which must render vicarious action unnecessary. I do not look for fatty and
other degeneration in India as a consequence of excesses in food, but as the result of
the lowered nutrition of the system, proceeding from the continuance of climatic
and other debilitating influences.

The diiFerent transient effects produced on the portal blood or its secretion by
different kinds of food, during the passage of those constituents which pass by this
channel, not by the lacteals, are not here adverted to.

In Dr. Budd's work, fatty liver, consequent on fatty food, removable by change of
diet and active exercise, is sufficiently explained ; and Fkerichs, in his late work,
*' Klinik der Leberkrankheiten," has added further to our knowledge by experiments,
which show that in dogs receiving in their daily food from half an ounce to one ounce
of oil, the following changes take place in the hepatic cells : — After twenty-four hours
there is an increase of molecular contents ; after three days, numerous fat globules
are apparent ; and, after eight days, the hepatic cells are almost completely filled with
larger and smaller fat globules. The fatty contents of the cells disappear after some
time, when the diet is changed ; probably a part, as supposed by Frerichs, returns to
the blood as fat ; and another, according to the functional design of the liver, is expended
in the formation of bile. This, however, is not fatty degeneration of the liver, but the
normal condition of the organ when certain articles of food are used. Mr. Macnamara
seems to confound this normal fatty state with fatty d^eneration. It is very

10 GENERAL REMARKS.

enhance the importance of the judicious use of tonic regimen* and
medicines, and to suggest further inquiry into the therapeutic
value and rational use of eliminants and alteratives.

likely that the fonner existed in some of his cases ; but when it is stated that not only
was there fatty degeneration of the liver in twenty-four cases, but also fatty degenera-
tion of the heart, kidneys, and blood-vessels, then some fallacy in the observations
may be suspected ; and the absence of careful clinical histories, and descriptions of the
post-mortem appearances, must be felt as decisive against the acceptance of these
cases as authority on this question.

* I use the term to signify those just arrangements of food, atmospheric air,
exercise and repose of body and mind, and of water as regards the functions of the
skin, and its tonic action when cold, which conduce to the maintenance of health and
favour the elevation of the animal system from a state of debility to one of strength.

CHAP. II.

REMARKS ON THE STATISTICS OF THE EUROPEAN GENERAL HOSPITAL,
AND OF THE JAMSETJEE JEJEEBHOY HOSPITAL AT BOMBAY.

In the clinical remarks on the various forms of disease treated in
this work, frequent reference will be made to the European
Greneral Hospital and to the Jamsetjee Jejeebhoy Hospital at
Bombay, because much of my practical acquaintance with disease
in India has been acquired in these institutions.

The first-named hospital has accommodation for 120 sick. The
inmates are Europeans, partly military, partly sailors, and partly
the poorer classes of the civil community. The wives and children
of these classes are also received. I was the Eesident Assistant-
Surgeon in this hospital for a period of six years, — from June,
1838, to October, 1844.

The Jamsetjee Jejeebhoy Hospital has 300 beds : of these 240
are for males, and 60 for females. It is for the reception of native
sick of all castes and countries (Europe excepted). A large pro-
portion of the inma,tes belong to the poorer classes of the civil
population, and many of them are received into the hospital in
a very destitute condition. A smaller proportion consists of sick
labourers, artificers, lascars, and watchmen who are in the employ-
ment of Grovernment. The hospital is open for the free admission,
on application, of the sick of those numerous classes for whose
relief it is intended. I discharged the duties of principal Medical
Officer of this hospital for a period of nine years, — from 1845 to
1854, and again for a year and a half between 1856 and 1859.

During the period of my service in the European G-eneral
Hospital, 9303 admissions took place: and during that in the
Jamsetjee Jejeebhoy Hospital 34,719 in-patients, and about
90,000 out-patients were treated.*

These statements are made with the view of showing a part of
the extent and kind of clinical experience, on the faith of which
I have ventured to express myself with some degree of con-

* The admissions during my service in this hospital sul>s^iient to the publication
of the First Edition of this work are not included.

12 REMARKS ON THE STATISTICS OF

fidence on several points of pathology and therapeutics. The
Tables hereto appended are inserted with a similar object, as
well as with reference to the few practical inferences which
may be deduced from them; and as affording data necessary
to the calculations in the tabular statements of particular diseases
which will be found in different parts of this work.

Tables I. and IV. relate to periods of my own service in these
hospitals: Tables II. and III. have been supplied to me by the
kindness of Dr. Stovell, when surgeon of the European Greneral
Hospital.

The inferences which may be drawn from these Tables, relative
to the proportion of sickness and death in Bombay in dififerent
seasons of the year, are not to be received as absolutely correct ;
because the classes of the community, both European and native,
whose sick resort to these hospitals, are a fluctuating body, of
whose varying numbers at different seasons of the year there is
as yet no accurate census. Still the inferences, such as they are,
may be stated here.

In the fifteen years from 1838 to 1853, the admissions into
the European Greneral Hospital amounted to 20,146, and the
average mortality to 6*3 per cent. Of these admissions 10,495
took place in the half-year from June to November*, and 9653
in that from December to May ; being an excess of 840 in favour
of the first period. But the mortality in the first stated half-
year was 5*7 per cent, and that in the second 6*9 ; being an
excess of 1 -2 in favour of the latter.

In the six years from 1848 to 1853 the admissions (Table IV.)
into the Jamsetjee Jejeebhoy Hospital were 25,190, and the
average mortality 16-3 f per cent. Of these admissions 12,465
took place in the half-year from June to November, and 12,725
in that from December to May; being an excess of 259 in favour
of the latter. But the mortality in the first-stated period was 154

* I cliyide the year in this manner, because in Bombay from June to November
includes the rainy season and that immediately succeeding it, and, therefore, the
season in which malaria is chiefly generated. From December to May in Bombay
includes the cold and hot months, and, therefore, the seasons in which both cold and
heat, as exciting causes of disease, are influential.

t The statistical inquirer, possessing no other information respecting these hospitals
than that supplied by the figures, would conclude either that disease is more fatal to
natives than to Europeans in Bombay, or that treatment was less judicious in the
Jamsetjee Jejeebhoy Hospital than in the European Hospital. Both inferences would
be erroneous. The explanation is simply this, that a large proportion of the inmates
of the Jamsetjee Jejeebhoy Hospital is admitted in a destitute state, and in far
advanced stages of disease ; hence the high mortality.

THE BOMBAY HOSPITALS.

per cent, and that in the second 17*1 ; being an excess of 1*7
in favour of the latter.

I learn from Mr. Leith's Mortuary Eeturns of Bombay, that
the deaths in five years, from 1848 to 1853, amounted to 68,423;
of these, 29,667 took place in the half-year from June to Novem-
ber, and 38,756 from December to May : being an excess of 9089
in favour of the latter period.

These Returns, however, enable us further to divide this mor-
tality into that proceeeding from all causes except epidemics
(52,450), and that proceeding from epidemic causes, viz. cholera,
small-pox, measles (15,973), and to show that in the half-year
from December to May there is of the first class (all causes)
an excess in the mortality of 2300 ; and of the second (epidemic)
an excess of 6789.

Though the half-year from December to May is that in which
the fluctuating population of Bombay is most numerous, still I
think it may be fairly inferred from these several statements,
that the period which includes the monsoon and succeeding
season is that of the greatest amount of sickness not epidemic ; but
that the half-year which includes the cold and hot months is that
of the greatest mortality both from general and epidemic causes.

Table I.* — Admissions and Deaths, with Per-centage, from all Diseases,
in the Eurojjean General Hospital at Bombay for the Five Years from
July, 1838, to July, 1843.

January
February .
March
April .
May .
June .
July .
August
September .
October
November .
December .

Total

July, 1838,

to July, 1843.

Monthly
Averuge.

Per Centage

Admissions.

Deaths.

of
Deaths on
Admissions.

549

7-6

411

7-7

506

Q>-b

581

860

9-3

781

6-6

718

607

5.7

546

9-5

722

3-7

685

6-8

613

7579

10-7

544

7-1

* In this Table, and in all the others throughout the work, the figured details
of each year were given in the First Edition, but it is now*considered convenient to
omit them.

REMAllKS ON THE STATISTICS OF

Table II. — Admissions and Deaths, with Per-centage, from all Diseases,
in the European General Hospital at Bombay for the Five Years from
1844 to 1848.

January .

February .

March

April

May

June

July

August

September

October

November.

December .

Total

1844 to 1848.

Monthly
Average.

Per Ccnlage

Admissions.

Deaths.

Deaths on
Admissions.

617

7-4

516

6-8

485

6-2

509

6-0

583

714

4-6

679

549

2-7

458

4-8

605

6-3

559

5-5

522

l-(s

6796

387

5-7

Table III. — Admissions and Deaths, with Per-centage, from all Diseases,
in the European General Hospital at Bombay for the Five Years from
1849 to 1853.

1849 to 1853.

Monthly
Average.

Per Centage

Admissions.

Deaths.

of
Deaths on

Admissions,

January

450

8-7

February

369

4-9

March

440

7-7

April

517

4-8

May

518

4-6

June

572

July

529

6-2

August

494

7-7

Septembe

356

7-0

October .

395

5-8

November .

524

5-7

December .

608

6-6

otal

5772

358

6-2

THE BOMBAY HOSPITALS.

Table IV. — Admissions and Deaths, with Fer-centage, from all Diseases,
in the Jamsetjee Jejeehhoy Hospital at Bombay for the Six Years from
1848 to 1853.

1848 to 1853.

Monthly
Average.

Per Centage

Admissions.

Deaths.

of
Deaths on
Admissions.

January

2090

450

21-5

February .

1894

319

16-8

March

2149

386

17-9

April . .

2105

343

16-3

May

2183

287

13-1

June

2083

307

14-7

July

2020

306

151

August

1999

328

16-4

September

2062

311

15.1

October .

2134

339

15-9

November .

2167

331

15-2

December .

2304

397

17-2

otal

25190

4104

16-3

CHAP. III.

GENEKAL KEMAKKS ON FEVEKS IN INDIA.

Idiopathic fevers constitute a very important class of disease
in India, as is apparent from the following statement* which
exhibits the per-centage of admissions and mortality from fevers
in the European and Native troops of the three Presidencies : —

Europeans.

Natives.

Presidency.

Per-centage of

Admissions to

Strength.

Per-centage of

Deaths
to Strength.

Per-centage of

Admissions to

Strength.

Per-centage of

Deaths

to Strength.

Bengal
Bombay .
Madras .

72-64
61-93
31-62

1-99
1-37
0-37

48-50
41-20
25-04

•528
•57
-30

When attention is directed to the Native civil population, abun-
dant evidence of the importance of this class of disease also appears.
In the Island of Bombay, the deaths from fever, in five years,
amounted to 27,212 f, which is in the ratio of 40-26 per cent of
the total mortality.

Exclusive of the eruptive forms, they are limited to inter-
mittent and remittent fever, caused by malaria; and to ardent
continued fever, and febricula (ephemeral, common continued
fever), excited by ordinary causes.

The occurrence of typhoid fever :[:, in some parts of India, has
also been lately established.

The plague, yellow fever, maculated typhus, and relapsing
fever, are as yet unknown in India.

*" Vital Statistics of the Armies in India." By J. Ewart, M.D.

t " Deaths in Bombay." By A. H. Leith.

X The term typhoid throughout this work is restricted to the sense in which it is
used by Dr. Jenner, as signifying the enteric or intestinal form of zymotic continued
fever.

CHAP IV.

ON INTERMITTENT FEYER.

Section I. — Different Types of Intermittent Fever f

I SHALL restrict my remarks to the three principal types of inter-
mittent fever, — quotidian, tertian and quartan. The further
varieties — double and duplicated tertian and quartan — doubtless
occur, but they are practically unimportant : indeed, when the
object of treatment from the very commencement of an attack
is to prevent the recurrence of the paroxysm by antiperiodic
remedies, the character not only of these varieties, but also of the
leading types, is liable to be modified, and the opportunity of
studying the natural course of the disease is lost.

It has been generally stated by systematic writers that, of the
three leading forms, the tertian is the most frequent, then the
quotidian, and lastly the quartan.

The statement, relative to the quartan type, will be generally
accepted. Of 243 cases of intermittent fever in Natives of different
castes in Bombay, selected for the purpose of clinical instruction,
there was not a single instance of the quartan form. Of 1344
cases of intermittent fever treated during the period of my service
in the European Greneral Hospital, the quartans, if any, were
very few in number.

That tertians are more common than quotidians, is not con-
firmed by my experience, and is opposed to that of observers in
India generally. Of the 243 clinical cases, 211 were quotidians
and 27 tertians, and of 5 the type has not been recorded. In
the European Greneral Hospital the greater prevalence of the
quotidian type, more particularly during the malarious months,
in first attacks, in seamen, the military staff of the garrison and
the poorer classes of the fixed resident European community, has
also been noted by me. Nor has my observation on this point
been confined to the Island of Bombay. At an earlier period of
my service, while doing duty with Her Majesty's 4th Light

18 INTERMITTENT FEVER.

Dragoons, at Kirkee in the Deccan, the same fact respecting inter-
mittent fever in that regiment during the monsoon season was
noticed by me.

Though the quotidian is the most common form in India*, still
the tertian is also of frequent occurrence. Nor is it difficult to
explain the different circumstances in which these types respec-
tively occur.

Quotidians will be found to prevail most generally at those
seasons of the year when the generation of malaria is supposed
to be actively going on ; and they may probably be viewed as
affording evidence of the recent action of the morbific cause. It
is the type which the disease for the most part assumes in first
attacks.

Tertians, on the other hand, usually occur in individuals who
have suffered on previous occasions, and in whom the fresh attack
is often traceable to ordinary and recently applied exciting causes,
as sudden alternations of temperature, atmospheric moisture, fatigue,
debauch, &c. The occurrence of this type may generally be re-
garded, not as the evidence of the recent introduction of malaria
into the system, but as that of a pre-existing abiding influence,
sometime dormant, now re-excited into action by an ordinary
cause.

If these views be correct, quotidians may be looked for chiefly
from May to October in districts within the range of the rains
of the S. W. monsoon, in November and December in those
subject to the influence of the N. E. monsoon, and from August to
October in tracts exposed to river-inundation and recession. Ter-
tians, on the other hand, may be expected in the colder months of
the year, December, January, and February ; also in the course of
the monsoon season on the occurrence of sudden changes of atmo-
spheric temperature or moisture.

Moreover, if it be true that the tertian type implies a pre-
existing malarious influence, then we may generally expect it to
appear in individuals who have been resident in malarious locali-
ties, and to be frequently complicated with splenic enlarge-
ment. Of the 27 clinical cases of tertian fever, the atmosph*eric

* Tliougli tlie quotidian is the most common type in India, and in other countries
also, it does not follow that this is the proportion observed in all countries in which
intermittent fevers prevail. It appears in the Statistical Report of the army of the
United States of j\merica, that in the Northern Division, north of 40° N., the Middle
Division, between 35° and 40° N., and the Southern Division, between SQ° and 35°
tertians predominate; but that in Florida, Texas, and California, quotidians pre-
ponderate.

DIFFERENT TYPES. 19

vicissitudes of the monsoon season were influential on 18 : of
these, 16 were dockyard peons*, and in 14 splenic enlargement
was present. In the European Greneral Hospital, the tertian type
was present most generally in individuals who had suffered from
the more obstinate intermittents of the autumnal months of other
localities; and who had been either sent to Bombay, with the
view of deriving benefit from change of climate, or who had arrived
there at certain seasons in the course of their professional duties.
They consisted chiefly of European seamen, who had acquired the
disease while serving in the Persian Grulf,' the Eed Sea, on the
Coast of China t, or in the steam flotilla of the river Indus. They
arrived in Bombay usually after the opening of the season subse-
quent to the monsoon, viz., in November, December, and January ;
and, under exposure to the atmospheric vicissitudes of these
months, became liable to tertian attacks. A cachectic state and
an enlarged spleen were also frequently present in this class of
seamen.

These opinions on the causes of the relative prevalence of the

* Of the 243 clinical eases, 85 were dockyard peons ; many of them, however,
readmissions, as the period extends to six years. I was previously familiar with the
dockyard at Bombay as a malarious locality, from my experience in the European
General Hospital, to which I shall have to allude in connection with remittent fever.
The frequent admission of these peons into the Jamsetjee Jejeebhoy Hospital, con-
firmed my former impressions, and I requested Dr. Bhawoo Dajee, at the time one of
my clinical clerks, to ascertain from one of the peons the leading facts connected \nth
their service. The following is a summary of the information thus obligingly obtained
for me : —

There are fifty dockyard peons. They wear a blue woollen dress, which they may
lay aside for a cooler material in the hot weather. Their pay is sufficient to supply them
with the food of good quality and adequate quantity used by their class. About one-half
are Hindoos, the other Mussulmans. They live within the precincts of the dockyard.
Their place of sleeping varies according to the duty of the day. They sleep in the
open air in the dry season ; in a shed during the monsoon, but are still liable to be
exposed to air currents. They are on duty four hours in the day and four in the
night. These periods are respectively diAdded into a service of two hours, and an
interval of rest for four hours ; for example, a peon serving from 6 a.m. to 8 a.m. returns
at noon, precisely, to serve two hours more — 12 till 2 p.m. The same order is observed
in respect to the four hours' night duty. While on duty they are walking about
as guards of the stores, &c. In the day many use an umbrella to protect themselves
from the heat of the sun, but many do not. They do not get wet in the monsoon, for
they resort to guard-rooms and sheds for shelter. The sickness from fever, which
they are aware is considerable, and chiefly in the rains, is attributed by them to the
air and water of the place. There is no complaint of want of attention to clean-
liness, nor are they annoyed by disagreeable odours. The water they use is not
brackish.

t This was at a time when military operations were being carried on in China.

no INTERMITTENT FEVER.

quotidian and tertian types*, might be readily strengthened by a
reference to other sources ; but they are not brought forward with
any claim to novelty, nor with any desire to enforce them.
They have seemed to me to suggest a generalisation practical
in its tendency, and probably the best which at present can be
offered.

Section II. — Simple Intermittent Fever. — Sym^jtoins, Pathology,

and Treatment,

Symptoms. — The intervals of twenty-four, forty-eight, and
seventy-two hours, which distinguish the quotidian, tertian, and
quartan types of intermittent fever, are so fully set forth in
systematic treatises on disease that it is unnecessary further
to describe them. The not unfrequent transition, however, of
one type into another, is a circumstance of practical im-
portance. The quotidian may become tertian in its character
before it finally ceases, and this change in type is an indi-
cation that the disease is in progress towards recovery. On
the other hand, the tertian (and it is occasionally observed in
the quartan also,) may pass into the quotidian type, or the
quotidian may assume the remittent form : these occurrences
evince an aggravation of the disease, and careful inquiry will
sometimes show that this has been coincident with the access of
inflammation in an important internal organ.

It is generally stated, that the period of attack of the quotidian
is the morning, of the tertian about noon, and of the quartan
the afternoon. Of the 243 clinical cases of which 211 were
quotidian, 27 tertian, and none quartan, the period is noted
in respect of 155 cases: of these it was between 6 a.m. and
2 P.M. in 74, and after 2 p.m. in 81. This statement, then,
does not accord with that of systematic writers, but their accu-

* The discrepancy in respect to the relative prevalence of tertians and quotidians
is also in part probably due to the very general sense in which the term tertian was
used by the old writers. Cleghoen, in his " Observations on the Epidemical Diseases
in Minorca from 1744 to 1749," uses the term in a generic sense, and includes under
it intermittents and remittents of various types and severity. It would seem that the
word tertian suggested to these writers the doctrine of the odd days of Hippocrates,
and by such phrases as simple, double, triple, and semi-tertian, they are made to
accord with it. Cleghorn describes a tendency in these fevers gradually to lessen
and to terminate on the odd days, as the 5th, 7th, 9th, and 11th; also the occasional
tendency of simple tertians to become double, then remittent, and ultimately con-
tinued.

SYMPTOMS — COLD STAGE. 21

racy is not, therefore, to be called in question, for it has been
already explained that the treatment of the disease by the
early exhibition of antiperiodics tends to destroy its natural cha-
racters, by either preventing or postponing the recurrence of the
paroxysm.

The division of the febrile paroxysm into cold, hot, and sweating
stages, the greater duration of the cold in tertians and quartans,
and that of the hot stage and indeed of the entire paroxysm in
quotidians are well known facts. It is assumed that the clinical
student is already acquainted with the phenomena characteristic of
these several stages ; but there are facts in respect to each which it
is important to impress upon him.*

First, of the cold stage it should be recollected that the action
of the heart is depressed from the sedative influence of the mor-
bific cause, and that the blood in consequence tends to circulate
languidly and to accumulate in important internal organs. Some-
times the congestion is present in unusual degree in particular
organs : giving rise in the brain to undue drowsiness and sense of
weight in the head, ringing in the ears, and various undefinable
sensations ; occasioning, when in the lungs, the heart, and great
vessels, a sense of great prsecordial oppression, a respiration un-
usually hurried and sighing, and a pulse very feeble and depressed.
Or the undue congestion may exist in the stomach and liver, and
lead to much retching and vomiting, and derangement of the
biliary secretion ; or it may be to the mucous membrane of the
intestinal canal, and be attended with copious intestinal discharges.
It should be further remembered that, associated with these several
local phenomena, there will be present some degree of the general
depressed state of the circulation characteristic of the cold stage,
indicated by a feeble pulse, a pale skin and features more or
less contracted. When these undue local congestions occur, the
duration of the cold stage is generally prolonged, and the hot
and sweating stages are sometimes so slight as readily to escape
notice.

These exceptional cases are important, not so much from being
generally attended with immediate danger to life, for such is not
usually the case; but from their nature being very often misunder-
stood. They are apt to be regarded as instances of congestion

* If the reader has not these details present in his mind, he should refer to some
systematic treatise ; otherwise the occasional facts to which allusion is chiefly made in
the text may assume undue prominence in his estimation.

C 3

22 INTERMITTENT FEVER.

or other derangement, independent of malarious influence, and
thus to suggest needless alarm, and prompt to injurious and un-
successful treatment. The right dia,gnosis can only be established
by a careful consideration of all the circumstances of each par-
ticular instance ; such as the existence or absence of previous
attacks of malarious fever, or of exposure to malarious season or
locality, and the periodicity or persistence of the phenomena.
Inquiry on these points, coupled with due attention to the habits
of the individual, and a careful scrutiny into the physical condition
and functional state of all important organs, will generally conduct
to a satisfactory conclusion.

The kind of phenomena just alluded to have frequently been
described under the name of "Masked Intermittent But as they
are evidently more related to one stage than to the entire paroxysm,
there is a practical advantage in noticing them in connectiou with
that stage.*

Hot Stage. — The degree of febrile reaction varies in the different
types of the disease, and is also related to the character of the
constitution of the individual affected. The excited circulation,
the increased heat of the surface, the diminished secretions, the
thirst, the coated tongue, the restlessness, and the headache are
present in greater degree in the quotidian than in the tertian type ;
and in the sthenic constitution of youthful Europeans lately
arrived in India, than in the more or less asthenic condition of
the old resident European and of the different classes of the
native population.

The state of the tongue is in many respects a useful practical
guide. It is frequently more coated in attacks of ephemeral fever
than in true intermittents : while in the latter the degree of fur
is not only related to the duration of the hot stage of each
paroxysm, but also to the state of the patient's system. The
tongue is more coated in the quotidian type and in sthenic
habits, than in the tertian type and in asthenic constitu-
tions: indeed, it frequently happens in tertians, sometimes even
in quotidians, in asthenic natives that the tongue is nearly
quite clean throughout the paroxysm as well as the inter-
mission. Again, in tertian fevers on the morning of the day
of the paroxysm we are occasionally, by the coated or clean

* The occasional occurrence of great and dangerous congestive phenomena at the
outset of malarious fevers will be noticed in connection with the remittent type of
fever.

SYMPTOMS — HOT AND SWEATING STAGES. 23

state of the tongue, enabled to judge of the probability of the
attack.

It is useful to bear these facts in mind, but in order to
appreciate them truly it is necessary to recollect another im-
portant fact, viz., that by the undue use, in fever, of mercurial and
other purgatives, and of preparations of antimony we may increase
and maintain a coated state of the tongue, and thus not only do
positive harm, but also vitiate the indications of a valuable
symptom.

Sweating Stage. — The disappearance of the febrile phenomena,
after more or less sweating, and the succession of a complete
intermission is the usual course observed in this disease. When
the subject of remittent fever comes under consideration, it will
be explained that occasionally, instead of the usual remission of the
febrile reaction, a state of dangerous — it may be fatal — collapse
unexpectedly occurs. Though an event of this kind is unusual
after a paroxysm of intermittent fever, still there are cir-
cumstances under which it is necessary carefully to guard against
it: in all instances of intermittent fever in very asthenic indi-
viduals, whether Europeans or natives, the degree of exhaustion
which attends the close of the paroxysm must be attentively
watched. If this precaution be neglected we shall assuredly,
from time to time, experience the painful surprise of learning
that our patient has died suddenly, and to us unexpectedly, with
perhaps merely symptoms of general exhaustion, or it may be
with some degree of diarrhoea, or tendency to coma. If in these
cases we are satisfied with judging of the progress of the disease
by the amount of the hot stage, a very serious error will often
be committed ; for it not unfrequently happens that a diminu-
tion in the degree of febrile reaction precedes death by ex-
haustion. Indeed, a failing pulse, increasing emaciation, and
decreasing heat, ought to lead us to anticipate early and rapid
sinking at the close of a paroxysm, and to provide against it
by assiduous care in the use of appropriate stimulants and
nourishment. My attention was first directed to these clinical
facts in respect to natives in the year 1831, when in medical
charge of detachments on field service, at Sassoor in the Deccan ;
then in January 1844, while serving at Hyderabad in Scinde, with
the 15th Eegiment Native Infantry; and latterly in the clinical
and other wards of the Jamsetjee Jejeebhoy Hospital at Bombay.
As regards Europeans, the most striking instance which occurs to
me is that of an officer of the 15th Eegiment at Grharra in Scinde,

c 4

24 INTERMITTENT FEVER.

who had suffered some months previously from several attacks of
intermittent fever while at Hyderabad. I saw this officer during a
recurrence of the disease at Gharra, and then the single paroxysm
was succeeded by a state of alarming collapse, requiring the free
use of alcoholic stimulants for its removal. My further experience
in India, subsequent to the publication of the first edition of this
work, not only in my own practice, but also in that of others
known to me, when officiating as superintending surgeon at
Poona, has again impressed upon me the importance of watching
for indications of exhaustion in intermittent fever in asthenic
subjects. Several fatal cases of this nature were reported to
me in the Poona division, and in all of them the medical
officers were unaware of the true explanation of the unlooked-
for event.

Pathology. — Mortality from. Simiple Intermittent Fever, That
in the cold stage of intermittent fever there is a sedative
influence exercised by the morbific cause on the heart, and
a tendency in the blood to circulate languidly and to accumulate
in the capillary system of important internal organs, may be very
safely affirmed. But whether this influence first acts on the blood,
and through it on the fibre of the heart, or intermediately on the
nervous system, or in any of the other various ways which the
imagination may suggest ; and what the nature of the changes
effected in the blood may be, are questions which have been much
discussed, without as yet having led to a satisfactory solution of
the difficulties with which the subject is beset.

Into these speculations I shall not enter. They are foreign to
the spirit of safe and useful clinical instruction.

The mortality in India, resulting directly from simple inter-
mittent fever, is not great ; but it is not accurately known, nor can
it be determined by ordinary hospital returns. During my service
in the European Hospital, the returns show a mortality of 1*33
per cent, from intermittent fever. But the complicated cases are
also included ; and, from the greater number of deaths having
taken place in December, February, March, and April, it is evi-
dent that the fatal result must have arisen from the sequelae of
the disease.

Though the immediate risk to life from a paroxysm of inter-
mittent fever is slight, still the mortality to which the disease
indirectly leads is very great, though not expressed in statistical
tables as at present framed.

Continued exposure to malaria or frequent recurrences of inter-

PATHOLOGY AND MORTALITY. ^5

mittent fever engender, as is well known, a cachectic state of
the system ; in which the nutritive processes of the tissues
and of the blood are defective and perverted, and in which
splenic, hepatic, and other local congestions, tend to occur. This
cachexia not unfrequently terminates in death by exhaustion.
But it is not in this manner that the indirect mortality from
intermittent fever chiefly arises. It takes place because the
cachexia caused by the fever is a state in which the system
becomes very predisposed to local inflammation or congestion under
the influence of external cold. The structure most liable to be
thus affected is the mucous lining of the intestinal canal ; and the
diseases induced are classed, in hospital returns, under the heads
diarrhoea and dysentery. There can be no question that much of
the mortality attributed in India to "bowel complaints" is, though
indirectly, yet fairly chargeable to the account of malarious fevers.
The principal season of malarious fever, excited by the direct
action of malaria, and consequently the chief season during which
this deterioration of the system occurs may, in general terms,
be said to range from June to the end of November. Then follow
December, January, February, and March, with their lower ab-
solute temperature, their greater range, their frequent chilling
winds ; and it is in these months that the asthenic constitution is
liable to suffer from dysentery and diarrhoea.

Further, if the malarious season be preceded by one of
exhausting heat, and succeeded by one of considerable reduction
and alternations of temperature, whether from great diurnal
range, varying humidity, or chilling winds, then we have con-
ditions of climate which lead to much mortality, from the conse-
quences of intermittent fever, unless it be prevented or lessened
by judicious sanitary measures.

It would be easy to accumulate illustrations of this pathological
law, but it will be sufficient to refer to the most striking which
have passed under my own observation. After the conquest
of the province of Scinde, in the spring of the year 1843,
troops were stationed in the fort and town of Hyderabad, and
in many of the adjacent villages. In July, the canals were
sensibly filling with the water of the Indus ; and during the
latter part of that month, as well as in August, the inundation
was at its height : the subsidence commenced in September and
continued during October.

The 15th Eegiment, Native Infantry, was stationed during
June, July, August, and part of September 'in a small village

INTERMITTENT FEYEB.

close to the west bank of the Indus, surrounded by broken
ground, water-cuts, and cultivated fields interspersed with trees
and covered with underwood. It was then moved to another
position not less malarious, and finally located in the fort of
Hyderabad, where I assumed medical charge of this corps at
the end of December, continued with it at Hyderabad throughout
the greater part of January, and accompanied it down the Indus
to Tatta, thence to Grharra (where we were detained about fifteen
days), and finally by Kurrachee to Bombay, which we reached
towards the end of February.

The following statement shows the strength of this regiment,
with the numbers ill from fever, and the total mortality during
the greater part of the period above adverted to : —

15th Eegiment Bombay Natite Infantry.

1843.

June

July

August .

September

October .

November

December

Strength.

Fevers.

Total Deaths.

887

958

1012

153

1046

580

1024

973

998

1095

948

896

The great increase of fever in September and October is well
shown ; and of the cases under treatment in November and
December, a large proportion remained from the admissions
of the two preceding months, proving the obstinacy of the dis-
ease, and the frequent occurrence of its sequelae.

In November the temperature at Hyderabad begins to fall,
and continues to decline in December and January. North-
easterly winds also commence, and are frequently fresh and
chilling. The comparison of the mortality of November and
December with that of the months preceding is very striking:
the great increase was caused chiefly by dysentery. The
precise number* of deaths in January and February is un-
known to me ; but the great mortality from bowel complaints

* The numbers given above, and those stated in Mr. Carter's paper on the preva-
lence of intermittent fever, &c., in Sindh (Transactions, Bombay Medical and Physical
Society, No. 8, p. 32), will be observed to be the same. Both are taken from the
same source, my MS. notes.

PATHOLOaY AND MORTALITY. 27

continued, and frequent bronchitic and occasional pneumonic
complications, with in some instances death, apparently from
oedema of the lungs, also occurred.

During part of the year 1843 the Bombay 2nd European
Eegiment was divided. One wing was moved to Kurrachee
in Scinde in May, was healthy, and lost few men ; the
other wing was stationed at Bhooj in the province of Cutch
during the monsoon and suffered much, chiefly in September,
from intermittent and remittent fever. The sick of this wing
were sent to Mandavie, on the coast of the province, with
a view to their transport to Bombay, but they were delayed
there about a month, badly supplied with quinine and other
necessaries ; and then, instead of being sent to Bombay, were
shipped to Kurrachee, and arrived there in November. About
the middle of December, through the kindness of Mr. Cahill,
the surgeon of the regiment, I was permitted to visit the hospital
at Kurrachee. It contained 237 sick, chiefly men from Cutch,
and there were still upwards of 100 sick left behind at Mandavie.
In many the spleen was enlarged, and some were anasarcous ;
and 40 deaths, chiefly from dysentery, had taken place between the
beginning of November and the period of my visit.

During the monsoon of 1841, Her Majesty's 17th Eegiment
was stationed in the barracks at Colaba, in the island of Bombay.
This season of that year was generally unhealthy in the island,
and the following admissions of malarious fever took place in
this regiment: —

In June

. 55

In November

. 180

July

. 136

December

. 180

August

. 165

January .

. 50

September

. 187

February .

. 38

October .

. 375

Dr. A. S. Thomson, from whose report * this statement is taken,
thus writes : — " In October a few cases of dysentery occurred ;
but when the cold nights of November and December came,
dysentery became more prevalent, and 130 cases were admitted
during these two months, and 23 died." .

During the month of October, 100 fever cases of the 17th
Eegiment were treated in the European Greneral Hospital ; all
came under my observation, and many under my immediate care.

•

* Transactions, Medical and Physical Society of Bombay, No. 5, p. 84.

28 INTERMITTENT FEVER.

I had, therefore, a personal knowledge of the character of the fever
and of the condition of the men.

Treatment of Simple Intermittent Fever. — The treatment must
be considered with reference to the several stages of the paroxysm
and to the intermission.

If the cold stage merely threatens, if it be the first or second
paroxysm, if the tongue be coated, expanded and not florid, and
the constitution of the individual be good, and evacuant remedies
have not been previously exhibited, then an emetic of ipecacuanha
may be given with advantage. If, on the other hand, the circum-
stances which indicate the use of an emetic are not present, a mode-
rate opiate may be substituted. But when the cold stage has fairly
formed, all that can be done is to lessen the discomfort of the
patient by additional covering, the use of external heat to the
extremities and the exhibition of warm diluents. It may occa-
sionally happen, when the depression is very great, that the use of
ammoniated and other stimulants is indicated ; but this is seldom
necessary in Indian intermittents, except in very asthenic indi-
viduals.

In the hot stage there is excess of vascular action, and the
indication is to carry the patient on to the sweating stage with
as little of this excess of action or of derangement of other functions
as can be safely effected. To prevent this stage or materially
to shorten it is beyond our power, but by judicious management
the general discomfort and the amount of derangement of par-
ticular functions may be considerably mitigated.

In youthful sthenic Europeans at the commencement of first
attacks, when febrile excitement runs high with headache and
much flushing of the face and a pulse full and firm, then
general blood-letting, to the extent of sixteen or twenty ounces,
may occasionally be an expedient and useful proceeding; but
when carried beyond this or used at more advanced periods or
in other states of constitution, it is not only unnecessary but
becomes positively injurious : it accelerates the cachectic condition,
and not only does not check the progress of the attack, but tends
to protract it.

Under the usual circumstances of intermittent fever in India,
it is sufficient to allay the vascular excitement by light clothing,
the removal of all Isedentia, sponging the surface of the body
repeatedly with tepid water, cold applications to the head, suitable
drinks, and the use of antimonials, ipecacuanha, aqua acetatis
ammonise, or nitrate of potash, in moderate doses. In cases in
w^hich headache is much complained of, and no contra-indication

TREATMENT — DURING THE PAROXYSM. _ 29

exists*, leeclies may be applied with advantage in the first or
second paroxysms. If the tongue be coated, expanded, not florid
at the tip and edges, the bowels confined, and the stomach not
irritable, and the paroxysm be the first or second, and not far
advanced, then an emetic of ipecacuanha, followed by a mild
purgative should be had recourse to. These evacuant remedies
are adopted partly with the view of lessening vascular excitement,
but chiefly with that of preparing the system for the fullest influ-
ence of the means of cure appropriate to the intermission.

During the sweating stage, under ordinary circumstances, there
is Httle to be done. The surface must be protected by adequate
coverings from the risks of too rapid evaporation on the one hand,
while on the other the excess of sweating which will result from
too much covering must be avoided. While these principles are
sufficient for the ordinary management of this stage, still what has
been already stated in respect to the occasional occurrence of great
and unlooked-for exhaustion must be carefully remembered. When
this event is indicated, then no suitable means of strengthening
the patient must be left untried, and towards the close of the
paroxysm stimulants and animal broths must be freely given.

It has been stated, that the treatment during the paroxysm is
palliative, and should be as little debilitating as possible ; but
nothing so certainly debilitates the system and accelerates cachexia,
with all its attendant evils, as a frequent recurrence of the febrile
paroxysm. Therefore, to prevent this is the leading indication in
the management of the interviission, and, it may be added, in
the treatment of this disease. This object is to be effected by the
exhibition of antiperiodic remedies ; and the earliest intermission
should, with this view, be taken advantage of. Quinine is the
only certain and generally appropriate medicine of this class.
There has been much discussion in respect to the best method
of using quinine ; but it will be sufficient for me to state the
opinions which I have myself formed from clinical experiment and
the study of the written observations of others : —

1. The quantity of quinine sufficient to prevent the paroxysm

* In recommending the use of leeches in India, it is impossible to be precise in
regard to the number. The leech varies much in size in different parts of the country.
The number must further depend on the state of the constitution and the degree of
local vascular derangement. I would, however, express my belief that local blood-
letting should, as a rule, not be carried to the degree of very sensibly depressing the
general action of the heart, but be used chiefly with a view to its local derivative
action. *

30 INTERMITTENT FEVEE.

varies according to the severity of the attack, or, in other words,
tlie intensity of the malarious influence.

2. It should be given during the intermission in such manner
as to ensure the whole quantity being taken at least three hours
before the expected paroxysm, so that it may be absorbed and
assimilated.

3. In Indian intermittents, from twelve to thirty grains are in
general sufficient. In more intense intermittents it may be neces-
sary to give sixty grains and upwards, but of these larger quanti-
ties I have no personal experience. The selection of the quantity
in the first intermission will depend on the circumstances of the
case, indicating the probability of much or little malarious in-
fluence; and correct judgment in this particular can only be
acquired by careful clinical observation.

4. According to Briquet, quinine in doses of from two and a
half to four and a half grains stimulates the circulation, respiration,
and nutrition ; but in doses of from nine grains and upwards it
exercises a disturbing and sedative influence on the nervous system,
the circulation and general muscular system, which, when present
in great degree, may endanger life. These are the efiects of qui-
nine on the system in a normal state ; but in intermittent fever
there is a tolerance of this agent, by which is meant that these
characteristic symptoms of depression (cinchonism) require a larger
quantity for their production ; therefore, generally speaking, there
will be tolerance of that quantity which, in particular cases, is
required to prevent the access of the paroxysm. Consequently
this quantity may be given in one dose with perfect safety. On
this point, however, my own experience does not extend beyond
doses of twenty grains.* But, in appl3dng this rule, it is necessary
to remember that an exhausted state of the system diminishes the
tolerance for quinine ; and that, therefore, even when there is evi-
dence of much malarious influence, large doses are unsafe in
states of exhaustion and collapse. From this it follows, that
where there is much sweating and debility at the close of the
paroxysm, the quantity of quinine allotted for the intermission
should be given at intervals, — in four or five-grain doses, — ac-
companied with suitable stimulants and nourishment.

5. The practice of giving the whole quantity at once, or in

* The exclusive exhibition of quinine in scruple or half-drachm doses, instead of
smaller ones frequently repeated, first followed by French and American physicians,
has been chiefly advocated in the treatment of Indian intermittents by Drs. Corbyn,
Mackinnon, Mactier, and C. Murchison (" Indian Annals of Medical Science," No. 1,
and "Edinburgh Medical and Surgical Journal for April, 1855").

TREATMENT — DURING THE INTERMISSION. 31

divided doses, should vary iu different cases. Assuming that the
quantity has been correctly determined with reference to the
tolerance, it will, in the great proportion of cases, be effective in
quotidians at whatever period of the intermission it is given, pro-
vided this be at least three hours before the expected paroxysm ;
and as the quantity in each case is supposed to be regulated with
reference to the tolerance, it may be given in one dose with safety,
and when there is not time for divided doses, it is best thus to
use it.

6. When there is doubt in respect to the quantity likely to be
required, when there is sufficient time, when there is an exhausted
state of the system, and when the type is tertian or quartan, then
quinine is most advantageously given at suitable intervals in from
three to six- grain doses, between the cessation of one paroxysm and
three hours from the expected period of the next.

7. It is unnecessary to give quinine till symptoms of cinchonism
begin to appear ; for this is to overstep the tolerance, in pursuit of
a guide which the experienced physician does not require.

8. Though the full quantity of quinine given in one dose in the
sweating stage is sufficient to prevent the accession in an ordinary
quotidian, still the conclusion, from my own clinical experience, is,
that its power is greatest when given nearer to the period of ex-
pected paroxysm, provided time is allowed for absorption and
assimilation.

9. The idea that quinine has a diaphoretic action would seem to
have arisen from inattention to the fact that a checked, but not
prevented, paroxysm may be evidenced merely by a sweating stage
unpreceded by a hot one; and this may suggest the belief of
diaphoresis from the quinine, when in fact the quantity had been
sufficient merely to modify, but not to prevent the return.

10. The efficiency of quinine is most certain when exhibited in
perfect solution.

11. When large doses of quinine are necessary, when it is of
much moment to ensure its fullest therapeutic effect, and an idio-
syncrasy adverse to its action is supposed to exist, it is of great
importance that the patient, after taking the quinine, should be
kept very quiet; that his senses should be little acted on by light,
sound, or other external influences ; and that the excitement of
trains of thought, by reading, or conversation, should be avoided
as much as possible.*

* I am indebted to Dr. McLennan for having called my attention to the great
advantage resulting from these precautions. He informs me tliat, by observing them,

32 INTERMITTENT FEVEE.

12. After the recurrence of the paroxysm has been prevented,
quinine should be continued in decreasing quantities for the three
or four succeeding days.

Ai'seniCf in the form of arsenious acid, is the antiperiodic remedy
next in power to quinine ; but it is not so generally appropriate,
and requires the exercise of much caution and the careful selection
of cases to insure its safe administration.

The results of my clinical experience* of this remedy are ar-
ranged under the following heads : —

1. The principles relative to the exhibition of quinine during
the intermission, and a tolerance proportionate to the intensity of
the malarious influence, equally apply to arsenious acid.

2. In Indian intermittents, an eighth to a fourth of a grain
— that is fifteen to thirty minims of liquor potassae arsenitis — given
in the intermission, has no evident antiperiodic power.

3. Half-a-grain— one drachm of liquor potassae arsenitis — given so
as to be all taken two hours before the expected period of paroxysm,

he had on several occasions been enabled to give quinine with excellent eifect to
patients with whom it had been previously believed to disagree, and that he is satisfied
that much of the utility of this essential agent in the treatment of malarious fever is
often lost from their neglect. Further, he is of opinion that this benefit derived from
mental repose may often be readily secured in practice by selecting, when the intermission
or remission corresponds, the stillness and darkness of night for the period of exhibition.

* These statements relative to the anti-periodic power of arsenic differ mate-
rially from those in the first edition. They consist, not of a correction of
previous error so much as of the results of an extended experience. When passing
through Paris, on my return to India, I was fortunate enough to meet M. Boudin in
his hospital. The use of arsenic in intermittent fever came under discussion. My
unfavourable results were stated. M. Boudin not only kindly showed me cases under
treatment, but favoured me with the subjoined memorandum on his method of using
arsenic —

" Acide ars^nieux, un gramme; eaxidistillee, mille grammes: /aire bouiller pendant
un quart d'heure. Ajoutez vin blanc, mille grammes.

"Cent grammes de cette liqueur representent cinq centigrammes, ou un grain
d'acide arsenieux. On donne a Paris en moyenne un demi-grain par jour, dans I'inter-
valle des acc^s. Mais on pent donner plus. II importe de fractionner la dose totale le
plus possible. La tolerance pour 1' arsenic baisse en general avec la disposition de la
fievre. Le premier signe d'intol^ranee est I'eau a la bouche, II faut profiter de la
tolerance pour saturer le malade. II faut eontinuer plus ou moins longtemps apres
la cessation de la fifevre. Opposer a la diathese paludienne un diath^se arsenicale ;
voila le but qui je me propose.

" BOTJDIN.

" Paris, le 14 JuiUet, 1856."

I have since carefully read M. Boudin' s paper on intermittent fever in the supplement
to the " Dictionnaire des Dictionnaires de Medicine," also the article at p. 530 of the
2nd volume of the " Traits de Geographic et de Statisques Medicales," by the same
author. To these works I would refer the clinical student for full information on
this interesting and important subject.

TEEATMENT DURING THE INTERMISSION. 33

is sufficient to prevent the recurrence in mild intermittents in
India. It may be exhibited with safety in this quantitjr in cases in
which there is no tendency to gastric or intestinal irritation, and most
advantageously in repeated doses of ten minims or less, sometimes
combined with a few minims of tincture of opium.

4. Half a grain of arsenious acid has seemed to me to be about
equivalent in power to fifteen grains of quinine. It may, therefore,
be easily understood why the quantity — an eighth to a fourth of a
grain — usually given, has no sensible effect in intermittent fever in
India. Three grains and a half to seven grains of quinine would
be equally inefficacious.

5. As fifteen grains of quinine are insufficient to prevent the
accession of the severer and greater number of Indian intermittents,
half a grain of arsenious acid is equally so ; but we may, in many
cases, without incurring the risk of larger doses of arsenic, econo-
mise quinine by preventing the recurrence in the first place by an
adequate quantity of quinine, and then trusting to arsenious acid
for the completion of the cure.

6. My experience is limited to the quantity of half a grain
in the intermission; but the practical question remains, whether
in intermittent fever in India, uncomplicated with gastric or
intestinal irritation, arsenic can with safety be given to the
extent of one grain and a half and upwards, as by M. Boudin,
and thus suffice for the cure of all cases? The answer may
probably be thus stated : — M. Boudin has shown that by divided
doses, enemata, &c., the full effect of arsenious acid may be
obtained ; just as former physicians, by pharmaceutic skill,
achieved more with the crude cinchona than is ever now
attempted. Used with the skill and precaution observed by
M. Boudin, arsenious acid may be adequate for the effective
cure of Indian intermittents ; but the treatment of a disease
so common cannot be safely left to the contingency of great
experience and tact.

My practical knowledge of other anti-periodic remedies * is con-

* The subject of febrifuge remedies has been fully discussed in the 3rd, 4th, and
5th Yokimes of the "Indian Annals of Medical Science," by Falconer, Cleghorn,
Macpherson, Cornish, and Waring,

There are questions of special therapeutic interest to the medical inquirer in India :
— (1.) To substitute cheap and common indigenous articles of materia medica for the
rarer and more expensive products of other countries is very expedient, as a measure
of convenience and economy. (2.) To strengthen the materia medica by the removal
of inert drugs and the addition of others of undoubted efficacy, is very essential to
the character and usefulness of practical medicine. The Indian Government and

34 INTEKMITTENT FEVER.

fined to the sulphate of bebeerine, muriate of narcotine, chiretta,
coesalpinia bonducella, berberry, and atees (Aconitum heterophyl-
lum). These in my hands have proved unequal to preventing the
paroxysm of ordinary intermittents ; and in estimating the value
of remedies of this class, it should be remembered that they are
of little value unless they produce this effect. The tendency
of a large proportion of cases, more particularly quotidians, at
the commencement of the rainy season, in climates in which the
rain-fall is not great, is to terminate spontaneously after from
the fifth to the ninth paroxysm: therefore there is no proof of
a febrifuge effect from remedies in fevers which have followed
this course.

The extent to which mercurial and other purgatives should be
given in the treatment of intermittent fever, depends upon the
state of the constitution, the duration of the attack, the apper.rance
of the tongue, the character and amount of the alvine discharges,
and the co-existence or not of hepatic or splenic congestion. When
the system is asthenic, when the disease has continued for some
time, and purgative remedies have not been neglected in the early
stages of treatment ; then it matters not what may be the state of the
tongue, or of the alvine excretions, or what the condition of the
liver or of the spleen, the period for further evacuation* by purga-
tives or other means has passed ; for, if now had recourse to, it will
favour the development of cachexia, the recurrence of the paroxysm,
and the persistence of the attack. Purgatives, moreover, under

Medical Boards have evinced a laudable desire to advance these objects; but the
means usually adopted have been insufficient, and have generally failed of success.
They have consisted of casual and hasty experiments, without reference to the prac-
. tical qualifications of the experimenters or regard to the adequacy or appropriateness
of the conditions of the experiment. The result is that medical literature has become
oppressed with feeble and trifling reports, and practical medicine invested with a
character of vacillating imbecility, which forms no part of its scientific pursuit. To
test and determine the properties of medicines is a work which can only be safely
entrusted to physicians of large clinical experience, and of calm and matured judg-
ment, familiar with an enlightened pathology, and acquainted with the natm^al history
of disease, and the action of existing medicines. It may be that these qualities are
rare ; but it is, nevertheless, true, that it is only by these qualities that therapeutic
science can be advanced and entitled to confidence and respect.

* The careful reader will not understand this passage as implying that in these
conditions of intermittent fever, the purification of the blood by excretion is to be
neglected. It must be remembered that this important function may be in very useful
action without very evident evacuation, by attention to the purity and temperature of
the atmosphere, suitable ablution and clothing, well-arranged food and drinks, and the
use of appropriate tonic and alterative medicines. The influence of tonics and altera-
tives — regimen and medicines — necessarily involves increased excretion.

TREATMENT — PUUaATIYES. 35

these circumstances, are apt, by irritating the intestinal mucous
lining, to excite dysentery.

The use of purgatives in the hot stage, with the view of lessening
vascular excitement, and preparing the system for the full beneJ&t
of anti-periodic remedies during the intermission, has been already
adverted to. Purgatives, however, act with more certainty during
the intermission, and when the object is merely to obviate con-
stipation, they are given with most advantage in this stage,
either in combination with quinine, or towards the end of the
paroxysm, so as to take effect early in the intermission ; but
they should never be used in such manner as to interfere with
the administration of the anti-periodic remedy. Further precau-
tions are also necessary. The free action of a purgative towards
the end of a paroxysm should be avoided ; for it may induce dan-
gerous exhaustion: it is also apt, in the intermission and during
convalescence, to re-excite the paroxysm.*

Attention to the diet of those suffering from intermittent fever
is of very great importance. In sthenic subjects, with deranged
alvine secretions, the food during the two or three first days should
be spare, and the strength be chiefly sustained by moderation in
treating the hot stage, and by the adequate use of quinine during
the intermission. In asthenic subjects, from the commencement,
and in all constitutions in the advanced stages, support by suit-
able alimentation, and occasional stimulants, is a leading indi-
cation of treatment. The intermissions are the periods when
these means should be most assiduously used. It is by the careful
observance of this rule that the occasional occurrence of the
unlooked-for, and sometimes fatal, exhaustion at the close of a
paroxysm, already alluded to, can alone be prevented. This pre-
caution, necessary in the management of intermittent fever in
all asthenic individuals, is very essential in the asthenic natives
of India ; for I have in many instances seen reason to attribute
death to its neglect.

* It would be easy to confirm this latter observation by references to established
authorities. For example, CuUen writes : " But I can say that Sydenham and many
other practitioners have observed that we are in danger of bringing back intermittent
fevers if we employ purgative medicines soon after we have stopped them with bark ;
and we have the same observation in De Haen." — TTie Works of Cullen, Edited by
John Thomson, M.D. vol. i. p. 642.

D 2

36 INTERMITTENT FEVER.

Section III. — Intermittent Fever complicated with Enlargem^ent
of the Spleen. — Symptoms. — Pathology. — Treatment,

Symptoms. — Enlargement of the spleen is the most common
complication of intermittent fever.* It does not usually occur in
first attacks, but after several recurrences of the quotidian or the
tertian type. If a first attack, however, has been badly managed,
and several paroxysms have taken place, then in it also splenic
enlargement may be looked for.f

This condition of the spleen is always associated with some
degree of cachexia ; and a dingy appearance of the conjunctivae,
with anaemic pallor of the surface and of the tongue, may serve to
excite suspicion and to direct inquiry. The enlargement may
range from the degree which can only be determined by jareful
percussion to that which causes an abdominal tumour reaching to
the crest of the ilium and inwards beyond the mesial line.

The co-existence of systolic cardiac murmur with enlargement of
the spleen is occasionally observed ; and when this occurs without
any other physical sign of cardiac disease, there should be no hesi-
tation in relating the murmur to the altered condition of the blood,
which so generally attends splenic cachexia. But it is of import-
ance further to be aware, that enlargement of the spleen may cause
abnormal praecordial dulness, and that cardiac murmur may be
associated with it. This dulness may be produced partly by dis-
placement of the heart upwards, and partly by the enlarged spleen
preventing the free descent of the diaphragm, and the full ex-
pansion of the lung, with complete overlapping of the left side
and base of the heart by its thin edge. The following cases will
illustrate this clinical observation : —

1. Abnormal PrcBcordial Dulness from Enlarged Spleen, — Abdoola Ibrahim, a
Mussulman labourer, eighteen years of age, had for upwards of a year been
the subject of frequent attacks of intermittent fever. He was admitted into
hospital on the 23rd of June, 1851, enfeebled and reduced by disease. The
spleen was much enlarged ; a line drawn transversely from the cartilage of the

* As evidence of its frequency I find that out of 243 clinical cases of intermittent
fever, enlargement of the spleen was present in 91. It is unnecessary to collect
further proof of so familiar a fact.

t Enlargement of the spleen is generally classed under " Splenitis" in Indian
Hospital Eeturns ; but this is very inaccurate. Inflammation of the spleen is very
rare ; abscess I have never seen. The only appearance probably related to inflamma-
tion which I have witnessed, was a thickened, almost cartilaginous, state of the
capsule.

SPLENIC ENLARGEMENT — SYMPTOMS. 37

left sixth rib to the vertebral column marked its upper limit, and a curved line from
the same cartilage to the umbilicus, and thence to about an inch above the crest
of the ilium, marked the lower limit. The apex of the heart beat between the thu'd
and fourth ribs ; and the prsecordial dulness was confined to the third and fourth left
costal *cartilages and the interspace between the second and third, and at the outer
lower limit was almost continuous with the splenic dulness.

2. Abnormal Precordial Dulness from Enlarged Spleen associated with Systolic
Murmur. — Hurreem Adamjee, twenty-three years of age, a Mussulman, native of
Ahmedabad, and frequently suffering from intermittent fever, was admitted into the
Jamsetjee Jejeebhoy Hospital on the 9th August, 1852, He was pale and anaemic. The
spleen was much enlarged, extending downwards almost to the crest of the ilium, internally
beyond the umbilicus ; and its upper limit, as indicated by percussion, reached to the
sixth left intercostal space. The prsecordial dulness commenced at the left second inter-
costal space, and became continuous with the splenic dulness. At the level of the third
intercostal cartilage it reached transversely from the middle of the sternum almost to
the nipple. The apex beat between the fourth and fifth ribs internal to the nipple.
A faint but distinct systolic murmur was heard at the left second intercostal space,
close to the sternum, but was not audible at the apex, where the sounds of the heart
were both distinct. There was no increased impulse. A distinct venous murmur
was heard at the junction of the jugular and subclaAnan veins of the left side.

3. Abnormal 'Prcecordial Dulness from Splenic Enlargement. — Systolic Murmur
present. — Abdul Cadux, fifteen years of age, a Mussulman peon, the subject of quo-
tidian intermittent fever for thirteen days before admission into hospital on the 16th
July, 1851. The spleen was not felt below the ribs ; but, as ascertained by percussion,
its upper limit was as high as the eighth rib, and its internal one was a vertical line
haK an inch external to the nipple. Prseeordial dulness extended from the third to
the fifth rib, and between the nipple and the sternum. There was a distinct systolic
murmur not louder at the base than at the apex of the heart. On the 2nd August,
the internal limit of the splenic dulness was a vertical line an inch external to the
nipple ; the upper limit was unchanged. The upper limit of the prseeordial dulness
was the upper margin of the fourth costal cartilage. The cardiac murmur was
disappearing.

4. Abnormal Precordial Dulness from Enlargement of the Spleen. — Systolic Murmur
present. — Francisco Antonio, twenty years of age, an inhabitant of Lisbon, of stout and
well-proportioned frame, the subject of tertian intermittent fever for fifteen days, was
admitted into hospital on the 25th July, 1851. The pulse was of moderate volume,
and somewhat jerking. The indurated edge of the spleen was felt below the margin
of the left ribs. Its upper limit was the ninth rib ; its internal limit a vertical line
about an inch external to the nipple. The prseeordial dulness extended from the
lower border of the third rib to the lower border of the fifth rib, and externally to
about half an inch internal to the nipple. There was a distinct systolic aortic
murmur. The recurrences of fever were prevented ; and on the 2nd August, the
internal limit of the splenic dulness was a vertical line from the posterior fold of the
axilla. The upper limit of the preecordial dulness was the interspace of the third
and fourth ribs ; and the external limit was a vertical line an inch internal to the
nipple. The systolic murmur had altogether disappeared.

These cases prove that disease of the heart is not necessarily
present when abnormal praecordial dulness, with or without cardiac

p 3

38 INTERMITTENT FEVEE.

murmur, is associated with enlargement of the spleen. The ab-
normal dulness has been attributed to the mechanical influence
of the enlarged spleen on the heart, and on the expansion of the
lungs. But there is more than this. The praecordial dulness and
murmur may exist in very anaemic states, without splenic enlarge-
ment, in consequence of the incomplete expansion of the lungs,
from the limited respiratory function, which necessarily attends on
a great degree of anaemia.*

The following case is illustrative of this last statement.

5. Extended Prcecordial Dulness, with Systolic and Venous Murmurs, without Splenic
Enlargement. — Antonio Domingo, a native of Goa, and following the occupation of a
shepherd. Had been out of health for some months, suffering from palpitation, praecordial
uneasiness, occasional dry cough, cedematous feet, and febrile accessions coming on
towards evening without distinct chills. He had never suffered from rheumatism.
He was admitted into hospital on the 1st January, 1854, presenting a very pnsemic
appearance. The pulse was small, jerking, and somewhat frequent. The praecordial
dulness was bounded superiorly by the third rib, internally by the median line, and
externally by a vertical line drawn a quarter of an inch external to the nipple, and
below by the sixth rib. A blowing systolic murmur was audible over the third left
costal cartilage, increasing in the line of the aorta upwards, loudest at the top of the
sternum, and decreasing in the direction of the apex, which beat in the intercostal
space between the fifth and sixth ribs, an inch and a half below and half an inch
external to the nipple. There was a venous murmur on the left side of the neck.
The abdomen was slightly full. There was slight enlargement of the liver, as indi-
cated by a distinct indurated edge felt below the right ribs. There was no enlargement
of the spleen. He continued under treatment till the 15th February. During this
time the febrile accessions frequently returned. The urine was often examined ; it
was of low density, but gave no traces of albumen.

When discharged, he had lost much of his anaemic appearance. The jerking
character of the pulse was no longer observed, and the cardiae and venous murmurs
had almost ceased. The last note of the praecordial dulness was on the 15th January;
and it gives, as the external limit, a vertical line drawn over the nipple.

Pathology. —In the cold stage of intermittent fever, the blood
is determined from the surface of the body to internal parts, and
is liable to accumulate in such venous arrangements as those
of the spleen, and the portal system of the liver ; and when
stagnating in the splenetic capillaries, its transfer, in undue
quantity, into the pulpy parenchyma of the organ, readily takes
place. Under recurrences of the cold stage, these events are
repeated, and the bulk of the spleen necessarily increases.

* Since these observations were written, I have had the advantage of referring to
Dr. Sibson's very valuable and instructive work on Medical Anatomy. In the first
fasciculus this extension of praecordial dulness, by shrinking of the lungs, is pointed
out. I leave the text as originally written, for I find nothing at variance with it in
Dr. Sibson's remarks. •

SPLENIC ENLARGEMENT — PATHOLOGY. 39

The density of the enlarged spleen bears relation to the quantity
and quality of the blood present in the vascular system of the
organ, as well as on the increase and the condition of the paren-
chymatous pulp ; as whether any of the fibrinous or albuminous
constituent has become converted into tissue of low organization.
When this change of part of the fibrine or albumen into tissue
takes place, then some degree of enlargement will become per-
manent ; but when the enlargement depends merely on excess of
blood in the vessels, or excess of unorganized pulp, it may be con-
cluded that the organ may still be restored to its normal condition
by a gradual, slow process of absorption and elimination.

This accumulation of blood in the spleen, being an abstraction
of it from the purposes of the circulation, must derange that which
remains in the general vascular system by reducing the proportion
of corpuscles, of fibrine, and of albumen, and by increasing the
proportion of watery constituent.

If enlargement of the spleen only occurred as a result of inter-
mittent fever, the statement just made of its relation to the altered
condition of the blood, viz., that the enlargement is the antecedent,
the altered blood the sequence, might be sufficient. But when it
is recollected that enlargement of the spleen and concomitant
cachexia may take place from the influence of malaria, without
the intervention of fever, then the belief must be entertained that
malaria exercises a primary deteriorating influence on the blood ;
and that the altered state thus induced favours stagnation, and
in some circumstances is the chief, if not the only proximate
cause ; but that in others, it merely co-operates with the favour-
ing conditions of the cold stage. This view of the injurious
influence of malaria may the more readily be assented to, when
it is found that nothing so surely leads to removal of enlargement
of the spleen as well-directed means for improving the state of the
blood.*

* Feeeichs — "Klinik der Leberkrankheiten" — endeavours to particularise the con-
dition of the blood brought about by recurring paroxysms of fever, and which leads to
general cachexia and structural change of organs, as the spleen, the liver, and kidneys,
and brain. He believes that it proceeds from an excess of dark pigment in the blood ;
that the blood, stagnating in the splenic venous system, has the colouring matter of
some of its corpuscles converted into black pigment ; that thus the corpuscular con-
stituent of the blood is diminished, and the pigment entering the circulation is
conveyed to, and accumidates in, the capillaries of different organs, causing dis-
coloration, with structural and functional derangement. The form of fever which he
has found usually to precede and accompany these changes he describes as inter-
mittent, generally quotidian or double tertian : of 51 cases, 38 proved fatal. In 28 of
the 51 cases, severe cerebral disturbance — delirium, convulsicftis, coma — was present;

D 4

40 INTERMITTENT FEVER.

Treatment — To prevent the paroxysms of intermittent fever,
to remove the cachectic state by all means which tend directly
to this end, and to avoid all measures which are calculated to
increase asthenia, or still further to deteriorate the blood, are
the leading indications of cure.

If the paroxysms still recur, they should be prevented by quinine.
When this has been effected, the cachectic state will be removed
more certainly by the continued use, for some time, of pre-
parations of iron in moderate doses than by any other means.
Sulphate of iron in combination with small doses of quinine, the
citrate of iron and quinine, the tincture of the sesquichloride and
the solution of the persesquinitrate are suitable preparations. The
treatment which lessens the cachexia will also be the most suc-
cessful in reducing the size of the spleen ; for improvement of
the general system and decrease of the splenic enlargement always
progress together, independent of any special local appliances.
Due attention must at the same time be given to all other
measures which are necessary to the preservation of health and
to its restoration when deranged, — as atmospheric purity, food
suited to the power of digestion and assimilation, and the judicious
regulation of the excretions. The state of the mind should also
be carefully considered, and cheerful occupation be provided.

The treatment of enlarged spleen by the periodical application
of leeches, and the daily use of moderate pm-gatives combined with
tonics, as recommended by Mr. Twining *, has not proved effica-
cious in my hands. The abstraction of blood is opposed to the
indications of cure, as already stated ; and though a mild purga-
tive, occasionally used when the alvine discharges are scanty and
cachexia not far advanced, is beneficial, still it may confidently

in 20 there was albuminuria ; and in 17 profuse diarrhoea. In all the fatal cases the
liver was rich in pigment. In 30 the spleen was enlarged and contained pigment.

The diagnosis chiefly rested on the peculiar ash-grey colour of the skin, and the
presence of numerous pigment particles in the blood when some drops were examined
under the microscope.

On these statements of Frerichs I can only observe, that intermittent fever, with a
mortality so large, and complications so various, acute, and severe, has not come
under my observation in India ; and I am not aware that this form of fever has
been described by any writer on tropical disease. Nor does it accord with my impres-
sions that the viscera, after death, in individuals who have suffered much from
intermittent fever, present any peculiar discoloration; but to this remark I attach
little importance, for it is the statement of a general impression, and not of the restdt
of attentive observation directed to the question.

*■ " Clinical Illustrations of the moSt important Diseases of Bengal," vol. i.
Second Edition.

SPLENIC ENLARGEMENT — TREATMENT. 41

be asserted, that when the cachexia is considerable, frequent
purgatives increase it and are very apt to excite dysentery.

The internal use of preparations of iodine and broTnine has
been recommended. Experience does not enable me to speak with
certainty on this question of practice. In the treatment of the
disease among the better classes of Europeans, after benefit has
ceased to result from the measures already advised, change of
climate would be had recourse to as the most likely means of
cure. In hospital practice the patient is generally so fully satisfied
with the improvement of the general health and of the spleen
by the use of quinine, preparations of iron, and general tonic
management, that he is unwilling to continue longer under treat-
ment. For these reasons the opportunity is not often afforded
to the practitioner in India of testing the powers of iodine and
bromine at the period appropriate for their use. I say appropriate
for their use ; for it would be a grievous practical error to turn to
such remedies as iodine and bromine, and neglect the tonic prin-
ciple of management, of which the efficacy has been well proved and
the theory is so much in accordance with physiological and patho-
logical doctrine. When this principle has been fairly applied
and enlargement still remains, then preparations of iodine and
bromine may, with propriety, be had recourse to, if no contra-
indicating circumstance exists in the general state of the system,
or the condition of the digestive organs. It may be urged that
iodine or bromine may be used at the same time with preparations
of iron, and tonic management. The objection to this course is its
inexpediency, for it is impossible to estimate justly the value of
subsidiary means applied at the same time with remedies of ac-
knowledged efficacy; and nothing so injures the character of
therapeutic science as desultory and inconclusive experiments.

To Mr. Twining * the merit is due of pointing out with
clearness and force the evils which attend the use of mercury
in enlargement of the spleen and its co-existing cachexia, viz. ;
the great susceptibility to, and the destructive effects from,
its action. The changes effected in the blood by mercury are
probably not very different from those caused by malaria ; at all
events both are favourable to degeneration and destruction of
tissue, and unfavourable to restoration and repair. To the unbiassed
judgment it seems a strange idea to endeavour to correct the evils
of the one by the super-addition of the analogous evils of the

* " Clinical Illustrations of the most important Diseases of Bengal," vol. i. p. 452.
Second Edition.

42 INTERMITTENT FEVER.

other. Mercurial preparations are unquestionably injurious in
splenic enlargement and cachexia, and their use should be care-
fully abstained from.

The application of external remedies to the region of the spleen

— as sinapisms, lotions with iodine or nitro-muriatic acid, &c., —
is sometimes useful in relieving local uneasiness; and the two
last remedies may possibly exercise a deobstruent action ; but as
they are seldom used singly, it must be very difficult to isolate
their therapeutic value. Applications which vesicate or cause
pustular eruptions, should be avoided in a state of the system
prone to destructive ulceration and sloughing. Mr. Twining's
suggestion of passing long needles into the enlarged spleen is
hardly in accordance with the spirit of rational medicine.

The means as yet described for the cure of splenic enlarge-
ment and cachexia very often prove inadequate, and then cnange
to another locality in India, or to more temperate latitudes, is
a measure essential to recovery. It is vain to expect much
benefit from medical treatment in the hot and malarious seasons,

— from March to the end of November, — in the alluvial and lit-
toral plains and jungly tracts of India. Nor in these states of the
system are the hill climates, from the middle of June to the begin-
ning of March, more suitable : malaria may not be equally
generated ; but they are cold and wet, and therefore liable in mala-
rious cachexia to excite tertian fever, diarrhoea, and dysentery.

The part of India least likely to be injurious in splenic cachexia
in the malarious season, from the middle of June to the end of
November, is the strip of the Deccan table-land, between 20° and
15° N. lat. and from 60 to 100 miles east of the Western Grhauts.
There the fall of rain is inconsiderable, the temperature moderate,
and, in well-selected localities, the generation of malaria is not
great. In December, January, and February, the climate of the
sea-coast, and from March to the middle of June, a hill station,
with an elevation of from 4,000 to 6,000 feet, will prove the most
conducive to recovery.

But when changes of climate such as these, and the use of
suitable remedies, fail in reducing the spleen and removing the
cachexia, then there should be no hesitation in recommending an
early sea voyage, and a prolonged residence in a temperate climate.
Care should be taken, when practicable, that the patient should arrive
in the temperate climate early in summer, and thus avoid the winter
and spring of the cold, and the summer and autumn of the hot lati-
tudes. In all changes from warm to cold, and from dry to damp

HEPATIC COMPLICATION. 43

climates, great attention to clothing is necessary, in order that im-
pressions of cold on the surface of the body, and consequent attacks
of tertian fever, diarrhoea, and dysentery may be prevented. When
the patient comes at first under observation in a state of confirmed
malarious cachexia, and the season for removal to a temperate
climate is suitable, time should not be lost in expectation of benefit
from treatment and change of air in India. A change from India
to Egypt in the winter, and to Syria in the summer and autumn,
is sometimes had recourse to ; but it is an inexpedient measure.
In the year 1840, a medical ofiicer of feeble constitution, who had
suffered from malarious fever in Guzerat, Bombay, and the Deccan,
left Bombay, on my recommendation, in the month of February,
for Egypt. At Cairo, from the influence of the Kamsin wind, he
suffered from congestion of the head and lungs ; was attacked with
remittent fever at Alexandria, and again in the month of May at
Smyrna, and subsequently at Constantinople, where the attack
proved fatal. Since the occurrence of this case, the history of
four other Indian invalids (two of them medical men) have come
to my knowledge, in which obstinate malarious fever was ac-
quired in Egypt or Syria; and it is a curious circumstance that
the febrile paroxysm was, in two of the cases, attended with severe
strangury.

Section IV.- — Intermittent Fever with Hepatic Complication, —
Symptoms. — Patho logy, — Treatment

Hepatic inflammation or enlargement in intermittent fever has,
in my experience, been of rare occurrence, both in Europeans and
natives.

Of the 243 clinical cases of natives in the Jamsetjee Jejeebhoy
Hospital, completion of hepatic affection was observed only in
eighteen ; in six, it was considered to be inflammatory ; in twelve,
to be passive enlargement. Two cases, one of inflammation and
one of enlargement, are subjoined. The first is of interest, because
death caused by cholera gave the opportunity of observing the
appearances presented by the liver. The absence of fibrinous
exudation is probably an illustration of the law established by
Dr. Alison, that when inflammation complicates idiopathic fever it
does not so readily pass on to its results, as when it is itself idio-
pathic. This pathological law, moreover, justifies caution in the
mercurial treatment of hepatitis when it co-existp with intermittent
fever: —

44 INTERMITTENT FEVER.

6. Intermittent Fever complicated with Hepatitis. — Death from Cholera. — Liver in a
state of vascular Turgesccnce. — Mohedeen, a Mussulman sailor, of twenty years of age,
a native of Cochin, and suffering there on two or three occasions from febrile attacks.
Wliile on a voyage from the Persian Gulf, he was wrecked on the coast adjoining the
island of Bombay, and consequent upon exposure to wet he became aiFected with fever,
which, preceded by chilliness, recurred in irregular paroxysms, and, after seven or
eight days' dxiration, was accompanied with pain of the right side of the chest. He
was admitted into hospital on the 17th June, 1851, ten days after the commencement
of his illness. There was pain of the right side of the chest, increased by full
inspiration and coughing ; also pain below the margin of the right false ribs, increased
by pressure. There was some degree of yellowness of the conjunctivae ; but no per-
ceptible induration or dulness below either margin of the ribs. The febrile accession
recurred twice in the twenty-four hours. He was treated with repeated four-grain
doses of quinine during the intermission. Leeches were applied to the right side of
the chest and to the margin of the ribs, followed by a small blister on the former.
Blue pill and ipecacuanha, with an occasional laxative, were also given. The fever
did not return after the 19th. On the 20th, the pain below the margin of the right
ribs was gone, and that of the chest very much lessened. In this state he continued
till 1 A.M. of the 27th, when he was attacked with cholera, and died at 3 p.m.

Inspection twenty-two hours after Death. — Both limgs collapsed freely, and were
crepitating. The costal and pulmonary pleurse of both sides were free of adhesions
or traces of lymph exudation. They were healthy, with exception that the inferior-
anterior part of the right costal pleura presented a slight blush of redness, which was
not the case with the corresponding portion of the opposite side. The heart was
somewhat flabby, but its size and structiire were healthy. The peritoneum was
healthy. The liver was much congested, and bled freely when cut into. The
stomach contained a small quantity of thin whitish fluid, and its mucous membrane
was pale. Peyer's glands in the ileum were slightly enlarged. The kidneys were
flabby, but healthy in structure.

7. Intermittent Fever with enlargement of the Liver. — Saccaram, a Maratha
labourer, of thirty-three years of age, addicted to the moderate use of spirits,
was admitted into hospital on the 9th December, 1849. He was much emaciated,
and had been for four or five years the subject of epigastric swelling, attributed
to frequent attacks of fever. The irregular febrile accessions, generally pre-
ceded by chills, with increased epigastric fulness, for which he sought admis-
sion, had been present five days. The hepatic didness reached to within an
inch of the umbilicus, and midway between the tenth rib and crest of the ilium.
There was sense of uneasiness and weight rather than distinct pain. He remained
under treatment till the 13th January. There was no return of fever after the day
subsequent to that of his admission. The urine was free, generally of low density,
and showing no traces of albumen. He was treated with quinine, the external
application of nitro-muriatic acid lotion, and latterly of an ointment containing
iodine. He was discharged much improved in general health, but with little
diminution of the size of the liver.

Pathology. — Enlargement of the liver, consequent upon in-
termittent fever or slow malarious influence, must be carefully
distinguished from that depending upon chronic inflammation.* J
The diagnosis may be determined by the history of the case ;

* It can hardly be necessary to suggest a caution against the possible error of mis-
taking enlargement of the liver from forming abscess, associated with hectic fever, for
the enlargement now under consideration, associated with malarious febrile accessions.

HEPATIC COMPLICATION. 45

and it is important, for the treatment of the two affections is
very different.

The pathology of this enlargement resembles that of enlargement
of the spleen. It may result from recurrences of the cold stage,
or from a gradual malarious influence without the intervention of
febrile disturbance ; and may be assumed to arise from stagnation
of deteriorated blood in the venous system of the organ.

The proximate cause of enlargement of the spleen was supposed
to be vascular congestion, and addition to the splenic pulp and
to the connecting fibrous tissue by low organisation of exuded
fibrine and albumen. These three conditions, however, are not
all necessarily present. The last is the one most frequently
absent, and probably only occurs in cases of long persisting
enlargement.

The same view may be taken of malarious hepatic enlargement,
— that there is stagnation of blood in the portal and hepatic
venous systems, addition to the contents of the hepatic cells, and
perhaps exudation into the meshes in which the cells are placed.
In cases of long standing, the connecting areolar tissue probably
becomes hypertrophied by a low organising process.

The chief points which the microscope has still to determine are
the degree and character of the additions made to the contents of
the cells ; also, whether there is deposit external to the cells or
not, and if so, its nature.

Treatment. — If there be much that is common in the patho-
logy of hepatic and splenic enlargement, it is reasonable to con-
clude that similar principles of treatment are applicable to both
affections, though not necessarily to be carried out by the same
means. It may be anticipated that enlargement, dependent on
vascular congestion and excessive deposit in the cells, may in time
be recovered from by processes of slow absorption and elimination.

If febrile accessions still recur, the first indication is to pre-
vent them by the adequate exhibition of quinine, and the next
is to lessen the cachexia by change of climate, attention to the
general state of the excretions, and the use of small doses of quinine,
the mineral acids, and extract of taraxacum. The diet should
be carefully regulated with reference to the state of the digestive
organs and the assimilating powers ; and nitro-muriatic acid lotion,
or preparations of iodine may be applied externally with advantage.

The preparations of iron, though very important in the allied
affection of the spleen, have not been generally used, but they
seem to me worthy of careful trial in small doses.

The reasoning relative to the exhibition of purgatives in splenic

46 INTERMITTENT FEVER.

enlargement also applies to the present affection. It is true that
derivation to the intestinal mucous surface reduces stagnation in
the vascular system of the liver more directly and surely than
that in the spleen, and that moderate purgatives may be used with
advantage in the early stages of enlargement, while as yet there is
little else than vascular congestion and only commencing cachexia.
But when the enlargement has been of some duration, and there is
probably more than mere congestion, and when the cachectic state
is fully developed, then even more caution than in the instance of
splenic enlargement must be observed, for the proclivity to dysen-
tery and diarrhoea is greater. Under these circumstances the first
indication is to mitigate the cachexia, and then, in addition, to have
recourse to gentle aperients.*

The observations made on iodine and bromine in relation
to the spleen may be repeated in reference to the liver, br.t with
the injunction of still greater caution and reserve. Lastly,
in respect to mercury. The milder preparations may be occa-
sionally used in small doses with advantage to produce a gentle
cholagogue action, but the constitutional influence of mercury is
as injurious in malarious cachexia with co-existing hepatic enlarge-
ment as in that with co-existing enlargement of the spleen, and for
the same reasons. That mercury acts on the secreting function
of the liver in a manner which may be turned to good practical
account in the treatment of various forms of disease is true ;
but that its constitutional influence has any effect on structural
changes of the tissues of the liver, different from that which it
exercises upon the analogous tissues of other organs, is, according
to my belief, altogether without proof; yet it would not be diffi-
cult to show that an opposite opinion has affected injuriously the
treatment of various forms of hepatic disease.

The occurrence of gastric or intestinal haemorrhage as a con-
sequence of enlargement of the liver or spleen and of the co-
existing cachexia, is an occasional, but, judging from my own
experience, a rare event, f

* It is after the cachectic condition has been materially lessened by change of
climate that hepatic and splenic enlargement is often advantageously treated by the
aperient natural waters of Grermany and other spas ; but it by no means follows that
this kind of treatment is safe in the same condition of these organs while the patient
is still in India, with a constitution unimproved by removal from malarious influence.
On the contrary, it may be asserted with confidence, that a routine treatment by
purgatives under these circumstances will frequently lead to a fatal result.

t IVIr. Twining's experience in Bengal on this point was difFerent. He says:
" During the existence of diseases of the spleen attended with much enlargement of

WITH JAUNDICE AND BOWEL AFFECTIONS. 47

Section V. — Intermittent Fever complicated ivith Jaundice, or
Affections of the Stomach or Bowels,

Jaundice. — This complication is not common in intermittent
fever. Of 243 clinical cases, it is noted only of three. Jaundice is
much more frequently observed in remittent fever, and will be
treated of in detail in connection with that type.

Affection of the Stomach and Bowels. — It is not my intention
to consider, under this head, those affections of the intestinal canal
which are produced in malarious cachexia by ordinary exciting
causes, to which the attention of the reader has already been
directed in my observations on the pathology of simple intermit-
tents, and which ought to be borne carefully in mind when we
estimate the direct and indirect mortality resulting from malarious
fever. These forms of disease will be elsewhere more appropri-
ately described.

My present inquiry relates to the complication of derangement
of the stomach and bowels with recent attacks of intermittent
fever.

In sthenic Europeans this form of fever is very rarely attended
with diarrhoea or dysentery ; and when gastric symptoms, as irrita-
bility of stomach,-a tongue florid at the tip and edges, and some degree
of epigastric uneasiness are present, then the habit of spirit drinking,
or too much drugging with medicinal irritants may be suspected.
At a very early period of my practice — first with natives at Sassoor,

the organ, hsemorrliages from the nose, lungs, or stomach, are very liable to occur."
Dr. Graham reports a striking case of gastric haemorrhage witnessed by him in the
Native General Hospital in Bombay — the same field in which, for many years,
my own observations have been made. (" Transactions, Medical and Physical Society,
Bombay," No. 5, p. 29.) In my notes of sick officers, I find a case reported by
Dr. Don of an officer at Poona under his care in 1842. This officer had been affected
with enlarged spleen for fifteen years. He died on the 14th April. On the 10th he
vomited two pints of blood, and on the 11th a similar quantity, and on the 13th
a pint and a half; on the day of his death there was also a recurrence of the
hsemorrhage.

In the year 1858-59, the 1st Bheel Corps was, consequent on the nature of
the service required of it, more than usually exposed to the malaria of Kandeish.
The mmiber treated was 266 ; of these 19 were remittent, and 234 quotidian inter-
mittent. Though a considerable number of the cases were adynamic, some with
jaundice, vomiting, and much headache, others with dark, grumous, bloody discharges
from the bowels, or obstinate epistaxis, yet no deaths occurred. These facts are
extracted from the report of Mr. Burn, the medical officer in charge.

48 INTERMITTENT FEVER.

and then with European soldiers of the 4th Light Dragoons at
Kirkee — I became convinced of the fact that irritability of stomach
was not unfreqently caused and kept up in quotidian fever by the
unnecessary use of calomel and purgatives during the hot stage.*

It is when intermittent fever attacks individuals of asthenic con-
stitution that it is apt to be complicated by gastro-intestinal irrita-
tion. The proportion of cases will be influenced by the system of
treatment ; for, as already explained, diarrhoea and dysentery are
in these states of constitution very readily excited by the injudicious
use of purgatives.

Affection of the stomach or bowels was present in twenty-two of
243 clinical cases, under the form of dysentery in eleven, diarrhoea
in seven, and gastric symptoms in one ; and to mark the relation of
this complication to diathesis, it further appears that, in seventeen
of the cases, an asthenic state was present. The tongue is usually
florid at the edges and tip, and not unfrequently is the first symp-
tom to arouse suspicion of the existence of this complication.
A florid tongue, however, may attend paroxysmal febrile phenomena
in asthenic individuals unaccompanied with gastric irritability or
diarrhoea ; and its presence should always excite apprehension, for
it not unfrequently exists in asthenic states in individuals affected
with hectic fever consequent on inflammatory action of some im-
portant organ. The practical rule in all asthenic cases is to main-
tain a careful watch over all important organs, for their structures
are apt to be invaded by processes of obscure degeneration and
destruction.

When diarrhoea co-exists with intermittent fever, a tendency in
the febrile accessions to alternate with the diarrhoea may occasion-
ally be noticed ; the one being present for three or four days, then
ceasing, and being succeeded by the other. This feature of these
cases has been observed by me in Scinde, as well as in the Euro-
pean Greneral Hospital and the Jamsetjee Jejeebhoy Hospital at
Bombay ; but it is generally a character of old fever cases, not of
recent ones. It was probably the observation of facts of this kind
that led Sydenham to regard dysentery as fever turned in upon the
bowels.

Treatment — The treatment of gastro-intestinal derangement, to
be explained in its appropriate place, should be applied with due re-
gard to the asthenia generally present in these complications. But the

* This question of practice is more important in reference to remittent fever, and
under that head will be again noticed.

AFFECTION OF STOMACH AND BOWELS. 49

important practical question is, whether, in consequence of these
affections, quinine is to be withheld during the intermission. In
reply, it may be affirmed that whatever the complication of an
intermittent fever may be, — the use of quinine during the inter-
mission is always a ruling indication of treatment; because the
local derangement is sure to be aggravated during the paroxysm,
and to be mitigated during the intermission. Grastro-intestinal
irritation is the complication to which the applicability of this
principle might be justly doubted; but it is no exception, as
the following case illustrates : —

8. Intermittent Fever with Gastric Irritation treated vnth Quinine. — Dowlut
Sabajee, a Maratha labourer, of twenty-nine years of age, frequently suffering from
intermittent fever in his native place, but free of it for a year past, during his
residence in Bombay. He was admitted into .the hospital on the 26th October,
1849. He was a good deal reduced in strength, and indulged occasionally in the use
of spirits. He had for eight days been suffering from daily accessions of intermittent
fever, commencing with chills in the morning, and terminating with sweating towards
evening. The febrile symptoms were accompanied with frequent vomiting, headache,
soreness of limbs and slight cough, with tenderness of abdomen during the last three
days. There was no diarrhoea on admission. The abdomen was retracted, resistent,
and tender on pressure chiefly in the epigastric and left hypochondriac regions. The
spleen was enlarged and reached nearly to the level of the lunbilicus. The tongue
was much coated, dryish, and rather florid at the tip and edges. The gums were
spongy, and somewhat discoloured. The pulse was very feeble. The day subsequent
to his admission was the single one of febrile recurrence. The only treatment used
was the exhibition of quinine, first in four-grain doses in powder, repeated six times
about the period of expected febrile accession, with intervals of two or three hoiirs ;
then in five-grain doses in solution, with dilute sulphuric acid. The quinine was now
gradually reduced to three and two-grain doses given four times in the twenty-four
hours, and latterly was combined with half a grain of sulphate of iron. The only
other means used were the application of one sinapism to the abdomen, and effer-
vescing draughts on the day that the quinine was exhibited in powder. Under this
treatment there was no recurrence of fever or of vomiting. The tongue became
gradually cleaner and moister, and lost its florid tip and edges, and the patient was
discharged on the 12th November in much improved condition, and with the spleen
so decreased that it could no longer be felt under the false ribs.

Section VI. — Intermittent Fever complicated with Cerebral

Affection,

Symptoms and Pathology. — Head symptoms — drowsiness, con-
fusion of mind, suffusion of countenance — dependent on cerebral
congestion and followed by imperfect reaction, are occasionally
observed in the cold stage in sthenic habits. But somewhat
similar symptoms may also occur, in all states of the constitu-
tion, from the direct sedative influence of the morbific cause on
the nervous system, irrespective of local congestion, and may

50 INTERMITTENT FEVER

in general be recognised by the co-existence of a feeble pulse,
pallid countenance, and low temperature of the general surface
of the body.

During the hot stage in sthenic habits there may also be
present such degree of headache as to call for special treatment ;
but there is seldom any considerable disturbance of the cerebral
functions.

In the congestive cases there is merely a greater degree, as
respects the head, of the kind of phenomena alluded to in my
remarks on the cold stage of simple intermittents : they are, how-
ever, apt to be misunderstood, as is shown in the treatment of the
following case : —

9. A gentleman, of stout habit, resident at Poona, on the 14tli, 15th, and 16th
July, 1837, suffered from pains of the limbs, lassitude, and furred tongue. On the
17th he experienced difficulty in articulating words, and numbness of the lower
extremities. The countenance was suffused. He was bled and leeched freely. At
noon on the 18th, 19th, and 20th, there was a slight recurrence of the same symptoms,
followed by sweating. He was now sent to Bombay, and experienced there several
febrile accessions ushered in with chills. In the treatment of this ease quinine was
very feebly given at Poona.*

After several paroxysms in asthenic habits, the hot stage may
terminate with incoherence or delirium. This symptom, under
these circumstances, is generally indicative of exhaustion, and is
usually attended by other evidences of this condition. These
cases are also liable to be misunderstood, and to be improperly
treated.

Head symptoms in intermittent fever may likewise be related
to organic lesion of the membranes of the brain. The two follow-
ing cases illustrate this, and are otherwise instructive. They both
show that though the symptoms were dependent on structural
change, yet they were absent during the intermission, and only
present during the period of febrile accession. They, therefore,
verify the therapeutic principle of preventing a febrile recurrence,
as a means of lessening a local derangement. The first is also
an instance of death by unexpected collapse at the close of a
paroxysm, favoured by the injudicious use of depletion at that
period. The second exemplifies the curious fact that in com-

* Though I did not see this patient, yet I was in the neighbourhood of Poona at
the time, and know that at first the nature of the case was not rightly understood.
Had it been so, there would have been less depletion and a freer exhibition of quinine.
This gentleman is now (1859) in good health, and has never, to my knowledge, been
the subject of apoplectic threatenings.

WITH CEREBRAL COMPLICATION. 5\

plicated intermittent fever, the period of accession is occasionally
characterised, not by febrile reaction, but only by symptoms of
the local derangement.

10. Intermittent Fever, with Chronic Meningitis. — Symptoms chiefly during
Accession. — Death from unexpected Collapse. — J. S., aged thirty- three, of stout
habit, not long resident in Bombay, and latterly occupied in conducting an
hotel, was admitted into the European General Hospital on the evening of the
24th September, 1840, at half-past 5 p.m. It was stated that for the five or
six previous days he had been affected with fever of the quotidian or tertian
type, and had suiFered from a paroxysm ushered in with rigors at noon on the
day of admission. Wlien seen he had pyrexia with slight wandering, tongue pretty
clean, pulse frequent and feeble, abdomen supple. An effervescing draught was
ordered every second hour for three or four doses, and twenty-four leeches were applied
to the temples and cold cloths to the head. A foot-bath was directed to be used
at bedtime, and a draught, c. tinct. muriat. morphia one drachm, to be exhibited,
should the headache cease and there be no delirium. Was reported to have had
no headache or wandering after the application of the leeches, and the skin to have
become cool. The draught was given about half-past 10 a.m. He was reported
to have got up to make water when he fell down convulsed. The head was imme-
diately shaved, and a blister was applied to the nucha. He died at 11 p.m.

Inspection fifteen hours after Death. — Body stout and loaded with fat. There were
purple sugillations of the depending and posterior parts of the body. Head. — The
sinuses and veins were turgid with blood, and there was a good deal of capillary vas-
cularity of the pia mater over the entire convex surface of the brain. The arachnoid
membrane was thickened and opaque, and in many places, chiefly at the dipping down
between the hemispheres, there were patches and granules of lymph between the
arachnoid and pia mater. The substance of the brain, when incised, showed nume-
rous bloody points, but was tolerably firm in texture. There was an ounce of serum
at the base of the skull, but not more than the usual quantity in the ventricles.
Chest. — The lungs were healthy and very little congested. The cavities of the heart
were moderately distended with blood. The inner lining of the aorta had a rosy
tint, and there was a commencing white deposit, in spots and streaks. The muscular
parietes of the heart were healthy. Abdomen. — The intestines and omentum were
loaded with fat. The former, distended with air, pushed the liver up to the level of
the fourth rib. The mucous coat of the stomach had a dusky leaden tint, and was
slightly more tender in texture than natural. The kidneys were healthy, and there
was no distension of the bladder. The spleen was considerably enlarged. The live?
was of a greyish tint when incised, but was natural in texture.

11. Intermittent Fever: some of the Paroxysms complicated with Convulsive Fits,
one of which terminated fatally. — Thickening and Opacity of the Arachnoid Membrane,
— Eichard Parkman, aged twenty-eight, seaman. Honourable Company's receiving
ship Hastings, after having been ill with intermittent fever for two or three days, was
admitted into the General Hospital on the 24th March, 1842. On that day he
experienced a febrile paroxysm attended with headach-e. An emetic was exhibited,
and followed by repeated doses of quinine. On the 25th, there was neither fever nor
headache. On the evening of the 26th,- he was seized with a convulsive fit, but
denied having been ever subject to such attacks. On the morning of the 27th, he
was free of fever or headache. Cold affusion to the head, with a hot foot-bath, was
used twice ; and the only complaint made that day was of a sense of constriction of
the throat towards night. On the morning of the 28th, he was free of fever, and
quinine was directed to be given. He had a con^iilsive fit in the course of the day.

E 2

52 INTERMITTENT FEVER

and again at night. On the morning of the 29th he was free of complaint, and the
ekin and pulse were good. The liquor arsenicalis was directed to be given thrice,
and cold affusion to be used to the head in the event of a recurrence of the fit.
Towards evening there was a slight febrile accession, but he slept well ; and, at the
morning visit of the 30th, he was reported to have no headache, and to have had no
return of the convulsions. The remedies used on the 29th were directed to bo
repeated. About half an hour after that report, he was seized with convulsions
(reported to be not more severe than the former ones), and he died in about five
minutes.

Inspection. — Head. — On the upper surface of the brain there was a thin veil of
serum between the arachnoid and pia mater. The former membrane was opaqxiish
in parts, with here and there deposit of distinct yellow points, but in no great
number. The substance of the brain was healthy. There were about two ounces of
serum at the base of the skull. Chest. — The right ventricle of the heart M'as dis-
tended with blood ; but the other contents of the chest were in a healthy state.
Abdomen. — Old adhesions bound the liver to the side. The viscera were otherwise
healthy.

Treatment — When cerebral congestion is present in the cold
stage, general or local blood-letting, according to the state of the
constitution, the pulse, and the urgency of the symptoms, must
be had recourse to ; but these measures are not to be used to the
same extent as would be necessary if the congestion were inde-
pendent of a transient influence. The application of heat to the
extremities, and the use of purgatives, are also indicated. The
important consideration, however, in such cases is, a careful
diagnosis, and then prevention, by the adequate exhibition of
quinine ; for it is a serious error to neglect this, and to rest
satisfied with endeavouring to remove the cerebral symptoms by
the repeated use of evacuant remedies.

In asthenic states, when the nervous symptoms seem to de-
pend on exhaustion, suitable nourishment and stimulants, with
quinine during the intermission, are the means of cure. The rest-
lessness and wandering may perhaps suggest a full opiate towards
the close of the paroxysm ; but this proceeding under these cir-
cumstances is very dangerous, as case 1 1 has already illustrated.

The use of opiates in the treatment of malarious fever is an
important subject, and will be fully considered in connection
with remittent fever.

Section VII. — Intermittent Fever complicated with Bronchitis,
Pneumonia, Rheumatism, Scorbutus, Pericarditis, Asthma.

Bronchitis, — This complication is not common in Europeans in
India; but in natives, next to splenic enlargement, is the most
frequent. The cause of this difference between Europeans and

COMPLICATED WITH BRONCHITIS, ETC. 53

natives is, probably, of easy explanation : the former are usually
much better protected from cold and wet.

Bronchitis has been observed by me in the fevers of natives in
the Deccaa, Scinde, and in the Jamsetjee Jejeebhoy Hospital at
Bombay. It is also common in Gruzerat, and presumably through-
out India generally, in places and at seasons when alternations of
temperature are considerable, rain frequent, and winds chilling.

It is in the cold months, December, January, and February, and
in June and July, — the months of commencing rain-fall in much
of the tract of country subject to the influence of the south-west
monsoon, — that this complication chiefly occurs.* It may be
associated with the quotidians and tertians of those seasons ; but
it must be remembered that bronchitis with febricula is apt to be
mistaken for the affection now under consideration.

Bronchitis is readily detected by the characteristic symptoms
and physical signs, and is usually slight; for when it becomes
extensive the fever tends to assume a remittent form. It was
present in 36 of the 243 clinical cases.

Treatment — Quinine, with small doses of tartarized- antimony,
is in general sufficient for the cure.

Febricula with a periodic tendency, associated with bron-
chitis, may be confounded with intermittent fever ; and this error
is sometimes corrected by the results of treatment. Cases, sup-
posed to be intermittents complicated with bronchitis, are occa-
sionally met with in which quinine fails, and antimony proves
successful. These have not, in all probability, been true inter-
mittents, but rather instances of febrile and bronchitic phenomena
excited by cold or wet in individuals in whom there lingers some
degree of previous malarious taint, to which the intermittent
character of the fever may be attributable. "Whether the expla-
nation now given be just or not, the therapeutic observation is
correct and useful to remember.

Pneumonia, — Pneumonia was present in 5 of the 243 clinical
cases of intermittent fever ; but this complication is much more
common in remittent fever, and will be considered in connection
with that type.

RheuTYiatism, — In 4 of the cases a degree of pain of the joints
coexisted with the paroxysmal febrile symptoms, sufficient to
justify the inference that some amount of the rheumatic diathesis
was present.

* In districts subject only to the north-east monsoon, the latter half of October and
November probably take the place of June and July.

£ 3

54 I2JTERMITTENT FEVER

Scorbutus, — In 5 cases sponginess and discoloration of the
gums indicated the presence of this taint. The fever was attended
with more pain of the loins and limbs than is usual in this type ;
and in this and allied forms of cachexia, though observing distinct
accessions and intermissions, it is usually characterised by a less
amount of reaction, and the distinction into stages is often inap-
preciable : still, it is to be regarded as malarious, and as requiring
anti-periodic remedies, combined with the appropriate means of
correcting the cachexia.

• Pericarditis. — This complication is rare, and the following
is the only case which has come under my notice. It illustrates
well the efficacy of that principle of treatment which combines
remedies for the inflammation and for the fever. The pericarditis
was accompanied with some degree of pneumonia of the right
lung.

12. — Intermittent Fever with Pericarditis and Pneumonia. — "Recovery. — Joaquira
Manoel, an African sailor, of stout liabit, and twenty-two years of age, was ad-
mitted into hospital on the 19th September, 1851, after four days' illness, which,
attributed to exposure to wet, commenced with febrile symptoms ushered in with
chills, and followed by prsecordial imeasiness. On the succeeding days inter-
vening between that of attack and admission into hospital, the febrile paroxysm
returned daily, with chills, at 11 a.m., and ceased, with sweating, at 5 p.m. When
first seen there was febrile excitement, with full pulse. The tongue was thinly coated,
and was florid at the tip and edges. There was abnormal dulness and bronchial
respiration in the right dorsal region. There was lancinating pain in the prsecordial
region, increased by cough and full inspiration. The prsecordial dulness was bounded
above by the third left rib, below by the sixth, internally by the left margin of the
sternum, and externally by a line perpendicular from the nipple. A rough murmur,
obscuring both sounds, was heard generally over the praecordial region; but it
was most distinct an inch internal to and a little above the nipple. There was
no induration or dulness below the margin of the false ribs of either side. He had
never suffered from rheumatism. He indulged moderately in the use of spirits.
Fifty leeches were applied to the prsecordial region ; and a pill of five grains
of calomel, with ipecacuanha and opium, one grain each, was given. On the morning
of the 2nd there was febrile intermission, the prsecordial pain was much less, the
murmur was not audible, and crepitus began to be heard in the right dorsal region.
Quinine, in five-gl-ain doses, was given in the usual way, a blister was applied to the
prsecordial region and warm turpentine to the right dorsal region, and the pill
was repeated at bed-time. From this time there was no recurrence of fever, and
there was gradual amendment of the signs of pericardial and pulmonic affection.
The quinine was continued; the pill was repeated on the 21st; then discontinued.
The quinine was subsequently given, in combination with Dover's powder. He was
discharged on the 28th, when the prsecordial didness was bounded above by the fourth
rib, below by the fifth, internally by the left sternal margin, and externally by
a perpendicular line half an inch internal to the nipple. With exception of slight
harshness of the first sound, nothing abnormal was heard. The dulness of the right
dorsal region was nearly gone, and vesicular respiration was present. The urine was
frequently examined. It was scanty at first; then became more abundant; the
specific gravity ranged from 1019 to 1025 ; it gave no traces of albumen.

COMPLICATED WITH ASTHMA. 55

Asthma. — The following is the only instance of this complica-
tion : —

13. Intermittent Fever complicated mth Asthma. — Chitim, a Hindoo drummer, of
thirty years of age, of stout frame, and a native of Golconda, had suffered for about
eight months from intermittent fever and asthma, which was liable to return at inter-
vals of fifteen days. He was admitted into hospital on the 2nd August, 1850. The
physical signs of emphysema of the lungs were present. The paroxysm of fever and
of dyspnoea recurred together at night, and ceased towards the morning. He
was treated with quinine in four-grain doses, at first uncombined, then with sulphate
of iron (one grain) and dilute sulphuric acid. No treatment, except rubefacients to
the chest, was specially directed against the asthmatic symptoms. On the first and
second day after admission, the fever and asthma were much less : they ceased on the
third day. He was discharged on the 8th August.

This case is interesting from its bearing on the therapeutic fact,
that some cases of spasmodic asthma in India are most successfully
treated with quinine and small doses of sulphate of iron during
the absence of the paroxysm, and in these it is reasonable to
infer that the asthmatic symptoms have been related to malaria
as a cause. To determine the probability of a previous malarious
influence, by inquiry into the history of the case and the condition
of the spleen, constitutes an important part of the examina-
tion of asthmatic patients in India. If there be good reason
for suspecting it, quinine and iron are indicated, and a more
favourable prognosis than in asthma under other circumstances,
provided the emphysema is not great, may be entertained.

Prevention of the paroxysm, by an anti-periodic remedy given
during the intermission, has throughout these remarks been in-
culcated as the ruling therapeutic principle in the treatment of
intermittent fever, simple and complicated; but means appro-
priate for the complications, when existing, are not therefore
excluded. On the contraiy, they are also to be adopted, in the
modified manner suggested by the diathesis, and the fact of the
control exercised by the prevention of the paroxysm.

E 4

56 REMITTENT FEYER.

CHAP. V.

ON REMITTENT FEVER.

Section I. — The Diagnosis of Remittent Fever, from Intermittent
Fever and ardent Continued Fever, — Division into Simple
and Complicated,

The causes of remittent fever are the same as those of intermittent
fever. The essential difference between the two types is, that in
the remittent there is merely an abatement — a remission — of
the febrile reaction ; but in the intermittent, a complete cessa-
tion— an intermission. As in the remittent form there is a
longer period of fever, it is necessarily a more serious disease;
and its prevalence may be looked for when the causes are intense,
or the state of predisposition is great.

The evidence that remittent and intermittent fever are different
degrees of the same kind of derangement, is of the following
nature: —

It is often observed that when the conditions of malaria exist
in great degree, remittent fever prevails; but that when these
lessen, the type becomes intermittent. It is not unusual for cases
of fever, remittent at their commencement, to become intermittent
before their close, or for cases that have been intermittent at the
outset to pass into the remittent form in their advanced stages.
Instances are also not unfrequently met with which seem to occupy
an intermediate position, which by some would be classed as inter-
mittents, by others as remittents, — cases in which there is an in-
termission of the pyrexia, but in which the tongue continues
coated, the secretions more or less deranged, and the succeeding
paroxysm comes on gradually without rigor.

In well-marked cases the diagnosis is easy ; and in respect to the
intermediate ones, it is not of much practical importance, for the
principles of treatment are similar.

DIAGNOSIS. 57

The common continued fever which occurs in many parts of
India in the hot, dry months of the year, chiefly in April
and May, in its most aggravated form in recently-arrived robust
Europeans, often favoured by intemperance and fatigue, also re-
quires to be distinguished from remittent fever.

This diagnosis is materially assisted by bearing in mind
whether the season is one generally free from malaria or not,
whether the temperature is high, and whether the sufferers have
been previously exposed to malarious influence or not. The
character of the febrile disturbance likewise assists us, — as whether
reaction is great, whether there is much cerebral or gastric com-
plication, and whether the remission is distinct.

If the attack be in a hot and non-malarious season, in a recently-
arrived European, and the febrile excitement be high and con-
tinued, there need be no hesitation in considering the disease to be
continued fever, not malarious remittent. The diagnosis is im-
portant, for, as will afterwards be explained, the principles of
treatment are different ; but unfortunately, it is not generally of
this simple nature. High fever with cerebral and gastric disturb-
ance may occur in lately-arrived sthenic intemperate Europeans
in June, July, August, September, October, months in which, in
many parts of India, elevated temperature and the conditions of
malaria coexist ; or fever in April or May (non-malarious months)
may attack Europeans or others, who, though tainted by the ma-
laria of a previous season, are still sthenic, perhaps intemperate,
and frequently exposed to the sun : but the fever, if closely watched,
will in both instances be found to be characterised by distinct,
though perhaps short remissions. The simplest and most practical
view of this last, and in European troops at some stations* in India,
not infrequent form of fever, is to consider it as compound in its
nature, the product partly of malaria., and partly of elevated tem-
perature conjoined with other ordinary exciting causes, acting on
sthenic constitutions. The principles of treatment will necessarily
consist of a combination of those applicable to the unmixed con-
tinued and remittent forms.

Eemittent fever may be divided into simple and complicated.
In the first, the derangement of different functions is not greater
than is usual in the severer forms of all fevers. In the second,
there is present either a local inflammation, or an aggravated de-

* As in the plains of the Ganges and Indus and their tribjitaries, the Coromandel
coast, and the table-lands of the Deccan and Malwa.

58 REMITTENT FEVER.

gree of some other kind of local derangement. It will be prac-
tical and convenient to treat of simple and complicated remit-
tent fever under the separate heads of Symptoms, Pathology, and
Treatment.

Section II. — Symptoms of Remittent Fever, — Ordinary, Inflam-
matory, Adynamic, Congestive, Badly developed, with un-
expected Collapse, with peculiar Features, — Also complicated
with Cerebral Affection, Irritability of Stomach, Jaundice,
Bronchitis, Pneumonia. — Diagnosis from Hectic and Sym-
ptomatic Fever,

Ordinary Remittent Fever. — The first accession of remittent
fever is generally preceded by a sense of chilliness, slight, however,
in comparison with the rigor which usually ushers in an attack of
the intermittent type. The chilliness is succeeded by heat of skin,
headache, flushing of the face, frequency of pulse, occasional vomit-
ing, furred tongue, thirst, pain of the loins and limbs, deficient,
vitiated alvine secretions, and scanty, high-coloured urine. These
symptoms continue for a period of varying duration, and are
then followed by a stage of abatement or remission ; when the pulse
falls in frequency but does not return to the natural standard ; the
headache, with the pain of the loins and limbs, becomes less, but
is not altogether removed ; the temperature of the skin decreases,
bat does not fall to the normal degree ; the skin becomes softer,
with even a little moisture about the head and trunk ; the thirst
decreases, and the tongue becomes moister, though still coated.

This remission of the febrile symptoms continues for a time
varying in different cases, or in different endemics ; and then the
exacerbation recurs, sometimes, but this is rare, with commencing
chilliness, as on the first accession. Most commonly, however, there
is no sense of coldness, but a gradual increase of the fever, till it
again reaches its acme.

In intermittent fever the duration of the paroxysm and of the
intermission, and the periods of accession, may vary ; and so may
the duration and periods of the exacerbation and of the remission
in remittent fever.

1. There are cases in which the exacerbation comes on about
noon and declines before midnight. The remission continues
during the night, and till the noon of the following day, when the
exacerbation again recurs.

2. The exacerbation comes on about midnight and continues

ORDINARY FORM SYMPTOMS. 59

till morning, when the remission takes place and remains till night.
It is not improbable that in these cases it will be frequently found
that the exacerbation has become postponed from the influence of
quinine : but on this point I do not speak with confidence,

3. The exacerbation comes on about noon, and is succeeded
towards evening by a remission which continues till midnight.
Then an exacerbation again takes place, to be followed by a morn-
ing remission. This variety is by no means uncommon, and in-
dicates a severe form of the disease, — one in which the fever shows
a tendency to become continued, and in which adynamic symptoms
are likely to arise.

4. It is sometimes observed that the exacerbation takes place at
different hours on alternate days, being on one day earlier, on the
other later. In this respect there is an analogy to the double
tertian.*

Such are the variations in regard to the duration and periods of
exacerbation and remission ; but it is impossible to anticipate which
of them a particular case will assume : nay more, the natural
course of the disease may be changed by treatment, as happens
in intermittent fever.

This uncertainty in regard to the periods of exacerbation and
remission makes it necessary that the peculiarities, in this respect,
of each case, should be ascertained by careful frequent observation.

It will not, however, fail to be remarked that there is one feature
common to all, — the morning is the most certain period of re-
mission.f

■* No observer of tropical fevers has written ynth. more accuracy on this and other
points than Dr. Francis Balfour, in his collection of treatises on the effects of sol-
lunar influence ; but his labour has been in a great measure lost, in consequence of
his practical researches being obscured by trifling theories and affected language.
His statement respecting the periods of exacerbation and remission in remittent
fever, divested of its peculiar phraseology, amounts to this. The day and night are
di^aded into four periods. Two consist of seven hours each, — ^viz., from 8.30 a.m. to
3.30 P.M., and from 8.30 p.m. to 3.30 a.m. These are the times of exacerbation, and
the latter or nocturnal one is that in which the paroxysms genierally appear first,
disturbing rest, obscure, often not recognised by the patient, or scarcely recollected
after the slumber which succeeds it ; and as the disease advances, the febrile symptoms
are higher in it than in the diurnal period ; and again, as the fever declines, the
paroxysm often continues to recur in the nocturnal, after it has ceased to appear in
the diurnal, period. The remaining two divisions consist of five hours each, — viz.,
from 3.30 to 8.30 p.m. and from 3.30 to 8.30 a.m. These are the periods of remission,
and at the beginning of fever the first or evening one is distinct ; but as the disease
advances, and the febrile symptoms run high, it becomes so obscure as not to
be observed. The second or morning period of remission is, in all cases, more dis-
tinct, and is almost invariably present in some degree,

t Hunter, in his observations on the diseases of the army in Jamaica (1779), states

60 KEMITTENT FEVEB.

These variations in the period of exacerbation and remission
are not peculiar to the ordinary form of simple remittent fever,
but are also observed in those other varieties which we shall find
owe their peculiarities to an aggravated degree of the stage of ex-
acerbation, or of that of the initiatory cold stage, or to a decreasing
period of remission and an increasing duration of exacerbation ;
while there are others characterised by adynamic phenomena, or
complicated by inflammation of an important organ, or other local
derangement.

This description of the symptoms of ordinary remittent fever
applies to the disease as observed in the European Greneral Hospital
at Bombay in seamen*, more or less habituated to a tropical

that the practice of visiting hospitals in the early morning originated in this being the
usual period of remission in remittent fever ; and it is very probable that the similar
practice in India had a similar origin. It is essential to the successful treatment of
remittent fever that this fact should not be overlooked, and that the tendency, which I
have noticed in medical officers not acquainted with tropical disease, to visit their
hospital at a later hour should be checked.

* In some — and these, in some instances, the worst cases — the fever was attributed
to the malaria of the dockyard, a locality abeady alluded to by me.

At the time of my service in the European General Hospital, with the view of
ascertaining to what extent the crews of ships undergoing repairs in the dockyard at
Bombay were liable to be affected with fever, I obtained, through the kindness of
Captain Ross, the Master Attendant, a list of ships of all kinds received into
the dockyard during the period (viz., from 1st July, 1838, to 1st July, 1843), to
which my notes on fever in the European General Hospital have reference, with
the date of docking and undocking each ship. The number of ships amounted to 170.
This list I compared with the Hospital Register, and noted opposite to the name of
each ship the number of the crew admitted for fever into hospital during the time the
vessel was in dock. The following is the result : — Of the steamer Atalanta, in dock
from the 23rd October, 1839, to the 19th February, 1840, 9 fever cases; of the
private ship Orleana, in dock from 13th October to 11th November, 1840, 12; of the
ship Herefordshire, in dock from the 13th October to 10th November, 1840, 10 ; of
the private ship Morley, in dock from the 22nd July to the 15th August, 1841, 10; of
the remaining ships, 3 fever cases were admitted from one, 2 cases from three, and
one case from ten, respectively. From the remaining 152 ships, there were not any
admissions of fever during the time they were in the dockyard.

The fevers from the ships Orleana and Herefordshire I recollect very distinctly: I
am in possession of a memorandum to the effect that, on the 8th November, 1840,
there were 26 cases of fever in the hospital, of which there were 22 from these two ships,
showing that the shipping in the harbour was comparatively free from the disease.
The type was chiefly the mild remittent. The admissions from the ship Morley were
of similar type ; and during the time that the ship was in dock, H. M.'s frigate
Endymion was also there, and part of her crew suffered severely from fever of a very
adynamic type. There were not more than 3 or 4 cases admitted into the General
Hospital from the Endymion ; but the follo-wdng facts have been extracted by me from
official records to which I have been allowed to refer.

The Endymion was in dock from the 19th July to the 19th August, 1841. On the
28th July, the first cases of fever among the marines took place ; from that date
to the 12th August, 27 cases occurred; and to the 23rd, 11 more, and 2 additional

INFLAMMATORY FOEM — SYMnOMS. 61 ^

climate, and usually seeking admission into hospital, after having
been ill three or four days : it also applies to the disease as occur-
ring in natives of good constitution.

Inflammatory Remittent Fever. — It was stated, in reference to
intermittent fever, that the amount of febrile reaction in the hot
stage had relation to the sthenic or asthenic state of the constitu-
tion : so it is also in remittent fever. In robust Europeans, lately
arrived in India, exposed to malarious influence, and neglectful of
the ordinary means of preserving health, remittent fever, with
severe exacerbations, is likely to occur, attended with much head-
ache, pain of limbs, restlessness, flushing of the face, perhaps deli-
rium. The skin is hot and pungent, and the pulse full and frequent.
A sense of oppression is experienced at the epigastrium, accompanied
by nausea and frequent vomiting. The tongue is much coated, and
its edges and tip are often florid. Thirst is urgent, and the excre-
tions are scanty and vitiated. The remissions are well marked, but
they are proportionate to the severity of the exacerbation, so that
the febrile state in them may almost equal in degree that of the
exacerbation in the ordinary mild form of the disease. The term
inflammatory, as applied to remittent fever, is not to be understood
as implying the presence of local inflammation : it is used merely
to express a high degree of febrile reaction.

If to this variety of remittent fever, as now described, the influ-
ence of exposure to elevated temperature, or of excesses in drinking
be added, then that compound form to which I have already alluded,
— in which the exacerbation is of longer, and the remission of
shorter duration, and in respect to the classification of which, as
continued or remittent, there is often doubt, — will be produced.

cases were subsequently admitted, making altogether 40 marines affected with fever
in one month, all of whom had slept on board in the tour of their duty during
the time the Endymion was in dock ; and in addition to these 40, there were only 2
others who slept on board. Thus of 42 who slept on board occasionally, 40 were
affected with remittent fever ; and to mark the severity of the type, up to the 30th
of August 14 had died, and 10, several of whom were in a doubtful state, remained in
hospital. Whilst such was the extreme suffering of the marines of the Endymion,
whose duty as sentries over stores led to their exposure to the noxious night air of the
dockyard, the following was the condition of the seamen. From the 24th Jxme, the
date of the arrival of the Endymion in Bombay, to the 30th August, there were
95 seamen (blue-jackets) ill with fever. In none of these did the type resemble that
of the marines, and none proved fatal ; and it is distinctly noticed that the carpenters
employed during the day upon the repairs of the bottom of the vessel, with one
exception, escaped any severe attack, and several of them were not attacked at all.

It is a rule of the dockyard that the crews shall not sleep on board whilst the ship
is undergoing repairs there ; and the statements which have been just made show the
salutary operation of this veiy necessary regulation.

62 REMITTENT FEVER.

Remittent Fever tending to become continued, then adynamic
in cliaracter, — It has been stated that sometimes in ordinary re-
mittent fever the exacerbations are double, — one in the day,
another in the night. Such cases are generally severe, because
the hours of exacerbation are increased in number ; and it often
happens that after the first or second day of the double exacerba-
tion, or it may be from the very commencement of the attack,
the remissions are so slight as to be hardly observed : the fever
becomes almost continued in character.* This may proceed from
the intensity of the malaria acting on an ordinary constitution, or
from a less degree of malaria acting on an asthenic constitution, or
(and this is probably a very frequent cause) from the early exacer-
bations not having been judiciously managed — from neglect of the
withdrawal of causes of irritation or excitement, or by the applica-
tion of means of cure too depressant. Finally, the continued form
may be favoured by the access of local inflammation.

When remittent fevers, which have thus passed into the almost
continued form, do not prove fatal in the early stages from sudden
depression of the vital actions of the nervous system or of the heart,
or from congestion, or inflammation of some important organ, but
continue beyond the eighth day, or earlier when the asthenia has
been great, then a new train of symptoms begins to appear. The
pulse becomes more frequent and feeble, the tongue dry, brown
and unsteadily protruded. The hands are tremulous, with tendency
to subsultus tendinum. There is more or less muttering delirium
and drowsiness, and death takes place from exhaustion or coma. In
other words, the remittent fever has assumed an adynamic character.
With this form of the disease in Europeans I became familiar in
the Greneral Hospital at Bombay ; and in natives not only in the
Jamsetjee Jejeebhoy Hospital, but also in all the other various
circumstances in which I have had the opportunity of observ-
ing their diseases.

When these phenomena of depressed vital action are present in
their most aggravated degree, petechial spots may show themselves

* The term '* continued " having been already applied to a different set of circum-
stances from that in which it is here used, it would have been well, to prevent the
risk of confusion, to substitute another term; but I am not prepared to suggest
departure from usage. It can only be a very careless reader who wiU confound
the common or ardent continued fever of the hot months, occurring in sthenic
individuals, with fever generally remittent at the beginning, then becoming continued,
oceiirring at malarious seasons, in constitutions asthenic at the outset, or made so by
the intensity of the cause or injudicious treatment in the early stages.

ADYNAMIC FORM — SYMPTOMS. 63"

on the surface of the body, or there may be oozing of blood about
the gums and lips, or epistaxis, or vomiting of blood or of
dark-coloured grumous-looking fluid ; or maelsena or haematuria may
be present. These symptoms prove that the chemical and vital
conditions of the blood have become signally deranged. To remit-
tent fever thus characterised by petechise and haemorrhages, the
term malignant has been applied. In its aggravated form it is
seldom observed in Bombay ; but in its slighter degree it occasionally
occurs.

To what are these adynauiic symptoms to be attributed ? To
the intensity of the cause, to the greater amount of febrile excite-
ment consequent upon the fever having become continued, to the
previous influence of predisposing causes, as insufiicient food,
lengthened exposure to hot weather, intemperance, depressing
passions, bodily fatigue, or previous disease : or they may arise from
medical treatment having been neglected at the commencement,
or from its having been too depressing in character, — too much
general blood-letting, leeching, antimony, calomel, catharsis, and
the neglect of quinine and nourishment.*

When several of these conditions co-exist, — as intense malaria,
predisposition, and injudicious medical treatment, — then are com-
bined the conditions most calculated to produce a feyer of a highly
adynamic and malignant character, ...

* Fever, with, an unusual proportion of adynamic cases, and consequent mor-
tality, prevailed in the gaol at Sattara from October 1858, to May 1859. A short
account of the leading facts wiU serve to illustrate some of the statements in the
text.

The gaol is very faulty in construction, and badly situated ; but, generally speaking,
has not been unhealthy. The system of dieting and general management has for
the most part been good. On the 4th of August, 1858, the dietary was modified by
the Assistant-Judge in such a manner as to create general discontent, and affect the
comfort and health of the prisoners ; but the original system was reverted to on the
2nd of October. The prisoners had also been imperfectly clothed during the greater
part of the monsoon and the commencement of the cold season.

A new gaol, distant about a quarter of a mile from the old one, was being built by
the prisoners. All, without reference to their previous occupations, were, after a
slight meal, marched daily at 6 a.m. to work at the new building, and continued
so engaged till 3 p.m., when the labour of the day was finished, and the prisoners
returned to the gaol for their principal meal. Consequent on the increase of fever,
and the discovery that some of the drains in the gaol were foul, the prisoners were
removed on the 23rd of December to the fort of Sattara, placed on a hill 1200 feet
above the city, nearly 4000 feet above the sea, and about a mile and a half distant
from the new gaol. Thus the prisoners were exposed to greater fatigue in going
to and from work, and to greater cold from elevation. The fever and mortality
increased, work was intermitted for a time, and the prisoners returned to the old
gaol, which had been thoroughly cleaned and whitewashed, on the 15th February, 1859.

The admissions and deaths from fever were as follows : -—

REMITTENT FEVER.

Congestive Remittent Fever. — The term congestive is used in
the sense in which it has been generally applied by late writers*

Admissions.

Deaths.

October

November -. .

December

January .

February .

March

April

178

With the view of determining the characters of the fever, I examined 93 diaries
of recovered cases, and made the following classification with reference to month of
admission and type : —

Intermittent.

Remittent.

Febricula.

November

December and \

January J" • • . •
February .....

March

April

4
5
0

0
0

7
2

The 75 intermittents and remittents presented no peculiarity; they were the ordi-
nary types which prevail in the Deccan, more or less, every year from October to
February. Slight jaundice was present in 16, delirium in 5, and epistaxis in 2.
The cases of febricula were also of the type usually prevailing in the Deccan in
February, March, and April, more or less, according as the ordinary exciting causes
— heat, exposure, fatigue, vicissitudes ef temperature — and the predisposition from
a plethoric or debilitated state, are present. They occurred in greater proportion
among lately arrived ramosees, goldsmiths, writers, and shopkeepers, — classes whom
the out-door labour of the gaol system was likely to aiFect injuriously. They were
mostly a few days under treatment, and there was nothing in their origin, type,
and course to justify a suspicion (which the gaol authorities were disposed to enter-
tain) that infection from old fever cases acting on new arrivals was the cause.

The notes of 21 fatal cases are before me. They are all remittent, with, in
some, a commencement as intermittent. Death was caused by prostration, in some
coming on quickly, in others after the lapse of several days. There was jaundice
in 7. Six of the fatal cases were under two months' residence, and their ages were, of
two 32, and one 35, 48, 65, and 80.

Of the recovered and fatal cases, 4 were stated to have been in attendance on the
sick when taken iU. Two recovered ; one an ordinary intermittent, the other a mild

* " Outlines of Physiology and Pathology." By Dr. Alison, p. 485.

CONaESTIYE rORM. — SYMPTOMS. 65

to a state of depressed action of the vascular and nervous systems
in the early stage of fever ; the former characterised by a feeble
pulse, a cold often damp skin, sighing respiration, and defective
secretions ; the latter by languor and drowsiness. This condition
is probably correctly attributed to the intensity of the malarious
poison. Death may take place speedily in the stage of congestion
-without distinct febrile excitement ; or reaction may follow, and
the remittent character become well marked and the disease
under careful management terminate successfully; or the remis-
sions may be indistinct, the fever almost continued in type, and
adynamic symptoms early evolved. There is, as has been re-
marked by Dr. Alison *, considerable analogy between the sym-
ptoms of this form of fever and those of cholera. The collapse
of cholera resembles 4n many features the stage of congestion, and
when secondary fever occurs, it is not unlike the reaction which
sometimes attends the congestive form of remittent fever. The
secondary fever of cholera is, however, apt to run a longer course,
and to be complicated with subacute inflammation of important
organs. Congestive remittent fever is occasionally observed in the
European General Hospital, as well as in Europeans elsewhere

remittent. Two died; one, set. 41, after one year and six months In the gaol, and
one month's attendance on the sick ; the other, set. 52, after 1-5 years and six
months in gaol, and three months' attendance on the sick. There is, therefore,
nothing in these facts to justify the suspicion of infection, and it is further probable
that these men were selected for this duty because unequal to hard labour. The
symptoms and course of the fatal cases — the prostration, the attendant jaundice — in
no respect differed from those usually observed in adynamic cases of remittent fever
in India, when occurring in persons previously debilitated and out of health.

The medical treatment was faulty ; it favoured the duration of the attacks, and the
change of type from intermittent to remittent, and from the latter to continued, with
development of adynamic phenomena. The defects were, 1. Too active treatment of
the stage of reaction by leeches, antimony, calomel, and purgatives, 2, The inadequate
use of quinine during the remission : it was often too long delayed, the period was
not watchfully selected, and the quantity was insulSicient. 3. Insufficient support
by frequently repeated suitable nourishment and stimulants chiefly during the
remissions. 4. The neglect of an improved and appropriate diet to restore
strength before discharge from hospital and return to the system and work of the
gaol ; hence relapses, with increasing adynamia in each. Several cases were said to
be free of fever, but they sank from exhaustion, or, to express it more distinctly, from
inanition. In this record there is illustrated — 1. The influence of temporary errors
in dieting and clothing, of fatigue, and of vitiated atmosphere, in creating a predis-
position to be acted on by the malaria of the locality, and the reduced temperature of
season and of elevation — thus increasing the [^qiiantity of fever. 2. The effect of the
predisposition thus engendered, and of ill-directed medical treatment and manage-
ment in aggravating the type and augmenting the mortality.

^ " Outlines of Physiology and Pathology," loc. citat.
F

66 REMITTENT FEVEK.

in Bombay, chiefly in the malarious season of the year : it has
also been noticed by me in the cold season in asthenic natives,
who had been badly fed and clothed, and exposed to inclement
weather.*

Remittent Fever with badly-developed Symptoms. — In inter-
mittent fever in asthenic individuals, there is not unfrequently, as
already explained, an irregularity in the characteristic stages of
the paroxysm. Instances of remittent fever similar in kind may
also occur : it is a form of disease little calculated to arrest at-
tention. The exacerbation is badly marked, is attended by little
heat of skin or vascular excitement; indeed, these symptoms of
fever may be absent, but instead of them, there may be some
degree of undue restlessness or fretfulness, or incoherence of mind,
with tremulous hands, and a tongue coated in the centre; or
nausea with tendency to vomit or to diarrhoea may be present.
The remission is distinct, but the nights are generally restless.
With each recurring exacerbation, the pulse loses strength, the
tongue becomes drier and tremulous, tremor of the hands in-
creases, the slight wandering passes into muttering delirium, and
perhaps unexpectedly, about the tenth or twelfth day or earlier,
the delirium lapses into coma; or the exacerbation terminates
with extreme collapse and death.

Mr. Twining's " Insidious Congestive Fever of the Cold Sea-
son," t is, it seems to me, of this nature. But this form of fever

* A greater degree of these congestive phenomena, in very malarious districts, has
been described by authors. The term has, however, been applied by English writers to
other forms of febrile disease. This is much to be regretted. Mr. Twining's " insidious
congestive fever of the cold season" is different, and relates to sets of symptoms,
some of which I have already alluded to under the head of adynamic remittent fever,
and others of which I shall subsequently have to advert to ; but none of Mr. Twining's
descriptions express merely an undue degree and continuance of the phenomena
characteristic of the cold stage. This seems to me the sense in which we should
apply the term congestive fever, and, while we thus use it, it by no means fol-
lows that we are subscribing to any particular pathological doctrine, as, for example,
that which attributes the phenomena of failing heart and nervous system to ante-
cedent congestion of blood ; on the contrary, all the phenomena seem to me to be
coincident and sequences of the influence of the morbific cause.

Again, the term congestive has been used, as in Eeports of the 4th Dragoons, in my
possession, in the sense of remittent fever, with marked congestion of the mucous
membrane of the stomach or bowels, or of the liver. This is also a faulty use of
the term.

t Dr. Edward Goodeve, in a clinical lecture on typhoid fever, published in No. XI.
of the "Indian Annals of Medical Science," suggests that Mr. Twining's "insidious
congestive fever of the cold season " is that form of continued fever now designated
"typhoid;" and much consideration is due to the opinion of this accurate and
experienced physician. Though the view taken in the text of similarity between

UNEXPECTED COLLAPSE. SYMPTOMS. 67

is not peculiar to this season, for I have witnessed it in Eu-
ropeans in June and July. The last case which came under my
notice was that of an old officer about to leave India, who, in his
journey to the coast, sustained a severe fracture of the fore-arm.
The injury with other causes of anxiety and long service in India
had impaired his constitution. He became affected by the obscure
symptoms just described, — restlessness, slight incoherence, then
delirium, tremor of the hands, tongue coated and tremulous.
The exacerbations and remissions were well marked, and death
took place by coma.

This form of disease is important, and liable to be over-
looked. It requires careful treatment and close watching. If
there be much prostration, increasing from day to day, without
any very evident cause, it may be assumed that at some time or
other in the twenty-four hours a febrile exacerbation takes place,
and the period should be ascertained without delay. If the tongue
tends to become coated in the centre, then brown and dry, the
existence of a febrile period becomes certain.

This variety of fever may be apprehended in persons whose
constitutions have become deteriorated by exposure for successive
seasons to elevated temperature, anxiety of mind, intemperance, the
causes of scurvy, secondary syphilis, the abuse of mercury, the in-
fluence of malaria ; and it is not unlikely that in some instances it
may depend on previously existing structural disease. But to this
latter condition further allusion will be made under the head
Pathology.

Remittent Fever ivith unexpected Collapse. — It was stated
that in asthenic individuals the third stage of intermittent fever
is sometimes attended by so much exhaustion as to require the
assiduous use of stimulants and nourishment. The same feature,
is much more frequently observed in remittent fever ; and there is
no practical fact of greater importance to remember in the manage-
ment of this disease, than the marked tendency to great collapse
so often evinced towards the close of an exacerbation — collapse
not unfrequently terminating in death.*

We have learnt that from malaria, habit of body, and continuance

Twining' s insidious congestive fever and the varieties described by me as adynamic,
remittent fever with badly developed symptoms may be incorrect ; still I retain
the conviction that none of the forms of ferer described in this chapter are of
the nature of true "typhoid."

* It is probably to the occurrence of this collapse early in the disease, that the
term Algide has been applied by Dr. Haspel and other Writers on the diseases
of Algeria.

F 2

68 KEMITTENT FEVER.

of febrile excitement, there takes place, sooner or later, in all pro-
tracted cases of fever, a marked depression of vital action, chiefly of
the heart and nervous system. In remittent fever, when this state
supervenes, it generally first appears at the commencement of a
remission, or just as the exacerbation is passing into it. Therefore,
under these circumstances, it is necessary that towards the close of
the exacerbation, all agencies — leeches, purgatives, antimonials,
— calculated to hurry on and increase the depression, should
be carefully avoided; for it is by the injudicious employment of
such means that unlooked-for collapse — thready pulse, shrunken
features, a cold and damp skin — is apt to occur.* Hence the
practical lesson, that in all remittents after the 7th or 8th day,
or earlier if the pulse has been feeble, or the hands and tongue
tremulous, or the mind wandering, or any other symptom of de-
bility present, we should be careful to avoid depressant means of
treatment, more especially towards the close of the exacerbations,
and to give suitable nourishment and stimulants assiduously during
the remission. At the close of a paroxysm symptoms of exhaustion
should be carefully watched for, and should they threaten, then
stimulants and nourishment, as ammonia, wine, and strong animal
broths, must be liberally administered. Cases of remittent fever
have, to my knowledge, been lost, from want of forethought and
preparation to carry out these very evident indications of treat-
ment. The following is an instance of unlooked-for collapse
terminating fatally. •

14. — Remittent Fever fatal from unexpected Collapse^ — ^A gentleman of about fifty
years of age, of sallow complexion, who had lived several years at different times in
tropical climates, and had experienced his share of the cares of life, became, in
Bombay, the subject of remittent fever. After the illness had continued four or five
days, his medical attendant, not satisfied with the state of his patient, yet not
anxious in regard to his safety, wrote to me at one of his evening visits a note request-
ing me to meet him the following morning. The note was not to be delivered tiU the
early morning, but it was sent at midnight, accompanied with an urgent verbal

* It was in Mr. Twining' s writings that I first became acquainted with the fuU
importance of this truth, and it is among the most valuable of his many excellent
clinical lessons. It is now upwards of twenty-five years since this accurate observer
published his *' Clinical Illustrations," yet I am satisfied, from personal observation
and the perusal of the diaries of cases, that this important feature of remittent fever
is not yet generally understood and appreciated by medical men in India. It is still
not uncommon to hear of "anomalous^' cases of fever terminating fatally, unex-
pectedly, "notwithstanding the usual treatment having been actively followed," — the
marvel being, not the occurrence of death, but the want of knowledge of the disease,
the consequent surprise at the result, and the neglect of the means of its pre-
vention.

UNEXPECTED COLLAPSE. — SYMPTOMS. 69

message, begging me to come immediately. The house was in my neighbourhood,
and I was there in a very short space of time, but I found that the patient had just
died. The evening febrile exacerbation had terminated in unexpected and fatal
collapse.

In Dr. A. S. Thomson s report * on fever in Her Majesty's 17th
Eegiment, at Colaba, in the year 1841, an epidemic to which I have
already alluded in the chapter on intermittent fever, there is the
following case : —

15.* Great Collapse in the course of Remittent Fever. — Recovery by Stimulants. —
" Private W. S., aged twenty-two years, in India three years, sanguine habit. Admitted
on the 1st July, 1840, complaining of general debility, &c. A vein was opened, but
he fainted before many ounces slowly came, and no more could be got ; had an emetic
and purgative ; he afterwards complained of headache and had sixty leeches applied
to the head, and a diaphoretic mixture constantly given. 2nd of July : Pulse 84,
skin hot and moist, no pain. Continued the diaphoretic mixture. At night occa-
sional delirium, skin moist and hot bowels open, eyes wild, pulse 124, soft ;
complains of abdominal pain. A blister was applied to the neck and head, and
a draught composed of wine, tinct. morph. muriat. and tartar emetic given ; the head
to be rubbed over with strong tartar emetic ointment.

3rd. Slept a little after draught; pulse 120, skin moist, bowels open, much
irregularity in his manner. Diaphoretic mixture and wine every second hour, with
forty drops of tinct. muriate of morphia at night.

4th. Pulse 79: skin moist; eruption on head from antimony ; slept none; bowels
open ; occasional delirium. The wine and diaphoretic mixture continued ; at night
five grains of calomel and five of hyoscyamus.

5th. Slept well last night, no fever ; pulse 76. Six grains of quinine every third
hour. Vespere. Calomel, antimony, and hyoscyamus.

6th. Fever with delirium came on yesterday at noon, and has continued since ; had
sixty leeches to the head, and this morning pulse 109; skin hot and dry; head warm
and temples throbbing ; thirty leeches applied to the head and diaphoretic mixture
given.

7th. The most fearful collapse followed the application of the leeches and the
fever; skin covered with cold perspiration and pulse scarcely felt. Brandy and
carbonate of ammonia given every ten minutes. Had forty drops of tincture of
morphia last night and slept well. Pulse 106 this morning; skin cold and clammy;
no pain ; the brandy and carbonate of ammonia to be continued.

8th. Strength impaired; pulse 120; skin hot. Diaphoretic mixture to be given
with wine ; bowels open.

9th. Pulse 96 ; skin hot and moist ; no pain ; occasional delirium.

It is useless to detail this case further. No violent paroxysm of fever occurred
again, although there was occasional slight increase of fever. He was convalescent
on the 31st of July, but was not fit for duty until the 11th of September, 1840."

It is almost a corollary from the feature of remittent fever which
has just been considered, that the period of death in protracted
fatal cases will be not the exacerbation but the remission.

Certain other occasional Features of Remittent Fever. — 1. It
occasionally happens that cases of remittent fever which ultimately

* " Transactions of the Medical and Physical Society of Bombay," No. 5, p. 84.

F 3

70 EEMITTENT FEVEB.

prove severe, have not this character at the commencement; but
assume it after two or three slight exacerbations. This is best
explained by supposing that at first the incubation is not per-
fected, and that its completion is followed by the aggravation.
It may be further suggested that, if this explanation be true, we
can readily understand how treatment, unduly depressing in the
early days, may intensify the action of the malaria and advance its
incubation.

2. In remittent fever in asthenic constitutions there may be
a decreasing degree of the febrile exacerbations, but, if this be at-
tended with marked increasing asthenia in the remissions, we must
be careful not to interpret favourably the lessening exacerbation :
it is generally otherwise — the febrile excitement has merely
diminished in consequence of the sinking power of the vital ac-
tions. Such cases if misunderstood, and not very carefully
watched and treated, are apt to terminate fatally by collapse at the
close of an exacerbation.

3. In remittent fever a state of great exhaustion sometimes
takes the place of the period of exacerbation ; and if such cases do
well, the recurrence of febrile reaction at the period of exacerba-
tion is probably of favourable import. I quote a fatal case in
which this feature was observed.

16. Exhaustion taking the 'place of Exacerbation in Bemittent Fever. — A gentleman,
some years resident in India, living freely, and suffering from occasional attacks
of intermittent fever with irritability of stomach in the malarious season of the year
consulted me for irritability of stomach, which soon ceased, but left complete disin-
clination for food. Some nights he slept badly, others well; sometimes from a
morphia draught, sometimes without one. He complained only of great languor, and
looked very exhausted. Three or four glasses of wine, with beef-tea and jellies, were
taken daily. He continued for three or four days to attend to his avocations, till one
afternooon febrile heat of the skin was for the first time noticed ; it was present
during the night and the following morning, but then in less degree. Eight-grain
doses of quinine and nourishment were given. At noon there was exacerbation, but
towards the after part of the day he became very feeble and exhausted. Wine
and nourishment were freely given. He rallied towards night, and passed the night
quietly. On the following morning he was free of all fever, and much less exhausted
than on the previous day. The quinine was resumed, and beef- tea and wine were
freely given. At 1 p.m. there was rather more exhaustion, but no fever. The wine
was more frequently given, and the quinine and novirishment continued, but without
effect. The exhaustion increased towards evening. Brandy was substituted for the
wine. He continued quite collected till midnight, when he became somewhat drowsy,
and died at four o'clock of the following morning. In this case there was no vomit-
ing. The wine and nourishment were retained. There was no diarrhoea.

Complicated with Cerebral Symptoms. — Under this head are
included cases of remittent fever in which there is evident de-

CEREBRAL COMPLICATION. — SYMPTOMS. 71

rangement of the cerebral functions, as delirium, drowsiness, con-
vulsion.

Delirium occurs under two sets of circumstances. It may-
come on in the early exacerbations attended with much headache,
flushing of the face, vascularity of the conjunctivae, and may be
more or less active : this is its usual character in sthenic con-
stitutions, and at the commencement it is unattended with failing
action of the heart. In less sthenic individuals there is inco-
herent rambling, with less headache and flushing ; and though
there may be no distinct adynamic phenomena, the pulse is
deficient in power. Delirium is present chiefly in the exacerba-
tions; and when not altogether absent in the remissions, is gene-
rally much moderated. Should medical treatment fail in check-
ing the fever and removing these head symptoms, then, after a
time, varying in different cases, the delirium gradually passes
into drowsiness, coma, and death. This change is generally
first observable towards the termination of an exacerbation,
and is always attended with failing action of the heart. When
these symptoms occur under the circumstances just described,
they may be regarded as depending upon the co-existence of
inflammation or undue determination of blood to the brain and
its membranes.

Delirium, however, may commence at a more advanced stage
of the fever, as after the eighth or tenth day, or later when the
constitution has been good, and earlier when it has been bad.
It is low and muttering, without headache or flushing of the
face; and is attended with commencing adynamic symptoms, as
tremor of the hands, twitching of the fingers, a tongue tremulous
and dryish, and a pulse of increasing frequency and decreasing
strength. Should amendment not take place, the delirium will
after a time pass iiito drowsiness, and death by coma will succeed,
unless this event has been anticipated by collapse at an earlier
period before the stage of coma has arrived. Symptoms of de-
ranged and failing cerebral function, in adynamic fever, merely
express the concurrence of the brain in the general failure of
vital actions.

From this description of delirium in fever, it would seem that
the diff'erence between that from adynamia and from active deter-
mination to the brain, is the co-existence, in the former, of tremors
of the tongue and hands, and twitching movem^ts of the fingers.
Too much importance, however, may be attached to these deranged
muscular actions as diagnostic of merely an adynamic state; for

F 4

^72 KEMITTENT FEVER.

they are not unfrequently met with in association with subacute
cerebral inflammation, either idiopathic or compHcating fever, and
are to be regarded as indicative of adynamic derangement of the
nervous system, only when the other phenomena of adynamia are
well marked, and the history of the case distinctly points to the
same conclusion.

It has been stated that the delirium when continued passes into
drowsiness.* This symptom, when thus arising, is of most un-
favourable prognosis. But drowsiness occasionally appears in re-
mittent fever, unpreceded by delirium, generally in the earlier
stages and usually associated with a slow pulse and other con-
gestive phenomena. Drowsiness under these circumstances is by
no means so dangerous a symptom as when it follows delirium :
care should be taken not to confound these two conditions. The
first is probably dependent on passive congestion ; the second on
commencing serous effusion. Lastly, there are occasional cases
with delirium or tendency to drowsiness coming on early in the
disease, towards the end of a paroxysm in fevers of bad type,
accompanied with signs of general collapse and dependent on en-
feebled nervous energy.

In the chapter on Intermittent Fever a case is narrated in which
only the period of paroxysm was marked by cerebral derangement.
This feature may also occur in remittent fever. In asthenic cases
with cerebral symptoms the period of exacerbation is sometimes
indicated by increase of delirium or of drowsiness, rather than
by distinct aggravation of febrile excitement.

In some cases convulsion comes on intermediately between deli-
rium and coma. This event may generally be referred to excesses
in drinking, to derangement of excretion from structural or other
causes, or to inflammatory action of the membranes or substance
of the brain.

Complicated with Irritability of Stomach, — Occasional vomit-
ing may be present in ordinary remittent fever, and may occur in
greater degree in the inflammatory form of the disease ; but under
these circumstances it is merely one of the symptoms of an uncom-
plicated type.

But gastric irritability may be urgent, attended with uneasiness
and tenseness of the epigastrium and a tongue florid at the tip or

*• The liability to retention of urine in this state of the cerebral functions is so
well known that it seems almost unnecessary to allude to it. Yet I have seen it over-
looked sufficiently often to convince me that attention cannot be called too frequently
to the fact.

JAUNDICE, BRONCHITIS, ETC.— SYMPTOMS. 73

edges. In this state there is probably some degree of gastritis,
and it may exist in constitutions either sthenic or asthenic. Re-
mittent fever thus complicated has been termed Gastric Remiiient
At other times the vomiting is frequent, and the matters ejected
are tinged with bile, and the tongue is covered with a yellow fur,
but without florid edges and tip. This form' of the disease is
confined to sthenic constitutions, and has been termed Bilious
Remittent

Complicated with Jaundice, — This complication exists occa-
sionally in Europeans, but still more frequently in natives. The
notes of twenty-seven cases treated in the clinical ward are before
me, and they will be particularly alluded to in the Section on the
Pathology of the disease.

The presence of jaundice is easily recognised by the tint of the
skin and conjunctivae, the state of the urine, and the generally
pale colour of the alvine discharges ; and there is usually present
some degree of tenderness below the margin of the right false
ribs. Jaundice is rarely observed from the very commencement
of the attack. It generally comes on after the fifth day, and
has not, as a rule, in my experience, been attended with irritability
of stomach. The tongue for the most part has a yellow slimy
appearance, and general soreness of the body is not unfrequently
complained of.

The few observations which I have to make on affections of the
bowels, the liver and spleen, as complications of remittent fever,
will be included under the head Pathology.

Complicated with Bronchitis and Pneumonia. — These affec-
tions do not frequently complicate remittent fever in Europeans in
India ; but we are told by Dr. E. H. Hunter *, in his interesting
Medical History of the Queen's Royal Regiment in Affghanistan
and Beloochistan, in 1838 and 1839, that in the colder climate
of these countries, chiefly in the winter months, pneumonia was
a frequent complication of remittent fever.

Bronchitis is a common accompaniment of remittent fever in
natives of India; and in the Jamsetjee Jejeebhoy Hospital at
Bombay pneumonia is the most usual of all the inflammatory
complications in asthenic subjects. Indeed, so often is pneumonia
present, that gi'eat risk is incurred of overlooking its existence in
this class of patients, unless, in the management of all fever cases,
we observe the rule of careful examination by percussion and

* " Transactions of the Medical and Physical Society of Bombay," No. 3, p. 183.

74 EEMITTENT FEVER.

auscultation. But it is not only in hospital patients that this com-
plication is met with. It occurs in all classes of the native com-
munity, and I have been consulted in not a few instances in which
it had been previously overlooked, to the great hazard of life,
merely because it had not been sought for.

The detailed consideration of this important subject will be
included in the Chapter on Idiopathic Pneumonia.

Diagnosis of Remittent Fever from Hectic and Symptomatic
Fevers, — The distinction of remittent from intermittent and con-
tinued fevers has already been noticed ; but the further diagnosis
will be more conveniently considered now. The frequent com-
plication of inflammation of important internal organs with this
type of fever has been stated. In a general hospital, into which
patients are admitted often at advanced periods of disease, and in
which a large proportion of the inmates are asthenic, affected with
local inflammations characterised by great obscurity of symptoms,
it may happen that hectic may be confounded by the superficial
observer with remittent fever.* Careful inquiry into the previous
history of the case and scrutiny into the state of all important
organs ought to prevent an error of this kind.

When an abiding malarious influence is present, febrile disturb-
ance excited by ordinary causes generally assumes more or less of
a periodic character; and when an individual thus tainted with
malaria becomes affected with idiopathic inflammation of an im-
portant organ, the symptomatic fever is also often characterised by
periodicity : it may,, indeed, be distinctly remittent. f

It is in individuals who have been long resident in tropical
climates that this tendency of symptomatic febrile disturbance to
become remittent is chiefly observed ; and consequently when local
inflammation and remittent fever co-exist in such subjects, it may
be often doubtful whether the fever is idiopathic and complicated
with an inflammation, or the inflammation idiopathic and the fever
symptomatic. In determining this question the history of the
attack affords material assistance. The inflammatory complications
of remittent fever do not generally arise till several days after the
commencement of the fever ; whereas the symptoms of idiopathic
inflammation and the febrile disturbance are nearly coincident.
Moreover, in idiopathic fever, the febrile phenomena are greater in

* The diagnosis between remittent fever and the adynamic febrile disturbance of
pyoemia will be considered in thfe Section on Pycemia in the Chapter on Blood Diseases.

t The same fact is often observed in surgical practice, when individuals of this
kind of constitution become the subjects of serious injuries.

PATHOLOGY.— MORTALITY. 75

proportion to the inflammatory action, and are attended by a greater
amount of general derangement of function than usually obtains in
symptomatic fever. Notwithstanding attention to these considera-
tions, the diagnosis is often uncertain, for in hospital practice the
history of disease is generally imperfect. It is fortunate, how-
ever, that the doubt which may thus arise does not affect the
treatment; for the same therapeutic principles are in a great
measure applicable to both forms of disease.

Section III. — Pathology. — Mortality from Remittent Fever, —
Relation of Type to Diathesis and 'previously existing Struc-
tural Lesions, — Complication with Cerebral Affection and
Consideration of the Pathological Import of Cranial Serous
Effusion. — Complication with Gastric Irritability, Affection of
the Bowels, — Hepatitis^ Jaundice, Parotitis, and Pneumonia.

When the effects of malaria are compared with those of the special
causes of the zymotic continued fevers of colder climates, this
striking difference is observable : in the former, there are daily
suspensions of the influence with a return more or less complete
to normal action ; in the latter, the influence is continuous for many
successive days. On this distinction centres the difference in the
principles of treatment.

The rate of mortality from remittent fever depends upon the
type of the disease. I am not acquainted with any data which
give the mortality of ordinary remittents separated from the other
forms : it is doubtless very small. The inflammatory, congestive,
adynamic and complicated varieties occasion the chief mortality ;
and in general hospitals the frequent lateness of the period of
admission tends to increase it.

In 113 selected clinical cases of natives, 19 deaths occurred.
Nine of these were complicated with jaundice, 3 with cerebral
affection, 3 with pneumonia *, 2 with bronchitis, 1 with dysentery,
and 1 with splenic enlargement. In 7 of the 19 fatal cases the
fever was adynamic, viz. in the 3 with cerebral affection, the 2 with
bronchitis, 1 with pneumonia, and 1 with jaundice.

Through the courtesy of the Medical Board of Bombay, the
opportunity has been afforded me of referring to the fatal cases
of European officers in the Bombay army and civil service ; and

* These are distinct from the cases which I shall have to notice when considering
idiopathic pneumonia.

76 EEMITTENT FEVEK.

also to the cases of those recommended for change of climate,
from the year 1829 to 1848. They amounted to 1699. Notes
were made of the recovered cases of chief interest : they were 372
in number, and 49 were of remittent fever. I have also notes of
311 fatal cases which constitute nearly the whole mortality of the
period : of these there were 90 deaths from remittent fever, that
is, 28-7 per cent, of the total mortality. On inquiring into
the character of the fever in these 90 fatal cases, it appears that in
33 death took place by coma preceded by delirium, vdth inter-
mediate convulsion in some. In a considerable proportion irrita-
bility of stomach was present : in 6 it was the most prominent
symptom. Death occurred from early and speedy collapse in 12
cases, and in the greater number of them the influence of depres-
sant remedies, pushed too far in the exacerbation, was very apparent.
Adynamic symptoms were present in 8, and congestive phenomena
also in 8. Jaundice complicated, 7, and hepatic inflamma-
tion, 2.*

Before proceeding to the consideration of the pathology of the
several varieties of remittent fever, it is desirable that attention
should be directed to two general observations which are applicable
to all.

Inattention to the diathesis and habits of the affected, and
to the intensity of the morbific cause, has led to needless con-
fusion in the pathology, and to serious errors in the treatment of
remittent fever. The discrepancy of opinion on these points, be-
tween the writers on tropical diseases towards the end of the 18th
century and those of a later period, is best explained by this over-
sight. The first class observed the disease in individuals tainted
with scurvy, and excited by intense malaria ; the second, in persons
of sthenic constitution, and excited by a less degree of the morbific
cause. The one trusted to bark and stimulants for the cure ; the
other, to bloodletting, mercury, and purgatives. Both were in
extremes. The truth lies between.

2. In my report f on remittent fever in the European Greneral
Hospital in Bombay, published in 1843, there is the follovnng re-
mark : "In regard to the character of the subjects in whom these
congestive symptoms are likely to appear, my impression is that
they will be found to occur most frequently in persons who have
passed the meridian of life, and in whom there exists more or less

* I shall return to the mortality from remittent fever in Chap. VI.

t " Transactions of the Medical and Physical Society of Bombay," No. 4, p. 186.

niE-EXISTINa LESIONS. — rATIIOLOGT. 77

long-standing organic disease of the heart, the liver, or the kid-
neys." Subsequent experience has confirmed the importance of
this suggestion, not only as regards congestive symptoms, but
also all other phenomena of depressed action, as well as some of
the complications, particularly the cerebral.

Indeed it is very evident that we cannot fully comprehend any case
of fever, or direct its treatment with advantage, unless by close in-
quiry into the previous history and careful scrutiny of the state of
all important organs, we have determined whether it is an idio-
pathic fever in a system previously sound, or in one generally
deteriorated or the subject of structural imperfection of an im-
portant organ.

Haspel*, in his treatise on the diseases of the French troops in
Algeria, expresses the same idea, when he suggests that the pheno-
mena of Algide fever are probably related to a structurally feeble
heart.

In my notes on the fatal cases of sick officers, there are three of
remittent fever in which after death Bright's disease of the kidney
was found ; but in only one is the character of the febrile symptoms
noted, they were obscure, the stomach was irritable, and death
took place by coma.

The five following cases f, illustrative of these remarks, were
observed by me in the European Greneral Hospital, and in the
Jamsetjee Jejeebhoy Hospital.

17. Bemittent Fever. — Death hy coma. — Brighfs disease of both kidneys. — John
Robinson, aged thirty-seven a stout sailor of intemperate habits, was in the European
General Hospital from June 28th to July 1st, 1838, aflfeeted with anasarcous swelling
of the feet and legs. He was discharged and had returned to his duty on board one of
the steam- vessels. He was again brought to the hospital on the 12th July in a drowsy
state. The pulse was frequent and small and the skin \varm. The tongue had a
yellow fur at the sides, but was florid in the centre. It appeared from his own state-
ment that he had suffered from fever since the 8th, with vomiting and diarrhoea, but
that he had not been ashore since he left the hospital on the 1st instant. The head
was shaved, a blister was applied to the neck, and ten grains of calomel were given.
At 6 P.M. the drowsiness had increased, the skin was moist and cold, the pulse
frequent and feeble, and the bowels had not been opened. A turpentine injection
was exhibited, sinapisms were applied to the feet, and a blister to the epigastrium,
and a draught with camphor mixture, carbonate of ammonia, and nitrous ether, was
given every third hour. On the 13th, the bowels had been freely moved, there was
less drowsiness, and the pulse was 100, smaR and sharp. The draughts were directed

* " Maladies de I'Algerie," vol. ii. p. 320.

t These cases are quoted merely as illustrative of febrile phenomena in individuals
with old structural disease of important organs. I do not stdp to inquire whether the
treatment might have been better or not.

78 REMITTENT FEVER.

to bo continuod, with the addition to each of fifteen minims of colchicum wine, and a
scruple of calomel was given at bed-time. The drowsiness recurred, and increased to
coma, the pulse sank, and he died at 4 a.m. of the lith.

Inspection four hours ajter death. — The body was stout and muscular. Head. — The
membranes and substance of the brain were congested. — Chest. The lungs did not
collapse fully, and there were costal adhesions of the right one. The heart was soft,
flabby, and contained fibrinous coagula. Abdomen. — The liver was pale, and parts of
its surface were marked with cicatrices, as if from former abscesses. The mucous
coat of the stomach was of dark red colour and softened. That of the colon and
rectum also was of dark red tint. Both kidneys were enlarged to double their
natural size, and had imdergone yellow degeneration.

18. Bemittent Fever with adynamic symptoms. — Serum underneath the arachnoid
and at the base of the cranium. — No coma. — The liver much enlarged. — Dark rosy
tint of the mucous coat of the stomach. — John Martin, aged fifty-eight, cook of
the ship Herefordshire, was admitted into hospital on the 31st October, 1840. He
stated that for two days he had suifered from vomiting, purging, headache, and sense
of oppression at the lower part of the sternum, attributed to exposure to the sun
whilst the ship was undergoing repairs in dock. On admission, the face was Pushed,
there was anxiety and oppression ; the pulse was 120, jerking and easily compressed,
abdomen full, tongue dryish and florid, and the skin hot and dry. He was freely
leeched on the epigastrium and blistered, was cupped on the nucha, and subsequently
blistered. He took two or three ten-grain doses of" calomel, and one of a scruple.
The symptoms altered little. There was much restlessness and moaning, oppressed
breathing, frequent vomiting, dejections of dirty light grey colour and watery, tongue
dry and florid, pulse frequent and compressible, skin dry and generally above the
natural temperature, and the abdomen full. He continued qxiite sensible, and died in
the forenoon of the 2nd November.

Inspection five hours after death. — Head. There was a thin veil of serum under the
arachnoid membrane on the convex surface of the brain, and an ounce at the base of
the skull. On incising the substance of the brain, more than the usual number of
bloody points were observable. Chest. — There were old adhesions of the right lung.
Both were moderately collapsed, and there was no congestion of the posterior parts.
The cavities of the right side of the heart were full of blood, and there was com-
mencing disease of the aortic valves and beginning of the aorta. Abdomen. — The
omentum was loaded with fat, and the intestines, both great and small, were col-
lapsed. The liver enlarged reached to the crest of the os ilium and to the umbilicus,
was of pale yellow colour, and, when incised, did not give out much blood. The gall-
bladder was rather flaccid. The spleen was soft and pulpy. The mucous coat of the
stomach had a dark rosy tiiat throughout, with dark brown patches, but the texture
was not softened. The kidneys were somewhat lobulated and rather small, but there
was no well-marked disease of their structure.

19. Remittent Fever with irregular symptoms in an intemperate man of very corpu-
lent habit, and in whose head, heart, liver, and kidneys there was extensive old
organic disease. — Thomas Moss, aged thirty-seven, an engineer of the steam depart-
ment, of full and corpulent habit, who had served ten years in the "West Indies and
ten months in Bombay, was admitted into the European General Hospital on the 5th
April, 1841. The abdomen was full and uneasy but not very tender on pressure, the
skin was dry and of the natural temperature, the pulse 100 and sharp, and the tongue
pretty clean. He stated that since the previous day he had suffered from pain of
abdomen with occasional bilious vomiting and purging. He was bled to twenty
ounces, and some leeches were applied to the abdomen, a warm l^ath used, and fifteen
grains of calomel, one grain of ipecacuanha, and two grains of opium given at bed-
time. He passed a restless night, and on the morning of the 6th the breathing was

PEE-EXISTINa LESIONS.— PATHOLOGY. 79

hurried and oppressed. The abdomen was full, with dulness on percussion for two or
three inches beyond the margin of the right ribs and extending across the epigastrium
to the left hypochondrium, and between the last left false ribs and the os ilium.
The pulse was 120, easily compressed but wiry, the action of the heart and the
sounds were confused, tongue coated, bowels not opened, no vomiting, and the
conjunctivse were yellowish. He was cupped on the cardiac region, a scruple of
calomel was given, and afterwards a purgative draught. The bowels were freely
moved, but the symptoms were unchanged, with exception that the pulse on the
evening of the 5th was feeble. It was now reported that he had been a man of
intemperate habits. A blister was applied over the cardiac region, and diuretics
with gin were given repeatedly. The symptoms continued with failing pulse and
coldish skin, and on the morning of the 7th, commencing coma: he died at 10 a.m:.
of that day.

Ins'pection five Jiours after death. — The body was extremely corpulent ; there was a
layer of fat fully two inches thick in the abdominal parietes. Head, — Much blood
flowed on separating the scalp from the cranium. All over the convex surface of the
hemispheres the arachnoid was pearly, and in many places much thickened; and
underneath it there was a layer of serum veiling in many places the interspaces of the
convolutions. There were about three drachms of serum in the lateral ventricles, and
two ounces at the base of the skull. In the coats of the basilar artery and of those of
the vessels forming the circle of WiUis, and given off from it, there was much thicken-
ing from white deposit, in places, almost ossific in character : in these vessels there
was a small eoagulum of blood moulded to their shape. Chest. — ^Adhesions connected
both lungs to the costal pleurae. The greater part of the lower lobe of the right lung
was in a state of red hepatisation, and when cut serum streamed from it. The left
lung was cedematous posteriorly, but not hepatised. The heart was the size of a
bullock's chiefly from hypertrophy with dilatation of the left ventricle, the right
ventricle was rather small, the right auricle was dilated and filled, as well as the
ventricle, by a firm yellow fibrinous eoagulum. There was commencing yellow deposit
on the inner surface of the aorta, but it had proceeded to no great extent. Abdomen.
■ — The contents of the abdomen ascended to the level of the fourth rib, and thus
encroached on the capacity of the chest. The omentum was much loaded with fat,
the mesentery consisted of a layer of fat fully a quarter of an inch thick, and the
intestines were in general contracted and looked like a fringe to the more conspicuous
mesentery. The liver was mu.ch enlarged, of bright yellow colour externally and
internally, and the incised surface had a smaU granular aspect. Spleen healthy.
Both kidneys were considerably enlarged, with cysts from the size of a pea to a
filbert standing in relief from the surface. The substance of the kidneys was also
occupied by similar cysts ; and the contents of some consisted of a dark grey
grumous flxiid, while that of others was straw-coloured serum. In one of the kidneys
there was also a good deal of yellow degeneration,

20. Remittent fever in ajper^on of very intemperate habits, with symptoms in some
respects resembling delirium tremens. — Death by coma, — Three ounces of serum
at the base of the skull ; Liver much enlarged, — Commencing degeneration of the
kidney. — Mucous coat of the colon softened with here and there red patches, with a
mucous follicle in the centre of each discoloration, — Softening of the mucous coat of the
stomach. — Thomas Chittenden, aged thirty-four, an engineer of the steam department, of
intemperate habits, and frequently in hospital suffering from febrile attacks, was
admitted on the 30th of August, 1839. He stated that for eight or nine days he had
been affected with febrile symtoms attended with irritability of stomach. On admis-
sion he complained much of headache, and the bowels were relaxed and the tongue
yellow. Thirty-six leeches were applied to the temples, and six grains of calomel, one
grain of ipecacuanha and one of opium were given. At the evening visit it was reported
that he had vomited frequently and been affected with general tremors which con-

80 REMITTENT FEVER.

tinued. The tongue was tremulous and yellow, the abdomen was somewhat fall and
tender on pressure at the epigastrium and right ribs, there was much headache, the
skin was covered with moisture, and the pulse was compressible. The bowels had not
been opened. A purgative enema was ordered, blisters were directed to the epi-
gastrium and to the nucha, and ten grains of calomel and two of opium were given at
bedtime. The blister acted well, and on the morning of the 31st (full moon) the
headache was lessened, the pulse 90, and the tongue not so tremulous. He was
ordered saline mixture with tartar emetic and tincture of hyoscyamus. He slept for
two hours during the day and his bowels were freely moved. During the night,
there was no sleep, and on the morning of the 1st of September the tongue and
hands were tremulous, the countenance flushed, the pupils dilated, and the pulse 96.
Cold aiFusion was ordered to the head, and saline mixture with two drachms of tinc-
tiu'e of hyoscyamus every second hour for three doses. At the evening visit he was
still tremulous, his manner was startled, and he muttered to himself, the pulse was
feeble and the skin moist. One dark-coloured dejection had been passed. Cold affii-
sion to the head. Camphor mixture one ounce and a half, antimonial mixture four
drachms, tincture of hyoscyamus two drachms every second hour till he sleeps ; brandy
one ounce every hour for three doses, and then every second hour, and calomel
eight grains, opium one grain h. s. The pills were taken, also four ounces of
brandy and the draught three times, but he continued agitated, talking incoherently
and tearing the dressings from the blister, and at midnight there was constant
inarticulate muttering, spasmodic action of the muscles of the face, pupils dilated and
insensible to light, skin hot, and the pulse rapid and feeble. Cold afiusion was
directed to be used to the head every hour while the scalp continued hot, sinapisms
were placed on the feet and the other remedies omitted. He became comatose and
died at 6 a.m.

Inspection nine hours after death. — The body stout, and the external surface
tinged deeply yellow. Head. — The dura mater was faintly tinged yellow. The
vessels of the membranes were moderately congested. The convolutions of the
convex surface of the depending parts of the hemispheres were veiled with serum
effused beneath the arachnoid membrane, and there were between two and three
ounces at the base of the skull. Chest. — The lungs were emphysematous and only
partially collapsed. The heart was healthy. The cavity of the chest was encroached
on by the liver which on the right side reached to the fourth rib and coursed
obliquely across to the seventh rib of the left side. Abdomen. — Omentum loaded
with fat. The liver weighed seven and a half pounds, was externally mottled choco-
late and buff, and admitted of a ready separation of the peritoneal coat ; the incised
surface was of yellow colour, mottled and softened. The gall-bladder contained about
an ounce of thin bile. The mucous coat of the cardiac end of the stomach was of
dark-marbled red colour, somewhat thinned and somewhat softened, of the pyloric end
pale and mammillated. There was vascularity of the commencement of the mucous
coat of the duodenum but the texture was sound. The large intestine was distended
throughout but there was no thickening of its walls, the mucous coat was tinged
yellow, thinned, and generally softened, the mucous follicles were in many places ap-
parent but not prominent ; and throughout the colon there were red patches here and
there, mostly the size of a split pea, some larger, with a follicle in the centre of many
of them, and in these places the mucous coat was thin, soft, and pulpy, and after its
removal the areolar tissue underneath presented in some instances a vascular patch.
The bowel was filled with thin yellow feculence. The spleen was of natural size.
The kidneys were nearly natural, with perhaps commencing yellow degeneration of the
cortical substance, evinced by buff streaks.

21. Bemittcnt Fever with adynamic symjptoms. — Obscure pneumonia. — Death
without coma. — Bright' s' disease of both kidneys. — Crooshnah Sutooa, aged twenty-
sis, a Maratha labourer, was brought to the Jamsetjee Jejeebhoy Hospital on the 6th

CEREBRAL COMPLICATION. — PATHOLOGY. 81

of July, 1852, being the first day of his illness, with febrile symptoms. There was
(slight jaundice, and he was reported to have been delirious during the night. There
were irregular exacerbations and remissions, and the pulse was frequently badly deve-
loped. He had uneasiness at the margin of the right ribs. There was not much
delirium, neither brownness nor dryness of tongue. The breathing was hurried, but
no signs of pneumonia were noted before the 13th, when there was slight dulness of the
right dorsal region which, however, did not increase, and on the 20th occasional
crepitus was detected in the right lateral region. He had occasional cough. On the
evening of the 20th there was commencing erysipelatous inflammation of the back,
with large bullge resting on a dark base. On the 21st the pulse became feeble, the
breathing more hurried, and he died without coma on the 23rd. The state of the
urine had not been inquired into.

Inspection eighteen hours after death. — Chest. There were old adhesions of the
third lobe of the right lung to the parietes and to the diaphragm, and slight
serous effusion in the sac of the right pleura. There was increased redness of the
substance, and considerable oedema of the right lung, with hepatised nodules here and
there in the upper and third lobes. Of the left lung there were slight adhesions,
slight oedema with increased redness, and here and there hepatised nodules. The
heart was healthy. Abdomen. — The stomach and intestines were distended with
flatus. The liver was slightly enlarged, flabby, and of pale yellow colour. The
kidneys were both enlarged, the right weighed seven ounces, the left six and a half.
On removing the capsule from the right kidney the surface was observed to be mottled
dark red and yellow, and the cortical substance was of dark red colour and encroached
on the tubular portion which was hardly distinguishable. The left kidney was exter-
nally mottled yellow and red ; the cortical portion internally was of fatty appearance
and yellow colour and was considerably increased in size, with merely traces of the
tubular part here and there.

This case was treated and reported by Mr. S. Carvalho. The treatment consisted
of quinine, diaphoretics, and stimulants. The wet sheet was twice used with removal
of the febrile heat ; but it seemed to me that it increased the internal congestions.

Complicated Remittent Fever, — Cerebral Complication. —
The pathology of this complication is very important; for fully
one third of the fatal cases of remittent fever in European
officers in the Bombay Presidency is of this nature, and it is
probable that the proportion is still greater in the remittents
of sthenic European soldiers. But the cerebral affection is
not, in all cases, attributable to malaria alone, but is often
caused by undue exposure to the sun, or intemperance. The
influence of mental anxiety ought also to be regarded; and, in
natives, the habit of opium eating and ganja smoking must not
be lost sight of.

When describing the symptoms of this complication, I stated that
they might depend on different conditions of the brain.

1. Headache, flushing of the countenance, delirium occurring
early in the attack — due to the direct influence of the causes,
and not merely to that of frequently recurring exacerbations —
depend, for the most part, on active determination of blood to
the membranes and substance of the brain which, unless re-

82 REMITTENT FEVEK.

moved or prevented by treatment, is likely to terminate in serous
effusion.

The following six cases are illustrative of cerebral symptoms
appearing under these circumstances, and in four of them the in-
fluence of intemperance is apparent.

22. Eemittent Fever — Death by convulsion and coma. — Vascular congestion of the
vessels of the pia mater. — Eosy tint of the substance of the brain. — One ounce of
serum at the base of the skull. — The heart dilated and its tissue pale and flabby. —
Partial redness, thinning, and softening of the mucous coat of the stomach. —
Beyer's glands enlarged. — The spleen enlarged and softened, and the kidneys con-
gested.— Laurence Fearon, aged thirty-seven, an engineer of the steam department,
and of full habit. During the four months of his residence in Bombay, he had been
several times in hospital ill with fever, attended with gastric irritability. He was
again admitted on the evening of the 2nd of September, 1839, having been ill with
fever for about a week before admission. There was headache with pain at the margin
of the right false ribs, diarrhoea, thirst, febrile heat, pulse 108, full. He was bled
to sixteen ounces, the head was shaved and cold cloths applied, a warm bath was or-
dered at bed-time, and six grains of calomel and one grain of opium with ipecacuanha.
On the morning of the 3rd there was no headache, and the epigastric uneasiness was
removed, the skin was covered with moisture, but the bowels had not been opened.
An ounce of castor oil was given. At the evening visit the pulse was 96, there was no
local pain, the bowels had been moved, and the evacuations were bilious. A warm bath
was directed at bed-time, and two grains of quinine early the following morning, and
to be repeated every second hour for three doses. On the morning of the 4th general
uneasiness of the upper part of the head was complained of, the pulse was upwards of
100, and the urine scanty. The quinine was omitted, and rhubarb and magnesia with
colchicum wine given. At the evening visit the bowels had not been moved, and at
noon there had been rigors followed by pyrexia; the pulse was 116, the epigastrium
tender, the pupils slightly dilated, and some confusion of thought and slight tremors
of the muscles were present. A purgative enema was exhibited, thirty leeches were
applied to the temples, and fifty to the hypochondrium, and a blister was placed be-
tween the scapulae. At midnight he had a convulsive fit, and about twenty minutes
afterwards, was found with dilated pupils, breathing heavily, and passing into coma ;
the skin was covered with sweat, and the pulse was full ; the bowels had not been
opened. He was cupped on the temples to ten ounces, a purgative enema with tur-
pentine oil was exhibited, fifteen grains of calomel were given, and after two hours,
four ounces of haust. cathart. were directed to be taken. About an hour afterwards
he was again miich convulsed ; the bowels had not been moved. A foot-bath at temp.
110° was ordered, and a blister to the epigastrium. At 2 a.m. he had passed into
perfect coma, with stertorous breathing and convulsive movement of the arms and
legs ; surface hot. He died at 1 p.m. of the 5th.

Inspection twenty-three hours after death. — Body stout. Head. — There was a
general bright red blush of the smaller vascvilar ramifications of the pia mater, and
the medullary substance presented a pale rosy tint. There was about an ounce of
serum at the base of the skull, but norre elsewhere. Chest. — The lungs were emphy-
sematous anteriorly, and adhered freely to the costal pleurae ; there was very little
congestion posteriorly. The heart was about twice the size of the fist ; all its cavities
were dilated, but chiefly the left ventricle, the walls of which were somewhat thinner
than natural. The muscular tissue of the heart was pale and flabby, there was a
fibrinous coagulum in the left ventricle, but the cavity was not distended with blood.
The lining membrane of the commencement of the aorta had a deep rosy colour (im-
bibition), and the surface was roughened by cartilaginous deposit. The aortic and the

CEREBRAL COMPLICATION. — PATHOLOGY. 83

auriculo-ventricular valves were l:ealthy. Abdomen. — The stomach was dilated. The
liver reached about two inches below the right false ribs, extended to the left of the
mesial line about four inches, adhered closely to the diaphragm, and was natiiral in
texture but of greenish olive tint. The stomach contained about half a pint of dark
green fluid, and at the cardiac end there was a dark red patch, and the mucous coat
was thinned and pulpy ; elsewhere the coat was of natural thickliess, of leaden grey
colour, and generally somewhat softer than natural. At the end of the ileum the
solitary glands were prominent. The mucous coat of the colon was of grey tint, but
of natural texture, with the follicles not distinguishable. The spleen was considerably
enlarged and softened. The kidneys were considerably congested, chiefly in their
tubular part.

23. Remittent Fever in a man of intem'perate habits. — Fatal with convulsion, coma^
and tumultuous action of the heart. — Considerable effusion of serum in the head. — ■
Streaked redness and softening of the mucous membrance of the stomach. — Deep red
tint of the endocardium and muscular tissue of the heart. — James Riley, aged
twenty, a boiler maker of stout habit and a few months resident in India, was
admitted into the European General Hospital on the 2nd of July, 1838, affected
with mild febrile symptoms. He stated that for several days previously he had
suffered from a sense of oppression of the chest which he had attributed to cold but
which did not prevent him from following his occupation of boiler-maker. It was
subsequently 'ascertained that he was a man of intemperate habits, and that he had
been drinking to excess before his present illness. On the morning of the 3rd, after
a restless night, the skin was warm and soft, piJse soft and of natural frequency,
tongue slightly fiu'red in streaks, thirst considerable, no uneasiness of the chest or
fulness of abdomen. About six p.m. there was tenderness of the epigastrium, pulse
frequent, hard, and sharp, manner excited and skin hot. He was Wed, but fainted
after the loss of sixteen ounces of blood. Ten grains of calomel with quarter of a
grain of tartar emetic and a similar quantity of opium were given. Diuring the night
the bowels were frequently moved and the evacuations were green and watery. On
the morning of the 4th the skin was warm and soft, pulse 80 and firm, tongue
moist and little furred, no excitement of manner. Five grains of calomel and twelve
grains of Dover's powder were given. At the evening visit he felt better, the bowels
had been twice moved, and the evacuations were dark and bilious. He was ordered
a warm bath and a powder of chalk and mercury with Dover's powder. The night
was passed without sleep ; skin cool. Cold affusion was used, and he took during the
daytime two doses of antimonial mixture with one drachm of tincture of opium.
Sleep did not result, and after the evening "sdsit the cold afiusion was again used, and
a draught with one drachm and a half of tincture of opium was given. He slept for
several hours, but on the morning of the 6th he continued nerv^ous and agitated, and
the action of the heart and of the carotids was strong. He was directed to be cupped
on the cai'diac region ; but whilst the operation was being performed he was seized
with convulsions, and died comatose after about an hour.

Inspection six hours after death. — Much of the external integuments was of
purple tint. Head. — There was considerable efiusion of serum at the base of the
skull and between the membranes of the brain. Chest. — There were old costal
adhesions and considerable infiltration of the lungs. The lining membrane of the
heart and also the muscular tissue were of a deep red tint : The .valves were healthy.
Abdomen. — The substance of the liver was paler than natural and variegated here
and there with large spots of dark red. The mucous coat of the stomach was
streaked dark red and softened. The spleen was soft and large ; and the kidneys
were normal.

24. Hemittent Fever in a man of intemperate habits. — Death by coma. — Increased
vasculariUj of the membranes of the brain and considerable effusion of serum. —

G 2

84 REMITTENT FEVER.

Softening and vascularity of the mucous coat of the stomach and large intestine. —
Commencing degeneration of the kidneys. — The commander of a merchant brig,
aged forty-seven, of intemperate habits, was brought to the European General
Hospital on the 13th July, 1838. It was stated that he had been feverish for
some days, and had been drinking to excess. On admission he laboured under
mental illusions, but when his attention was kept fixed on one subject he answered
questions rationally regarding it. There was no tremor either of the hands or
tongue. After cold affusion and a draught with a drachm of tincture of opium
and a third of a grain of tartar emetic he became composed but did not sleep.
The tongue was clean and the pulse frequent towards night. The bowels were
freely moved, but the pulse became feeble. Stimulants were substituted for the
antimonial, and after the second dose he slept several hours. On the morning of the
14th, the hands and tongue were tremulous, skin natural, pulse 96, full and
soft. Camphor mixture with difflisible stimulants was directed to be given eveiy
second hour. Towards noon, the skin became hot, the pulse increased in frequency,
the tongue became dryish and more tremulous, and the delirium and general tremors
increased. Twenty-four leeches were applied to the temples, and at 8 p.m. a blister
to the back of the neck, and a draught with two drachms of tincture of opium was
given. An hour afterwards he fell asleep. In the middle of the night the pulse
became thready. He was roused with difficulty, then became completely comatose,
and died at 10 a.m. of the 15th.

Inspection five hours after death. Head. — There was much vascular congestion of
the pia mater, with considerable effusion of serum between that membrane and the
arachnoid, and also into the ventricles. Chest. — The lungs did not coUapse. The
heart was flabby, and filled with fluid blood. Abdomen. — The liver was of dark
grey colour and softened. The mucous coat of the stomach and large intestines was
vascular and softened. The spleen was enlarged and reduced to a bloody pulp. In
both kidneys the distinction between the tubular and cortical substance was ill
defined.

25, Bemittent Fever. — Simulating delirium tremens. — Tia mater very vascular,
with hullcB of air between the arachnoid and pia mater and in the vessels. — WiUiara

, aged twenty-nine, a conductor in the Ordnance Department, of slight frame

and frequently affected with febrile attacks in which the head was more or less
implicated. On the 11th May, 1839, he was admitted into the General Hospital,
suffering from diarrhoea for which chalk mixture and calomel with opium were given.
On the morning of the 13th (new moon), his skin ^as hot, he was excited, talked
incoherently, and had been walking about the ward a great part of the night. The
pulse was frequent and the tongue rather furred in the centre. Cold affusion was
used, and antimonial mixture with tincture of hyoscyamus was directed every two
hours. At the evening visit the skin continued hot, and he had not been asleep.
The cold affusion was repeated, and calomel four grains, tart, antimon. quarter of a
grain, opium two grains were directed to be given at bed-time, and ol. ricini. four
drachms the following morning. Towards midnight he became troublesome and
excited, and the scalp was hot. Cold lotion was applied to the head, and a blister to
the nucha. About 5 a.m. of the 14th he became comatose with sinking pulse and
aboured respiration. Green-coloured dejections were passed in bed. He died at
8 A.M. *

Inspection five hours after death. — Examination of the head was only permitted.
The vessels of the pia mater were generally turgid with dark-coloured blood to their

* In these three cases the influence of intemperate habits is well marked. In all
the full opiate was injudiciously given. In the two first the remissions were well
marked, but no advantage was taken of them in the treatment.

CEREBBAL COMPLICATION. PATHOLOGY. 85

minute ramifications, and there were bullse of air here and there in the vessels and
also between the pia mater and arachnoid membrane. The sinuses were filled with
blood which was coagulated in some of them. There was about half an ounce of
serum in the ventricles, and an ounce at the base of the skuU. The substance of the
brain was natural, and did not present many bloody points.

26. Bemittent Fever proving fatal by collapse and coma at the close of an exa-
cerbation. — No serous effusion in . the head. — Dotted redness and softening of
the mucous membrane of the stomach. — E7ilargement of the mucous follicles of
the colon and of Peyer's glands. — Lumbrici in the small intestine. — George
Castor, aged twenty, a seaman of stout habit, was admitted into the European
General Hospital on the 23rd of June, 1838. He stated that he had been ill with
fever for five days, during which time there had been headache and occasional vo-
miting. On admission his manner was sluggish, skin hot, pulse 120, full, but com-
pressible, tongue furred and expanded. Six dozen leeches were applied to the temples,
and pills of extract of colocynth, calomel, and tartar emetic were given. On the 24th
the head, though relieved, was still uneasy, the skin was cool and moist, pulse 120
and feeble, the abdomen was soft, and during the night there had been seven watery
bilious evacuations. A blister was applied to the back of the neck, which rose well,
but caused strangury. At the evening visit there was less sluggishness, the skin was
cool, pulse 120, soft, the bowels had been freely moved, and the tongue was cleaner.
Draughts with nitrous ether were ordered, and pills of blue pill and ipecacuanha.
The night was passed without sleep. On the 25th questions were answered freely, but
giddiness was complained of. There was also uneasiness across the umbilicus, and
there had been several inelFectual calls to stool, thirst moderate, tongue more furred
and expanded. Compound powder of jalap was given with ether and camphor mix-
ture. At the evening visit it was reported that he had slept, the skin was cool and
moist, and no medicine was given. During the early part of the succeeding night he
rested well, but towards morning there was a return of slight headache, increased by
motion, with some intolerance of light, and flushing of the face. The skin was cool
but dry, pulse 100, soft and of good strength, bowels freely opened, the tongue less
furred, but somewhat florid at the edges. Six dozen leeches were applied to the
temples, and a diaphoretic draught given every three hours. At the evening visit the
head was easier, and the skin cool and moist. The succeeding night was passed
without sleep, and at 3 p.m. of the 27th, there was a febrile exacerbation followed
by much collapse in the night time. He became comatose and died at 7 a.m. of
the 28th.

Inspection five hours after death. — Head. There was no increased vascularity of
the membranes, or substance of the brain. There was about one drachm of serum in
the left lateral ventricles, and about half an ounce at the base of the skull. Chest.
— "With the exception of some old costal adhesions, the thoracic viscera were healthy.
Abdomen. — The liver was healthy and the gall-ducts free. The mucous lining of the
cardiac end of the stomach for a space larger than the hand was of dark red colour,
dotted, marbled, and its texture softened : towards the pyloric end the colour was na-
tural, but the tissue was softened. The small intestines were filled with lumbrici.
The aggregated glands of Peyer were enlarged. The mucous coat of the coecum and
colon was of dark grey colour, and studded throughout with dark points (enlarged
follicles).'*

* This case will be again alluded to as the single instance in my notes of head
symptoms during life, without morbid appearances in the head after death. The
treatment was defective in the neglect of quinine during the remissions, and too much
depletion in the exacerbations. The appearance of the mucous lining of the large in-
testines indicated an undue use of irritants.

O 3

86 REMITTENT FEVER,

27. Ttemittctit Fever. — Drowsiness and coma. — Considerable quantity of serum effused
in the head. — Vascularity and thickening of the mucous membrane of the stomach. —
Mary Anne Moor, aged forty-seven, a native of India, a fat corpulent woman of in-
temperate habits, was admitted into the Euiopean General Hospital on the 8th Oc-
tober. She stated that she had suffered from fever for five or six days. The skin, on
admission, was hot, but soft, pulse 112 of good strength. The abdomen was dis-
tended but without pain. On the 9th there was slight delirium, and her hands were
tremulous. This state continued till the 11th, when she was roused with difficulty,
and when so, moaned and muttered to herself, the tongue was dryish, and the central
part furred. This state continued with little alteration — the skin was dry but not
often above the natural temperature, the pulse frequent and becoming feebler — till
the 15th, when the drowsiness had increased and on the morning of the 16th had
passed into coma. She died at 10 a.m. The treatment consisted in shaving the
head, applying blisters to the nucha and scalp, free purging, and the use of antimo-
nials with small doses of tincture of opium. Quinine and calomel were given in com-
bination on occasions when there appeared a remission in the symptoms.

Inspection eight hours after Death. Head. — There was a considerable quantity of
serum effused between the layers of the arachnoid membrane, and into the ventricles.
The brain was firm in substance. Abdomen. — The integuments were loaded with fat.
The mucous coat of the stomach was thickened and vascular, with abrasions here and
there.

In the section on symptoms it was stated tliat delirium with
tendency to drowsiness, associated with signs of general collapse
and depelident on enfeebled nervous energy, was apt to come on
early in fevers of bad type towards the end of a paroxysm.
Head symptoms very similar in character sometimes occur, after
the fifth or sixth day, in cases in which the treatment of the re-
missions has been neglected and that of the exacerbations has been
injudiciously depressant.

In my notes on the cases of sick officers there are several which
seem to have been of this nature, and it is of importance to bear
them in recollection, for it would be a serious error to treat head
symptoms thus arising in the same manner as those caused by
cerebral determination. The following may be received as an
illustration.

28. Eemittent Fever. — Coma from exhaustion. — A gentlemen in the public service
became affected with febrile symptoms at Tauna on the 4th of September. No treat-
ment was adopted. He went to Bombay, and remained there also without treatment,
experiencing febrile accessions till the 8th, when he returned to Tauna. He had rigors
in the boat two hours before landing. On the morning of the 9th there was remis-
sion, and towards evening an exacerbation, for which an emetic and a purgative of
calomel were given. On the 10th, at 4 p.m., there was again an exacerbation, with
sense of swimming in the head. Eight dozen leeches were applied to the temples.
There were rigors at midnight, followed by coma and death at 8 a.m. of the 11th.

2. Cerebral symptoms depending on inflammation of the mem-
branes or substance of the brain also occur in the course of
remittent fever; but this event is rare compared with determi-

CEEEBRAL COMPLICATION.— PATHOLOGY. 87

nation of blood. Among the fatal cases of sick officers there are
only two of this nature. The following three illustrations are taken
from my own observations.

29. Bemittent Fever. — Meningitis. — Effusion of serum in the cavity of the arach-
noid and suh-arachnoid space. — Opacity and thickening of the arachnoid membrane.
— ^William Woodward, aged seven, an Indo-Briton, was admitted into the sick ward
of the Byculla Schools on the 6th June, 1838. He was aiFected with febrile symptoms,
which did not attract much attention till the 10th, when there was increased heat of
skin, and frequency of pulse, with a tendency to drowsiness. Twenty-four leeches
were applied to the temples, a blister to the nucha, and the bowels were freely acted
upon. During the two succeeding days the skin continued hot, the pulse was about
120, and the drowsiness remained unabated. An attempt was made to aflfect the sys-
tem with mercury, the bowels were kept free, and a blister was applied to the scalp.
On the 13th, there was frequent screaming and moaning, there was strabismus with
dilated pupils, and the head was frequently raised from the pillow and moved slowly
about, as if in search of some object. The symptoms progressed ; the pulse continued
frequent, and became feeble, the coma became more complete, and death resulted at
midnight of the 14th.

Inspection twelve hours after death. — Head. There was more than usual vascu-
larity of the pia mater, where it dips down between the convolutions of the brain.
There was a considerable quantity of serum effused between the arachnoid membrane
and the pia mater, chiefly on the superior and posterior parts of the hemispheres, and
in these situations the arachnoid membrane was milky, firm, and thickened. There
were adhesions between the arachnoid membrane and the falx, caused by small gramdes
of lymph. There was also a considerable quantity of serum at the base of the skull,
and more than the natural quantity in the ventricles. There were bloody points
apparent on slicing the substance of the brain. The viscera of the thorax and abdo-
men were healthy.

30. Remittent Fever admitted after a weeJtS illness. — Head symptoms' chiefly mar Jccd
by unsteadiness of manner, and latterly drowsiness. — Arachnoid membrane opaque and
thickened. — Increased serous effusion. — "William Subbeter, aged sixteen, after having
been ill for a week with headache and fever, was admitted into the G-eneral Hospital on the
9th May, 1842. There was heat of skin, flushed countenance, undecided manner. The
tongue was yellow in the centre and florid at the tip, and the epigastrium was tender.
Twenty-four leeches were applied to the temples, and thirty-six to the epigastrium, the
head was shaved, cold applications were used, sponging of the general surface had recourse
to, effervescing draughts were exhibited from time to time, and some blue bill and ipeca-
cuanha given at bed-time. On the morning of the 10th there was still heat and dryness of
of skin, but in other respects the symptoms were improved. In the evening there was a dis-
tinct febrile exacerbation. Sponging, cold applications, and effervescing draughts were
continued, and the blue bill and ipecacuanha were repeated. On the morning of the
11th, still pyrexia, pulse 92, tongue slimy and tremulous, bowels rather relaxed, and
manner unsteady. The remedies were continued, with addition of spirit, aether, nit. to
the effervescing draughts, and the application of a blister to the nucha. On the 12th,
febrile heat and other symptoms continued, accompanied with slight subsultus. Cam-
phor mixture c. spirit, sether. nit. was given every third hour, also chicken soup. On
the 13th, pulse 104, fotir dejections feculent. In other respects as on the 12th. Sago
and milk morning and evening, chicken soup for dinner, and the camphor mixture con-
tinued. On the morning of the 14th there was a distinct remission, and quinine and
blue pill were ordered every second hour, with effervescing draughts. The evening
accession was milder. On the 15th and 16th, tho febrile exacerbation seemed to be

G 4

88 REMITTENT FEVER.

somewhat checked under the use of the quinine ; but on the 17th the symptoms were
all again aggravated. On the 18th he vomited several times, and passed three copious
watery evacuations, followed by sunken features, feeble pulse, and damp skin. These
symptoms continued, with the addition of drowsiness on the 21st ; and death took place
on the morning of the 24th.

Insmction eight hours after death. — Head. The arachnoid membrane over the con-
vex surface of the brain was opaque and thickened with here and there small rounded
granules of lymph, the size of a pin's head. There was about an ounce of serum in the
lateral ventricles, and about an ounce and a half at the base of the skull. The sub-
stance of the brain was firm. Chest. — Old adhesions connected the right lung to the
pleura ; but the substance of the lungs was crepitating. Heart healthy. Abdomen. —
The liver was healthy. The colon distended, but its mucous coat healthy. The
mucous coat of the stomach was of dark grey tint with dark red streaks, but was sound
in textiire.

31. Eemittent Fever admitted in an advanced stage. — Death by coma. — Extensive
lymph and serous effusion in the sub-arachnoid space. — Hepatisation of both lungs.
— Bappoo Mahomed, forty years of age, a Mussulman sailor, was admitted after twenty
days' illness with fever on the 10th September, 1849, into the clinical ward of the
Jamsetjee Jejeebhoy Hospital. There was trembling of the whole body and frequent
twitching of the muscles of the forearms. He was affected -with low muttering, deli-
rium and drowsiness, the skin was above the natural temperature and dry, the pulse
was frequent and feeble, he could not protrude the tongue, and the respiration was
short and hurried. Anteriorly and laterally on the right side of the chest there was
dulness on percussion and absence of breath sounds. He died on the afternoon of the
11th.

Inspection seventeen hours after death. — Between the pia mater and the arachnoid
over the entire convex surface of both hemispheres of the brain, but greatest in degree
on the left side and depending parts, there was effusion of lymph and serum, to such
extent as to give a yellow opaque appearance to the surface. Similar effusion also
existed over the cerebellum and in a slight degree over the pons varolii and medulla
oblongata, but not elsewhere at the base of the brain. The surface of the convolutions
of the brain was of natural appearance and consistence, and the substance of the brain
elsewhere was also quite healthy. There were from six drachms to an ounce of
serous fluid in the lateral ventricles, and about two ounces at the base of the
skuU.

The whole of the upper lobe of the right lung, except about half an inch of the apex,
and also the whole of the middle lobe, were in a state of red hepatisation, having,
when incised, a granular appearance with considerable oozing of frothy serum on pres-
sure, and readily breaking down under the finger. The rest of the lungs was crepita-
ting. The free anterior border of the lobe of the left lung, for about three inches, was
in a state of red induration ; the rest was healthy. The heart and pericardium were
healthy. The large and small intestines were distended with air. The liver was of
natural size and consistence, but was congested. The kidneys were not examined.

3. When delirium, drowsiness, and coma come on in the more
advanced stages of remittent fever, associated with adynamic phe-
nomena, then more or less increased serous effusion in the cavity
of the cranium, unattended, however, with any great degree of
vascular turgescence, is generally found after death. But it is
very doubtful, for reasons presently to be particularly alluded to,
whether, in a large majority of cases of this kind there is any

CEREBRAL COMPLICATION. — PATHOLOGY. 89

relation between the head symptoms and the increased effusion.
The following are cases of adynamic remittent fever fatal with
coma.

32. Remittent Fever with ^adynamic symptoms. — Slight vascularity of the mem-
branes of the brain with air in the vessels and beneath the arachnoid. — Turgescence
and ulceration of Peyer's glands at the end of the ileum. * — John Steptoe, private
of her Majesty's 15th Hussars, two months resident in Bombay, was admitted into
hospital on the 6th February, 1840, and died on the 15th. He had been ill before
admission. The following were the leading features of the disease. Pyrexia almost
constant with an occasional remission in the middle of the day, hands tremu-
lous, pulse from 100 to 120, and compressible, tongue coated and dry in the centre,
florid at the tip, sordes about the teeth, thirst, and more or less diarrhoea. On one
occasion there was pain between the right ribs and crest of the os ilium. The eyes
were suffused. At first there was wandering delirium at nights, and on the latter days
drowsiness not amounting to coma.

Inspection. — Head. There was moderate turgescence of the vessels of the mem-
branes of the brain, with numerous globules of air in the vessels or underneath the
arachnoid. More than the usual number of bloody points in the brain, and an ounce
of serum at the base of the skull. Abdomen. — The liver was quite healthy. The
mucous coat of the cardiac end of the stomach was dotted dark red, but without soften-
ing. The mucous coat of t^e end of the ileum was of dark red colour, the patches of
Peyer's glands were red, turgid, and prominent, and several of them were in different
stages of ulceration. Close to the ileo-colic valve there was an ulcerated patch the
size of a rupee. The mucous coat of the ccecum was of dark red colour, but not ulcer-
ated. The rest of the large intestine was healthy.

33. Remittent Fever. — Symptoms adynamic and badly -developed. — Serous effusion
and slight vascular congestion in the head, also air in the vessels. — The colon dis-
tended and in part displaced. — Neil Wallace, aged twenty-eight, seaman of the ship
Samuel, was admitted into the European General Hospital, on the 21st October, 1841.
He stated that for a fortnight past he had experienced a sense of weight at the centre
of the chest, for which he had taken much medicine. On admission he inspired freely,
and there was neither pain of chest nor cough, the skin was dry and above the natural
temperature, the pulse frequent and of moderate strength, and the tongue florid. It
was supposed that he had been living freely for some days. On the 22nd and
23rd the abdomen was full, the pulse from 88 to 92 and feeble, and on the latter
day his manner and expression were dull and heavy. He was blistered on the
nucha, a full dose of calomel (ten grains) was given, followed by castor oil, and
on the morning of the 24th he was more alert. The bowels had been opened
twice, the skin was moist, and the pulse 92 and feeble. Port wine and sago were
given. At the evening visit the pulse still feeble, but there was febrile heat of skin,
the tongue was florid, and the sluggishness of manner had increased. The head was
shaved, cold applied, and a nitro-muriatic acid foot-bath used. He continued
to lose ground, there was generally a morning remission and evening exacerbation
of fever, the pulse became feebler, the hands tremulous and with subsultus ten-
dinum, the tongue dry, the drowsiness increased, and at last passed almost into complete
coma. He died on the 31st October.

Inspection fourteen hours after death. — Head. A thin veil of serum was effused
between the convolutions on the convex surface of the brain. The small vessels

* While retaining this case in its original position I must admit that recent inquiry
may suggest that it was true typhoid, not adynamic remittent.

90 EEMITTENT FEVER.

of tlie pla mater were in part injected with blood and the larger ramifications con-
tained air. No increased quantity of serum in the ventricles or at the base of the
skull. Chest. — The lungs did not collapse freely. Heart healthy. Abdomen. — The
liver was healtliy. The colon was much distended with air and the sigmoid flexure
thrown across the small intestines was applied to the inner aspect of the ascending
colon. The large intestine was sound in texture.

When, as in the first* series of cases, we find head symptoms
coming on early in the disease, and after death more or less vas-
cular turgescence with increased serous effusion in the cranium, or,
as in the second, head symptoms with opacity of the membranes or
with lymph and serous exudations, there need be no hesitation in
relating the morbid appearances found after death to the symptoms
present during life.

But when, as in the last set of cases, the head symptoms which
indicate failing function of the brain have been coincident with
failure of other vital actions then it is very doubtful whether
a relation between these symptoms and increased cranial serous
effusion can be viewed as a probable inference. This so-called
morbid appearance may, in adynamic states, be otherwise ex-
plained.

Thus, on carefully examining the reports of 205 fatal cases of
disease observed by me in the European Greneral Hospital at
Bombay, it appears that while, on the one hand, of 59 cases in
which head symptoms during life were well marked there is only
one in which there was an absence of morbid appearances after
death I, there are, on the other hand, 50 cases in which there were
no head symptoms during life, but in which appearances in the
contents of the cranium generally considered morbid were observed
after death.

Of these 50 cases, the ages of the individuals were as fol-
lows : —

Between 10 and 15 years, inclusive 2

Ages not given 2

^ With one exception, No. 26. t No. 26.

, 20

, 25

, 30

, 35

, 40

, 50

, 60

, 70

CEEEBEAL COMPLICATION.

PATHOLOGY.

The deaths took place in the following months

January
February
March .
April .
May .
June

Months not stated

4
5
6
5
6
2

July .

August .

September

October

November

December

Of these 50 cases, the deaths were occasioned by the following
diseases : —

Tubercular Phthisis 7

Pleuritis 1

Disease of the Heart 1

Hepatic Abscess 8

Dysentery 11

Peritonitis 4

Scurvy 3

Spasmodic Cholera 14

Eupture of the Spleen 1

In 4 of the 50 cases the morbid appearance consisted of increased
vascularity of the membranes of the brain. These were all in-
stances of epidemic cholera.

In 1 9 cases both increased vascularity and increased serous effu-
sion within the cranium were present. Death took place from
the following diseases : —

Epidemic Cholera 9

Disease of the Heart .1

Dysentery 4

Peritonitis ........... 2

Hepatic Abscess 2

Grastro-enteritis 1

In 27 cases there was increased serous effusion within the, cranium
without increased vascularity.

Death in these instances was caused by the following diseases : —

Tubercular Phthisis . .* . . • ' • • • '7

Hepatic Abscess 6

Dysentery 6

Peritonitis 2

Epidemic Cholera 1

Pleuritis 1

Eupture of the Spleen 1

Sciu'vy

Eheumatism (Scorbutic)

92 REMITTENT FEVEE.

In regard to the facts which have just been stated, it may be
observed.

1. They do not show any relation between absence of head
symptoms, associated with increased vascularity and serous effusion
within the cranium, and particular age or season.

2. They show a relation between the absence of head sym-
ptoms, associated with increased vascularity with or without increased
serous effusion within the cranium, and a state of general venous
congestion dependent upon a feebly acting heart.

3. They show a relation between absence of head symptoms,
associated with increased serous effusion without increased vascu-
larity within the cranium, and death taking place by gradual
asthenia. When death takes place after this manner, serous trans-
udations from serous linings and into areolar tissue are familiar
events : the cerebral serous effusion now referred to is analogous
to these.

4. The increased vascularity in these cases is of congestion,
not of inflammation. The increased serous effasion is not the
result of inflammation, but of congestion and of those conditions of
the tissue and of the blood which are believed to favour serous
transudation.

They confirm therefore the opinion of Dr. Abercrombie, — that
the head symptoms of acute hydrocephalus do not depend upon the
presence of serous effusion within the cranium, so much as on the
deranged capillary circulation (inflammation) of which the serous
effusion is the consequence.

The serous effusion in the cases of which I now treat was not the
result of this deranged state of the capillary circulation (inflamma-
tion) ; hence, though present within the cranium, head symptoms
were not necessarily induced by it.

5. It should be borne in mind that increased vascularity and
serous effusion within the cranium, found after death, does not neces-
sarily prove their presence there during life. They may have taken
place in some instances during the agony of death, or after the fatal
event.

6. These facts which show a want of relation between increased
vascularity and serous effusion within the cranium found after death
and the proximate cause of the fatal result should be remembered
injudicial inquiries on bodies found dead, and of the previous history
of which nothing is known. In such cases, if there he ^present
within the cranium only increased vascularity or increased
serous effusion separately or associated together, we can never

GASTRIC C03IPLICATI0N. --PATHOLOGY. 93

he justified in attributing death to these conditions. These
statements have been entered into not only from their relation to
the similar after-death appearances in fatal cases of adynamic re-
mittent fever, but also because they tend to confirm observations
of a like tenor in the writings of Louis*, Abercrombie f, and
Bright I; and because facts of this kind are of much importance
in reference to the pathology of the brain.

Gastric Irritability. — I pass over the occurrence of occasional
vomiting as one of the deranged actions of the febrile state and
here direct attention to those greater degrees of irritability of the
stomach which depend upon local disease.

In the severe forms of remittent fever in sthenic Europeans
cerebral symptoms and gastric irritability are very frequently com-
bined. This was the case in the remittent fevers from which her
Majesty's 4th Light Dragoons suffered so much at Kaira. In
these it was very common to find after death increased vascularity
of the vessels of the brain with some degree of increased serous
effusion, and at the same time a deeply reddened state of the
mucous membrane of the stomach and sometimes of the intestinal
canal. It is very probable that the deranged capillary circulation
was similar in both organs, — not inflammatory but rather pas-
sive congestion or active determination. In other instances the
gastric complication is the principal : this occurred in 6 of the 90
fatal cases of officers formerly alluded to.

As respects the pathology of that form of remittent fever called
bilious, I cannot view it in any other light than as a coincidence
of the state now under consideration and the presence of a con-
siderable quantity of bile in the gall-bladder and in the biliary
ducts, — hence the notable admixture of bile in the ejected
matters. § The term has been too frequently and too vaguely
used by writers on tropical fevers, and will not be repeated in this
work.

Irritability of stomach also occurs in the course of remittent
fever, both in sthenic and asthenic constitutions, developing itself
somewhat more gradually, generally mth distinct epigastric un-
easiness, and a tongue more or less florid at the tip and edges and
depending on inflammation of the mucous membrane. Evidence

* "Eesearches on Phthisis."

t " On Diseases of the Brain."

I " Keports of Medical Cases."

§ I am aware that there may also co-exist a similarly deranged eapillaiy condition
of the liver ; but that this, during the presence of the febrile state, leads to increased
hepatic secretion is very doubtful. It is more likely that the secretion is antecedent
and in excess in the biliary passages and reservoirs at the onset of the fever.

94 REMITTENT FEVER.

of this will be found in cases 17, 18, 20, 22, 30, quoted in this
chapter.

In 114 selected clinical cases of natives, gastric irritability is
noted of 2 only.

Habits of intemperance as an auxiliary cause of head symptoms
have already been adverted to. The same remark applies still
more forcibly to irritability of stomach, whether of the nature first
noticed, or that depending on gastric inflammation.

When treating of intermittent fever I expressed my conviction
that irritability of stomach was not unfrequently caused and kept
up in the quotidian type by the unnecessary use of calomel and
purgatives in the hot stage ; and this belief is still stronger in re-
spect to remittent fever, because in it these means have been abused
in still greater degree. The practitioner who uses these medicines
guardedly, and with a clear apprehension of their evils as well as of
their advantages, will find vomiting a less frequent symptom of
remittent fever than it has usually been represented to be. This
impression, left on my mind from a careful review of the whole
subject, is sustained by the fact that in 357 cases of fever inter-
mittent and remittent treated by me in natives in the clinical ward
gastric irritability was present only in 6.

Affection of the Bowels. — The occurrence of dysentery in the
early or advanced stages of remittent fever in sthenic or asthenic
constitutions has been a rare event in my experience. From the
writings of Mr Twining, and more lately from those of Mr. Hare*,
it would appear that this complication has been more frequently
observed in Bengal, and that the type of the fever has generally
tended to be congestive or adynamic and the dysentery to be
hsemorrhagic in character. It may be also inferred from Has-
pel's work on the diseases of Algeria and Bleeker's report on the
dysentery of Bataviaf that the co-existence of dysentery and of
remittent fever is not unusual in these countries. It is in localities
in which the period of the production of malaria is coincident with
much atmospheric moisture and vicissitude that dysentery occurs,
combined or contemporaneous with remittent fever. Since the doc-
trine that malaria is the exciting cause of intermittent and remit-
tent fever became established, the co-operating and modifying action
of ordinary causes — cold, wet, heat, intemperance — has been too
much overlooked, and our knowledge of the etiology of the dif-
ferent forms and varieties of fever has in consequence been im-
paired ^

* "Indian Annals of Medical Science," No. 2.
t Ibid. No. I.

ENTERIC COMPLICATION. — PATIIOLOaY. 95

Diarrhoea is, according to my observation, a more frequent com-
plication of remittent fever, and is sometimes accompanied with
gastric irritability ; but it cannot be said to be common, for it was
present in only 6 of 114 clinical cases in natives.

In fatal cases in which increased alvine discharges have been
present dming life we may expect to find evidence of inflamma-
tion having existed in the mucous membrane of the end of the
ileum or of the large intestine. Cases 17, 26, 32, illustrate this
observation, and the two following are further confirmatory of it.

34. Remittent Fever, with head and gastro-enteric symptoms ; two or three ounces
of serum in the cranium. — Firm granular exudation on the mucous surface of the
colon. — Dark rednes^ of the end of the ileum. — The subject of a large hydrocele. —
John Daniel, aged fif1!y, a person of colour, born in Ceylon, of feeble and emaciated
habit, was sent to the hospital on the 5th September, 1839, having been found in a
state of destitution on the road. He was unable to give any account of himself, his
tongue was dry and covered with a yellow crust, pulse 116, skin not of increased tem-
perature. He was also the subject of a large hydrocele. He died on the 16th Sep-
tember. The leading symptoms during his residence in hospital were frequent hiccup
and incoherent muttering, pulse generally about 100 and feeble, tongue crusted in the
centre, and florid at the tip, the skin generally not above the natural temperature, two
or three evacuations daily, passed in bed, feculent and containing lumbrici. Little food
was taken. The treatment consisted of quinine with small doses of calomel, a blister
to the epigastrium, wine and light nourishing food ; and on one occasion an enema with
ol. terebinth.

Inspection eight hours after death. — Body much emaciated, the skin and fibrous
tissues deeply tinged yellow. Head. — The convex surface of the brain was partially
veiled with serum ; and there were between two or three ounces of it effused at the base
of the skull. Chest. — Both lungs adhered to the costal pleurae, but their substance was
healthy. In both sides of the heart there were fibrinous polypi, entwining round the
cords of the auriculo- ventricular valves. Abdomen. — The intestines externally had a
dark greenish tint. The liver was of dark green colour and the gall-bladder was nearly
empty. The stomach was contracted, and much of its mucous lining was mammillated,
and thickened, — this was chiefly in the body and at the pyloric end. The mucous
coat of the colon had a general dark grey tint, and in the ccecum, the descending
colon, and the rectum there were extensive patches of lymph effused in detached
pieces, presenting a roughened surface like shagreen. This lymph adhered firmly
to the mucous coat which underneath presented a dark dotted red appearance, was
firm and somewhat thickened with the submucous tissue more fibrous than is natural.
At the end of the ileum there was much dark vascularity of the mucous coat.
There was one lumbricus in the colon and one in that part of the small intestine which
was opened. The kidneys were healthy. There were about ten pints of dark red
turbid fluid, in the tunica vaginalis which was thickened, cartilaginous, and pre-
sented an inner surface of dark red tint roughened by closely adherent fragments of
very firm lymph.

35. Bemittent Fever. — Peyer's glands enlarged and ulcerated. — Head symptoms
with moderate turgescence of the vessels. — Caroline Smith, an Indo-Briton, aged nine.
On the 7th July, 1839, after having been in the sick ward for two or three days with
mild febrile symptoms was observed to be affected with slight drowsiness and heat of
head, for which twelve leeches were applied to the temples, and the bowels freely acted
on with calomel, followed by senna mixture. On the 8th the1*e was still heat of skin
and of the head. The head was shaved and cold applications used. On the 9th she

06 REMITTENT FEVER.

seemed drowsy and tlie scalp was hot and the pulse frequent, the tongue was more
florid than natural, she had vomited several times, and the bowels were open. Six
leeches were applied to the temples and six to the epigastrium, cold applications were
continued to the head, a blister was applied to the back of the neck, and effervescing
draughts were given every foiirth hour. She passed an uncomfortable night with fre-
quent moaning. On the morning of the 10th there was a good deal of heat of scalp,
and the general surface was above the natural temperature ; the pupils contracted freely,
but she lay with her eyes shut as if annoyed by the light, there was tenderness on
pressure of the epigastrium ; and the bowels had been opened during the night. Six
leeches were applied to the margin of the right ribs, cold wash continued to the head,
and an enema directed at noon. At the evening visit she was reported to have been
cool and more lively at noon, but there was again a febrile exacerbation, bowels moved
orce. Calomel grs. iii. pulv. jalap grs. vi. to be taken at bedtime. She vomited the
powder but passed the night quietly. On the morning of the 11th, bowels not opened,
abdomen full, tongue pretty clean, skin cool but dry, pulse rather frequent, and she
was still sluggish. A domestic enema, with turpentine oil, wa^ directed to be used,
and the following piUs prescribed : — quinine sulph. and pil. hydrarg. aa. grs. iv.
ipecac, gr. iss. tere bene ft. pil. iii., one to be taken every second hour, for four doses,
should there be no fever, also chicken soup. She vomited several times duiing the
day, and at the evening visit the pulse was 104, slight heat of skin and less di'owsi-
ness, and abdomen still full ; the bowels had been opened by the enema but not other-
wise, tongue not furred, and tolerably moist. Eepet. enema c. ol. terebinth, and give
an effervescing draught every fourth hour. During the night time, she vomited fre-
quently, and was purged four or five times. Sinapisms were applied to the stomach,
and a powder with hydrarg. c. cret. given. At half-past 7 a.m., of the 12th, the
skin was cold, the pulse thready, and the tongue not coated. Eecipe : quinine grs. vi.
opii. gr. half, confect. aromat. q. s. at. ft. pil. iv. one to be given every third hour, and
sago with wine or brandy occasionally. She vomited the sago and brandy. There was
no recurrence of purging. At noon the pulse was hardly perceptible. Liquor lyttae
was applied to the epigastrium, and the remedies continued. The vomiting of ingesta
continued, and she died about 10 p.m.

Inspection ten hours after death. — Head. There was moderate vascular turgescence
of the membranes of the brain, and dotted points on incising its substance, and about
an ounce and a half of serum at the base of the skull. Chest. — The lungs, partially
collapsed, were somewhat emphysematous, and without congestion of their posterior
part. Abdomen. — The liver was healthy. The stomach was contracted, and its mucous
coat normal. At the end of the ileum the glands of Peyer were distinct, and there
were three or four round ulcers, each the size of a split pea; cicatrization had
commenced. In the colon the follicles were distinct, but the mucous coat was
healthy. The mesenteric glands ranged in size from a pea to "a horse bean, but were
not tubercular.

The observation made in reference to affection of the bowels in
intermittent fever, viz., that its frequency will be found to bear
relation to the injudicious use of purgatives, is equally applicable
to remittent fever.

Hepatic Affections. — Hepatitis has been, in my field of practice,
an unusual feature of remittent fever. It was so in the European
G-eneral Hospital and in 138 cases of remittent fever in European
officers it is noted only of 7, and of these 5 were recoveries.
In 114 clinical cases in natives, hepatitis was present in 3. The
liver may be enlarged in the early stages of remittent fever from

WITH JAUNDICE. — PATHOLOGY. 97

congestion, and this enlargement may also be an occasional
sequence of the remittent just as it frequently is of the inter-
mittent type.

Splenic enlargement existed in 20 of the clinical cases, and
when occurring in remittent fever it may generally be viewed as
indicative of former attacks of the intermittent form. This lesion
has been already so fully considered in connection with inter-
mittent fever, that further notice here would be superfluous.

Jaundice wsiS present in 28 of 114 selected clinical cases of
natives, and 10 of them proved fatal. Of the 90 fatal cases of
remittent fever in European officers 7 were of this complication ;
and though it was not a common occurrence in the European
General Hospital at Bombay, yet a season seldom passed without a
few instances being met with. It varies in frequency, however,
in different years: it was more common in 1848 in the clinical
ward than in any of the five following years.

As the pathology of jaundice is not yet well understood, the narra-
tion of the 10 fatal cases will be useful. When these are compared
with the recoveries it appears that the average duration of illness
of the former before admission has been about eleven days, and
that of the latter about eight, a difference of three days.

Mr. Twining believed that jaundice was sometimes caused by
the mechanical pressure of enlarged Ijnmphatic glands situated near
the entrance of the common biliary duct into the duodenum, and
the confirmation or correction of this opinion is important. With
this view the state of these glands is generally noticed in the
reports of the fatal cases : they were considered to be enlarged in
6 of the 10, but, with one exception, there was no reason to
think that they had pressed on the duct ; and in this case (39) the
pressure was caused rather by the head of the pancreas than by the
enlarged glands. In one of the 6 cases the hepatic and common
ducts were obstructed by an impacted lumbricus ; and in 2 there
was constriction of the cystic duct but it was independent of
glandular enlargement, and in both the gall-bladder was full of
bile.

Traces of inflammation of the mucous membrane of the duode-
num and stomach were observed in 6 cases, and in 3 of them the
lymphatic glands were also enlarged, but in 2 of the remaining 3
the glands were not enlarged, and in one their condition was not
noted. Of the remaining 4 of the 10 fatal cases, in one the state
of the duodenum was not noticed, in one there was obstruction of

98 EEMITTENT FEVER

the ducts from a lumbricus, in one neither enlarged glands nor
gastro-duodenitis, and in one enlarged glands and pancreas without
gastro-duodenitis.

These data are not sufficient to justify a positive opinion,
but they cannot be regarded as confirmatory of Mr. Twining's
views. When it is recollected that jaundice seldom comes on
before the fifth day of the fever and is almost invariably attended
with tenderness below the margins of the seventh, eighth, and
ninth right ribs, it is probable that its most important relation is
to inflammation of the mucous membrane of the duodenum. This
conclusion is supported by the fact that remittent fever compli-
cated with jaundice is best treated by the moderate use of leeches,
small blisters, mild alterative aperients and quinine in the re-
missions, and is sure to be aggravated by the injudicious use of
calomel and purgatives. As vomiting is frequently absent, the
symptoms appear to be referable rather to the inflammatory
condition of the duodenum than to the gastritis which generally
co-exists.

These cases do not indicate a frequent dependence of jaundice
on inflammation of the mucous lining of the ducts, for it was
not observed in any of them. They are defective in that the
microscope was used only in three, but in these the hepatic cells
presented no abnormal appearance. None of these cases, however,
had the characters of the yellow atrophy of Eokitansky in which
head symptoms are prominent and the course rapid from probable
direct destruction of the vitality of the cells by the influence of the
morbific cause.*

36. Remittent Fever with jaundice. — Drowsiness. — Biliary congestion of the liver.
Enlarged lymphathic glands in the course of the common duct. — Slight dilatation
of the hepatic duct. — Grastro-dvx)denitis. — Grantdar exudation on the mucous sur-
face of the ileum and colon. — Nodides of ptdmonary apoplexy, one softened into '.a
cavity. — Nuthagee, a Hindoo labourer of twenty -five years of age, was admitted into
hospital, after ten days' illness with fever, on the 14th of September, 1848. The pulse
was feeble, the skin was coldish, the bowels relaxed, the tongue coated and slimy, hic-
cup was present and the conjunctivae were yellow. He was somewhat drowsy, but
pointed to the right side as the seat of pain. The symptoms continued with little
change till the 18th, when he became more drowsy and died, having expectorated some
bloody serous fluid about ten hours before death. He was treated with quinine and
Dover's powder, light nourishment and stimulants, and a blister was applied to the
right side.

Inspection fourteen hours after death. — Abdomen. The liver, somewhat enlarged, _
was connected to the diaphragm by old adhesions, and was of olive-green tint when

* I shall again return to the Pathology of Jaundice in connection with the diseases
of the liver.

WITH JAUNDICE. — PATHOLOGY. 99

incised. The gall-bladder was full, but not distended. Just beyond the junction of
the cystic and hepatic ducts there commenced a chain of lymphatic glands, which sur-
rounded and accompanied the common duct to its point of entrance into the duodenum.
The thickness of the chain of glands was equal to that of a swan's quill. The hepatic
duct was somewhat dilated. There was no redness of the mucous lining of the biliary
ducts. The mucous lining of the duodenum presented a surface of bright red patches
covered with adhesive mucus, but the tissue was not softened : similar patches were
observed at the commencement of the jejunum. About two feet of the end of the
ileum and the ccecum were laid open. The inner surface of the ileum was bright red
in patches, wliich followed the transverse folds of the membrane, and were covered
with granular lymph ; in scraping off the lymph no softening of the membrane was
found. Similar red patches, but without the granular efiusion, occupied the mucous
surface of the ccecum and commencement of the colon. There was not a trace of ulcer-
ation, and the groups of Peyer's glands at the end of the ileum were free of disease.
The mucous surface of the stomach presented patches of redness at its cardiac end.
Chest. — Lungs did not collapse. In both, but chiefly in the left, there were several
black nodules from extravasated blood (pulmonary apoplexy) ; in one the texture of
the lung had been broken down, and cavities had formed, the smallest was the size of
a pea, the largest that of a pigeon's egg. There was also a good deal of oedema of the
lungs. The heart was healthy.

37. Eemittent Fever with jaundice. — Tenderness at margin of right ribs. — Coma.
— Gastro-duodenitis. — Enlarged lymphatic glands in the course of the common
Duct. — Biliary congestion of the liver. — Meerza Khan, a Mussulman peon of
twenty-six years of age, a native of Peshawur, was, after eight days' illness, admitted
into hospital, on the 21st of October, 1848. The surface of the body and the con-
junctivse were tinged of a deep yellow colour. He complained of pain, much increased
by pressure at the margin of the right false ribs, and there was some fulness there.
The tongue was much coated and dryish in the centre, and the bowels were reported
to be confined. The pulse was quick, full, and soft. No heat of skin. He continued
in hospital till the 26th, when he died. The exacerbations were marked by excitement
of manner, not by increased heat of skin. The alvine and renal excretions were scanty.
The pulse lost strength. The jaundice continued. He became drowsy on the 25th,
then comatose. He was treated with twenty-four leeches to the margin of the right
ribs, followed by a small blister. Mercurial purgatives were given, also quinine in two
or three-grain doses with an equal quantity of blue pill, every third or fourth hoiir.
As the pidse failed, wine and ammonia were given, and attention was paid to suitable
nourishment. On the 25th a blister was applied to the nucha.

Inspection five hours after death. — All the tissues were deeply tinged yellow.
Chest. — The lungs did not collapse freely, but were otherwise free of disease. The right
side of the heart was distended with blood. The ascending aorta was a good deal
dilated, and part of its inner surface was irregular. Abdomen. — The liver was not
enlarged, but was of olive-green tint. The mucous membrane of the stomach and
duodenum was dotted red, but sound in texture. The lining of the ileum was also red-
dened, but neither softened nor ulcerated. Lymphatic glands the size of a small bean
embraced the common biliary duct near to its termination in the duodenum. On the
external surface of both kidneys there were puckered cicatrices, which gave a lobulated
appearance to the organ. In the left kidney, situated in a calyx, and branching into
others, there was a calculus. The spleen adhered closely and firmly to the stomach
and diaphragm. The head was not examined,

38. Fever with jaundice. — Tenderness at the margin of the right ribs. — Drowsi-
ness. — Biliary congestion of the liver. — Obstruction of the hepatic duct by a lum-
bricus, of which there were many in the duodenum and stomach. — No gastro-duode-
- Enlargement of the lymphatic glands in the course of the common duct. —

H 2

100 REMITTENT FEVER

Hepatic cells distinct. — Chottoo Ram, a Hindoo peon of twenty-five years of age, was,
after ten days' illness, admitted into hospital on the 2nd February, 1849, He was
much exhausted, there was heat of skin, a feeble pulse, yellow conjunctivse, tenderness
at the margin of the right ribs, and some degree of drowsiness. He died on the 4th,
two days after admission.

Inspection twelve hours after death. — The tissues were tinged deeply yellow. The
viscera of the chest healthy. Abdomen. — There was no peritonitic inflammation. The
colon and ccecum were distended with air. The stomach contained greenish viscid
mucus, and five or six lumbrici, and the contents of the duodenum were similar, with
four or five lumbrici ; the mucous coat of both was healthy. lAver. — The substance
was of very yellow tint in places. The hepatic cells were seen distinctly under the
microscope. The gall-bladder, not distended, was, however, full of dark thick bile.
The hepatic duct was distended by a lumbricus, the sharp end of which extended into
the common duct for about an inch beyond the junction of the cystic duct. The lum-
bricus was traced in the duct beyond its division, for about three inches into the
substance of the liver, and in following the branch of the duct had been subjected to
considerable curvature ; but it was not traced to its end in the liver, for it had been
accidentally cut across. There was no redness of the mucous membrane of the duct.
The chain of glands along the lower side of the common duct equalled a swan's quill
in thickness.

39. Remittent Fever with jaundice. — Tenderness at the margin of the right ribs.
— Drowsiness. — Enlarged lymphatic glands. — Enlarged head of the pancreas. —
No duodenitis. — Biliary congestion of the liver. — Balloo, a Hindoo labourer of
thirty-five years of age, after suiFering for fifteen days from fever characterised by even-
ing exacerbations and morning remissions, was admitted into hospital in a reduced
state on the llth June, 1849. He had been jaundiced for six days. The tongue was
streaked yellow, and somewhat florid at the tip and edges. There was tenderness,
with resistance, below the margin of the right false ribs, and the edge of the spleen
was perceptible under the left. During his stay in hospital the evening exacerbation
was well marked, but frequently the remission in the morning was very slight. The
jaundice persisted, the urine was of a deep brown colour, generally about twenty ounces
in the twenty-four hours. The alvine discharges were of a pale colour, and there was
no vomiting. He was quite collected on admission, but on the 20th June muttering
delirium was first noticed. The pulse became feebler. There was subsultus on the
25th, and bleeding from the gums on the 26th. He became drowsy on the 28th, and
died on the 6th of July, but without complete coma. The treatment consisted of
twenty-four leeches to the margin of the right ribs, followed by a small bKster, mer-
curial and other purgatives, quinine in three and-four grain doses, with blue bill and
ipecacuanha during the remissions, frequent sponging of the surface of the body with
tepid water, saline diuretics, sago and chicken broth.

Examination eight hours after death. — All the tissues were tinged yellow. Chest. —
Left lung was collapsed, crepitating, and healthy. The right lung adhered by tender
bands to the costal pleura, but was crepitating and healthy. Abdomen. — The intestines
both small and large were contracted. The liver was somewhat enlarged, yellowish in
colour, but natural in consistence. The gall-bladder contained some bile, but it was
not distended. The common duct was surrounded in three fourths of its circumference
by the head of the pancreas, which seemed somewhat indurated, and larger than
natural, and there the duct was somewhat contracted. On the other side of the duct,
in contact with it, was an enlarged lymphatic gland, about an inch and a half in
length and a quarter of an inch thick. The common, hepatic, and cystic ducts were
permeable. The mucous membrane of the duodenum was healthy, and covered
with bile.

40. Bemittcnt Fever with jaundice, — Tenderness at the margin of the right ribs.

WITH JAUNDICE. — PATHOLOGY. 101

Death from e:chaustion. — Enlargement and biliary congestion of the liver. — Gasiro-
duodenitis. — Hejjatic cells distinct. — Sutwa Purojee, a Hindoo rope-maker of
twenty-seven years of age, and stout habit of body, after suffering for twelve days
from febrile symptoms, without, as reported, distinct remissions, was admitted into
hospital on the 7th August, 1849. The abdomen was full, without induration, but with
tenderness at the margin of the right ribs. He had occasional vomiting, and the
tongue was coated. The bowels were reported to be regidar. He admitted that he
made occasional use of spirits. Thirty-six leeches were applied to the epigastrium,
quinine in four-grain doses, with blue bill and ipecacuanha, was given during the
remission. There was not much heat of skin on the 9th and 10th, the pain was re-
lieved, and the vomiting had ceased. Some compound powder of jalap was given on
the 10th. On that evening there was a febrile exacerbation, which continued on the
11th (there having been shivering at midnight), with increase of tenderness at the
epigastrium and margin of right ribs, dulness to within an inch and a half of the um-
bilicus, and commencing jaundice. Eespiration short and hurried, pulse frequent and
small, and tongue dry, with dark fur. Fifty leeches were applied to the margin of the
ribs, and ten grains of calomel, with four of compound extract of colocynth, were given.
At noon, the skin was cool, the pulse feeble, and one pale evacuation had been passed.
The side was said to be easier, but the breathing continued hurried, and he died about
an hour after the report,*

hispection three hours after death. — The body was not much reduced, and the
tissues were tinged deeply yellow. Chest. — The lungs were crepitating, but somewhat
inflated. There were no adhesions between the pulmonary and costal pleurae. The
heart was healthy. Abdmnen. — The liver was much enlarged, and reached beyond tho
margin of the false ribs, from the tenth rib of the right side to within an inch and a
half of the umbilicus, and thence to the most prominent part of the seventh left rib.
No adhesions existed between it and the surrounding parts. When incised, the surfaces
were of a mixed red and olive-green tint, and the stibstance was softer than natural
throughout. The gall-bladder contained serous-looking bile. The stomach was full
of half digested food, and its mucous membrane was of a uniform rose colour except in
a few places where there was a deeper dotted redness with sOme degree of softening.
The inner surface of the duodenum was tinged with bile, and its mucous membrane,
as weU as that of the large intestine, was of a redder colour than natural. Tho
kidneys were large, and of a dark (almost black) red colour throughout, evidently
from congestion of blood. The spleen was not enlarged. The head was not examined.
— A small portion of the glandular substance of the liver was examined tinder the
microscope, and exhibited the hepatic cells distinct.

41. 'Remittent Fever with jaundice in an o^ium'^eateti — Tenderness at the epigas-
trium. — No coma. ■ — Death from exhaustion. — Enlargement and biliary congestion of
the liver. — No duodenitis. -^— No enlargement of the lymphatic glands. — Synd Bux,
a Mussulman, a native of Mooltan, sixty years of age and following the occupation of
a Fakir, was in the habit of taking opium, but only he said to the extent of two grains
daily. After twelve days' illness with fever and epigastric tenderness he was ad-
mitted into hospital on the 23rd January, 1850. There was tenderness on pressure at
the epigastrium, and duLness for two inches and a half below the ensiform cartilage.
The spleen was also enlarged. The pulse was frequent and feeble. The tongue
dryish with a yellow central coat and florid tip and edges. The conjunctivae wore
yeUow. On the 23rd, 24th, and 25th there was a febrile exacerbation. The urine
was high coloured, the alvine discharges scanty and pale. From the 26th to the

* In tliis case the fatal result was expedited by the injudicious use of depressants
in the advanced state of fever ; indeed, it is not improbable f hat the exacerbation oii
tlie 10th was fiivom-ed by tli£ purgative then given.

II 3

102 BEMITTENT FEVER

1st of February, there was very little febrile disturbance and the jaundice seemed to
lessen somewhat, but there was no improvement in the strength of the pulse, the
emaciation rather increased, and the movements of the limbs were tremulous. On the
1st of February, his manner was sluggish, and from this time increase of the febrile
disturbance and of the asthenia took place. He died on the 7th without coma.

The treatment consisted of a small blister to the epigastrium, an occasional
laxative, and quinine in four-grain doses in solution combined with nitrate of potass
and spiritus setheris nitricus during the remission, also chicken soup and wine.

Inspection seventeen hours after death. — The tissues of the body, chiefly the adipose
and areolar, were tinged yellow. On opening the chest the lungs remained slightly
inflated. There were some old adhesions between the outer and back part of the
right lung and the costal pleura. The substance of both lungs was crepitating. The
walls of the heart generally were thin, but there was no structural change of the
organ. Abdomen. — The liver was enlarged and extended across the epigastric region
reaching on the right side to the ninth rib, and on the left to the cartilage of the
eighth rib. The liver presented a uniform olive-green appearance, evidently
from biliary congestion, but there was no structural change. The gall-bladder con-
tained some bile. The common, hepatic, and cystic ducts were pervious. Theve was
no enlargement of the lymphatic glands or of other structure about these ducts. The
contents of the duodenum were tinged with bile and the mucous membrane was
apparently healthy. The spleen was considerably enlarged, reaching from the sixth
to the last rib. The stomach was somewhat contracted. The transverse colon was
displaced, one portion of it forming an angle with another which was directed down-
wards. The kidneys were healthy.

42. Bemittent Fever with j aundice. — Tenderness at the margin of the right ribs. —
Death from exhaustion. — Cirrhosis. — Gall-bladder distended. — Enlarged lym/phatic
glands around the common duct. — Duodenitis. — Granular exudation on the mucous
membrane of the ileum and large intestine. — Elaee Buccus, a Mussulman subsisting
by begging, of sixty years of age and visiting Bombay on his way to Mecca, was
admitted into hospital in a reduced state on the 10th July, 1850.^ He stated that
he had been ill with fever for about thirteen days. He was jaundiced. There was
tenderness below the margin of the right ribs and dulness for the extent of two inches,
enlargement of the spleen, increased heat of skin, tongue dry and coated in the centre,
and florid at the tip and edges, and the bowels were reported to be slow. Calomel
six grains with extract of colocynth eight grains were given, and on the foE owing
morning pulv. jalap, comp., one drachm, but with the effect of causing little action of
the bowels. Twelve leeches were applied to the margin of the ribs followed by
a small blister. On the 13th, quinine in four-grain doses was given and repeated
daily, and from that time to the 24th there was no recurrence of fever. The abdo-
minal tenderness and the jaundice also gradually disappeared, the urine was no longer
tinged green by nitric acid, and the tongue cleaned and became moist ; but there was
little improvement in strength. On the 24 Ih, abdominal uneasiness was complained
of and a rhubarb draught was given, but it produced no effect. In the evening there
was recurrence of febrile exacerbation, and on the 26th dysenteric discharges. Under
these symptoms, but without return of jaundice, he continued losing strength till the
2nd August, when he died without coma.

Inspection ten hours after death. — The body was much emaciated. Chest. — The right
lung collapsed freely and there were two or three large emphysematous bulla at its
anterior margin, but otherwise it was healthy. The left lung was connected to the

* In this case, as well as that which immediately precedes it, there was a check to
the fever from the use of quinine, but no tendency to the recovery of strength, owing
probably to the advanced age and asthenia of the subjects.

WITH JAUNDICE. — PATHOLOGY 103

costal pleura by firm adhesions, also its base to the diaphragm and its anterior edge
to the pericardium, but its substance was crepitating. The heart was healthy.
Ahdomen. — The liver consisted almost entirely of the right lobe. The gall-bladder
distended, reached nearly to the centre of the epigastric region, and was situated over
the gastro-hepatic omentum. The external surface of the liver was somewhat irregular,
but the substance was not indurated, and though when incised the surface presented
here and there white streaks apparently from hypertrophy of areolar tissue, there was
however no distinct lobular appearance. The lymphatic glands about the common
duct were about the size of an olive, but they did not press upon the duct, which
seemed more dilated than usual: this duct, and the hepatic and cystic ducts, were
permeable, and when laid open the mucous membrane presented the usual reticulated
character, but not a trace of redness. The contents of the gall-bladder were dark
green, and very adhesive from admixture of mucus. The mucous membrane of the
stomach was very rugous, mottled red towards the pyloric end, but without softening.
There was a good deal of dark redness of the mucous coat of the duodenum arranged
in streaks and patches, and chiefly occupying the apices of the rugse. Brunner's
glands were distinct, numerous, and elevated, and the mucous lining of the duodenum
was neither softened nor thickened. The inner surface of the lower end of the ileum,
— about two feet of it — also of that of the ccecum, the ascending and transverse
colon presented a dark red mottled appearance, with exception of the coecum, where
the redness was uniform. Here and there there was granular exudation on the sur-
face, to a slight degree in the ileum, but more general on parts of the large intestine,
and in places the exudation had a dark grey colour, and there was abrasion of
portions of the mucous membrane, as if from superficial ulceration. In these situations
the lining membrane was connected to the subjacent tunic more closely than natural.
The spleen was somewhat enlarged (six inches in length), but apparently healthy in
structure. The kidneys were healthy.

43. Fever with jaundice, — Died exhausted. — Biliary congestion of the liver. — No
enlargement of the lym/phatic glands. — Contraction of the cystic duct. — Distension of
the gall-bladder. Mucous tmmbrane of gall-bladder and ducts normal, with exception of
slight vascularity of common duct at point of entrance into duodenum. — Hepatic cells
distinct. — Sukeah, a Hindoo, of twenty-two years of age, was admitted into hospital
after nine days' illness on the 28th of August, 1850. He was jaundiced, drowsy, and
very exhausted. He died ten hours after admission.

Inspection ten hours after death. — All the structures were tinged yellow.
Abdoynen. — The liver projected about two inches below the ensiform cartilage and
right false ribs ; and its incised surface presented generally a yellowish appearance
with natural consistence. On examination under the microscope the hepatic cells
were distinctly seen. The hepatic and common ducts were of natural dimensions, not
turgid with bile, and when laid open, the mucous surface presented its normal
appearance, with the exception of slight vascularity at the termination of the common
duct in the duodenum. The lymphatic glands around the common duct were
not increased in size. The gall-bladder was distended with bile of a dark green
(almost black) colour. The cystic duct was very much contracted, aiid there wa^
some obstruction at its commencement which prevented the point of a probe from
entering the gall-bladder, but the mucous lining was healthy. The mucous membrane
of the duodenum presented a dark grey colour, with here and there Streaks of redness,
and the glands of Brunner were very turgid, but neither softening nor ulceration was
detected. The stomach contained a few ounces of dark-coloured liquid, its mucous
surfiice was of dark grey colour with patches of redness over the prominent rugae, and
two or three small projections apparently caused by some deposit, one (the largest)
about the size of a pea, was covered with coagulated blood. There were also two or
three small ulcerated spots on the mucous membrane of the stomach which could be

H 4

104 REMITTENT FEVER.

easily peeled off from the subjacent tissue. The small intestines wore rather con-
tracted. The kidneys were natural in size and structure, but the substance was tinged
yellow. The heart was healthy.

44. Bemittent Fever with Jaundice. — Drowsiness. — Enlarged lymphatic glands in
course of common duct. — Constricted cystic duct. — Gall-bladder full. — A Hindoo,
about thirty years of age, was admitted into the hospital in February 1849, with fever,
drowsiness, and jaundice, and died about twenty-four hours after admission.

Inspection thirty-three hours after death. — The gall-bladder was full of bile but
not distended. Along the common duct for about two inches and reaching almost
to the duodenum there were enlarged lymphatic glands, both below and above the
duct, each about the size of a small olive, and when cut giving out a brown
turbid fluid the result of decomposition. The hepatic duct was pervious, but the
cystic duct above its junction was so constricted as not to admit the small end of the
blow-pipe.

45. Bemittent Fever with jaundice. — 'No tenderness at margin of ribs. — Drowsi-
ness. — No enlargement of lymphatic glands. — Dark redness of mucous membrane of
duodenum. — Syed Mohedeen, a Mussulman beggar of forty years of age and of feeble
constitution, after suffering for twelve days from febrile symptoms coming on at
irregular periods, preceded by chilliness and attended during the last eight days with
looseness of the bowels, was admitted into hospital on the 28th August, 1850. He
was jaundiced. There was no induration or dulness at the margins of the ribs and
he made no complaint of pain. The pulse was feeble, and the tongue coated in the
centre was florid at the tip and edges. He died on the 12th September. Whilst
under observation the bowels were relaxed; the evacuations were generally of a
yellowish colour, sometimes scanty and passed with straining, but not tinged with
blood. From the 31st to the 5th there was improvement, the febrile disturbance
lessened, the tongue became more natural, and the jaundice decreased ; but from the
6th there was again aggravation with (on the 10th) tremulous hands, brown diy
tongue, and drowsiness. The urine throughout was scanty and high-coloured, but
showed no traces of albumen.

Examination thirteen hours after death. — Head. The vessels of the dura mater
were found turgid with blood, and the tissue somewhat tinged yellow. The vessels
of the pia mater were also congested. On the inferior surface of the posterior lobe of
the right side, and extending into its sulci, there was some extravasation of blood
into the meshes of the pia mater. The substance of the brain was free from structural
change, but when incised it presented some bloody points here and there. There was
no increased serous fluid found in the ventricles, and no extravasation of blood into
the substance of the brain. Chest. — The upper lobe of the left limg and the thin
anterior edge of the lower one were soft and crepitating, but the rest of the
lower lobe was in a state of red hepatisation. The whole of the right lung
was healthy, excepting the thin posterior margin of its lower part which was in a
state of red engorgement. The structure of the heart was healthy, but its valves
were tinged yellow. Abdomen. — The substance of the liver was healthy in
structure. The stomach contained yellow brown mucous-like contents with several
lumbrici, but its inner coat was healthy. The lining membrane of the duodenum
presented dark red patches, and the glands of Brunner were more than usually
prominent. No compression of the biliary ducts from enlarged glands was detected,
and the common and hepatic ducts were found permeable. On the mucous membrane
of the large intestines there were patches of red and grey discoloration, most marked
in the ascending colon and ccecum, but no traces of ulceration nor change in the
consistence of the tissue were obser\'ed. The mucous membrane of the ileum was
healthy with the exception of patches of faint redness here and there and the glands
of Peyer were normal. The spleen was much enlarged, measuring six inches by five,

GENERAL PKINCIPLES OF TREATMENT. 105

but was of natural structure, except at its convex surface, where there were two
deposits of tubercular-like matter each the size of a small bean. The kidneys
were healthy in structure, but tinged yellow.

Parotitis, — Considerable tumefaction, ending in suppuration,
in the situation of one or both parotid glands is an occasional
occurrence in remittent fever. I have witnessed it only in natives
and always associated with febrile symptoms of marked ady-
namic character. The notes of three cases, the subjects of which
recovered after a long and tedious illness are before me.

Pathology of Inflammatory, Adynamic, and Congestive
ReTYiittent Fever. — The pathology of these modifications of
remittent fever has already been incidentally considered in con-
nection with the symptoms : their relation to particular states of
the constitution, degrees of the morbific cause, and previously
existing structural disease are the leading facts which should be
borne in mind.

Pneumonia, — This complication and idiopathic pneumonia
will be treated of together.

Section IV. — Treatment — Contrast of the Principles of Treat-
ment of Malarious Remittent Fever, and the Zymotic Continued
Fevers of Cold Climates. — Treatment of Ordinary, Inflam-
m^atory, Congestive, Adynamic, and Irregular Types of
Remittent Fever. — Then of those complicated with Cerebral
Affection, Gastric Irritability, Jaundice, Hepatitis,

It has been already stated that the essential difference between
intermittent and remittent fever is that in the former a periodic
cessation — intermission — of the febrile phenomena takes place,
while in the latter there is only abatement — remission.

Both these forms of fever depend on difierent degrees of the
same morbific cause — malaria, — a materies morbi generated
without and received into the blood. Theory suggests that similar
principles of treatment must apply to diseases so nearly allied, and
clinical experience confirms the inference.

It may, therefore, be useful to preface the details of the treat-
ment of remittent fever by recapitulating the leading principles
which have already been inculcated in respect to intermittent fever,
and then pointing out the general character of the modifications
which the difference in degree of the morbid actions in the two
types may require. When a paroxysm of intermittent fever has

106 REMITTENT FEVER

fairly commenced, a certain course which we are unable to check
must be run before it comes to a close ; and this fact of clinical
observation is in harmony with the nature of the cause.

The susceptibility of enfeebled persons to attacks of intermittent
fever and the tendency of the disease in them to be protracted, that
is, to be liable to recurrences of the paroxysm — may be safely
admitted. Clinical observation teaches us that if much debility be
produced by treatment in intermittent fever, this greater liability
to a protracted course becomes materially increased, and serves to
illustrate the law that a morbific cause when in action is always
more influential on the predisposed from debility, however in-
duced.

If there co-exist with the febrile disturbance such derangement
of the capillary circulation of important organs as is likely to injure
their structures, or otherwise seriously to impair their functions,
then the means appropriate for the removal of this complication
must be had recourse to.

Though a paroxysm of intermittent fever cannot be stopped, yet
the degree of vascular excitement may be modified in such manner
as to lessen discomfort and mitigate local derangements when
they exist. This object may be effected by ventilation, purity
of atmosphere, reduction of the temperature of the surface of
the body by the external application of cold, and attention to
quietness and repose. These means do not abstract any of the
constituents of the blood, and therefore do not debilitate. But the
same end may be accomplished by blood-letting, purgatives or other
evacuants, but agencies of this kind enfeeble, and they ought not
to be used except in cases in which the necessity for decided and
prompt reduction of vascular excitement or for free elimination is
so pressing as to justify our disregarding for the time the lesser
because the remoter evil.

Although a paroxysm of intermittent fever when once formed can-
not be checked, yet after in its natural course it has ceased we have
in quinine an effective means of preventing its return ; and when
we compare this statement with that of our inability to stop the
paroxysm, it becomes evident that therapeutic force in this disease
is confined to the period of intermission.

These general principles are equally applicable to the treatment
of remittent fever, and it shall now be my endeavour to explain in
what respect they require to be modified when applied to this
type.

In intermittent fever there is for the most part little risk of

GENERAL PRINCIPLES OF TREATMENT. 107

injury to important organs during the stage of febrile reaction. A
frequent recurrence of the paroxysm is not in general attended with
immediate danger to life, but injures by deteriorating the constitu-
tion. In remittent fever, on the other hand, there is greater likelihood
of harm from the increased vascular excitement of the exacerbation,
and therefore recurrences of this stage are not unfrequently attended
with immediate danger to life from lesion of important organs, or
depression of vital actions. Hence, in the treatment of remittent
fever, though there is often necessity for the reduction of febrile
excitement in the exacerbation by depletory means, yet at the same
time there is greater demand for the exercise of discriminating judg-
ment, for the evils of the injudicious use of depressant remedies are
more immediate, more certain, and more serious. If such are the
dangers which may attend the exacerbation of remittent fever, then
the prevention of its recurrence by the efficient use of quinine given
during the remission is even more urgent than the same indication
in the intermission of intermittent fever.

If it be true that at some periods of the exacerbation of remittent
fever there may be risk of injury to important organs from excessive
vascular action calling for control by depletion, and that, at other
periods, there may be danger to life from exhaustion requiring the
prompt use of stimulants and nourishment ; if it be also true that
the time of exacerbation and remission is liable to vary in different
cases, that it is most important to prevent the exacerbation, and that
we are able to effect it ; then it follows that there cannot be success-
ful treatment of remittent fever, justice to the sick, or loyalty to
the profession of medicine, unless our visits to the sick be frequent
and our watching attentive and well-timed.*

* Since the publication of the first edition of this work, I have found in " Obser-
vations on the Diseases of the Army in Jamaica, by John Hunter, M.D., Physician
to the Array, 1788," these principles inculcated with so much truth and force, that I
here quote the passage for the instruction of the reader, and with the view of enforcing
the analogous statement in the text :

" A surgeon that would do justice to the men under his care must be very frequent-
in his visits to the hospital ; for unless he watch assiduously the remissions of the
fever, and be ready to take immediate advantage of them, he will not be able to check
the disease speedily, without which both the constitution and life of the patient will
be in imminent danger. A man that has three or four fits of the fever is in greater
danger of dying than one that has only one or two ; but laying the risk of death out
of the question, a man that has his fever stopped after the first or second fit, will ge-
nerally be restored to health in a few days, whereas if he have four or five fits, it will
often require as many weeks to recover the same degree of strength in the latter case
as days in the former. It must, therefore, be obvious how much the diligence and
attention of the surgeon importeth, of which a vq|j/' striking ptoof occurred in a regi-
ment wliich was strong and consisted of twelve companies. The regiment was pro-

108 REMITTENT FEVER.

At the opening of the section on the pathology of remittent fever
it was stated that when remittent fever is compared with the
zymotic continued fevers of the colder climates this striking dif-
ference is observable. In the former there are daily remissions of
the fever, that is a return, more or less complete, to normal actions ;
but in the latter the fever is continuous and unabated for many suc-
cessive days. This difference materially affects the principles of
treatment. In both the febrile reaction is caused by a materies in
the blood whose power when thus in operation we are unable to
stop. In both, but more in remittent fever than in the others, there
may be danger to important organs from deranged capillary circu-
lation rendering necessary the adoption of means for lessening vas-
cular excitement. In both there is danger to life from depression
of vital actions — from the sedative influence of the cause, the con-
tinuance of the febrile disturbance, the previous condition of the
subject, or of all combined — requiring stimulants and support.

In remittent fever there are periodic abatements of the febrile
state, and there is an agent which, when effectively used in the re-
mission, tends to prevent the recurrence of the exacerbation, and
thus most materially to shorten the general course of the disease.
On these circumstances our chief power in the treatment of remit-
tent fever depends, but it has no place in that of the zymotic con-
tinued fevers. In these there is less frequently necessity for con-

vided with two hospitals and two surgeons, each of whom took charge of the sick of
six companies. It was presently found that one hospital was much fuller than the
other, which did not appear to proceed from a greater sickness among one di^asion of
the companies than the other, for there was no material difference in the number of
sick sent from the several companies. In order to bring the sick in the two hospitals
to an equality, a company was taken from one division and annexed to the other. The
sick of the five companies were, however, still more numerous than that of the seven ;
and after a short trial, they were divided into four and eight companies, and then the
sick in the two hospitals were nearly equal, and varied from forty to sixty in each. It
may be supposed that so great a difference depended upon the method of treatment
being entirely different in the two hospitals. That, however, was not the case ; the
general plan of treatment was nearly the same in both, and not materially different
from what has been mentioned in speaking of the cure of the remittent fever. It was
owing to the following circumstances : one surgeon visited his hospital four or five
times a day, the other only twice a day ; the first seldom allowed any remission to
pass without taking advantage of it, the latter often; one was always at hand to pal-
liate the untoward symptoms, as vomitings or purgings, proceeding either from the
medicines or the disease ; the other not. Add to these, that vigilance in the surgeon
at the head of an hospital extends itself to the servants and nurses under him, and
thence a greater degree of attention both in administering nourishment and medi-
cines. The effect of all those causes was, that the men recovered in half the time in
one hospital that they did in the^pther, and therefore the hospital for eiglit coni-
pauies had no greater number of sick than that for four."

ORDINAKY FORM. — TREATMENT. 109

trolling local capillary derangements and little risk of sudden
unexpected exhaustion. The course of the disease is, compared
Avith that of remittent fever, steady and prolonged, and the main
indication of cure is, by warding off undue prostration, to conduct
the patient safely to its close. The treatment is, therefore, expec-
tant and for several days in succession may be continued with little
change. Contrast this with what has been already said of remit-
tent fever, the changes from exacerbation to remission taking place
within a few hours at varying periods, and requiring a decided
modification of the remedies.

It was in order to point to this contrast in the principles of treat-
ment that I have entered into this comparison between remittent
and zymotic continued fever and have shown the invariable
necessity of constant watching and action in the one, and the suf-
ficiency, for the most part, of expectant principles in the other. It
is well to fix attention on these doctrines, for observation has con-
vinced me that medical men whose practical knowledge of fever
has been acquired in hospitals in European countries do not quickly
realise to themselves the frequent changes which take place from
the very outset in remittent fever, the importance of watching them,
and of regarding them in treatment. On the other hand, when we
look back to the state of practice in fevers in India twenty years
ago, it is evident that principles of treatment in the zymotic fevers
of the colder climates which are equally applicable to remittent
fever were lost sight of and neglected ; principles which acknow-
ledge our inability, in the present state of medical art, to cut
short the febrile * disturbance of a zymotic cause, and which
admit great danger to life from depression of vital actions, con-
sequent on the persistence of the febrile state.

The treatment which is applicable to the different circumstances
of remittent fever will be first described, and then a few observa-
tions will be offered on some of the principal remedies.

Ordinary Remittent Fever. — The description of the treatment
of this form is chiefly derived from my experience in the European
Greneral Hospital at Bombay. The subjects were, in great part,
seamen, and were admitted generally about the third day of the
disease. In the exacerbation there was headache, with flushing of
the countenance, and, in a small proportion of cases, vomiting, with
some degree of epigastric tenderness. In the greater number the
tongue was coated yellow in the centre, in some expanded, in othei*s

* In applying this principle to remittent fever, I speak of .the febrile disturbance of
tlie stage of exacerbation. .

110 REMITTENT FEVER.

contracted and pointed with florid edges and tip. The pulse was
generally neither firm nor full, but frequent and moderate in
strength. In a great many instances the secretions from the
bowels were dark or greenish in colour, but became natural as
the tongue cleaned. The remittent character of the fever was
well marked.

In treating the exacerbation, general blood-letting was un-
necessary. In cases in which there was much headache and
flushing of the face, from thirty-six to sixty leeches to the temples,
and cold applications to the head were required. In cases in
which there was tenderness at the epigastrium, and a contracted
tongue with florid edges and tip, there was necessity for more or
less leeching of the epigastrium, the use of effervescing draughts,
cold drinks in small quantity at a time, and the avoidance of eme-
tics, antimonials, mercurials, and purgatives. When the headache
was moderate, and gastric irritation was absent, then cold applica-
tions to the head, frequent tepid sponging of the surface of the body,
antimony in small doses, or aqua acetatis ammonise, sufficed for
reducing the febrile excitement.

Emetics were often useful at the commencement of the attack, but
it was necessary to give them with much discrimination. In cases
in which the tongue was foul and expanded but not florid, and in
which there was nausea without vomiting or epigastric tenderness,
twenty-five grains of ipecacuanha was the emetic which was generally
used with advantage.

During the first two or three days of the attack, when the tongue
Was foul but not florid, the alvine excretions vitiated, the abdomen
full and resisting, and the vascular excitement steady and without
tendency to depression, it was an important part of the treatment
to give a ten-grain dose of calomel, combined with a few grains of
antimonial powder, and some hours afterwards an aperient, as the
compound powder of jalap. The calomel was most generally ad-
ministered at bed-time, and the compound powder of jalap in the
morning. Calomel and purgatives, even to the extent now recom-
mended, are seldom expedient after the third or fourth day of the
disease, and they are unnecessary, even at an earlier period, if the
abdomen be soft and without fullness, notwithstanding the presence
of disordered alvine excretions and a coated tongue.

After the first or second exacerbation a full dose * of muriate of
morphia was exhibited in many cases at bed-time with much bene-

* This recommendation must be carefully considered in connection with my subse-
quent remarks on the use of full opiates in remittent feyer.

ORDINARY FORM. TREATMENT. HI

fit. When there is headache with great heat and dryness of skin
and a full and frequent pulse, morphia is contra-indicated; but
in most cases when there has been good management at the com-
mencement — adequate leeching, the appropriate use of calomel and
purgatives — there follows, on the succeeding night, slight pyrexia
with restlessness, but without headache, a supple abdomen, a tongue
still foul but moist, a pulse above the natural frequency but soft.
In a case of this kind, calomel or blue pill, in a dose proportioned
to the state of the tongue and the condition of the secretions in
regard to quantity and quality, with a grain of ipecacuanha and one
of muriate of morphia, preceded by a foot-bath, perhaps by a few
leeches to the temples, will generally be succeeded by a quiet night,
and a forenoon remission so distinct as to admit of quinine being
freely exhibited. This -method, moreover, tends to restore a natural
state of the secretions with less risk of gastro-enteric irritation.

The remedial means as yet referred to are used with the view of
decreasing the vascular excitement of the exacerbation, protecting
organs important to life from harm by u];idue determination of
blood, and correcting deranged functions. These are very important
considerations^ but they are subordinate to the main indication of
cure in remittent fever, which assimilates in every respect to that
already insisted upon in the intermittent type, viz. to take advan-
tage of the earliest remission by adopting means to prevent a return
of the exacerbation, or failing this to postpone its access or lessen
its severity : and for this purpose quinine is as efficacious as in the
intermission of intermittent fever. The same course should be ob-
served in all subsequent remissions, irrespective of local complica-
tions, which may require special means for their removal, and which
it is very important not to neglect, but which should not be allowed
materially to interfere with the steady pursuit of the leading indi-
cation of cure as now stated.

The earliest remission should be regarded, and quinine be given
in from four to six-grain doses every second or third hour, for four
or five times. Should the exacerbation return the quinine is to be
omitted, but should it not recur, the quinine is to be continued
every third or fourth hour, till the febrile phenomena have disap-
peared, and the probability of return has ceased.

But in ordinary remittent fever derangement of functions
often co-exists with the remission, and requires attention in the
treatment. Though such derangements are most certainly and
speedily corrected by the mere prevention of the exacerbation, yet
advantage may often result from remedial means more especially

112 REMITTENT FEVEK.

directed against them. It may be acknowledged as a therapeutic
principle in remittent fever, that all medicines not used merely to
reduce excessive vascular action, are given, with less likelihood
of harm and more probability of benefit, during the remission
than during the exacerbation. Nor is it difficult to suggest the ex-
planation. The less abnormal state of the general and capillary
circulation, characteristic of remission, is more favourable to absorp-
tion and the other processes concerned in therapeutic actions.
Thus it will sometimes be useful, when an aperient is indicated, to
combine two drachms of sulphate of magnesia with the first and
second doses of quinine, or when the bowels are slow and the tongue
much coated, a grain or two of calomel or blue pill with aloes may
be substituted for the salt. If there be tendency to diarrhoea,
the quinine may be combined with appropriate opiates. If there
be nausea, the use of effervescing draughts with the quinine is often
beneficial. But while we act on these principles we must always
remember that they are subordinate to the prevention of the exacer-
bation, and if their application at all interferes with this they ought
for the time to be set aside.

These remarks on the treatment of ordinary remittent fever,
though based on clinical observation in the European Greneral
Hospital, are equally applicable to this form of the disease in more
sthenic Europeans and at earlier stages, with this addition, that at
the outset of the attack a general blood-letting of from sixteen to
twenty ounces may often be an expedient measure. They also
apply to the same type of fever in natives of good constitution, with
this exception, that in them there is less necessity for leeching,
calomel, purgatives, and a full opiate used in the manner recom-
mended.

In regard to diet. - In ordinary remittent fever so treated that
there occurs no undue exhaustion from the injudicious use of
depressant means, stimulants are unnecessary, and animal broths
are not required till convalescence has fairly commenced.

On examining the diaries of sixteen well-marked cases of ordi-
nary remittent fever treated in the European Hospital in accordance
with these principles, it appears that from the commencement of the
attack to the perfect cessation of all febrile symptoms, the average
period was six days and a half : of these, two were passed before
admission, and four and a half under treatment in hospital. The
time occupied in the cure is an important consideration from its
bearing on the degree of efficiency of the patient after recovery : this
will always be in proportion to the judgment displayed in abstaining

INFLAMMATORY FOEM — TREATMENT. Il3

from unnecessary depressants in the exacerbations, and in the early-
prevention of exacerbations by the adequate use of quinine in
the remissions. The stage of convalescence, moreover, will vary
according to the nature of the treatment and the duration of the
attack. If the management has been skilful, convalescence will be
attended by little derangement of function, and will require only
a moderate use of stimulants and special articles of diet ; but if
depletion, purgatives, and mercury have been used in excess, and
quinine insufficiently in the remission, convalescence will be cha-
racterised by much debility, splenic enlargement, dyspepsia, palpi-
tation, intermittent headache, and tendency to diarrhoea or dysen-
tery ; and stimulants and extras will be largely consumed.

When a body of men — a regiment — in India is not, or has
not lately been very unfavourably placed, as respects locality and
general sanitary conditions, and its hospital returns show a large
proportion of dyspepsia and cardiac affections — palpitation — with
a large consumption of wine and beer, the inference may be safely
hazarded that its fevers have been unskilfully treated.

Inflammatory Memittent Fever. — In this form in sthenic
Europeans recently arrived in India, in consequence of the
greater febrile excitement, and cerebral and gastric derangement,
depletion is more indicated in the exacerbation. There is more
need for general and local blood-letting, and the assiduous appli-
cation of cold to the head. In many cases in which the skin is dry
and steadily hot, cold affusion may be used from time to time with
great advantage ; but emetics and antimonials are in general contra-
indicated from the tendency to gastric irritability which usually
exists.

Though to increase hepatic and intestinal excretion, with the
view of lessening febrile reaction by evacuation and of removing
the products of augmented metamorphosis of tissue, is a distinct
indication, yet we are frequently obliged to be very cautious
in the use of calomel and purgatives ; for there is often present
congestion of, or determination to, the gastro-intestinal lining,
very apt to be increased or to pass into inflammation by the
use of irritants, and thus to aggravate the fever. In this difficulty
we must keep these opposing principles before us, and lean to one
or other as our judgment may dictate in particular cases. We
shall often succeed best by premising leeches to the epigastrium
during the exacerbation, and deferring the one or two ten-grain
doses of calomel which may be necessary till the period of remis-

114 KEMITTENT FEVER.

sion, and then combining them with opium, while at the same
time we exhibit quinine.

In the treatment of inflammatory remittent fever, freer deple-
tion is required, but still it should be used with watching and
caution, and the safest time is at the height, not the close, of
an early exacerbation. Nor should we forget that evacuants are
had recourse to, not in the hope of cutting short the attack,
but merely of lessening the risk of injury from vascular excite-
ment; and that they are being used in a disease which, if it
persists, is sooner or later sure to terminate in signal depression of
the vital actions. The best guide to the successful application of
depletory remedies is the presence of a dry skin of steadily
increased temperature, and a pulse frequent, firm, and of good
volume, associated with hyperoemia of an important organ ; but it
must not be supposed, that a sthenic constitution, and an early stage
of the attack, necessarily indicate the propriety of free depletion and
other depressing means. It should be borne in mind that in all
states of constitution, the sedative influence of malaria may be great
at the very outset of the disease, and that then depressants are
likely to be injurious. If then (it matters not what the consti-
tution, or the duration of the attack may be) the pulse be badly
developed and easily compressed, and the general surface of the
body not steadily dry and of augmented temperature, we must be
very cautious. I do not say that under these circumstances general
blood-letting may never be had recourse to ; but I am certain that
we should be very watchful, that the finger should be on the pulse
as the blood flows, and if the action of the heart does not speedily
improve, which it seldom will, then the further abstraction of blood
must be stopped.

Such then are the principles to be observed in the treatment of
the exacerbation in inflammatory remittent fever. They must be
considered in connection with what has previously been said on the
management of the same stage of the ordinary form of the disease.

In the remission the principles advocated in ordinary remit-
tents still more forcibly apply to the present form. Quinine
in from five to eight-grain doses should be given every second
hour, or it may be necessary, when the remission is very short, to
give it every hour ; and continue or intermit it in the manner
already explained.

In the first section of this chapter, the diagnosis between remit-
tent and common continued fever is stated, and it is remarked
that under certain circumstances, in the plains of the Ganges and

CONGESTIVE FOBM — TREATMENT. 115

Indus, the Coromandel coast and the table lands of the Deccan
and Malwa, a compound type is occasionally met with, in which
the remissions, though more marked than is usual in continued
fever, are slighter than is commonly observed in the remittent
form. This variety bears depletion better than pure remittents,
because the sedative influence of malaria is less operative ; and
though quinine, in doses of from two to five grains, is necessary in
the remission, a larger quantity is often badly borne, because the
tolerance is less. It not unfrequently happens, in cases of doubtful
diagnosis, that we are materially assisted by watching the effect of
quinine.

Congestive Remittent Fever. — Having in the course of my re-
marks on the treatment of inflammatory remittent fever enjoined
caution in the use of blood-letting, when the symptoms tend to be
congestive, there need be no hesitation in condemning it when the
congestive form is distinctly developed.

Viewing the internal congestion of blood, which doubtless exists
in these cases as one of the conditions necessarily resulting from a
depressed state of the vital actions of the vascular and nervous
systems, general blood-letting has always seemed to me contra-
indicated in theory ; and my experience, so far as it has gone, has
confirmed this opinion.

The treatment should consist of the judicious external use
of stimulants, and the exhibition of calomel and quinine fre-
quently repeated. The instance in which I have witnessed the
most marked benefit from these remedies was in a seaman
of the name of Crookberry, attacked with fever after exposure
in the dockyard at Bombay, in October 1840. The skin
was coldish and damp, the pulse frequent, compressible and
becoming feeble, the manner heavy, with drowsiness and wander-
ing delirium, and the secretions from the liver and intestines
suppressed. He continued in this state for twenty-four hours, not
improving under the use of free doses of calomel, a blister to the
nucha, and wine. Quinine and calomel were then given in two-
grain doses of each, and repeated at intervals.* The pulse and
the skin improved, then followed two or three days of febrile
exacerbation, succeeded by recovery.

When the symptoms of congestion cease and reaction follows,
then the subsequent treatment should accord with the principles
already inculcated in the ordinary and inflammatory forms, or
with those which are about to be noticed in the continued and

* The quinine should certainly be given in larger doses than in this case.

I 2

116 IlEMITTENT FEYEB.

adynamic types — as the one or the other happens to apply to the
particular instance.

The suggestion made at the commencement of the pathological
remarks on remittent fever — that congestive symptoms may in
some cases be related to old-standing disease of the heart, the liver
or kidneys — is an additional reason for observing great caution in
the treatment of this form, more particularly in the use of deple-
tion and other sedative remedies.

Remittent Fever tending to become continued, then adynam^ic
in character, — In years and at seasons when the causes are intense
or the predisposition great, remittent fever is frequently of an
aggravated character, evinced not by assuming the inflammatory
form, but by the remissions becoming less apparent, and the exacer-
bation, in the worst cases, putting on an almost continued form for
two or three successive days. Cases of this kind are more difficult
to cure, because quinine, in doses sufficiently large to make any
great impression on the -disease, is for a time often inappropriate ;
still even when the remission is very imperfect, it should be tried,
and repeated, or not, in subsequent remissions, according to the
effect.

When the evidence is good that quinine is not beneficial,
all that can be done is to recollect the principles applicable to
typhus and typhoid fever, and guide the patient through the
attack, protecting important organs from undue determination of
blood, and taking care that this indication is not effected by
means which will too much depress the vital actions of the system,
and favour the accession of adynamic symptoms ; and then, so
soon as a remission becomes marked, to have recourse to quinine.
Though thus conceding that cases of remittent fever may occur in
which, unfortunately, it is not admissible to use quinine very early
in the disease, still I am convinced that the more closely such
doubtful cases are watched, the more frequent the opportunities
of exhibiting this remedy will be found to occur. This watchful-
ness should be enforced from the very commencement of the
attack ; for, as already stated, the tendency to a fair remission
is very often greater during the two or three first days, — the
continued character coming on as a subsequent event.

When remittent fevers have thus passed into the almost con-
tinued form, they are, after a time, as explained in my notice
of the symptoms, liable to evince a train of adynamic phenomena,
and then the only method of managing them is, to recollect the
principles laid down by CuUen, that " fevers tend to cure them-

ADYNAMIC FORM — TREATMENT. 117

selves," and that the indication of cure is " to obviate the tendency
to death."* In fact, all that can be aimed at in such cases is to
reduce the increased temperature of the surface by tepid spong-
ing; to sustain the pulse by light nourishment, wine and other
stimulants ; to attend to the excretions ; and to apply cautiously
small blisters over the organs which seem to be chiefly affected,
taking care that they are not used to the degree of increasing
febrile excitement, and recollecting that in the adynamic state of
remittent fever, in the advanced stages, a tendency to run into
gangrene is evinced equally as in European typhus.

Such are the resources to which we are restricted when adyna-
mic symptoms co-exist with fever in which the remissions are not
marked ; but should a remission become distinct, dryness and
brownness of the tongue offer no drawback to the use of quinine.
I have seen cases, and of one the diary is before me, that of Penn,
aged twenty-one, of her Majesty's ship Endymion, ill with dock-
yard fever, in which, after about ten days of almost continued
febrile excitement, attended in the last days with brown dry tongue
and other adynamic symptoms, a remission was taken advantage
of and quinine was freely given and continued with marked benefit
through each succeeding remission. The exacerbations decreased
and quickly ceased, and, coincident with this result, the tongue
became cleaner and moister, — because the dryness was but a
sequence of the persistence of the febrile state, and one of the
proofs of diminished secretion. Not only did the tongue in this
instance become moist, but, for a similar reason, the secretions
from the bowels became more regular, freer, and more natural
in appearance.

We have every encouragement, under these circumstances, to
persevere in the appropriate course of treatment ; for, in young and
previously healthy subjects, recovery not un frequently takes place
from an unfavourable train of adynamic symptoms, including more
or less delirium, with well-marked tendency to drowsiness.

Remittent Fever with badly developed symptoms ; with
symptoms of unexpected collapse; luith certain occasional
features. — Under these heads, in the Section on Symptoms,

* Under tliese circumstances to attempt to aifect the system with mercury, or to
hope to control local inflammations by free leeching, or to correct the abdominal secre-
tions by active purgatives, are measures so totally at variance with the indications of
cure, and so destructive of the faint hope of recovery which it is useful to maintain,
that were it not for the indiscriminate manner in which these means have been and
still are frequently used it would be unnecessary to allude to them here.

I 3

118 REMITTENT FEVER.

phenomena are described, which all point to the tendency, in
remittent fever, of vital actions to become depressed, and thus
lead to death. In noticing these phenomena, with reference
to treatment, all that can be said is, that they forcibly inculcate
the necessity of familiarising ourselves with the principles which
regulate the application of depressant remedies ; and while
they impress upon us the evils of the injudicious use of these
means, they teach us to be prompt with those appliances —
quinine, stimulants, and nourishment — which prevent prostration,
or counteract it when present.

Remittent Fever with Cerebral Affection. — We have found that
this complication is a frequent and fatal one in the remittent fevers
of sthenic Europeans, and also in the adynamic forms of the disease.
In order to understand the treatment, the remarks already made on
the symptoms and pathology of this complication must be borne
in mind. Headache, delirium, flushed countenance, with steady
heat of surface, and a well-developed and firm pulse — present
in sthenic Europeans — should be met during the exacerbation
by detraction of blood, both general and local, the appli-
cation of cold to the shaven head, free action of the bowels by
mercurial purgatives, and the use of small doses of tartar emetic,
when the state of the stomach will admit. But it is only in the
very early exacerbations that we may hope to use these means with
good effect. So soon as the pulse, still increasing in frequency, dis-
tinctly fails in strength, and the delirium becomes muttering and
alternates with tendency to drowsiness, the stage for evacuants has
passed, — their use will merely hasten the fatal issue. In bad re-
mittents this state may come on as early as the fourth or fifth day
of the attack, or earlier where the phenomena have been congestive
at the commencement. Further, the remark made under the head
Pathology, that undue depletion in the exacerbation sometimes leads
to the development of head symptoms — muttering delirium, and
tendency to drowsiness — at the close of a paroxysm, must be
remembered.

These facts, which bring again before us the important truth of the
marked tendency to prostration in remittent fever, and again point
to the evils of undue depletion, are not, however, to be advanced as
arguments against the use of evacuant means in appropriate cir-
cumstances. They teach us to be very watchful for the first symp-
toms of cerebral complication, and to be very prompt, but not rash,
in the application of our remedies ; to observe with care their effect
on the cerebral symptoms and on the pulse ; to be very assiduous

CEREBEAL COMPLICATION TREATMENT. 119

in the application of cold to thehead, and to enjoin great quietude,
and the removal of all sources of excitement. It is by attention to
principles such as these that we may hope to secure those advan-
tages which depletory treatment, used with judgment and caution,
is most certainly capable of conferring, and to avoid those evils
which will as surely result from its abuse in unsuitable states of
constitution and stages of disease.

When the period for local detraction of blood has passed, but
head symptoms still continue and tend to drowsiness, a blister *
may be applied to the nucha with advantage ; and the time which
should be selected is the commencement of a remission, not the
height of an exacerbation.

Such, then, are the means of treatment when cerebral symptoms
depend on determination or congestion. They must be viewed in
connection with the principles elsewhere laid down for the treatment
of the exacerbation in uncomplicated remittents.

Head symptoms, dependent on inflammation of the membranes
of the brain passing on to effusion of lymph, are rare compared with
those caused by other conditions. They are usually characterised
by milder delirium, by less febrile reaction, by greater persistence
of the S3rmptoms during the remission, by agitated movements of
the hands and fingers, and occasional convulsion ; and are most
likely to occur in the less sthenic states of constitution. They
must be met by a judicious application of antiphlogistic therapeutic
principles.

The muttering delirium and tendency to drowsiness coming on
in more advanced stages of fever, and associated with adynamic
phenomena, are to be controlled by means altogether different.
The adynamia must be treated by appropriate stimulants and
nourishment, and depressant remedies of all kinds must be abstained
from. When, however, the tendency to drowsiness begins to ap-
pear, a small blister should be applied to the nucha, or, should that
be inconvenient, to some part of the head. Under these means
recovery not unfrequently takes place, particularly in youthful
subjects.

Treatment of the pathological states of the brain, which cause
head symptoms, by the induction of mercurial influence, has been
practised, and the question of its propriety may be here discussed.

* The blistering preparation which I have generally used was introduced into hos-
pitals in India on the recommendation of Dr. Donald Young in 1835, under the name
of liquor lyttse. It is considerably stronger than the acetum cantharidis of the
Pharmacopoeia. The latter preparation often fails.

I 4

120 REMITTENT FEYEll.

Viewing the head symptoms apart from the fever which they com-
plicate, mercurial action is clearly contra-indicated in the ady-
namic form, as well as in that depending on determination or
congestion of blood, with threatening serous effusion : it is not
sanctioned by any reasonable therapeutic doctrine. But in that
train of head symptoms depending on inflammation tending to
terminate in exudation of lymph, mercury may be proposed on
theoretic grounds ; and in occasional cases, in which the diagnosis
is clear and the constitution suitable, it may be expedient to have
recourse to it in the remission. Yet on the whole my judgment
is opposed to this means as a rule of practice, for the following
reasons. 1. Meningitis is rare, compared with other proximate
causes of head symptoms in remittent fever, and it occurs more com-
monly in asthenic than sthenic constitutions. 2. It is often dif-
ficult to distinguish the symptoms depending on inflammation from
those resulting from other pathological states, for which mercury is
either unnecessary or injurious. 3. Mercurial influence and the
process by which it is induced very generally prove injurious in that
state — the fever — of which the meningitis is a complication ; and
it may be received as a pathological law, that whatever aggravates
an idiopathic fever must aggravate the local derangement which
complicates it.

The general question of the mercurial treatment of remittent
fever will be considered in a subsequent part of my observations ;
and the use of opiates, which has also reference to the management
of head symptoms, will likewise be afterwards discussed.

These remarks on the treatment of cerebral complication have
hitherto referred to the stage of exacerbation. When explaining
the treatment of the complicated forms of intermittent fever, I
took the opportunity of stating my conviction that, whatever the
complication might be, the adequate exhibition of quinine during
the intermission was a ruling indication of cure. This rule of practice
is equally true of remittent fever. It matters not what the nature
of the cerebral symptoms may be, the sufiicient use of quinine must
never be neglected. There has, I am aware, been very often doubt
and hesitation in giving quinine in the remissions of fever with
head complication ; not only is this unnecessary, but the suspicion
may be entertained that part of the mortality from this compli-
cation has been due to the want of the remedial benefit of this
agent. It is almost needless to add, that while we exhibit quinine
we are not to neglect the other efficacious means which are also
applicable to the stage of remission.

GASTEIC COMPLICATION — JAUNDICE — TREATMENT. 1 2 1

Remittent Fever with Gastric Irritability. — The observations
made on the symptoms and pathology of this complication suggest
the treatment. It should consist chiefly of local abstraction of
blood from the epigastrium, followed by blisters when the further
loss of blood is contra-indicated. As in the case of all inflammatory
complications of remittent fever, the exacerbation is the appropriate
period for leeching, the remission for blisters. The internal use of
ice is also important.

We must be very guarded in giving mercurial preparations
and purgatives, and should, on other grounds, the indication for
their exhibition be pressing, then, after preliminary leeching in
the exacerbation, they should be used in the remission rather than
the exacerbation, ^nd the calomel should be combined with opium.
Quinine should be had recourse to in the remission, and it is im-
portant on this account so to manage the irritability of stomach
during the exacerbation, as to render the rejection of the quinine
in the remission less likely. Should this fail, it may be exhibited
by enema.

Remittent Fever with Jaundice. — The co-existence of tenderness
at the margin of the right ribs, with jaundice, suggests the presence
of inflammatory action, and our pathological research has shown
that the mucous membrane of the duodenum and of the stomach is
frequently the seat of the inflammation. Observation has further
taught us that jaundice generally does not appear till several days
after the commencement of the fever. These facts inculcate
watchfulness for the first indication of tenderness below the right
ribs, and on its appearance, without reference to the presence or
not of jaundice, the adoption of the remedies for inflammation
appropriate to the particular case, as well as abstinence from the
means likely to excite irritation of the mucous lining of the
stomach and duodenum.

When jaundice is present, the treatment should consist of the
application of leeches or small blisters to the tender part below the
right ribs, and the use of quinine during the remission, combined
with small doses of aloes and mild mercurials, or of some saline
aperient.

Of the ten fatal cases which have been detailed by me (36 to
45), there are five in which, judging from the colour of the liver,
biliary congestion was present ; in 3 the colour of the organ is not
mentioned, and in one it was streaked white. It may, therefore,
be inferred that in cases of jaundice complicatiug remittent fever,
the proximate cause is usually not defective action of the hepatic

122 REMITTENT FEVER.

cells, but rather some obstacle to the passage of the bile from the
liver. The occm-rence of jaundice in cases of remittent fever in
which there had been free use of calomel and purgatives, is a fact
which has long been familiar to me, and I deduce from these two
statements, and the two previously made, viz. — that gastro-duo-
denitis is frequently present, and that jaundice is generally not a
complication of the early stage of fever — that full doses of calomel
and the free use of purgatives form no part of the treatment of re-
mittent fever complicated with jaundice. On the contrary, they
are likely to cause an aggravation of the symptoms, and to accelerate
the period of prostration.

As a subsidiary means benefit is sometimes derived from the
use of saline diuretics, at the same time with th^ remedies already
advised. They seem to expedite the elimination of the biliary pig-
ment from the blood.

Remittent Fever with Hepatitis. — As already stated, the com-
plication of remittent fever with hepatitis, either in Europeans or
natives, is, according to my observation, a rare occurrence. The
only question of treatment which arises is the expediency or not of
inducing mercurial influence. On this point of practice it may be
assumed that the doctrines advanced on the treatment by this
means of a complicating meningitis, are equally applicable to a
complicating hepatitis.

The management of hepatic and splenic enlargement, co-existing
with or subsequent to intermittent fever, has been fully explained.
The same principles apply to these enlargements when co-existing
with or consequent on remittent fever.

Remittent Fever with Dysentery. — The general rule which I
have endeavoured to establish in respect to the treatment of all the
complications of remittent fever, should be also observed in this
particular one. While we treat the fever with quinine during the
remissions, we must fulfil, in so far as it may be practicable, the
indications which I shall have to explain elsewhere, as appropriate
in the treatment of dysentery.

Section V. — Treatment further considered inRemarJcs on Blood-
letting, Mercury, Cold Affusion and Wet Sheet Pacldng, Pur-
gatives, Emetics, Blisters, Opiates, Quinine, Diet, and Change
of Air.

General Blood-letting. — It has been explained that general
blood-letting is an expedient and useful measure — sometimes a

GENERAL BLOOD-LETTING TREATMENT. 123

very necessary one — in reducing the high vascular excitement of
the early exacerbations of remittent fever in sthenic and lately
arrived Europeans, as well as in lesser degrees of excitement, when
in this state of constitution and stage of fever there co-exist con-
siderable determinations of blood to important vital organs. The
extent to which blood-letting should be carried in suitable cases is a
point on which the physician must exercise his discretion — keep-
ing in view the ultimate advantage of effecting the indication aimed
at with as little loss of blood as practicable, and recollecting that
the judicious removal of sources of irritation, the adoption of free
ventilation, the well-timed use of emetics, cold affusion, tepid
sponging, and antimonials, are all measures of considerable influ-
ence in lowering febrile excitement, which it is of essential conse-
quence to employ with assiduity in order to lessen the necessity of
large evacuations. In the treatment of remittent fever in Euro-
peans some time resident in India, and in all classes of the native
community, general blood-letting is, with few exceptions, an unne-
cessary and often injurious proceeding.

Throughout these observations it has been my object to inculcate
the following principles : — 1. That in the great majority of in-
stances the danger in remittent fever consists in prostration
of the vital actions of the heart and nervous system. 2. That
not only exhaustion, but also the protraction of the disease, is
favoured by needless and undue evacuations. 3. That evacuant
means used in the exacerbation have no power in shortening the
duration of the attack.

The opportunity has at different times been afforded me of wit-
nessing the treatment of the exacerbations of remittent fever by
repeated venesection, and its injurious tendency was very ap-
parent. It is true that the vascular excitement of an exacerbation
may be lessened, and the symptoms depending on that excitement
may be for the time alleviated by blood-letting ; but the par-
oxysm nevertheless recurs, and after repeated depletion the febrile
disturbance becomes more severe and continuous, with not un-
frequently an aggravation of all the local complications. This
latter fact was known to Pringle, who says : "But repeated bleed-
ings, unless upon evident marks of a fixed inflammation, were so
far from producing the desired effect, that they were apt to render
the fever more obstinate." * Lind writes much to the same pur-
pose : " This fever (remitting), unless brought to a speedy remis-

* " Observations on the Diseases of the Army." Londo^, 1765, p. 208.

124 REMITTENT FEVER.

sion, is attended with considerable danger ; and if large quantities
of blood be repeatedly taken from patients labouring under it, by
mistaking their disease for a true inflammatory fever, its obstinacy
and fatality are greatly increased."* . Dr. Stokes remarks : " P'rom
what I have seen I am disposed to conclude that bleeding in the
cold stage, when it does alter the type of intermittent fever, has a
tendency to convert tertian into quotidian and quotidian into re-
mittent or continued fever. I never saw any example of the con-
verse, or in which quotidian was converted into tertian."f Mr.
Twining observes : " A remarkable fact may be here noticed,
namely, that the employment of blood-letting in the cold stage
of intermittent fever is occasionally, though rarely, followed by
continued fever." |

The practice of blood-letting in the cold stage of intermittent
fever, first recommended nearly thirty years ago by Dr. Mackintosh
of Edinburgh, was warmly advocated by Mr. Twining in his clinical
illustrations of the diseases of Bengal. Though this mode of treat-
ment is not, so far as I am aware, at present followed in any part
of India, I may not, on an important point of practice, pass unnoticed
the opinion of one of our best authorities on Indian disease. It is
not my intention to enter into any examination of the principles
on which this practice is grounded, or on the evidence on which its
efficacy is supposed to rest. The perusal of Mr. Twining's remarks,
in connection with what I have myself written on the treatment of
intermittent fever, will at once show the reasons of my dissent
from the course which he recommends.

The question was ably inquired into by Dr. Stokes of Dublin in
1829 ; and the evidence on both sides has since been fairly stated
by Mr. Martin § , and a conclusion unfavourable to the practice has
been drawn by him.

Dr. Stokes thus states the results of his observations : —

*' From the examination of these cases I apprehend that an impression will he re-
ceived certainly against the indiscriminate or even frequent use of bleeding in the
cold stages of ague. It may be remarked that, in the great majority, quinine had to
be administered before the disease was eradicated ; that many of them had an ex-
tremely slow and dangerous convalescence ; that in several instances the disease, so
far from being relieved, appeared exasperated by the practice ; that local inflammatory

* " Essay on Diseases incidental to Europeans in Hot Climates." By James Lind,
Physician to the Hospital at Haslar. 3rd Edition, London, 1777, p. 310.

t "Edinburgh Medical and Surgical Journal," vol. xxxi. p. 13.

I " Clinical Illustrations of Diseases of Bengal." 2nd Edition, vol. ii. p. 233.

§ "On the Influence of Tropical Climates, &c." By James Johnson and James
Ranald Martin. 1841. P. 159.

MERCURIAL TREATMENT CONDEMNED. 125

affections occurred several times after the operation ; and lastly, that the bleeding ap-
pears to have a tendency to convert intermittent into continued fever. In one case,
that of Casey, death from pneumonia and softening of the brain occurred. In none
of my cases did any bad effects from sinking of the powers of life foUow the practice
immediately. But I am informed that in the practice of a highly respectable indivi-
dual, there occurred two cases in which the patients did not recover from the collapse
produced by bleeding in the cold stage. Those facts should make us very careful how
we interfere with nature by means of the lancet, when we have so certain, and, as far
as I have seen, so infallible a remedy as the sulphate of quinine." *

Calomel and other Mercurials. — The circumstances under
which calomel may be used with advantage in the treatment of
remittent fever, with the view of increasing the excretions from
the liver and intestinal canaly have been already explained.

The practice, at one time too common, of exhibiting calomel
in doses of four or five grains three or four times in the course of
the day, without any very definite object, and continuing it for
a succession of days, cannot be too strongly condemned. Not only
is it unnecessary, but, for the following reasons, often positively in-
jurious. 1. In watching the progress of cases thus treated, it is
not difficult to detect a train of symptoms more fairly attribu-
table to the treatment than to the disease, because it is in cases
thus treated that it has been chiefly observed. The symptoms
alluded to are uneasy feelings, sometimes amounting to pain, with
a sense of oppression or sinking at the epigastrium, and occasional
griping of the abdomen, for which leeches are not unfrequently
applied, and purgatives unnecessarily given. 2. The frequent repe-
tition of the calomel keeps up a furred state of the tongue, with
nausea and irritability of stomach, aggravates the febrile excitement,
and produces an irritable state of the bowels, indicated by frequent
watery discharges. 3. The convalescence of cases thus treated is
always tedious, and frequently complicated with diarrhoea and clay-
coloured dejections.

The question of the efficacy of the constitutional effect of mer-
cury in stopping the febrile excitement of remittent fever, and the
expediency of, at all hazards, endeavouring to produce it, has been
at different times much debated. To induce mercurial influence
with this view was, when I entered on practice in India and for
many years afterwards, an article of therapeutic f^ith, and possibly
this grave error may not yet be altogether dispelled. I shall first
state the conclusions to which I have myself arrived on this question
of practice, and the reasons upon which they are groimded ; then
notice the opinions of some other writers ; and finally examine the

* "Edinburgh Medical and Surgical Journal," vol. xxxi. p. 17.

126 REMITTENT FEVER.

origin of the practice and the nature of the experience which gave
rise to it, and exercised so much influence upon the minds of
others.

Cases have occurred under my own observation in which fever
persisted notwithstanding well-developed mercurial influence.

An officer in Gruzerat was attacked with remittent fever on the
16th of June ; he was salivated on the 18th, but the febrile state
recurred and continued. The salivation ceased. The fever became
adynamic with sense of great exhaustion. There was again a free
exhibition of calomel, and an inefficient use of quinine ; finally de-
lirium and death on the 23rd.

Dr. Stovell, in his reports* of the European General Hospital,
details two cases of remittent fever, continuing, becoming ady-
namic and proving fatal with co-existence of mercurial salivation :
and in his statistical notice of this hospital for ten years, from
1846 to 1856, he thus concludes his matured review^ of this
question : —

" I need not waste time by giving more proofs of the correctness of my statement.
It was the observation in earlier days of cases and facts such as these that assisted in
shaking my faith in the soundness of the mercurialising doctrines of Drs, Annesley
and Johnson, whose works were in those days unfortunately the chief authorities for
Indian practice. Greatly should I deplore a retrograding return to these mercurialising
views ; and I shaU therefore, I trust, be excused for venturing to caution the inexpe-
rienced against the injudicious use of mercury, in any shape or form, either in remit-
tent fever, or in any disease whatever." f

Mr. Walbran, surgeon of the 4th Light Dragoons, thus writes f
of the fevers at Kaira in 1824 : —

" To affect the system with mercury, with the object of restoring the balance of the
sanguiferous system, was always kept in view as a primary object. When ptyalism
was induced, the patient generally recovered. There have been, however, instances
in which the ptyalism had been free for some days, the evacuations had assumed a
healthy colour, and every trace of fever had gone off, yet, notwithstanding the greatest
care, the ptyalism was checked, the patient immediately became anxious and restless,
pulse quick and full, skin burning hot, restlessness and delirium supervened, and death
followed in a few hours. This suppression of ptyalism taking place in the course of a
few hours is not of very frequent occurrence in other fevers, and I can only account
for it in the cases above alluded to by supposing that the inflammation of the viUous
coat of the stomach and intestines was incompatible with life, and the cessation of
ptyalism was the forerunner of that state of the system previous to death."

If the diaries of fatal cases of remittent fever, treated on the
mercurial plan, be carefully studied, it will be found that the

* " Transactions, Medical and Physical Society of Bombay." No. ix. p. 54, and
No. X. p. 88.
t lb. New Series. No. iii. p. 17. \ MSS. Reports.

MEECUEIAL TREATMENT CONDEMNED. 127

prominent facts are a free use of calomel, persistence of febrile
disturbance, and the non-induction of mercurial influence.

If, on the other hand, the diaries of recovered cases, treated
on the same system, be considered, then a free use of calomel
with coincidence of ptyalism and cessation of febrile disturbance
will be frequently observed. This coincidence, however, is some-
times only temporary, and followed by recurrence of fever and
cessation of ptyalism.

The difficulty of affecting the system with mercury during the
presence of high febrile excitement is acknowledged by all ; but
when ptyalism and cessation of fever concur, the advocate of mer-
curial treatment looks upon the former as the cause, the latter the
effect; and when there is coincidence of febrile recurrence and
cessation of ptyalism, then the latter is regarded as the cause, and
the former the effect. Such reasoning, however, is surely erroneous.
It is not an unusual circumstance, in remittent fevers treated in
their early stage with calomel, to observe, after the recurrence of
the fever has been prevented by quinine, slight mercurial action
on the second or third day ; though not more than a few grains of
calomel or blue pill, in combination with quinine, had been given
on these days. Under these circumstances the relation of events
is so evident that the question of antecedence and sequence is no
longer open for argument ; and surely in other instances in which
the only difference is that there has been no agency employed of
acknowledged power to prevent the return of fever, we ought to
recollect the natural tendency of the disease to remit, and after a
time to cease; and avoid the illogical position of attempting to
account for the same coincident phenomena by inverting the order
of causation.

For -these reasons, then, an endeavour to induce mercurial
action in remittent fever appears to me erroneous in theory and
of no value in practice. But the question may not thus easily be
disposed of. Not only is the practice unsound in theory and of
no value, but it is contrary to all rational theory, and very injurious.
If it be true that prostration of vital actions and a deteriorated
state of the blood are very unfavourable conditions in remit-
tent fever, and that mercury deteriorates the blood and favours
prostration — on what principle of reasoning can it be maintained
that mercurial influence induced by the physician can have any
other than an injurious effect in remittent fever ? I have, on
several occasions, pointed out the tendency of malarious fever to
produce a cachectic state of the system, and have endeavoured to

128 REMITTENT FEVER.

inculcate the importance of guarding against the increase of this un-
favourable diathesis b}^ medical treatment. To all who, within the
last twenty years, have had the opportunity of extensively observing
disease in India, in the various classes of the European community —
asthenia, dyspepsia, injured teeth, pains of sides and loins, palpita-
tion, habitually foul tongue, constipated bowels, pale alvine evacua-
tions, depressed spirits, and a sense of sinking at the epigastrium
— all clearly traceable to the abuse of mercury — must be familiar
facts.

Such then are the reasons, drawn from my own sphere of obser-
vation, which have led me to the conclusion, that the induction of
merciu-ial influence in the treatment of malarious fever has been
a great and grievous error in therapeutics. I now inquire whether
other observers have held similar opinions.

Dr. Leonard Grillespie, in his observations on the diseases which
prevailed in a naval squadron on the Leeward Islands Station, be-
tween November 1794, and April 1796, at a time when salivation
by large doses of calomel was the system of treatment of disease in
full force in the West Indies, ably discusses the practice, and un-
equivocally condemns it.

Dr. Eobert Jackson, in the year 1817, concludes his review of
the mercurial treatment of fever in the following words * : —

" Upon the whole, I venture to maintain, that if the results of what is termed
mercurial treatment in fever, and even in dysentery, particularly in British military
hospitals, where it has been most extensively employed, be candidly reviewed, the
high, or rather the extravagant, opinion which has been, and which is even now, en-
tertained of the salutary powers of that remedy, is not well supported. The advocates
of mercurial treatment generally assert that no one dies from fever after salivation is
fully established. The assertion is not altogether correct ; but even if it were, and if
it appear, on a reference to hospital case books, that there is one in three of the more
concentrated forms of endemic fever in which calomel, given alone or in combination
with opium, to the amount of a thousand grains or more, produces no increase of the
salivary secretion, consequently does not produce the effect which controls the fatal
tendency of the disease ; and further, if it appear, through the same channel of infor-
mation, that the same disease, when left to its own course or opposed by ordinary-
means of treatment, does not destroy life in moi-e than one case in three, the most
prepossessed in favour of the remedy will hot maintain that we gain anything by the
experiment ; and it is evident that, if we gain nothing certain, we lose time and
chances of gain from other means. But though the effect of mercury, even where it
does produce an increased discharge of the salivary secretion, is not uniformly decisive
of tlie cure of fever ; and though the action of the remedy, without artificial prepa-
ration, by bleeding or other means not implied in the plan of mercurial treatment, be
extremely uncertain, the practice still holds its ground, and it probably will maintain
it for many years to come. It hangs on a specious delusion, vi^;. the expectation of

* " Sketch of the History and Cure of Febrile Diseases," &c. By Eobert Jackson,
M.D., 1817, p. 243.

MERCURIAL TREATMENT CONDEMNED. 129

an effect considered as in some measure specific of cure. I abstain from further re-
mark on the subject, only adding, that if the case be viewed without prepossession,
and if the hospital returns of the person* who first adopted the practice at Grenada
in the year 1793, and of those who have pursued a similar practice in the different
military hospitals in the West Indies since that time, be admitted as documents of
effect, the arguments for the continuance of it do not appear to be strong."

Dr. Copland observes : —

" Mercury t, pushed so far as to affect the mouth, or to produce salivation, has been
considered both a prophylactic \ and a cure for fever. I have tried to affect the
system in the most malignant forms of fever in warm climates without succeeding ;
and where I have succeeded there was every reason to believe that recovery would
have taken place nevertheless."

Mr. Martin, in the last edition of Dr. Johnson's work on tropical
diseases, after long and varied experience in India, says, " I have
also seldom had occasion to urge mercury to the degree of saliva-
tion, during the whole period of my service in India."

Dr. Greddes, in his " Clinical illustrations of the diseases of
India," wiiting of eighty-seven cases of fever in the 1st Madras
European regiment, treated with mercury, concludes his remarks
with the following words § : —

" The number of those altogether in whom the disease was stopped before the
affection of the mouth by mercury, amounted to 48 ; and of those in whom this cir-
cumstance took place after such an event to 28. From these facts, there is reason to
doubt whether the mouth becoming affected is not rather a consequence of the cessa-
tion of the fever than the latter a result of the system having come under the
influence of mercury; but in some chronic cases, where the contrary appeared to
occur, an increase of frequency of the pulse, and of feverish irritation in the remis-
sions, has been' observed to take place in a gradual manner as the mercurial action

* Dr. Colin Chisholm is referred to by Dr. Jackson.

t " Medical Dictionary," vol. i. p. 928.

\ But the induction of mercurial influence has been looked upon as not only
curative of malarious fever, but as also preventive of the action of malaria, and has
been recommended as a prophylactic measure. It can hardly be necessary to observe,
that the relation between debility as a predisposing, and malaria as an exciting, cause
is weU understood. It is irrational to suppose that debility caused by mercury can
differ in this respect from that induced in any other way. On this question Dr. Cop-
land remarks, "That mercury possesses no prophylactic influence against fevers has
been satisfactorily shown by several able writers, and proved by my own experience.
A person whose mouth was affected for the cure of syphilis was seized with malignant
remittent fever in Africa, in 1817, and came under my care soon after the attack. He
died a few days afterwards ; the most active treatment having failed in developing
vascular reaction and in supporting the vital powers. A nearly similar case is men-
tioned by Dr. Graves in his excellent lectures." — Dictionary, vol. i. p. 929.

Hunter, in his " Obser\'ations on the Diseases of the Army in Jamaica" (p. 287),
writing of syphilis, says : " It is worth remarking that mercury had no effect upon the
constitution to render it less susceptible of fevers ; for persons under a couxse of that
medicine were seized with the remittent fever, which, however, did not appear to bQ
aggravated by the presence of the mercury in the body."

§ Page 189.

130 REMITTENT FEVER.

showed itself; and this was considered to act by breaking in upon the habitual pro-
gress of the disease, whieli accordingly ceased to recur. In many instances, however,
after a short interval of freedom from its attacks, these have rctiirued before the
affection of the mouth had entirely left the patient ; and otherwise, it will be seen
from the Table now alluded to, that 37 of those who had been under the influence of
mercury in the earlier months of the season had been seized with relapses before its
expiration. From these circumstances — combined with a consideration of the occa-
sional affection of the bowels, often amounting to a dysenteric state, produced by the
calomel ; and of what has been mentioned in speaking of the prognosis regarding the
lengthened sickness of the patient, in consequence of his sore mouth — the reader will
readily form an opinion of the relative value of mercury and quinine in putting a
stop to that tendency to febrile exacerbation which constitutes the main feature of the
remittent and intermittent fevers of the East."

The history of the mercurial treatment of fever in India may
now be briefly noticed. In the last quarter of the eighteenth cen-
tury, hepatic affections were treated in India by mercurial influence,
and Clark thought highly of a combination of calomel and opium
in allaying irritation of the bowels, and promoting their secretions
in malarious fevers ; but I am not aware that mercury had been
much given in fevers to the degree of producing salivation, before
it was used with this view, in Grenada in 1793, by Br. Colin
Chisholm.*

The general introduction of this system of treatment into India
must be traced to Dr. James Johnson's work on Tropical Diseases,
first published in 1813.t

At this period there were, as authorities on the treatment of
remittent fever, Pringle, Cleghorn, and Jackson, who advocated
the use of blood-letting and other evacuants, with bark during the

* Page 110.

t Wade, whose work was published in 1791, is mentioned as one of the earliest
writers on Indian disease who recommended tlie mercurial treatment of fever, by Dr.
H. H. Goodeve, in his very interesting " Sketch of the Progress of European Medicine
in the East," published in April, 1837, in the " Quarterly Journal of the Medical and
Physical Society of Calcutta." This sketch fairly represents the opinions of Bontius,
Clark, Lind, and others; but from the too great prominence given to the phraseology
of the time, it is evident that there was not a full appreciation of the merits of tliese
eminent men. Indeed, it could not be otherwise, for at the time when Dr. Goodeve
WTote, medical opinion in regard to the treatment of tropical disease was in a very
vacillating state. I feel assured, however, that I do not go beyond my knowledge
of the present opinions and sentiments of the able author of this sketch — with whom
for a long series of years I have enjoyed the privilege and advantage of a free inter-
change of opinion on this and kindred subjects — when I say that were he now to
review the progress of European medicine in the East, the sketch would, in some
respects, evince a different spirit. No one more early than Dr. Goodeve became
satisfied of the evils of an excessive depletory and mercurial treatment, and of the
advantages of quinine, in malarious fevers. No one, whether in medical practice or
in the diffusion of medical education in India, has been more liberal in his judgment
of others, or has co-operated with them in a freer and a franker spirit.

HISTORY OF THE MERCUKIAL TREATMENT. 131

remissions. Clark and Lind, on the other hand, deriving their
experience from observation in Bengal, in 1762 and 1773, of
an adynamic type of the disease in seamen of scorbutic taint,
enjoined extreme caution in blood-letting, and recommended
a moderate use of purgatives, opiates, stimulants, and bark.
Moreover, in Cullen's "First Lines of the Practice of Physic,"
there was open to the medical inquirer a philosophic statement of
the principles v^^hich should regulate the treatment of the diifer-
ent forms and modifications of febrile disease. At this epoch Dr.
James Johnson, at an early period of his professional life, arrived
in the Hooghly in the month of September, after a short run of
little more than three months from England, in charge of a crew
untainted, we may presume, with scurvy. He adopted, as he
believed, Clark and Lind, as his practical guides, to the neglect, it
would appear, of all other authority and in forgetfulness of the
circumstances under which these excellent physicians had observed
the disease, and to which their system of treatment exclusively
applied.

Dr. Johnson * makes the following quotation from Dr. Clark :
" As soon as the intestinal tubes have been thoroughly cleansed,
the cure must entirely depend upon giving the Peruvian bark in
as large doses as the patient's stomach will bear, without paying
any regard to the remissions or exacerbations of the fever.^^ He
then continues : " Such are the plain and easy instructions which
Dr. Clark and Lind have left for our guides in this fearful
endemic. They certainly are not apparently difficult to follow ;
and Heaven knows, I endeavoured, most religiously, to fulfil every
iota of their injunctions ; but with what success a single case will
show."

It is true that Clark recommends the use of bark in the
exacerbations, but it would have been just to that physician
had Dr. Johnson extended his quotation to the sentence which
immediately follows that which he has cited, viz. — " If the re-
missions be distinct, the bark, indeed, will have a more speedy
effect in subduing the fever ; but even if it become continual, by
a regular and steady perseverance in the medicine, it will be effec-
tually prevented from growing dangerous or malignant." t

It is evident from this sentence, as well as from a perusal of the

* " On tlie Influence of Tropical Climates." By James Johnson. London, 1841,
p. 107. The italics are Dr. Johnson's.

t " Observations on the Diseases which prevail in long Voyages to hot Countries."
By John Clark, M.D. Second Edition, 1792, p. 184, vol. i.

K 2

132 REMITTENT FEVEE.

cases recorded by Clark, that his practice was to give bark chiefly
in the remission ; but to use it also in the exacerbation, in those
cases which from the remittent had passed into the continued
type.

Lind is represented by Dr. Johnson as holding the same
opinion as Dr. Clark relative to the use of bark in the exacer-
bation. Such, however, does not appear to have been the case.
Dr. Lind of Windsor, the author, referred to, of a " Treatise on
the Putrid and Eemitting Marsh Fever of Bengal," not only did not
give bark in the exacerbations, but not even in the first remission.
His words are : " For my part, I have always given the bark during
the second remission, as all my care during the first was to cleanse
the primae vise. But it is to no purpose to give the bark till the
necessary purgations are over." *

I shall now quote that case in which Dr. Johnson believed that
he was religiously endeavouring to fulfil every iota of the injunc-
tions of Clark and Lind, and the ill success of which led him
to abandon the therapeutic principles of a long line of able
and observing men, and to promulgate a very different system of
practice : —

" A young man of good constitution, in the prime of life and health, had been
assisting, with several others, to navigate an Indiaman through the Hooghly. The
day after he returned he was seized with the usual symptoms of this fever. I did
not see him till the cold stage was past ; but the reaction was violent — the headache
intense, skin burning hot, great oppression about the prsecordia, with quick hard
pulse, thirst, and nausea. An emetic was prescribed, and towards the close of its
operation discharged a quantity of ill-conditioned bile, both upwards and downwards :
soon after which a perspiration broke out, the febrile symptoms subsided, and a
remission, almost amounting to an intermission, followed. I now with an air of con-
fidence began to ' throw in ' the bark, quite sanguine in my expectations of soon
checking this formidable disease. But, alas ! my triumph was of short duration ; for
in a few hours the fever returned with increased violence, and attended with such
obstinate vomiting, that, although I tried to push on the bark through the paroxysm
by the aid of opium, effervescing draughts, &c., it was all fruitless ; for every dose
was rejected the moment it was swallowed, and I was forced to abandon the only
means by which I had hoped to curb the fury of the disease. The other methods
which I tried need not be enumerated ; they were temporising shifts, calculated, in
medical language, ' to obviate occasional symptoms.'

" The truth is, I knew not what to do ; for the sudden and unexpected failure of
that medicine on which I was taught to depend, completely embarrassed me, and
before I could make up my mind to any feasible plan of treatment, my patient died
on the third day of his illness, perfectly yellow, vomiting to the last a dark fluid
resembling vitiated bile, and exhibiting an awful spectacle of the effects which a
Bengal fever is capable of producing in so short a period on a European in the vigour
of manhood." f

^" , ' ' ' ' ' ■ — - — , —

^ Page 65. f Page 107 of Edition of 1841.

HISTORY OF THE MERCUIIIAL TREATMENT. 133

The body was examined after death, and Dr. Johnson found —

"The liver so gorged, as it were, with, blood that it actually fell to pieces on
handling it. Indeed, it appeared as if the greater number of the vessels had been
broken down, and almost the whole of the interior structure converted into a mass
of extravasation. The gall-bladder contained a small quantity of bile, in colour and
consistence resembling tar, and the ductus communis choledochus was so thickened
in its coats and contracted in its diameter that a probe could scarcely be passed into
it, Marks of incipient inflammation were visible in some parts of the small intes-
tines, and the internal surface of the stomach exhibited similar appearances. The
thorax was not examined, on account of the time taken up in getting at the brain.
Marks of turgescence, in the venous system of vessels particularly, were there quite
evident, and more than the usual quantity of lymph was found in the ventricles, but
no appearance of actual inflammation."

The narration of this case is followed by remarks on the unsuit-
able character of the treatment, on the uncertainty of medicine,
and the evils of being led by authority.

It is far from my desire to review in a critical spirit the practice
of one who, after a life of active usefulness, has passed away. Still
it is impossible to avoid observing, that a dispassionate considera-
tion of this case — upon which so much of the treatment of fever
in India for a quarter of a century has rested — and of the thera-
peutic principles of the best authorities in medicine of that day,
must lead to the conclusion that these principles were not rightly
appreciated or correctly applied by Dr. Johnson. To say nothing
of Pringle, Cleghorn, Cullen, and Jackson, I cannot suppose that
either Clark or Lind would have treated a case, even of the ady-
namic type, with which they were familiar, in the manner which
has just been detailed. Be that as it may, it is difficult to believe
that either of these observant and able men would have treated
remittent fever in a sthenic European after the fashion which has
been attributed to them.

After this first failure. Dr. Johnson treated his subsequent cases
by free blood-letting and alvine evacuations. But there were men
of the crew who, from various circumstances, did not bear deple-
tion so well as others. This led to treatment by induction of mer-
curial influence, by repeated doses — from five to ten grains — of
calomel " as the sine qua non in the medical treatment of this
fever as well as many other fevers in the East." *

Dr. Johnson's treatment of remittent fever consisted, then, in
free bloodletting and alvine evacuations, opium combined with
calomel t in large doses when the stomach was irritable, the

* " On the Influence of Tropical Climates," p. 110.

t The combination of calomel and opium — five grains of tHe former and one of the
latter — was highly thought of by Dr. Clark when the stomach was irritable, and as

K 3

134 REMITTENT FEVER.

induction of mercurial influence, with subsidiary measures, as
leeches and cold applications to the head — and neglect of the use
of bark.

It appears, then, that on the authority of a single case — the
first seen by a young naval medical officer in the Hooghly — the
principles in respect to the use of bark in remittent fever, laid
down from observations made in various countries and circum-
stances by Pringle, Cleghorn, the two Linds, Clark, Cullen and
Jackson, were ignored for a quarter of a century by the medical
profession in India ; and, it may be added, in tropical countries
generally.

As to the treatment recommended by Dr. Johnson, we are
left in ignorance of the amount of experience on which it was
based. There is no statement of the length of his stay in the
Hooghly, of the number of cases treated, or of the proportion of
recoveries. But of this we may be certain, that the experience of
a few months, in the crew of a single ship, could not be authority
sufficient for that subversion of medical doctrine and practice
which unfortunately resulted from it.

But, while we deplore this defection from sound principles, and
the evils to which it gave rise, we must not be unjust to its author.

Dr. Johnson did not appreciate the circumstances under which
remittent fever was observed by Clark and Lind. Nor have his
followers in this respect been just to him.

Dr. Johnson says *, " I now carried the evacuating plan with a
high hand, and with much better success than I expected. For-
tunately for my patients, a great majority of them were fresh from
Europe, and high in previous health and strength ; these recovered
wonderfully after bleeding and evacuations, though not always."
Again f : " The fear of debility and putrescency still paralyses the
arms of medical men in hot climates, notwithstanding the clearest
evidence in favour of general and local bleeding, particularly where
the subject is lately from Europe, and not broken down by the
climate."

Yet — notwithstanding these clear indications that a system of
treatment based at best on very limited experience, could only be
successfully followed in fresh Europeans high in previous health

favouring the subsequent action of mild purgatives. It would have been right on the
part of Dr. Johnson, while condemning Dr. Clark, to have acknowledged the source
from which he probably derived the calomel and opium part of his own system.

* Page 109.

t Page 110.

HISTORY OF THE MERCUIIIAL TREATMENT. 135

and strength, and not broken down by climate — the followers of
Dr. Johnson have applied the treatment to the long resident as
well as to the lately arrived, and to asthenic natives as well as to
sthenic Europeans.

But it is necessary to explain why I have now entered into
these details on a mode of practice at present generally disapproved
of, and one which its talented author had himself virtually
abandoned before the close of his long and useful career — as we
learn from the following observations written in 1841 : —

" It is necessary to observe, also, that the fevers, even of the same place, are not
of the same type in all years ; and consequently they require modifications of treat-
ment. The above was the nature of the fever on the banks of the Granges thirty-five
years ago, and the generai mode of treatment described was found most beneficial. I
have no doubt, however, that fevers in such places will often be effectually combated
by early depletion, especially purging, and then, when a remission takes place, by
administering bark, particularly the quinine, so as to prevent the return of the
paroxysms. Particular organs are to be guarded by local blood-letting and blister-
ing, while the glandular secretions of the chylopoietic viscera are to be kept in order
by appropriate doses of calomel or the quicksilver pill."*

My reasons for having enlarged on this subject are —

1. The importance of the lesson which it teaches. The cau-
tion which it enjoins against accepting new systems of treatment
without a careful examination of the evidence and the principles on
which they rest. The practice of medicine will never be free from
errors of this kind, unless all who exercise it give their minds to
patient observation and the study of principles, and are fully
impressed with the responsibility which it involves.

2. In the second number of the " Indian Annals of Medicine," f
there is a paper on " Tropical Fever and Dysentery " by Mr. Hare.
He speaks with much truth of the opinions of several of the older
physicians, and also treats of those historical details with which
we have just been engaged.

But in Mr. Hare's communication are the following remarks,
from which, after the opinions expressed in various parts of this
work, I need hardly say that I altogether dissent : -^

" There cannot be a doubt, that if not calomel, yet certainly salivation, is an
antidote to malarious fever. The instant a patient's mouth is sore the fever leaves
him ; the mercury produces not the slightest effect till then, but from that moment
the disease vanishes as if charmed ; the change is from death to life, from extremity
of suffering to calm and comfort." J

* Page 113. .t April, 1854.

I " The Annals of Medicine," Ko. 2, pp. 468, 469.

K 4

136 REMITTENT FEVER.

Again : —

*' Numerous instances, too, of the safety wliicli salivation gives from the effects of
the malarious poison may be found in Dr. Johnson's hook, viz. patients salivated for
syphilis sleeping with impxmity in places which were fatal to every one of their com-
panions; and also many cases on record of officers in India passing in a state of
salivation by dak unharmed through the most deadly jungles."

It is this revival at the present day of doctrines from whose evil
influence the practice of medicine has too slowly emerged, that has
induced me to deviate from the course which I pursued in 1843,
when writing on this disease.* Then I assumed that the necessity
of discussing the question of the treatment of remittent fever by
mercurial salivation had passed away.

The supposed sedative influence of large Jloses of calomel on
the mucous membrane of the stomach, first assumed by Sir James
Annesley, and then adopted by many writers on materia medica
and on tropical disease, may now be shortly noticed.

Annesley's opinion was founded on the results of some experi-
ments on dogs. In the year 1841 Mr. Murray, at the time surgeon
of the convalescent station on the Mahubuleshwur Hills, and well
known to his professional brethren in India as a zealous and suc-
cessful cultivator of medical science, published in the fourth
number of the " Transactions of the Medical and Physical Society
of Bombay" a paper entitled "Experiments illustrative of the
physiological effects of calomel on the gastro-intestinal mucous
membrane of dogs," which proved that Annesley's conclusion was
erroneous — and that large doses of calomel increased the vas-
cularity and secretions of the gastric as well as of the intestinal
mucous membrane.

But the question is now one of comparatively little importance,
for the latest investigations seem to show that only a very small
portion of the insoluble preparations of mercury — blue-pill and
calomel — are dissolved by the gastric and enteric secretions and
absorbed. Dr. Headland thus alludes to the subject f: —

"Some have, without sufficient reason, assumed calomel to be a sedative when
given in large doses. To act in this way, very large doses have been recommended,
and given in fever and malignant cholera. Calomel is naturally an insoluble sub-
stance ; and in these cases the function of absorption is at the very lowest ebb ; so
that it is probable that the large doses are often left unabsorbed, and pass out of the
bowels very much as they entered, producing scarcely any more effect than so much
chalk mixture." — Page 391.

* " Transactions, Medical and Physical Society of Bombay," No. 6, p. 199.
t "An Essay on the Action of Medicines." By P. W. Headland, M.D. «&c.
Third Edition, 1859.

COLD AFFUSION — WET-SHEET PACKINa. 137

Again : —

" Their action does not in reality depend much on the dose given. This may be
often increased with little effect. Until the amount of solvent matter in the stomach
or bowels is increased, the amount of mercury taken into the system will be much the
same. In fevers and cholera, when the dissolving power is little, and the fnnction of
absorption at a low ebb, calomel may often be poured in with no effect at all. As the
patient recovers, a dangerous salivation may occur ; and in some idiosyncrasies, some
peculiarly susceptible states of the absorbent surfaces, one to two grains of calomel in
the stomach, or one drachm of mercurial ointment rubbed into the skin may be followed
by violent mercurialism, or produce necrosis of the jaw and death." — Page 381.

Cold Affusion — in cases and stages of the paroxysm in which
the skin is dry and steadily above the natural temperature, and the
pulse of good volume — is of great use, by lessening vascular ex-
citement, and, when the head is the organ affected, alleviating
the headache, and either doing away with the necessity of applying
leeches, or reducing considerably the number required. But it is
contra-indicated in fever, as in other diseases, when there is com-
plication of pectoral affection, and also probably when gastro-enteric
symptoms are present.

When cold affusion is doubtful, or when the suitable stage has
passed, tepid sponging may be had recourse to with very good
effect whenever the skin is above the natural temperature. And in
all cases of remittent fever extending to two or three paroxysms, in
which the vascular excitement during the stage of exacerbation is
considerable, or in which the head is affected, the scalp should be
shaved, and cold assiduously applied.

Wet-Sheet Packing. — Within the last few years the treatment
of remittent feve^ and other acute forms of disease by this
method has at different times been brought under my notice in
India ; and it has seemed to me that injury to medical practice
is not unlikely to result from the routine and injudicious use of
the wet -sheet.

I have tried it in a few cases, and have watched its application
by others in a greater number, with the following results: —

1. In the conditions which justify cold affusion, it is possible
enough that the wet sheet, renewed every ten minutes, or quarter
of an hour, for two or three times, may be a convenient and effective
manner of reducing the temperature of the body ; but on this point
I do not speak from experience. Should there be tendency to hepatic
or splenic congestion, then the wet sheet used in the manner above
stated is likely to do harm by increasing the congestion : this state-
ment is made from personal observation. *

2. The treatment of the height of the exacerbation, by wet-

138 REMITTENT FEVER.

sheet packing after the manner of the hydropathic system, has been
to my knowledge adopted in some cases. Without denying that
the moisture of the surface of the body may somewhat modify
the action, there can be little doubt that this mode of treating
fever is a retrograde movement towards that sweating system
which, nearly two centuries ago, the genius of Sydenham
banished from the practice of medicine. But even if it can be
shown that wet-sheet packing is useful in lessening the exacerba-
tion of remittent fever, surely it is well understood that this is not
a leading indication in the cure of the disease ; and that means
which merely aim at this can never occupy other than a subsidiary
position.

3. If wet-sheet packing be used towards the close of an exacer-
bation, when the cii-cumstances have been such as to render undue
collapse at this period an event not improbable, then there can be
no doubt that the increased diaphoresis caused by the wet sheet
will increase exhaustion, and may produce it when it otherwise
would not have occurred. I have never witnessed this effect from
the wet sheet in remittent fever ; but I have observed it in the
treatment of tetanus — a disease in which a tendency to death
by failure of the action of the heart is also well marked. In the
case alluded to, death was undoubtedly hastened by this proceeding,

4. A routine system of wet-sheet packing, by directing the
chief curative means to the reduction of febrile heat, must tend to
withdraw attention from the sedulous use of those methods by
which local inflammation or other disease may be detected. It is
opposed to careful and accurate diagnosis. Then in regard to the
diaphoretic action of the wet sheet in the treatment of disease,
there can be no question of the advantage of making the skin per-
form its share of increased elimination when this becomes an
indication of cure ; but can there be a greater error in practice
than that of acting on the skin alone, and neglecting the other
important excretory organs ?

These are not theoretic objections. I have witnessed the diag-
nosis of local inflammation overlooked, and the symptomatic fever
treated by wet sheets to the neglect of the inflammation — under
circumstances in which I felt convinced that treatment conducted
on generally received principles, and by ordinary means, would
have led to a different course and termination of the disease.

On the Use of Purgatives. — Of the necessity in remittent fever
of the moderate use of purgatives, more or less active according to
the circumstances of particular cases, no question can arise ; but the

USE OF PURaATIVES — TREATMENT. 139

bad effect of keeping up a constant state of irritation of the intes-
tinal lining is equally certain.

After the first two or three days, if the secretions dependent
directly or indirectly on the portal system have been freely solicited,
farther purging is unnecessary. It will be sufficient that the bowels
are moved once gently in the course of twenty-four hours. The
effect of the opposite and too common practice is to irritate the
mucous membrane, to hurry on and very much aggravate the ady-
namic symptoms in protracted cases ; and, in recoveries, to leave
during the convalescence a deranged condition of the bowels, with
a decided proclivity to attacks of dysentery, more especially in the
cold season.

Whether purgatives should be given during the exacerbation or
the remission of remittent fever, is an important point to determine.
In the Medico-Topographical Report of the Presidency division of
the army, published by the Medical Board of Madi-as, a very de-
cided opinion on this point is expressed by the surgeon of the Pre-
sidency General Hospital. He is opposed to the use of purgatives
in the exacerbation, because they do not act readily, and they tend
to perpetuate the exacerbation and interfere with the access of the
remission. There is much practical truth in this remark, but it is
hardly sufficiently precise and discriminating.

There can be no doubt that a state of febrile disturbance is ad-
verse to the action of all remedies, purgatives included. It is also
true that the too free use of purgatives favours the continuance
of the exacerbation and interferes with the remission, partly from
undue evacuation, and partly from irritation of the intestinal
mucous lining. This influence is most likely to be exercised in
asthenic constitutions.

In the fevers of sthenic individuals, however, evacuation by pur-
gatives is adopted with the view of moderating the excitement of
the exacerbation ; and if this be one of the indications for their use,
it is evident that it can only be carried into effect during the exa-
cerbation itself. But in following out the other indications for
which purgatives are given, as removing constipation, correcting
deranged secretions, or eliminating morbid matter from the blood,
the remission is the suitable period for their exhibition. They
should be administered in moderate doses early in the remission ;
and probably there is no better method than by combination with
the first doses of quinine in the manner already recommended.

The imperfect action of purgatives in the exacerbation of fever
is partly due to defective secretion and partly to impaired irrita-

140 REMITTENT FEVER.

bility of the intestinal muscular fibre. This latter condition is
sometimes made evident by the retention of enemata when used
in the exacerbation : this circumstance is known to me from my
own observation; and Grillespie, in his remarks on the diseases
of the Leeward Islands station, notes the retention of enemata
during the exacerbation, and their action during the remission. *

The practice of Cleghorn, as explained in his observations on the
epidemical diseases in Minorca, was to give purgatives in the
morning with the first remission. He attaches importance to their
use at this stage, but does not allude to their exhibition in the
exacerbation.

Balfour recommends purgatives at the commencement of the
remission, or, when this is not well marked, at the periods when the
remissions usually occur. He says : " I have learnt by experience
that all laxative and purgative medicines, as well as injections, are
very uncertain in their operation, and generally disappoint so long
as any degree of fever is present." f

Emetics. — The occasional utility of emetics in the early stage
of fever, and the circumstances for which they are suitable, have
been already explained.

The treatment of fevers by a solution of tartar emetic and
Epsom salts in frequently-repeated doses, to the causing of free
vomiting and purging, is unsuited to febrile disease as occurring in
Bombay, and as a routine system of practice must always be
hazardous. Even in the quotidian and ephemeral fevers of more
phlogistic type, in the Deccan, in well-conditioned Europeans, I
have witnessed an alarming state of collapse brought on by this
mode of treatment. It is not disputed that many cases of fever,
thus managed, recover well ; but they must be selected with care,
for in every epidemic of tropical fever there occur many cases for
which this kind of treatment is not only unsuited, but also very
dangerous.

Blisters applied with the intention of controlling local ca-
pillary derangement when the stage appropriate for topical blood-
letting has passed have already been adverted to ; and, I would
only here repeat what has already been previously stated, that
when blisters are used in remittent fever the stage of remission is
the suitable time.

On the Use of Opiates. — In my remarks on the treatment of

* Page 73.

t " Collection of Treatises on the EflFects of Sol-lunar Influence in FeA^ers." By
Francis Balfour, M.D,, late President Medical Board, Bengal. First Edition, 1816.

USE OF OPIATES — TREATMENT. 141

ordinary remittent fever the circumstances in which an opiate often
acts with advantage, and the precautions which should be kept in
view, have been explained. At the period when this practice was
followed by me in the European General Hospital, I was not aware
that Lind * had given opium still more freely and with less pre-
caution in the hot stage of intermittent fever. His belief was, that,
when administered early in the attack, it shortened the duration
of the hot stage, and favoured the access of the third stage and of
the intermission. He did not give opium when delirium was pre-
sent, but considered that headache was no contra-indication to its
use.

Whether the favourable opinion entertained by this high author-
ity on tropical fevers, of the beneficial effects of this free use of
opium, be just or not, I am unable to judge from experience. As
already explained, I have always, before exhibiting opiates in the
hot stage of fever, had recourse to certain precautionary measures
for reducing general and cerebral vascular action : these I still think
must be very expedient. But, whatever view be taken of Lind's
opinions, there are certainly other conditions of fever, in some
respects analogous, in which a full dose of opium cannot be
given without much hazard. I allude to its use after a lengthened
period of restlessness, in which the skin is not steadily warm or
rather is coldish, and in which the pulse is frequent and feeble.
This state occurs either in cases which have been for some time
protracted, or towards the end of a paroxysm. These symptoms
indicate that the nervous influence on the organs of circulation is
failing, and the sedative action of a full opiate, under these cir-
cumstances, is apt t to increase the state of collapse, to mask the
degree in which it exists, and to hurry on coma and death. Such
cases should be treated by the assiduous use of stimulants.

Again, when in the remittent fevers of the intemperate, there
exist delirium and tremors with slight febrile heat and a pulse fre-
quent and compressible, there is — in consequence of the resem-
blance of these symptoms to those of delirium tremens, and of the
erroneous views entertained on the treatment of this latter disease
— often a great temptation to give a full opiate to overcome the
delirium and to cause sleep. This is, assuredly, in general, a most
hazardous and not unfrequently a fatal proceeding, as is illustrated
by cases 23, 24, 25. It is very probable that in the treatment of

* " Lind's Essay on Diseases incidental to Europeans in Hot Climates," 1777,
p. 343. •

t Case No. 9 is an illustration.

142 EEMITTENT FEVEK.

such cases the exhibition of quarter-grain doses of tartar-emetic,
with five minims of tincture of opium, on the principles advocated
by Dr. Graves, in the management of some forms of delirium in
European continued fever, may prove appropriate and useful.

The use of opium in remittent fever demands our careful
study, for the cas^s which have been now specially alluded to
are not the only instances of error which I have myself witnessed ;
and others have been noted by me in the perusal of the diaries of
cases which had not come under my own observation. These
circumstances have fixed my attention on this question of prac-
tice, and after much reflection it has seemed to me that the
following are the principles which should be kept in view in giving
full opiates in remittent fever.

1. Opium can be used with safety only in the restlessness of the
early stage of remittent fever, when there are not symptoms of
marked determination to the brain, and when the pulse is of good
volume, and soft, and not much above 100.

2. When remittent fever has persisted for six or seven days,
each recurring exacerbation is attended with increasing frequency
and decreasing strength of the pulse. This depression of the
heart's action is most observable towards the close of the paroxysm,
and is not unfrequently attended with general restlessness, and then
the temptation to give an opiate is often great, in the hope that sleep
and its consequent advantages may be secured ; but, under these
circumstances, the proceeding is always dangerous. A pulse that
ranges towards 120, or one not so frequent, but feeble and compres-
sible; or still more, a pulse that has the frequency of 120, and is,
at the same time, feeble and compressible, are conditions which
may be held to contra-indicate the use of a full opiate — even
though they should not be associated with headache, wandering,
delirium, or tendency to drowsiness. Nor is it difficult to under-
stand why this should be. These conditions of the pulse indicate
that the tendency to death is by syncope — a tendency sure to be
most marked towards the close of the paroxysm, and to increase
with each returning exacerbation of fever. In this depressed state of
the heart's action, the functions of the brain also become impaired,
and, under the influence of a full opiate, are not unlikely to be sus-
pended ; in other words, the opium is apt to induce coma, and its
sedative influence on the brain, acting through the nervous system,
still further depresses the action of the heart ; and thus, under these
circumstances, an opiate, injudiciously given, favours death both in
the way of syncope and coma.

USE OF QUININE — TKEATMENT. 143

3. As yet no derangement of the brain itself has been assumed.
But in a great proportion of cases of remittent fever, of six or seven
days' duration, the earlier exacerbations are marked by flushing
and headache, the later ones by slight wandering or tendency to
drowsiness. This condition of the cerebral functions, whatever the
state of the pulse may be, contra-indicates the use of opium ; for
in such cases the tendency to death is by coma. If the opiate be
given at the close of the earlier paroxysms, it may only increase the
restlessness ; but if it be given at the close of the later paroxysms,
when wandering or tendency to drowsiness is present, it will most
surely expedite the supervention of coma, and ought to be most
scrupulously abstained from.

4. But in those cases of remittent fever in which the wander-
ing delirium, or drowsiness of the later paroxysms shows a ten-
dency to death by coma, there is also, most generally speaking, a
frequent and failing pulse. Whenever an exacerbation of remittent
fever which has been attended with wandering delirium, or a
tendency to drowsiness, terminates with a quick and feeble pulse,
it may be inferred with tolerable certainty that death by coma is
not Ja>T distant, is only to be warded off by the most judicious
management, and is most certain to be hurried on if we commit the
grievous error of attempting to lessen the delirium and restlessness
by the exhibition of opium. To conclude, then, whenever in re-
mittent fever the pulse is towards 120, feeble and compressible,
and whenever there is wandering delirium, or slight drowsiness,
the exhibition of a full opiate is a measure of danger, more parti-
cularly towards the close of a febrile exacerbation. In other words,
whenever in remittent fever the tendency to death by asthenia
or by coma is well marked *, a full opiate will expedite the fatal
result.

On the Use of Quinine. — The manner in which quinine has
been used by me in the treatment of intermittent and remittent
fever has already been fully detailed.

On investigation it is evident that the principles inculcated
differ little from those of the older writers, chiefly the Linds f,
Cleghorn, and Balfour, in respect to bark.

* I need hardly observe that, in these remarks, I refer exclusively to opiates given
with the intention of, and in doses calculated to produce the soporific action of the
drug. Whether opiates given in small doses, with a view to their stimulant effects,
may or may not he admissible in some of the states of fever adverted to by me, is a
question altogether apart from my present subject, and one in regard to which I am
unable to express any opinion from experience.

t I may here state that there are two Dr. James Linds ; one of Haslar Hospital,

144 REMITTENT FEVER.

Cleghorn remarks : —

" Inflammations of the abdominal viscera are likewise natural eifects of tertian
fevers. For we find that they often come on little by little, and increase \vith
every paroxysm till at last they end in a gangrene. Whereas the cortex, by bringing
the fever to a speedy conclusion, impedes the further progress of the inflammation, so
that it afterwards goes oiF gradually of its own accord ; as I have had occasion to
observe in a multitude of instances, where acute fixed pains, tension, and other
symptoms made the nature of the disease too plain to be doubted."

Again : —

" Upon the whole I am convinced that the unhappy metastases, which some have
observed to follow the use of the bark, are exceeding rare, and ought rather to be
ascribed to other causes than to this medicine. And I will venture to affirm that
more bad consequences ensue from giving it too late than too soon. Prostration of the
strength, sudden death, or the most obstinate chronic diseases, if the sick recover,
being the usual effects of delay. Whereas the worst that commonly happens from the
too early use of it is that it does not at once restrain the paroxysms, Hke a charm
without any sensible evacuation as it frequently does when given after the fever has
arrived naturally to its height, and begins to decline of its own accord." *

Balfour's principles, in respect to the use of bark, are, on the
whole, practical and sound. He advocates evacuants in the first
exacerbation, and then gives bark in powder freely, increasing the
retaining power of the stomach by opium. He prefers the inter-
mission and remission, but does not scruple to use it under gome
circumstances in the exacerbation. His words are : " This becomes
absolutely necessary when you happen to be called too late, for
after the third or fourth day the fits are protracted so long as to
run into one another ; and when this is the case, whoever waits for
complete remission will find himself wofully disappointed." f He
recognises cases, however, in which reaction is high, remissions
short, evacuations more required, and bark less. He insists
upon bark being of as great importance in remittents as in inter-
mittents. " All the arguments," he observes, " I have been
advancing in favour of an early exhibition of the bark in inter-
mittents are equally applicable in the case of remittents, whether
attended or not with symptoms of obstruction. And as these
disorders are more rapid in their progress, and more dangerous,
so is the necessity of this practice in proportion more urgent." f
After stating that a complicating hepatitis, or other inflammation
in intermittent and remittent fever, is to be met by venesection,
other evacuants and blisters, he adds : " If it be not likely to stop

who writes on scurvy and diseases incidental to Europeans in hot climates ; the
other, Dr. James Lind, of Windsor, who writes on putrid and remitting marsh fever of
Bengal.

* " Observations on the Epidemical Diseases in Minorca, from 1744 to 1749." By
George Cleghorn, pp. 223 and 225.

t Page 34. t Page 39.

USE OF QUININE — TKEATMENT. 145

by prosecuting this plan, the bark is to be given without hesitation,
for in all the partial determinations I have met with, I have ever
found the fever do much more harm in one fit than all the bark
that is necessary to stop its return."

The following are the rules laid down by Cull en : — *

"1. That the bark may be employed with safety at any period of intermittent
fevers, providing that, at the same time, there be neither a phlogistic diathesis pre-
vailing in the system, nor any considerable or fixed congestion present in the abdo-
minal viscera.

" 2. The proper time for exhibiting the bark in intermittent fevers, is during the
time of intermission ; and where intermissions are to be expected, it is to be abstained
from in the time of paroxysms.

" 3. In remittents, though no entire apyrexia occurs, the bark may be given during
the remissions ; and it should be given, even though the remissions be considerable,
if, from the known nature of the epidemic, intermissions or considerable remissions
are not to be so soon expected, and that great danger is apprehended from repeated
exacerbations.

"4. In the case of genuine intermittents, while a due quantity of bark is to be era-
ployed, the exhibition of it ought to be brought as near to the time of accession as the
condition of the patient's stomach wiU allow.

" 5. In general, in all cases of intermittents, it is not sufficient that the recurrence
of paroxysms be stopped for once by the use of the bark ; a relapse is commonly to be
expected, and should be prevented by the exhibition of the bark, repeated at proper
intervals."

When we recollect the difficulties with which the older physi-
cians had to contend in the exhibition of the crude bark, we cannot
sufficiently admire the ingenuity with which they endeavoured to
overcome them, and the constancy with which they adhered to
those sound principles of therapeutics which the means at their
command enabled them so inadequately to apply. The great
advantage which the modern physician enjoys, is simply this, that
he is able by means of quinine to carry out those same principles
more easily, completely, and safely.

Dr. Greddes was> at an early period (1828), instrumental in
establishing the use of quinine in India. In his later work
published in 1846t, there are valuable practical suggestions on the
use of quinine in fever, which well deserve attentive consideration.
They are too long for insertion here, but I cannot deny myself the
satisfaction of quoting that part of Dr. Greddes' remarks which
relates to the exhibition of quinine in complicated cases.

" The exhibition of quinine," he writesj, " can go on along with that of any remedy
for attendant symptoms ; and, inasmuch as the latter may depend upon or be aggra-
vated by the febrile accession, this medicine must be considered as an auxiliary to any

* Thomson's Edition, vol. i. p. 673.

t " Clinical Illustrations of the Diseases of India." By William Geddes, M.D.,
p. 175. X Ibid. p. 176.

146 REMITTENT FEVER.

remedial means, even of a supposed discordant nature, whicli may be employed for
the relief of such symptoms. Thus quinine has been combined with the treatment
suitable to inflammatory, dysenteric, and other affections; and by preventing the
increased febrile action of the paroxysmal disease, it has tended, in a material degree,
to the diminution and ultimate removal of all the accompanying morbid phenomena,"

Dr. Haspel *, in his treatise on the diseases of Algeria, inculcates
the same principles on the use of quinine in complicated cases of
remittent fever.

In the year 1851 the treatment of Bengal remittent fever with
scruple doses of quinine repeated several times during the height
of the exacerbation, was advocated by Mr. Hare of the Bengal
Medical Service. The subject attracted considerable attention at
the time, and was much discussed. The tendency of the system is
to favour superficial clinical observation, as is evident in the follow-
ing extract from Mr. Hare's Eeport : — f

" I thus treated 421 cases in all of Bengal fever, and during the experiment some
remarkable facts were observ^ed. My orders to my apothecary in both wards were to
give scruple doses of quinine to every patient with symptoms of fever, from the
very first moment of admission, and they often thus got forty grains of quinine before
I saw them. During part of the year, viz., March, April, and May, small-pox and
measles raged like an epidemic in Calcutta. Numbers of these patients in their
early stages, before the appearance of any eruption, were sent to my ward as fever
cases, and were treated as the rest with large doses of quinine, sometimes for
thirty-six hours before I could detect their disease. Almost all these cases termi-
nated fatally. Latterly, however, I was able to avoid these errors, by watching the
effect of the first dose of quinine. For in cases not malarious it invariably caused
great uneasiness, without any benefit to the general symptoms. Moreover, deafness
and singing in the ears were very quickly induced ; whereas in malarious fever, with
the same ardent symptoms, the quantity of quinine taken without producing any
cinchonism was often extraordinary, and so far from uneasiness, it seemed always to
give relief, and the febrile symptoms yielded rapidly under its use."

.We may, with Balfour, admit, that when the exacerbations so
run into each another that the remissions are hardly observed,
quinine may be given with care at the periods which, in the ordi-
nary course of the disease, are those of remission.

The question of the free use of quinine in the exacerbations of
remittent fever is so important, that no apology is necessary for
submitting the reflections which its consideration has suggested
to me.

1. There is no evidence that quinine has the power of dimin-
ishing existing febrile excitement in the manner of evacuants and
cold. The disturbed action of the heart and nervous system,
described by Briquet J as resulting from large doses of quinine,

* " Maladies de I'Algerie," vol. ii. pp. 176, 184.
t " The Indian Annals of Medical Science," No. 2, p. 474.

X " Medical Times and Gazette," May and June, 1855; " Indian Annals of Medical
Science," vol. iii. p. 281.

USE OP QUININE TREATMENT. 147

resembles that from hydrocyanic acid ; and it cannot be safe in
therapeutics to produce such disturbance of these important
organs.

2. When the action of a remedy is distinct in its nature, and
opposed to that of a morbific cause, it is a therapeutic law that
such remedy will be more effective before the action of the
morbific influence is in full force. For example : an anodyne, in
anticipation of pain, an anti-spasmodic in anticipation of a par-
oxysm of asthma, a soporific in anticipation of a season of restless-
ness, are more certainly effective than when postponed till these
several derangements are in full force: in the latter case they
often fail. Anti-periodics are so called because their peculiar
action is unquestionably of this character. They are comparatively
powerless if not given to anticipate derangement, as appears in
intermittent fever and neuralgia : why should it be otherwise in
remittent fever ?

3. Admitting that quinine in the exacerbation may be benefi-
cial rather than otherwise, still we know that the greater the febrile
disturbance, the less likely the action of remedies which require
to be previously absorbed and assimilated. The exacerbation must
therefore be the period least suited for ensuring their action, and
if not then injurious they are at best in a great measure useless,
because necessarily inert.

4. That quinine has no power of directly reducing febrile
excitement is clear from its inutility in continued fever, symptoma-
tic fever, and the eruptive fevers : why should it be otherwise in
the exacerbation of remittent fever ?

5. Febrile disturbance in zymotic continued fevers may be in-
creased by injudicious and moderated by judicious management;
increased by stimulants, heat, imperfect ventilation, and mode-
rated by evacuants, cool and pure air, sponging, affusion, and the
wet sheet. It is of as much, if not more, importance to attend
to this indication in remittent fever, not only on account of
the reaction and the immediate danger to important organs, but
also because it favours an early and more complete remission — that
is, brings about the opportunity of giving with good effect — quinine
— the agent most potent in the cure of the disease.

6. By administering quinine in the exacerbation, we give it at a
time least appropriate for its peculiar action, and when its action,
if any, is as likely to be injurious as useful. Moreover, attention
thus misdirected tends to induce neglect of tkose means for re-
ducing febrile excitement, — applicable to all types of fever, - —

L 2

148 BEMITTENT FEVER.

and which are additionally useful in remittents, because they favour
the access of a distinct remission.

7. Under wavering principles the appropriate treatment of the
exacerbation is liable to be neglected. The difficulty seems to be
in keeping clearly before the mind, that the principles for the
exacerbation are distinct from those for the remission ; that both
are important, and require to be modified in particular cases, but
should never be confounded and transposed.

8. We cannot, with certainty, distinguish remittent fever, first
seen during the exacerbation, from continued fever, or the ini-
tiatory stage of an eruptive fever, or that type compounded of
remittent and common continued fever — for all of which large
doses of quinine are unquestionably unsuitable.

9. I know, from clinical experience, that there are febrile states
in which quinine is injurious, and others in which large doses do
harm, and small ones good. All that we practically know of the
action of anti-periodics is, that when given, at seasons of subsidence
of deranged action, in diseases in which there are remissions and
exacerbations, they are efficacious ; that the dose varies, that it
ought to be sufficient to prevent the recurrence of the derange-
ment, but not to cause its own abnormal actions. If we use these
agents at other periods of disease, and with other views, we are
misapplying remedies, and acting with needless empiricism.

] 0. The indications of treatment in remittent fever are three,
and each has its own appropriate means. 1. To control the ex-
citement and complications of the exacerbation. 2. To act in
the remission so as to prevent a recurrence of the exacerbation.
3. To ward off exhaustion by the timely use of stimulants and
nourishment.*

I would, in conclusion, remark, that my opinions respecting
quinine are the result of clinical observation, and were formed
irrespective of those of other observers. This statement (and a
similar one might be made relative to my opinions on the mer-
curial treatment of fever) is advanced simply that the authority
of my own investigations may be added to that of others who,

* Warburg' s fever drops have at times acquired a reputation in parts of India.
In 1844, when attached to the European General Hospital, eleven bottles were tried
by me. In one or two of the cases there was a decided sudorific action from the
medicine, and the febrile paroxysm seemed to be shortened, and did not recur for
several days ; but in none was a cure eflfected. In other cases there was no sudorific
action from the medicine, and the fever was in no respect benefited by its use. In
one case the fever was checked for a time, but marked subacute inflammation of the
stomach was excited. From these trials I drew the conclusion that Warburg's drops
were an addition of very little value to the means which we already possess of con-

TltE PEOPHYLACTIC USE OF QUININE. 149

through the same process^ have arrived at similar and independent
conclusions.

On the prophylactic use of Quinine.— The prevention of inter-
mittent and remittent fever in malarious districts by the daily use
of a small quantity of quinine is an important consideration, but
the evidence in its favour is as yet neither extensive nor conclusive.

There is no want of instances which are supposed to prove this
prophylactic power, but they are generally deficient in some of the
conditions essential in experiments of this nature. For example :
detachments of the 18th Eoyal Irish, the 92nd Highlanders, the
3rd Dragoon Guards, with the 4th troop Bombay Horse Artillery
and native details, were engaged on field service in the latter half
of November and beginning of December, 1858, in the jungly
tracts along the southern base of the Sautpoora Hills, in localities
usually considered to be malarious at that season of the year. The
men of the 92nd took two grains of quinine twice daily from the
27th November to 6th December, and the immunity from fever
which they enjoyed was attributed by the medical officer to this
measure. On inquiring into the state of health of the other detach-
ments, I found that they had been equally free of fever, though
they had not used quinine as a prophylactic. The comparison of
the 92nd and Horse Artillery troop was instructive : the men of the
92nd had been conveyed to the scene of service by bullock train,
but the troop had reached it by forced and fatiguing marches. The
men of the latter were consequently more predisposed, yet they did
not suffer from fever. The immunity of the 92nd therefore did not
depend on the small quantity of quinine consumed daily, but, with
that of the other troops engaged, on the circumstance that the
malarious season had passed. Further careful investigation is, in
my opinion, necessary before the prophylactic value of quinine
can be received as an established fact.

Diet. — In order to control the undue vascular action of the
exacerbation, the regimen must in all respects be antiphlogistic.

trolling the fevers of India ; and that, in some cases, their use is not unattended with
risk of injury.

In 1851 I was asked to see an English merchant in Bombay, who in the month of
July, from residence in a swampy locality, became affected with remittent fever com-
plicated with diarrhoea. He was moved to a better situation. The state of the
bowels interfered, it was said, with the'use of quinine. I saw this gentleman on tlie
eleventh day of the fever, the third after it had become continued, and one after
a bottle of Warburg's drops had been given. It caused profuse sweating, which con-
tinued at the time of my visit ; the adynamic symptoms were well marked. He died
twenty-four hours afterwards. Here the profuse diaphoresis from the medicine mxist
have increased the exhaustion.

Ju 9

150 REMITTENT FEVER.

It has, however, been stated, that in remittent fever we must be
on the outlook for prostration, and prepared to prevent it by the
adequate use of farinacea, milk, and animal broths during the re-
mission. The usual error in practice on this point — a very serious
one — is to postpone the use of nutritious food till prostration is
urgently present. The judicious physician, however, foresees its
advent, appreciates its earliest signs, and strives to prevent it by
the timely and skilful use of nourishment and stimulants. The
adjustment of the food and of stimulants to the state of the consti-
tution and typQ and stage of the fever is a very important part of
the management, and one on which, in bad cases, success very often
mainly depends.

Change of Air. — To place a fever patient in the most advan-
tageous circumstances at our command as respects house and
apartment, ought to be an invariable rule. If the situation be
decidedly malarious, and that in which the fever has been acquired,
then the removal of the patient to a more suitable adjoining
locality, where medical treatment and care are also available, is a
very necessary measure. But this necessity does not frequently
occur in India, for hospital patients, by their removal to hospital,
experience the benefit of change from the locality in which the
attack has been excited ; and officers do not frequently suffer from
fever caused by malaria generated in the neighbourhood of their
residences, but from exposure on the occasion of a hunting,
shooting, or pic-nic expedition. When remittent fever persists,
uncontrolled by remedies, change of air often holds out the pros-
pect of benefit, particularly when residence on the sea-coast
admits of change to sea, provided the patient can enjoy at the
same time the advantages of careful nursing and medical treat-
ment. The necessity for a measure of this kind will be frequent
or rare, according to the knowledge and skill evinced in the
medical treatment. The contingency often occurred in former
years, when remittent fever was treated with mercury, without
bark or quinine ; and the change was so generally carried into
effect, without sufficient provision for the essential medical manage-
ment of the patient, or reference to fatigue and exposure, that
much suffering and increased mortality resulted from it.

That this evil has really existed, is very evident from the fol-
lowing facts : —

A medical officer, on the 10th October, 1829, was taken ill
with fever at Jumbooseer, in Guzerat. The attack was treated
with depletion and mercurials, and was characterised by tendency

CHANGE OF AIR — TEEATMENT. 151

to exhaustion. He went to Tankariabunder, and embarked there
for Bombay on the 1 9th ; suffered in the boat from nightly-
exacerbations, and sense of exhaustion in the day. He reached
Bombay on the morning of the 23rd with a thready pulse, and
died at 9 p.m.

A military officer was taken ill with remittent fever at Raj cote
on the 18th October, 1834; treated with mercurials and purga-
tives; and sent on the 22nd to the coast and Bombay, supplied
with fever pills and purgatives. He died on the road on the
26th.

An officer at Ahmudnuggur, in Gruzerat, after ailing for two or
three days, became affected with remittent fever on the 13th
August, 1835. There were noon and midnight exacerbations and
morning remissions. He was bled, used calomel and purgatives,
and was sent to Hursole on the 18th. He reached it exhausted on
the 19th, and died on the 20th. He was on his way to the sea-
coast.

A military officer, in the month of October, 1839, was ill for a
week with fever at Ahmedabad. He was sent to Cambay; was
exhausted ; there was wandering delirium, with oppression of
breathing. Leeches were applied to the head, a blister to the
epigastrium, and several free doses of calomel were given. He
was then embarked for Bombay, and died at sea the night of his
departure from Cambay.

The wife of the subject of the last case, also ill with remittent
fever, left Cambay at the same time in another boat. I went on
board to receive this lady on her arrival at Bombay, and found her
suffering from adynamic fever. I attended her for two or three
days, when she died. It was this case that first fixed my attention
on the evils of this routine and injudicious system.

An officer ill with remittent fever at Tatta, in Scinde, in De-
cember, 1840, was sent to Kurrachee, and was seen there three days
afterwards in a state of febrile excitement with delirium and ful-
ness of both hypochondria. He was bled, and purgatives were
given, also a draught with half a drachm of solution of muriate of
morphia. He became comatose, and died twelve hours after his
arrival. The head was not examined. The liver and spleen were
enlarged, congested, and friable.

An officer of intemperate habits, and often injudiciously exposing
himself to the sun, suffered from two or three attacks of fever at
Tatta in December, 1840; these were followed by dysentery. He
proceeded to Kurrachee, and arrived there in an adynamic state,

L 4

152 REMITTENT FEVER.

and died the following day. The liver was much enlarged, and
there was softening of the gastro-intestinal mucous lining.

A gentleman had fever at Poona on the 21st of November, and
was first seen on the 23rd. The morning remission and noon
exacerbation were marked on the 24th, 25th, 26th, 27th, 28th, and
29 th. He was treated with leeching, mercurials, purgatives ; and
general blood-letting on the 28th : no quinine. He was sent from
Poona on the morning of the 29th, and was seen at Bombay on
the evening of the 30th. There was exacerbation with stupor and
asthenia. On the morning of the 1st, a remission; at noon, an
exacerbation with increasing stupor. He died comatose at 10 a.m.
of the 2nd.

These cases will suffice*; they show unmistakeably the injurious
effects of the excitement and fatigue of travelling, and the neglect
of medical treatment. It is not difficult to understand how this
system of mismanagement obtained currency. It is very evident
that depletory measures and mercury are quite unequal to the cure
of remittent fever. In this difficulty medical men and the public
clung to the hope of benefit from change of air, and have been
slow to interpret rightly the casualties which have resulted from it.

When treating of splenic cachexia, I pointed out the necessity
of change of air with the view of improving the state of the consti-
tution. When health has been injured by remittent fever, and
convalescence is in progress, then change of air becomes, on the
same grounds, a very useful and important measure.

* To satisfy myself on the question of change of air in remittent fever was a
principal object with me in examining the cases of sick officers. From the ninety
fatal cases of which I have notes, I have selected the eight just quoted. On the
other hand, of 1,388 successful cases of officers recommended for change of air on dif-
ferent accounts, I do not find that I have noted a single instance of benefit from the
measure adopted under those circumstances of fever to which these remarks have
been directed.

Note. — The principles of treatment of remittent fever have been considered at some-
what greater length, and with more precision than in the first edition of this work.
The discussion on the mercurial treatment has been reproduced with a greater conviction
of its importance and necessity, because the nature of my duties on my return to
India has affi^rded me the opportunity of becoming acquainted on a more extended
scale with the present state of medical practice in that country, and I have been often
astonished at the want of sound principles on the use of mercury, and of fixed princi-
ples of any kind on the general treatment of fever.

153

CHAP VI.

ON CERTAIN OBSCURE PHENOMENA, PROBABLY RELATED TO MALARIA.

Intermittent and remittent fever are attributed to malaria as a
cause, and the presence of these diseases may be received as evidence
that this agency is active.

The observations made on the symptoms of the cold stage of
intermittent fever, and on the diagnosis between remittent and
symptomatic fever, have evinced my belief that the influence of
malaria may be indicated by phenomena less marked, but still par-
taking somewhat of the character of those of intermittent and
remittent fever. This subject may be -pursued still further, and
with much advantage by the practitioner in malarious countries.
Careful observation in tropical climates will satisfy the inquirer
that there is a tendency in all forms of disease to put on more
or less of a periodic character in the malarious months of the year.
This feature is more likely to be observed in the natives of India,
and in long resident Europeans, than in the recently arrived. It
is practically important ; for when observed, it may be viewed as
suggesting caution in the use of antiphlogistic means, and indi-
cating the expediency of quinine.

After a period of residence in tropical countries, occurring sooner
in some localities and constitutions than in others, an influence
becomes operative on the system, produced perhaps by general
climatic conditions, but more probably by malaria. There are
many phenomena which may be taken as indicating the presence
of this influence, — as restless nights, pain of limbs, frequent
yawning, depression of spirits, giddiness, booming sounds in the
ears, a sense of faintness or chilliness with vomiting, defective
secretion of the liver leading to pale alvine discharges without
jaundice; defective irritability of muscular fibre giving rise to
palpitation, a feeble, sometimes intermitting pulse, constipation
and dyspeptic symptoms. In these phenomena, if watched, a

154 EFFECTS OF MALARIA.

marked periodic tendency may often be observed. They are more
apt to occur at times of considerable atmospheric changes, and
very frequently about full or new moon.* All these symptoms are
distinctly controlled by the use of quinine. The occurrence of night
paroxysms of malarious fever is a familiar fact. The phenomena
of the lesser influence of malaria may occur at the same diurnal
period. In this way restless nights may often be explained :
at all events, five or six grains of quinine, given at bed-time under
these circumstances, cause sleep more certainly than opium.

The correct interpretation of these symptoms of deranged health
leads to the use of quinine, and, to great caution in local blood-
lettings, purgatives, and mercury; but the measure which they
most clearly indicate, is change to a suitable temperate climate free
from malaria. This is a most necessary step ; for in the stace of
constitution of which these phenomena are the evidence, there is
unquestionably a general tendency to fatty or other defeneration
of tissue, which can only be prevented by forethought on our part,
in recommending a suitable change of climate. To wait for the
occurrence of structural change as the signal for removal from
India, is a great practical error, and pathology has been studied to
little purpose if its lessons have not taught us when to expect
structural lesions, and how best to prevent them.

* The question of lunar influence on disease in India lias been mucli discussed at
different times. In the 2nd and 6th. numbers of the " Transactions of the Medical
and Physical Society of Bombay," the reader will find the latest consideration of
this subject with which I am acquainted. The first paper, by Mr. Murray, details
what the author conceived to be illustrations of lunar agency in chronic disease. The
second is by Dr. Peet, and embraces an inquiry into the evidence on which the opinion
rests.

On this question I shall merely observe : 1. To find on the same day several of the
asthenic inmates of his wards affected with febrile disease, though all had been free
of it for many days previously, is a fact familiar to the hospital physician in India.
The days on which this is observed are often coincident with new or full moon.

2. To find those who have suffered from malarious fever experiencing recurrences
at the periods of new and full moon, is a fact familiar both to patients and to medical
men in India.

3. When this coincidence of febrile disease and these lunar phases are noted, there
will generally be found to be present an appreciable atmospheric change of tempera-
ture, of moisture, of direction of the winds, &c. It is this atmospheric vicissitude, I
apprehend, which is the determining cause of the febrile disturbance. Dr. Balfour,
the great advocate of sol-lunar infiuence, admits this coincidence of atmospheric
changes. His words are: "But I can declare in general that in India the meridional
periods, both diurnal and nocturnal, W^ere distinguished by remarkable changes or
paroxysms in the state of the weather ; and that these paroxysms were most remark-
able at the lunar periods."

155

CHAP. VII.

ON ADYNAMIC REMITTENT FEVER OF SUSPECTED INFECTIOUS CHARACTER.

That malarious fevers are liable, under circumstances favourable
to the spread of infection, to become infectious, is an old opinion.
Fordyce held this view, and Clark and Lind believed that Bengal
remittent was at times invested with this character.

We shall do well to bear this old doctrine in recollection,
because, though with our present greater attention to cleanliness
and ventilation, remittent fever is not infectious, it does not follow
that it may not become so from overcrowding and neglect. From
1815 to 1820 a febrile disease* of very adynamic type prevailed in
Kattywar, Kutch, and parts of Guzerat. A similar affection appeared
at Pali in Marwar in July, 1836 ; was more or less present there,
and extended to the towns in the adjacent districts up to the middle
of 1838. Again, we have notices of a like disease in 1849 in
Grurhwal, in Kumaon, and, more lately still (1853), in Eohilcund.

The fever was remittent in character, with great tendency to
become continued, and the adynamic phenomena were well marked.
It was attended, in the great majority of instances, with glandular
swellings of the groins, axillae, and neck ; and, in the cold season,
there was in some of the fatal cases dyspnoea, with cough and
bloody expectoration. In none were carbuncles and petechiae or
purple patches present.

The number of cases seen by Dr. Forbesf at Pali, from January

* The terms Pali disease and Mahamiirree have been given to this fever. It
is much to be desired that the too common practice of giving local or native
names to diseases in India be altogether abandoned, as tending to lead to careless
diagnosis and vague pathology; I allude to such terms as Scinde, Guzerat, Mysore,
Bengal, Deccan, Jungle, Pucka fever, Liver, Spleen, Beri-b^ri, Hill diarrhoea, and
many others.

t " Transactions, Medical and Physical Society of Bombay," No. 2, p. 14.

156 ADYNAMIC EEMITTENT FEVEK.

29th to February 3rd, 1848, amounted to forty-eight. He thus
describes the symptoms : — *

" Of these many liad reached from the tenth to the twentieth day of the disease,
with large buboes, no particular degree of fever, parched skin, tenderness of epigas-
trium, tongue white and moist, eyes dull and watery, bowels generally very slow, but
sometimes loose, and the greater part with more or less cough ; some few complained
of little else than th% pain of the buboes, with great weakness and loss of appetite.
All, without exception, had buboes, but I met with no instance of carbuncle or
vibices.

" In the mildest form the buboes make their appearance with little constitutional
disturbance, attended only by languor, debility, and a general feeling of indisposition ;
they go on slowly to suppuration, and health is very gradually restored.

" In the most common variety the invasion is sudden, not being preceded by any
feelings of disorder or "uneasiness sufl&cient to engage the notice of the patient, gene-
rally takes place in the evening, and is rarely attended with rigors. The occurrence
of the febrile symptoms, and the pain and swelling of the glands, appear to be in
most cases simultaneous ; in many the buboes showed themselves before the fever,
•vrhile in none were they developed at a later period than the second day of the
disease. The symptoms most generally present are great prostration of strength,
giddiness, headache confined to the forehead, excessive thirst, dry burning skin,
tongue moist and white, pulse from 110 to 130, small and weak, slight vomiting and
tenderness of epigastrium, bowels confined, urine scanty and high coloured, great
indifference as to recovery, and disinclination to speak or answer questions. The fever
is of the remittent type, with marked tertian exacerbations, often attended with low
delirium, but the crises are very imperfect. If uncomplicated with any thoracic or
abdominal affection, and if the patient survives the fifth day, it commonly abates in
%dolence after the seventh or eighth, so that in the third week little else remains but
extreme debility, and sympathetic evening flushes from the buboes, which by this
time have advanced to suppuration. In most of these cases, however, more or less
cough is present through the height of the disease ; it is generally dry, but sometimes
accompanied by white frothy expectoration.

" In the more violent and malignant forms the attack sets in suddenly, with severe
headache, staggering, and giddiness, quickly followed by delirium. The morning
remission is scarcely perceptible, except by the abatement of the delirium. No
glandular swellings appear, or they remain small, hard, and exquisitely painful ;
vomiting of bilious matter, and latterly of dark coffee-coloured fluid, comes on ; the
bowels are either constipated or the stools black and fetid, the teeth are covered with
sordes, and the patient tosses and moans in bed. A dry cough now supervenes,
attended with severe pain in the region of the heart, and laboured respiration;
partial insensibility passes into profound coma with trismus, and death takes place
early in the morning of the fourth day, or, in cases where the symptoms are less
violent, on the morning of the sixth.

" The most fatal modification of the disease, from which no recovery has been
known, sets in without any febrile excitement whatever, if we except a very slight
acceleration of the pulse. The most prominent symptoms from the commencement
are slight cough, and expectoration of blood ; the cough appears to an observer more
like a voluntary act to relieve oppression or constriction about the chest than to
be caused by pain or irritation. The body is covered with frequent clammy SM^eats ;
the countenance exceedingly anxious and wild ; thirst urgent, tongue clean, bowels
slow ; the urine increased in quantity and loaded with blood, which also oozes from

* This enterprising officer subsequently lost his life in Central Asia, while travelling
on his return from Europe to India.

ADYNAMIC KEMITTENT FEVER. 157

tlie gums. The expectoration of blood becomes more copious. To the anxiety and
oppression of the chest is added pain in the cardiac region, the pulse becomes quick
and thready, the action of the heart tumultuous, faintness and complete exhaustion
come on ; and a fatal syncope puts an end to the sufferings of the patient, generally
within forty hours from the attack, the intellectual faculties remaining perfect till
nearly the last moment.

" It is, however, by no means rare to see the different forms mixed or merging in
each other. The attack may be at first mild and apparently without much danger, the
buboes well developed and the fever slight ; when from the third to the fifth day, and
sometimes so late as the seventh, the occurrence either of delirium, coma, bloody expec-
toration, diarrhoea, retention of urine, or recession of the bubo, point out an unfavour-
able change, and the fatal termination soon follows, as in the more aggravated forms."

Dr. Forbes alludes' to the treatment, and points out the inap-
plicability of all depressant remedies.

This fever has been observed at all periods of the year, and has
prevailed chiefly amongst the poor, in filthy, badly-ventilated
houses and villages, and has been preceded by seasons of famine.
The mortality has been very great. Dr. Forbes thinks four-fifths
of those attacked died. The circumstances just stated sufficiently
explain the occurrence of adynamic fever; but they have been
viewed chiefly with reference to the question of the contagious cha-
racter of the fever, and its identity, or not, with the plague of Egypt
and the Levant. Hence speculations arose relative to the manner of
its introduction into India in the course of commerce from the Eed
Sea or Persian Grulf ; and quarantine measures were on occasions
strictly enforced.

It would be unprofitable, and foreign to the objects of this work,
to enter into discussion on a subject of which I have no personal
knowledge ; but my impression is in favour of the opinion that it
was a fever of endemic origin, of very adynamic type from the
state of constitution of the attacked, assuming infectious properties
from filth, crowding and imperfect ventilation, and having features
in common with the plague of Egypt, — as is more or less the case
in every fever in which adynamic symptoms and deteriorated blood
are well marked.*

* The first known reports of this disease are by Messrs. McAdam, Whyte, and
Gilder, in the 1st Number of the " Transactions of the Medical and Physical Society
of Bombay."

The disease, as appearing at Pali and the adjoining districts, has been described
by Messrs. McLean, Irvine, Keir, and Eussel, of the Bengal Medical Sendee;
and the results of their observations have been brought forward in an able memoir,
by Dr. James Eanken, at the time Secretary to the Medical Board of Bengal.
It was also reported on by Mr. Cramond and Dr. Forbes, of the Bombay Medical
Service. The latter gentleman published a very interesting report of his observations
in the 2nd Number of the " Transactions of the Bombay Society," already referred to
in the text.

The accounts of the disease in Kumaon and Eohilcund are given by Drs, Pearson,

158 ADYNAMIC REMITTENT FEVER.

The description of jail or hospital fever by Pringle, in the
seventh chapter of the third part of his work on the diseases of the
army, has considerable resemblance to that of the fever observed at
Pali. There were the same kind of adynamic phenomena, with sup-
puration of the axillary and parotid glands, with, in addition, the fre-
quent presence of petechial spots. The causes were supposed to be
crowding, filth, and effluvia from decomposing animal and vegetable
matters. In some cases it was attributed to the effluvia from putre-
fying marshes ; and in these the type was more remitting. The
fever was regarded as infectious, but in no great degree, unless
there had been continued exposure to the foul air.

In a Report on the Medical Topography and Diseases of Aden*, by
Mr. Ruttonjee Hormuzjee, it is stated that intermittent fever is not
so common there as in India ; but the station is not exempt from
the occasional visitation of febrile disease of severe type. During
two of the years embraced in the report, 270 cases of remitt-ent
fever of adynamic type were treated, and of these 77 proved fatal.
It prevailed with greatest severity from February to April, 1856,
during which time there were 188 admissions and 60 deaths. The
outbreak occurred among the native labourers engaged in the public
works, and was attributed to undue crowding in a hot and badl}^-
ventilated valley, in close, badly-constructed huts, in the proximity
of sources of foul effluvia from decomposing animal excreta and
other matters, coupled with poor living, and especially an in-
adequate supply of fresh water. The fever was characterised by
evening exacerbations and morning remissions. The complications
were various : cerebral disturbance in some indicated by delirium,
drowsiness, and coma, attended with adynamic phenomena, as sub-
sultus tendinum and dry tongue. Pneumonia, bronchitis, dysen-

Francis, Eenny, and Stiven, of the Bengal Service, and are noticed in the 2nd and 3rd
Numbers of the "Indian Annals of Medical Science."

The subject is also ably discussed by Dr. Mackinnon, in his treatise on the "Pre-
vailing Diseases of Bengal and the North-west Provinces," published in the same
journal.

In the 4th Number of the " Indian Annals of Medical Science," received since these
remarks were written, I find a report, by Dr. Farquhar and Mr. Wallick, of an
.^idynamic remittent fever which prevailed in the valley of Peshawur in 1852 and
±853, and was believed to be contagious. The worst cases were complicated with
jaundice, and a relapsing tendency would seem to have been well marked in the
disease.

It is important to note that this form of fever would seem to be confined to extra-
tropical India, or to districts — Cutch, Kattywar — not much to the south of the
tropic.

* Grant College Medical Society, Retrospective Address for the year 1857, by the
author.

ADYNAMIC REMITTENT FEVER. 159

tery, diarrhoea, and jaundice were the complicating conditions in
other cases. In the general immunity from intermittent fever at
Aden, there is evidence that the true ague-malaria is not abundantly
generated there, and this view is further supported by the physical
characters of the locality — the absence of vegetation and moisture.
It is therefore reasonable to conclude that this fever of bad type
was due, in great part, to the defective sanitary conditions which
existed, and was probably allied to the fever described in this
chapter as having occurred at Pali, and other localities in the
northern parts of India. The question of infection is not noticed
by Mr. Hormuzjee in his report.

160 TYPHOID FEVER.

CHAP. VIII.

ON TYPHOID FEVEE.

In the first edition of this work I stated that typhoid fever was
unknown in India. Shortly after my return to Bombay a case of
fever came under my observation towards the end of November,
1856, which led me to doubt the correctness of this opinion. The
subject was a European female, and the attack commenced the day
after her arrival from England by the overland route. The symp-
toms were febrile heat without distinct remissions, much prostration,
febrile expression of countenance, tremulous hands, dry lips, the
tongue dry and brownish in the centre, and some degree of tym-
panites. The bowels were very readily acted on by small doses of
laxatives, and on one or two occasions blood was intermixed with
the feculent discharges. Quinine was given without effect, and
then omitted after two or three days, when the treatment con-
sisted of small opiates, and attention to suitable nourishment The
fever persisted for twenty-one days, after which there was slow
amendment, but the patient was not able to leave the house till the
thirty-fifth day from the commencement of the illness.

This seemed to me to be a mild case of typhoid fever, and not
long after its occurrence the reports* of Dr. Ewart and Mr. Scriven
on typhoid fever Came under my notice, and, more recently, the
doubts which I still entertained were removed by a clinical
lecturef by Dr. Edward Groodeve, in which seven cases of un-
doubted typhoid fever are detailed. As the object of this work
is to record my personal experience, a detailed description of
typhoid fever would be misplaced, as it could only be drawn from
sources equally open to my readers.

The investigation which has thus been commenced is of much
practical importance, in consequence of the principles of treatment

* ''Indian Annals of Medical Science," vol. iv, pp. 65, 511.
t ma. No. xi. p. 141.

TYPHOID FEVER. 161

of typhoid fever differing so materially from those of malarious
fevers ; and it will require to be prosecuted with much care, in order
that the tendency so common in medical research to exaggerate the
importance of new subjects of inquiry, to the neglect of established
truths, may be sufficiently controlled. With this view I would
venture to suggest : - -

1. That the locality, season and supposed causes be always
stated, for it is not improbable that typhoid fever will be chiefly
found in extra-tropical India, or in inter-tropical provinces, in the
near proximity of the tropics and in the winter rather than the
autumnal malarious season.

2. That it be recollected that disease of Peyer's glands, either in
the stage of turgescence or ulceration, is not a morbid state peculiar
to typhoid fever. It occurs in cholera, in protracted diarrhoea, in
acute muco-enteritis, as an occasional complication of remittent
fever, and a frequent one of phthisis pulmonalis.

3. From the last statement it follows, that we are not justified
in asserting the existence of typhoid fever from the mere character
of the post-mortem appearances. These require to be interpreted
by the symptoms which have been present during life, in order
that they may be correctly understood.

4. The observation made by Dr. Jenner, and confirmed by Dr.
Watson, that they never saw jaundice in typhus or typhoid fever,
is important to remember.

5. That' the so-called typhoid (adynamic) symptoms are not
I^eculiar to one form of fever, but may occur in all, is well known,
and should not be forsfotten.

162 COMMON CONTINUED FEVER — FEBRICULA.

CHAP. IX.

ON COMMON CONTINUED FEVER — FEBRICULA — AND ARDENT
CONTINUED FEVER.

Section I. — General Remarks,

In India and other tropical countries, in addition to intermittent
and remittent fevers, there occur forms of idiopathic fever produced
by ordinary exciting causes, — as vicissitudes of temperature, great
heat, violent exercise, excitement of mind, excesses in eating,
intemperate habits, and imperfect excretion. The fevers thus
excited differ in degree rather than character. To the milder form,
the terms ephemeral fever, common continued fever and febricula,
have been almost indiscriminately applied. To the severer form,
the designation ardent fever has been given.

They are most common in those parts of India which do not
experience much of the influence of the monsoon rains, and whose
hot season is not tempered by regular breezes from the sea. They
are .more met with in the central parts of the table land of the
Deccan and Mysore, the Ceded districts, the coast of Coromandel,
Scinde, and the Punjaub, than in Bengal or Bombay, and the
western coast line south of Surat. They chiefly occur in March,
April, and May ; but also prevail in June and July in localities
where the temperature is elevated, and the conditions of malaria
are absent.

Section II. — Common Continued Fever — Febricula.

The mildest variety — ephemeral — may proceed from any of the
ordinary exciting causes which have been mentioned, and though
most common in unseasoned Europeans, may occur in Natives as
well as in Europeans who have been some time resident in India.
It consists of febrile symptoms without local complication, com-
mencing with chills, followed by reaction, and this by perspiration,

COMMON CONTINUED FEVER — FEBRICULA. 163

and thus is removed in from twenty-four to thirty-six hours. But
the febrile reaction may continue for periods of four or five days ;
and then the term covimon continued fever is more correctly
applied. It would be convenient, however, to substitute for these
two designations, the single name, febricula. For the treatment of
ephemeral and common continued fever, such means as an emetic,
purgatives, tepid sponging, diaphoretics, and antiphlogistic regimen
are employed. In plethoric individuals, when there is much
headache and flushing of the face, a moderate general blood-
letting, or leeches to the temples, may be an expedient measure,
but they are not often necessary. These are not serious affections,
and do not differ from the fehricula of the colder climates ; but
the degree of reaction has always relation to the state of constitu-
tion, whether sthenic or not.

This form of fever occurred under my observation in the troops
at Poena, in 1858 and 1859. In March, April, and May, the 17th
Lancers, the 3rd Dragoon Guards, the 18th Eoyal Irish, and the
D Troop, Horse Artillery — all recently arrived — suffered from
febricula, marked by headache, flushed face, coated tongue, and
pains of loins and limbs, subsiding and disappearing in from two to
four days under moderate treatment. The 3rd Dragoon Guards were
affected in greatest degree, consequent, as was supposed, on an im-
perfect head-dress, late morning parades, and suspected excesses in
drinking. In the D Troop there was in some cases an eruption of
roseola, or erythema, about the loins and thighs, which came and
disappeared with the fever. The recruits of the Native Eegiments
at Poena were also sickly from febricula during the rains — June,
July, August — of this year, consequent, in all probability, on too
much drill and insufficient protection from cold and wet, owing to
the badness of their huts.

A comparison of the state of health, as respects febricula, of the
31st Eegiment and the Grerman Legion, at Poena, from December
1858, to April 1859, is interesting, because both regiments arrived
from the Cape of Grood Hope about the same time, and the differ-
ence was doubtless due to the different sanitary conditions of the
two bodies of men.

The 31st was composed of seasoned, well-equipped, and disci-
plined soldiers, and not, as was the case with many regiments sent
to India to meet the late exigency, in great part of young recruits.
They also occupied the best barracks at the station.

The Grerman Legion consisted of badly-selected volunteers,
who had been ill-cared for at the Cape, and a considerable number

164

AIIDENT CONTINUED FEVEE.

of whom left the colony tainted with scurvy and syphilis, and
reached India in that condition. They were ill-equipped, occupied
the worst barracks at Poona, were, perhaps, too much exposed
at drill, but were not intemperate. The Indian ration was much
more than they had been accustomed to. The scorbutic taint
rapidly disappeared, and the men gained in flesh and strength.
In fact, the Indian ration, and the Deccan cold season, so
raised the constitution of these men, that it was, at the commence-
ment of the hot months, similar to that of troops freshly arrived at
that season. They were therefore more predisposed than the men
of the 31st, who had not, in the cold months, undergone a change
of this kind.

The general symptoms in the Grerman Legion were considerable
febrile excitement, flushing, headache, coated tongue, occasional
vomiting, and sometimes cramps of the legs : with recovery in
from three to four days. In a small proportion a remittent
tendency was noticed. The treatment consisted of an ipeca-
cuanha emetic, — which generally acted also on the bowels — acid
drinks, and antiphlogistic regimen. There was no fatal case ;
seldom a readmission.

Admissions from Fever in the 31st Eegiment and the German Legion, at
Poona, from December, 1858, to April, 1859.

December
January
February
March .
April

31st Regiment.
Strength ranged
from 864 to 1116.

14
24
37
25

103

German Legion.
Strength, 1027,

8
65

127

283

548

During the hot season, a squadron of the 6fch Inniskilling Dra-
goons (late arrival) suffered from severe febricula at Sattara,
consequent chiefly on insufficient protection in temporary barracks.
The 22nd Native Infantry were sickly at Ahmednuggur from
febricula at the same time; of a strength of 886, there were 214
cases of fever^ chiefly febricula, admitted in April.

Section III. — Ardent Continued Fever.
Ardent continued fever is almost confined to tropical coun-
tries, and is a very serious disease. The exciting causes are

SYMPTOMS AND PATIIOLOaY. 165

elevated temperature, exposure to the sun, excessive exercise,
mental excitement, excesses in eating, intemperance, defective
excretion. There may be several of these causes combined.
But in order to produce the disease in its most aggravated form
elevated temperature is a necessary condition ; and another is, that
there should be present that kind of predisposition peculiar to the
robust European lately arrived in a warm climate. This form
of fever, then, is almost confined to the hot and dry months of the
year in arid localities, and to regiments or recruits recently arrived
from Europe.

Symptoms. — The attack is generally sudden, often without
much chilliness. The face becomes flushed, and there is giddiness
with much headache, and intolerance of light and of sound. The
heat of skin is ^reat, and the pulse frequent, full and firm. There
is pain of limbs and of loins. The respiration is anxious. There
is a sense of oppression at the epigastrium, with nausea and
frequently vomiting of bilious matters. The bowels are sometimes
confined ; but, at others, vitiated bilious discharges take place.
The tongue is white, often with florid edges. The urine is scanty
and high coloured. If the excitement continues unabated, the
headache increases, and is often accompanied with delirium. If
symptoms such as these persist for from forty-eight to sixty hours,
then the febrile phenomena may subside, the skin may become cold,
and there will be risk of death from exhaustion and sudden collapse;
or in cases in which the cerebral disturbance is great, death may
take place at even an earlier period in the way of coma ; or when
symptoms of gastritis are very prominent, exhaustion may hasten
the fatal result ; or jaundice may appear and increase the danger.

The continuance for two or three days of excessive vascular
action, such as that now described, must necessarily be followed by
a corresponding depression ; and in this we have the explanation of
the collapse and exhaustion which become developed as the febrile
excitement subsides. Again, the excessive action, with the addition
of retained excretions, must vitiate the blood ; and in some cases
there is evidence of this condition in the dark grumous matters
vomited and evacuated from the bowels. When these phenomena
are present, exhaustion and collapse become very prominent, and
are no doubt in a great measure attributable to the influence of the
deteriorated blood.

The diagnosis between this form of fever, and inflammatory
remittent has been already considered (p. 57), and the remarks
then made should now be referred to.

M 3

166 ARDENT CONTINUED FEVER.

Pathology, — In the excessive vascular action of this form of
fever there is risk to important organs, as in the stage of exacer-
bation of the severer remittents. There is also danger from
prostration, after a time, in consequence of continuance of high
febrile excitement.

But between the pathology of ardent and remittent fever there
is believed to be this great difference. In the former there is no
materies in the blood, as in the latter, exercising a sedative
influence on vital actions, and requiring time for its elimination.
Therefore, we may hope that by subduing the vascular excitement
at the outset of ardent fever we are adopting the most efficient
means for shortening the duration of the disease.

Treatment. — There is much more scope in the treatment of
ardent fever for the use of free and repeated general and local
blood-letting, cold affusion, tartar emetic when * tolerated, and
mercurial and other purgatives. It must, however, be borne in
mind, that these means are only effective when used promptly in
the early periods of the fever, and that, if they be delayed till the
third or fourth day, — when in the course of the disease the pheno-
mena of prostration may be looked for, — their effect must be to
hurry on the fatal result. They must be adopted also in recollec-
tion of the difficulties which sometimes beset the diao^nosis of this
from the remittent form of fever, and of the greater caution
required in their use in the latter disease.

The symptoms of ardent fever, and the success of prompt and
active treatment, are well illustrated in Dr. Arnott's Medical
History of the Bombay Fusileers in the Punjaub.* The fever
prevailed chiefly in the months of June, July and August at
Peshawur, when the men were in tents imder a temperature
ranging from 70° to 114°, described by the author as intense, with
hot blasts and thick suffocating clouds of dust, and as fearfully
oppressive day and night, and completely breaking and disturbing
rest. In these months 884 admissions from fever took place, and
not a single dea,th.

Dr. Arnott thus describes the character of the fever and the
nature of the treatment which he followed : —

" The character of the epidemic fever which prevailed in July and August may be
inferred, when I mention that out of the 798 cases admitted in these two months, not
a man died. The symptoms on admission, it is true, were often very urgent, and
demanded the most prompt and decided measu.res for their relief. There was pungent

* "Transactions of the Medical and Physical Society of Bombay," 1st Series.
10th Number, p. 34.

TKEATMENT. 167

lieat of skin ; great thirst ; parched, red, and dry tongue ; quick, full, and strong
piilse ; racking pains in diiFerent parts of the body and acute headache, with flushed
countenance ; throbbing of the temples, restlessness, nausea, and vomiting of bilious
matter, &c. ; which symptoms, no doubt, were in many instances aggravated by the
indifferent shelter the men had from the inclemency of the weather in that hot
Vidley. The autumnal fever, which afterwards appeared, was almost equally mild, as
we lost only three men from fever in October, November, and December,*

" To describe the plan of treatment of a disease having such marked symptoms
seems almost superfluous. Evacuants fully and freely employed, with copious and
repeated venesection, cupping and leeches (in fact, I never at any former time had
occasion to prescribe bleeding, either to the same extent or so frequently), aided by
tartar emetic, till all local determination and the chief urgent symptoms were removed,
and afterwards quinine, were the means had recourse to."

It is not to be supposed that all the cases in the Fusileers were
of the ardent variety, and presented the symptoms and required the
treatment described by Dr. Arnott ; doubtless, the greater number
were febricula, and yielded to moderate measures. But as there
was a proportion of ardent cases, and no deaths, the statement
shows that the active treatment followed in these was appropriate.

* In these three months the range of the thermometer was from 42° to 91°.

31 4

1G8 FEVER IN CIIILDllEN.

CHAP. X.

ON THE FEBEILE AFFECTIONS OF CHILDEEN IN INDIA. — FEBRICULA.
INTERMITTENT AND REMITTENT FEVER.

The fevers of children in India are best understood by keeping in
view the principles which have been stated in respect to adults.

During the period of infancy — from birth to the end of the
second year — attacks of febricula occur from errors in diet or the
irritation of teething, just as in the colder climates, and they
require the application of the same general principles of treatment.
It is also necessary in the management of the febrile affections of
early life, in India as elsewhere, to be careful in our diagnosis, and
not to mistake the fever symptomatic of an internal inflammation
for simple febricula. This caution is very necessary in regard to
native children in the cold season in Bombay, for I have seen
several cases in which pneumonia had been overlooked.

Intermittent or remittent fevers are, according to my experience,
not common in the period of infancy ; they doubtless occur, and
probably much more frequently, in very malarious districts, than I
have myself witnessed. The most striking instance that I have
seen was early in November 1837. On the Ehore G-haut, midway
between Campooly and Khandalla, on the route from Bombay to
Poona, there is a small house situated on the margin of a ravine
for the accommodation of the gatherer of the tax levied on carts
and bullocks passing over the mountain. At the time adverted to
it was occupied by an old European pensioner and his wife ; they
had both suffered from intermittent fever. In the woman the
indications of malarious fever were well marked in her sallow
countenance and emaciated frame, and at the time I saw her she
was suffering from tertian fever. She had an infant six weeks
old, whom she was nursing, and it also experienced regular febrile
paroxysms commencing with a well-marked cold stage. I saw the
child in the cold stage of one of the attacks.

FEVEK IN CHILDREN. 169

During the period of childhood, from the third to the tenth year
and upwards, febricula is met with as in colder climates, proceeding
from the same ordinary causes, and exhibiting that feature of re-
mittence characteristic more or less of all the febrile affections of
early life. These should be treated on the same principles as in
other countries.

But in India, during childhood, just as in the adult, malarious
fevers are by far the most frequent idiopathic forms. I have
before me the diaries of many cases of intermittent and remittent
fever treated by me in the Byculla Schools, while I held medical
charge of that institution. They resemble the same affections in
the adult, and require the same means of treatment modified to
difference of age and peculiarities of constitution. Quinine may
be used with the same freedom as in the adult, and it constitutes
as essential a part of the treatment. There has been hesitation on
this point in the minds of many ; but I can state, on the authority
of my own experience, and that of friends in whose judgment I
place confidence, that two or three-grain doses may be given with
safety, in necessary cases, in a child of three years of age. A
European child of about seven years of age, ill for several days with
intermittent fever, uninfluenced by a grain and a half dose of
quinine, was brought to me. The recurrences were at once pre-
vented by five or six-grain doses.

From the results of recent research, it may be concluded that
occasional attacks of typhoid fever may also be looked for in
children in India.

170 STATISTICS OF FEVE15.

CHAP. XI.

STATISTICS OF FEYEK IN THE EUROPEAN GENERAL HOSPITAL, THE
JAMSETJEE JEJEEBIIOr HOSPITAL, AND BYCULLA SCHOOLS, AT BOMBAY.

Section I. — European General Hospital, — Total Fevers,

Tables V., VI., VII. represent * the total * admissions of fever
(4,037) into the European Greneral Hospital at Bombay for the
fifteen years from 183-8 to 1853, arranged in quinquennial periods.
Table V. is for a period during which I was assistant surgeon in
the hospital, and includes cases from which a part of the clinical
observations recorded in these pages has been drawn. For
Tables VI. and VII. I am indebted to Dr. Stovell, when surgeon
of the hospital.

When we compare the proportion of fever admissions in these
three quinquennial periods, we find a remarkable difference be-
tween the first and the last. In the former (1838 to 1843^ the
fevers to the total admissions were 24*2 per cent. In the latter
(1849 to 1853) only 13-5. In the middle period (1844 to 1848)
they were 20*6.

In the three tables the greater proportion of admissions in the
six months, from June to November, is well shown — it is 24*1 ;
whereas that from December to May is 14. And if we omit the
last quinquennial period — that in which fever admissions were
comparatively few — we find that the proportion differs still more
widely. That from June to November the fevers are 28-8 per cent,
of the total admissions. From December to May they are 15.
The month of October, however, is that of greatest prevalence —
they amount to 37*5 per cent.

When we regard the mortality from fever in this hospital, we
find it to be very uniform for these three periods. In the first
table it is 3*5 per cent, of the admissions; in the second 3-3;

* They are chiefly intermittent and remittent. The proportion of ephemeral fevers
is very small; it is only given for the first quinquennial period, in which they
amounted to 87 per cent, of the total fever admissions.

EUROPEAN GENERAL HOSPITAL.

171

in the third 3*1.* From 1838 to 1848 the proportion of fever
mortality to total hospital deaths is 12*1 ; but from 1849 to 1853
it is only 6-7.
Table Y. — Admissions and Deaths^ with Per-centage^ from Fever of all

hinds, in the European General Hospital at Bombay, for the Six Years

from July 1838 to July 1843.

July 1838 to July 1843.

Monthly Average of the Six Years.

Admissions.

Deaths.

Deaths on
Admissions.

Admissions

on total
Admissions.

Deaths on
total Deaths.

January-

105

4.7

19-1

11-5

February

3-6

13-3

6-2

March .

14-5

April .

5'Q

151

121

May

154

1-9

17-9

3-7

June .

219

2-7

28-4

11-7

July .

219

3-1

30-5

18-9

August .

179

4-4

29-3

22-8

September .

141

5-Q

25-8

15-3

October

318

1-8

44-

22-2

November .

193

2-5

28.1

10-6

December
Total .

8-5

15-3

12-1

1839

3-5

24-2

12-1

Table VI. — Admissions, and Deaths, with Per-centage, from Fever of all
kinds, in the European General Hospital at Bombay, for the Five Years
from 1844 to 1848.

1844 to 1848.

Monthly Average.

Admissions.

Deaths.

Deaths on
Admissions.

Admissions

on total
Admissions.

Deaths on
total Deaths.

January

105

5-7

17-0

13-0

February

4-7

16-5

11-5

March .

1-7

12-2

3-3

April .

3-0

131

e>-o

May

4-0

16-9

13-3

June

172

2-9

24-1

15-2

July .

196

2-0

28-8

11-1

August

154

2-6

28-1

26-6

September

100

2-0

21-8

9-1

October

188

4-2

31-1

21-0

November .

136

3-7

24-3

16-4

December

3-4

11-1

5-0

Total .

1419

3-3

20-6

12-1

* Dr. Stovell's report (" Statistics of European General Hospitals for Ten Years,"
" Transactions of Medical and Physical Society, Bombay," New Series, No. 3) extends
to March 1856 ; and shows a decreasing mortality from fever, that for the five years
from 1851 to 1856, being 0'789.

172

STATISTICS OF FEVER.

Table VII. — Admissions and Deaths^ with Per-centage, from Fever of all
hinds, in the European General Hospital at Bomhay, for the Five Years
from 1849 to 1853.

1849 to 1853.

Monthly Average.

Admissions.

Deaths.

Deaths on
Admissions.

Admissions

on total
Admissions.

Deaths on
total Deaths

January

8-3

10-6

10-3

February-

7-8

10-3

16-6

March .

—

9-8

—

April .

6-6

8-7

12-0

May .

—

17-5

—

June

1-3

13-6

3-4

July .

4-6

16-4

12-1

August .

4-8

12-0

7-8

September

—

13-8

—

October

—

13-2

—

Noyember

5-3

17-8

16-6

December

1-1

15-3

2-5

Total

779

3-1

13-5

6-7

Section II. — European General Hospital. — Intermittent Fever.

Tables VIII., IX., X. give the admissions from intermittent
fever, from 1838 to 1853, also arranged in tliree quinquennial
periods. They show that the proportion of this type to the total
admissions from fever has been 73*6 per cent.

We found from Tables V., VI., VII. that the proportion of fever
admissions from June to November was nearly double that of from
December to May ; but the present Tables show that the excess of
the first half year is not due to admissions of the intermittent
type, for the proportions of intermittents to total fevers is from
June to November 72*3, and from December to May 75*1.

The deaths are 1*1 per cent, of the admissions. It has been
stated (p. 24) that we have no data which correctly show the
mortality from simple intermittent fever. Much of the mortality
stated in these tables (and I may add in hospital returns generally)
is, I am satisfied not accurately recorded as directly proceeding
from intermittent fever. It occurs from inflammations arising in
malaria-tainted constitutions, and should be entered under the
head of the inflammation, whatever it may be.

Table XI. shows the ephemeral fevers from 1838 to 1843.

EUROPEAN GENERAL HOSPITAL.

173

Table VIII. — Admissions and Deaths, with Per-centage, from Inteimiitlent
Fever, in the European General Hospital at Bomhaij, for the Five Years
from July 1838 to July 1843.

July 1838 to July 1843.

Monthly Average.

Admissions.

Deaths.

Deaths on
Admissions.

Admissions

on
total Fever
Admissions.

Deaths on

total Fever

Deaths.

January-

1-3

73-3

20-0

February

2-3

78-2

50-0

March .

3-4

79-7

66-0

April .

3-4

68-2

40-0

May .

109

0-9

64-3

33-3

June

169

0-6

77-2

16-7

July .

i;i6

0-8

62-1

14-3

August .

113

—

631

—

September

2-2

65-2

25-0

October

262

115

82-4

500

November

151

—

78-2

—

December

77-7

50-0

Total

1344

1-3

72-0

27-3

Table IX. — Admissions and Deaths^ with Per-centage, from Intermittent
Fever, in the European General Hospital at Bombay, for the Five Years
from 1844 to 1848,

1844 to 1848.

Monthly Average.

Deaths

Admissions

Deaths

Admissions.

Deatno.

on
Admissions.

total Fever
Admissions.

total Fever
Deaths.

January

82-9

16-6

February

1-4

81-2

25-0

March ..

—

86-5

—

April .

—

85-1

—

May .

—

88-8

—

June

144

0-7

83-7

20-0

July .

163

1-8

83-2

75-0

August .

116

—

74-0

September

—

81-0

—

October

167

2-4

88-8

50-0

November

114

1-7

83-8

40-0

December

—

76-0

—

Total

1181

1-02

83-2

25-0

174

STATISTICS OP FEVER.

Table X. — Admissions and Deaths, with Per-centage, from Intermittent
Fever, in the European General Hospital at Bombay, for the Five Years
from 1849 to 1853.

1849 to 1853.

Monthly Average.

Deaths

Admissions

Deaths

Admissions.

Deaths,

on
Admissions.

total Fever
Admissions.

total Fever
Deaths.

January

6-3

66-6

50-0

February

—

65-8

—

March ,

74-4

April .

3-3

66-6

33-3

May .

—

65-9

—

June

58-9

July .

1-9

60-9

25-0

August .

2-7

59-7

33-b

September

—

61-2

—

October

—

61-5

—

November

72-0

December

—

72-0

—

Total

511

0-98

65-6

20-8

Table XI. — Admissions and Deaths, with Per-centage, from Ephemeral
Fever, in the European General Hospital at Bombay, for the Five Years
from July 1838 to June 1843.

July 1838 to June 1843.

Monthly Average.

Admissions.

Deaths.

Deaths on
Admissions.

Admissions

. on
total Fever
Admissions.

Deaths on

total Fever

Deaths.

January

Februar

March

April

May

June

July

August

Septeml

October

Novemb

Decemb

)er

er
er

13
5

23
8

0
0
0
0
0
0
0
0
0
0
0
0

12-4

8-9

10-8

10-2

13-6

10-5

3-7

9-5

10-5

7-2

4-6

8-5

0
0
0
0
0
0
0
0
0
0
0
0

To1

.al

159

8-7

JAMSETJEE JEJEEBHOY HOSPITAL. 175

Section III. — Jamsetjee Jejeebhoy Hospital, — Total Fevers.

Table XII. gives the total admissions of fever into this hospital
from 1848 to 1853, a period of six years ; they amount to 2,473.*
Compared with the European Greneral Hospital, it shows a smaller
proportion of fevers to total admissions ; it is 9*8, that in the
European Greneral Hospital for the same years is 13*5 per cent. In
the half year from June to November the excess is also less ; the
proportion is 10*8 per cent, of the total hospital admissions, while
in the half year from December to May it is 8*6. But in compar-
ing this proportion with the average of the European Greneral
Hospital we must bear in mind that for the years included in this
Table (XII.) the difference between the two half years was in the
European Greneral Hospital much below that of the ten preceding
years. It was from June to November 14*4 ; from December to
May 12.

The mortality from fever in this Hospital has been 12*4 per cent.;
that in the European Greneral Hospital was 3*3.

In this difference we have an illustration of the kind of errors to
which statistical statements must inevitably lead when applied ta
etiology and therapeutics, unless used by those who are familiar
with all the circumstances of the individuals to whom the figures
relate.

A statistical inquirer, from a comparison of the mortality in the
European Greneral Hospital for Europeans, and the Jamsetjee
Jejeebhoy Hospital for Natives, as shown in Tables V., VJ., VII. and
XII., might infer that fever is a more fatal disease in Natives than
in Europeans, and that the treatment of the disease was not so well
understood in the one hospital as in the other.

But I, who have had a lengthened clinical experience in both
liospitals, know that these inferences would be altogether erroneous.
The high mortality in the Jamsetjee Jejeebhoy Hospital is simply
due to the very destitute state of a large proportion of its inmates,
and the very advanced stages of disease at which they seek for
admission.

* The clinical cases, so frequently adverted to, were selections from this nximber.

176

STATISTICS OF FEVEE.

Table XII. — Admissions and Deaths, with Per-centage, from Itemittent
and Intermittent Fever *, in the Janisefjee Jejeehhoy Hospital at Bombay,
for the Six Years from 1848 to 1853.

1818 to 1853.

Monthly Averag

Deaths on
Admissions.

Admissions

; Deaths

Admissions.

Deaths.

on total
Admissions.

on total
Deaths.

January

183

21-8

8-7

8-9

February

146

20-6

7-2

9-4

March .

139

16-0

6-0

5-9 .

April .

168

9-5

7-9

4-6

May .

218

9-1

9-9

6-9

June .

194

10-3

9-3

6-5

July . .

210

9-04

10-4

6-2

August .

214

8-4

10-8

5-5

September

202

12-3

9-8

8-3

October

274

9-9

12-8

7-9

November

251

10-3

11-6

7-8

December

274

15-7

11-8

10-8

Total

2,473

308

12-4

9-8

7-5

Section IV. — Jamsetjee Jejeehhoy Hospital. — Interwiittent Fever.

The proportion of admissions of this type to the total fevers is
69*1 ; that for the half year from June to November being 72*5 ;
that from December to May 63-9. The mortality is 0*9.

In the proportion of intermittents in the two half-yearly periods,
we have the converse of what is stated in respect to the European
General Hospital : in it the greater proportion is in the half year
including the cold months of the year. In the Jamsetjee Jejeeh-
hoy Hospital it is in the half year which includes the malarious
months.

This discrepancy is to be explained by the fact, that, in the Eu-
ropean Greneral Hospital, a considerable proportion of the admis-
sions from intermittent fever are of individuals who have arrived
from other malarious countries, and who, reaching Bombay in the
cold season, have the disease re-excited, not by the malaria of
Bombay as an exciting cause, but by cold or other atmospheric
states acting on a tainted system. This is not the case in the
Jamsetjee Jejeehhoy Hospital to nearly the same extent.

* This Table might have been entitled " Fevers of all Kinds," for the admissions
under the head "Ephemeral" have been very few.

EUROPEAN GENERAL HOSPITAL.

177

Table XIII. — Admissions and Deaths^ with Per-centage, from Intermittent
Fever, in the Jcmisetjee Jejeehhoy Hospital at Bombay /for the Six Years
from 1848 to 1853.

1848 to 1853.

Monthly Average.

Admissions

Admissions.

Deaths.

Deaths on
Admissions.

on
total Fever
Admissions.

Deaths on

total Fever \

Deaths.

January

107

5-6

58-5

15-0

February

3-4

60-6

100

March .

56-8

April .

111

—

66-1

May

148

1-4

67-8

10-0

June .

152

78-3

July .

169

1-8

80-4

15-8

August ,

140

65-4

5-5

September

141

69-8

October

185

0-5

67-5

3-7

November

186

74-1

December

202

0-49

73-7

2-3

Total .

1709

0-9

69-1

5-5

Section V. — European General Hospital — Remittent Fever,

Tables XIV., XV., XVI. show that the proportion of this type,
to the total fevers, is 16*6 * per cent.

When we compare the proportion in the half-years, from June to
November, and December to May, we find that it was 19*8 per cent,
in the former, and 13 "6 in the latter.

The mortality from this type is, for the 15 years f, 15*1 per
cent, on the admissions, and 76*1 per cent, of the total deaths
from fever.

In regarding the mortality from remittent fever in this hospital,
it must be borne in mind that, from the variety in the inmates,
and the not unfrequent advanced periods of admission, it is neces-
sarily higher than that of European regimental hospitals.

* That 16-6 of this type, with the proportion of Intermittents, does not complete the
total admissions, is to be explained by the abstraction of 8*7 for Ephemerals in the
first quinquennial period.

t Dr. Stovell's decennial Beport shows a remarkable decrease in the mortality, from
1853 to 1856. For the five years from 1846 to 1851, the ratio keeps up to that in the
text— it is 15-423 ; but for the five years from 1851 to 1856, it falls to 4-838 per cent.

178

STATISTICS OF FEVEK.

Table XIV. — Admissions and Deaths, with Per-centage, from Remittent
Fever, in the European General Hospital at Bombay, for the Five Years
frcm July 1838 to June 1843.

July 1838 to June 1843.

Monthly Average for the Five Years.

Deaths

Admissions

Deaths

Admissions.

Deaths.

on
Admissions.

total Fever
Admissions.

total Fever
Deaths.

January-

26-6

14-1

80-0

February

14-2

12-7

50-0

March .

14-2

9-4

33-3

April .

15-7

21-5

60-0

May .

8-3

15-5

66-6

June .

18-5

12-3

83-3

July .

8-0

34-7

85-7

August .

16-3

27-3

100 0

September

17-6

24-1

75-0

October

9-0

10-3

50-0

November

15-1

170

100-0

December

30-0

13-7

50-0

Total

336

14-2

17-6

72-7

Table XV. — Admissions and Deaths, with Per-centage, from Remittent
Fever, in the European General Hospital at Bombay, for the Five Years
from 1844 to 1848.

1844 to 1848.

Monthly Average.

Deaths

Admissions

Deaths

Admissions.

Deaths.

on
Admissions.

on
total Fever

Admissions.

Deaths.

January

31-3

15-2

83-3

February

20-0

11-7

50-0

March .

20-0

8-5

100-0

April .

10-0

14-9

50-0

May .

36-4

111

100-0

June .

16-0

14-5

80-0

July .

12-0

12-7

75-0

August .

11-1

23-4

100-0

September

12-5

16-0

100-0

October

23-8

11-2

62-5

November

15-0

14-7

60-0

December

18-2

18-9

100-0

Total

206

17-4

14-5

76-6

JAMSETJEE JEJEEBHOY HOSPITAL.

179

Table XVI. — Admissions and Deaths, with Per-centage, frmn JRemittent
Fever, in the European General Hospital at Bombay, for the Five Years
from 1849 to 1853.

1849 to 1853.

Monthly Average.

Admissions.

Deaths.

Deaths

Admissions.

Admissions

on
total Fever
Admissions.

Deaths

total Fever

Deaths.

January
February
March .
April .
May .
June .
July ,
August .
September
October
November
December

2
3
0
2
0
1
3
2
0
0
5
1

250

42-8

50-0

6-2
14-3
13-3

38-4

16-7
18-4
4-6
8-9
14-2
20-5
24-1
25-8
16-4
30-8
13-9
16-1

50-0
100-0

66-6

100-0
75-0
66-6

100-0
100-0

Total

138

13-7

17-7

79-2

Section VI. — Jamsetjee Jejeebhoy HospitaL — Remittent Fever,
The proportion of remittents to intermittents is 32-1 per cent. :
double that of the European Greneral Hospital. If the inference
be drawn from this statement that the remittent is more frequent
in Natives, compared with the intermittent type, than in Europeans,
it would be a correct deduction from the tables ; but it would be
an application of the figures to a question which they are not
calculated to solve. The fact is, that natives do not readily
resort to a civil hospital for mild attacks of fever ; therefore the
proportion of the severer type is greater than in a European hos-
pital, partly civil and partly military in its character.

In the half year from June to November the proportion of
this type is 29 ; in the half year from December to May it is 36
per cent. We have found that, from June to November the pro-
portion of remittents was greater, but that of intermittents was less,
in the European Greneral Hospital; whereas in the Jamsetjee
Jejeebhoy Hospital the proportion of remittents was less, that of
intermittents was greater. On the other hand, in the half year
from December to May intermittents were proportionally greater,
and remittents less, in the European Greneral Hospital ; but in the
Jamsetjee Jejeebhoy Hospital the proportion of remittents ex-
ceeded that of the intermittents, and fell short of that of the other
half year.

N 2

180

STATISTICS OF FEVER.

It may be suggested, in explanation of the greater proportional
prevalence of remittent fever in the native inmates of the Jamsetjee
Jejeebhoy Hospital, in the half year including the cold months,
than in that including the malarious months — that many of
them are instances of malarious fever, assuming the remittent
character in consequence of inflammatory complication — pneumonia
or other — induced by cold, to the influence of which, as an exciting
cause, the badly fed and clothed classes of the native community
are very susceptible.

The greater proportion of fever deaths in natives in Bombay,
in the half year from December .to May, also appeai-s in Mr.
Leith's Mortuary Eetm-ns ; it is — for the five years from February
1848 to January 1853 — 54*44 of the total mortality; whereas the
proportion for the half year from June to November is 45-55.
This fact is also to be explained in the same manner, with the
addition that, as a large number of the returns are made from non-
professional sources, it is probable that part of the mortality
recorded as due to fevers has been caused by inflammations with
symptomatic fever. This is Mr. Leith's opinion.

I have already explained the probable cause of the proportional
excess of intermittents in the European Greneral Hospital in the
non-malarious half of the year. We have found, however, that the
remittent type is in greatest proportion in the malarious six months
— for then we have a more fixed community, and more of the
influence of the malaria of the island as an exciting cause.

Table XYII. — Admission and Deaths^ with Per-centage, from Remittent
Fever, in the Jamsetjee Jejeebhoy Hospital at Bombay, for the Six Years
from 1848 to 1853.

1848 to 1853.

Monthly Average.

Admissions

Deaths

Admissions.

Deaths.

Deaths on
Admissions.

on
total Fever
Admissions.

total Fever

Deaths.

January-

44-7

41-5

850

February

47-3

39-04

90-0

March .

38-3

43-1

100-0

April .

28-1

33-9

100-0

May-

25-7

32-1

90-0

June .

47-6

21-6

100-0

July .

31-4

24-3

84-2

August .

22-9

34-6

94-4

September

36-6

35-1

100-0

October

29-2

32-5

93-3

November

0,5

40-0

25-9

100-0

December

58-3

26-3

97-7

Total

784

291

37-1

321

94-5

BYCULLA SCHOOLS.

181

Section VII. — Byculla Schools, — Intermittent and Remittent

Fever.

The averages are not given in the following table, because the
" strength" of the children and the total admissions are not known.
The strength has ranged from about 235 to 355.

It will be observed that there are no deaths from intermittent
fever, and that the ratio of mortality from remittent fever is 2*8
per cent, of admissions.

Table XVIII. — Admissions and Deaths, from Intermitent and Remittent
Fever, in the Byculla Schools, for the Seventeen Years from 1837 to
1853.

Intermittent Fever.

Remittent Fever.

Admissions.

Deaths.

Admissions.

Deatlis.

January

160

February

149

March .

153

April

172

May

184

June

214

July

284

August .

260

September

250

October .

226

November

197

December

117

Total

2,366

213

182

ERUPTIVE FEVEES.

CHAP. XII.

ON ERUPTIVE FEVERS.

Section I. — Prevalence in the Native Army,

The following statement exhibits the comparative prevalence of the
different kinds of eruptive fever in the native army of the Madras
and Bombay Presidencies for the five years from 1851-52 to
1855-56: —

MADRAS.

BOMBAY.

Admissions.

Deaths.

Admissions.

Deatiis.

Variola

Varicella ....
Eubeola ....
Scarlatina ....

Total .

495

1,229

114

22
1

310
612
113

1,839

1,035

The proportion of small-pox in the Bombay Presidency is probably
understated, in consequence of cases being returned ^* varicella,"
which are in reality modified small-pox. At all events, I observed
in the hospitals at Poona, in the early part of 1858, when small pox
prevailed, several cases in which this error of diagnosis had been
committed.

Section II. — Small-pox, as observed in Bombay.
Prevention by Vaccination.

Prevalence.

During five years of my service in the European Greneral
Hospital, from July 1838 to July 1843, 32 cases of small-pox
were admitted. Of these 25 took place in the months of January,
February, March, and April ; 4 in the month of November, that of
1839 ; and 3 — one in each month — in May, June, and July ; and
in the months of August, September, October, and December, there

SMALL-POX — STATISTICS.

183

was not, during these five years, a single admission from small-
pox. There were 5 deaths, which gives a mortality of 15*6 per
cent.

Dm*ing the ten succeeding years — from 1844 to 1853 — there
were 49 admissions of small-pox into the European Greneral Hos-
pital, and of these 44 were in the five months from January to
May. The deaths were 12, being a mortality rate of 25*6 per
cent.

In the course of the seventeen years from 1837 to 1853, 23
children of the BycuUa Schools suffered from small-pox, and 3 of
them died, a mortality of 1 3 per cent ; but the disease did not pre-
vail in each year of this period, 1838, 1841, 1843 to 1848 inclusive ;
1852 and 1853 were exempt.

,The subjoined tabular statement shows the admissions from
small-pox into the Jamsetjee Jejeebhoy Hospital for the six years
from 1848 to 1853 : —

Total.

Monthly Average.

Admissions.

Deaths.

Deaths on

Admissions.

Admissions
on total Ad-
missions.

Deaths on
total Deaths.

January

Februar

March

April

May

June

July

August

Septeml

October

Novemb

Decemb

)er

er
er

28-1
30-5
38-8
53-8
64-6
16-6
30-0
15-0

100.0
14.3

1-5
3-1
3-4
2-4
0-7
0-2
0-5
0-1
0-05

0-05
0-3

2-0
5-6
7-5
8-1
3-8
0-3
0-9
0-8

0-3
0-3

otal

•

261

104

39-8

1-03

2-5

Though daily ^dsiting the small-pox ward during the pre-
valence of the disease in these six years and the three preceding
ones, it was in the months of December 1845, January, February,
and March 1846, that I took immediate charge of the small-pox
patients, and made the following notes on the disease, as it occurs
in the hospital frequenting classes of the native community of
Bombay.

The number of admissions, and deaths from small-pox, during
these four months, are shown in this tabular statement : —

184

ERUniVE FEVEES.

►«

Monthg.

•a
3

1845

December

1846

January .......

February

»>

March

Total . . .

—

It exhibits a mortality of 46 per cent. The fatal cases were,
with very few exceptions, markedly confluent, and death took place
on the 3rd, 4th, 6th, 7th, 8th, 9th, 10th, and 11th days of the
eruption.

The cases which proved fatal before the seventh day of the erup-
tion, were generally instances in which the eruptive fever had been
characterised by very urgent symptoms, as delirium, much anxiety,
vomiting, pain of loins, badly-developed pulse, and had extended
beyond the usual period, having in two instances continued till the
fifth day. These symptoms were succeeded by a badly-developed
eruption. In these cases the urgent symptoms abated somewhat
on the first appearance of the eruption, but they in general re-
curred on the second and succeeding days, and proved fatal about
the fourth and fifth, with delirium, sinking pulse, and coma. Such
form of fatal result is to be accounted for, in a majority of cases, by
the circumstance of the febrile state being more or less congestive
and adynamic in tjrpe. There are, however, cases occasionally
to be observed which prove fatal under very much the same train
of symptoms, and at the same stage, in consequence of con-
gestion taking place in important organs, — as the lungs, —
during the eruptive fever, and, by its presence, preventing the
free development of the eruption. I have seen more than one
case fatal on the third or fourth day of a badly - developed
eruption, with complication of pneumonia marked by hurried
breathing and rusty sputa, dating back to the period of the erup-
tive fever.

The cases fatal after the seventh day of the eruption (and they
constitute the greater number) were generally those in which the
eruption had been copious and very confluent, and in which there
had been present hoarseness, with more or less dyspnoea and cough.
These signs of laryngeal and tracheal irritation increased towards
the eighth day, and proved fatal then, or in the early stage of

SMALL-POX — SYMPTOMS. 1 85

the secondary fever. The eleventh was the latest day of fatal
termination.

In none of the fatal cases were the symptoms usually termed
malignant observed, as petechise, the pustules filling with dark-
coloured serum, hsematuria or other haemorrhage. In a few of the
successful cases, glandular swellings, and the formation of small
abscesses, were troublesome during convalescence. In none of them
did injured vision take place.

The admissions from small-pox were, with four exceptions, con-
fined to Mussulmans and Portuguese : many of the former were
sailors, and probably strangers in Bombay ; several of the latter
had recently arrived from Groa. Of the affected with small-pox
7 were females, the rest males. The ages of 48 of the number
were —

5 years anc^Binder
15

20
30
40

to 20

to 30 inclusive

to 40

to oldest, 55

Total .

4
3

It is probable that almost all the admissions were of parties
unprotected by vaccination or previous small-pox, but on this point
it is often impossible to obtain trustworthy information from the
inmates of our hospitals ; for they are admitted, not unfrequently,
at stages of the disease when incapable of giving a connected history
of themselves, and are often unattended by friends able to supply
the deficiency.

Of the admissions which form the subject of these notes, there
was only one in which vaccination was undoubted and the marks
on the arms distinct. In this case the disease was very modified,
and confined to a few vesicles on the face, — and this, though
(as is usually observed) the initiatory fever had been very well
marked.

Several interesting cases of the modifying influence of vaccina-
tion came under my notice at Poona in 1858, especially one in the
hospital of the Bombay Artillery, and another in that of the 18th
Eoyal Irish. In both the initiatory fever ran high, and the
eruption came out copiously, with confluence on the face, and
up to its fifth day there was every indication of a dangerous attack,
when the distinct vesicles acuminated, and became turbid. On
the sixth day desiccation was in progress on the face, and before

186 ERUPTIVE FEVERS.

the acme of the natural disease — the eighth day — had arrived,
convalescence was well advanced.

As already stated, I have reason to think that modified
small-pox, in its mildest form, is liable to be mistaken for
chicken-pox. In chicken-pox there is little initiatory fever. The
pellucid vesicles are without central depression ; they come out
in successive crops, seldom appear on the face, and their contents
become turbid before desiccation begins. In modified small-pox the
initiatory fever is always well marked, often severe. The eruption
first appears on the face, then on the trunk and extremities, and
is often very scanty. The vesicles are depressed in the centre at
first, but they acuminate on the fifth day, their contents become
turbid, and on the sixth day they dry into small dark-coloured
crusts. In consequence of the eruption on the face preceding that
on the other parts of the body, — the character and development by
successive crops is in a measure simulated. But the liability to err
in the diagnosis turns on this point, that the period of depression
of the vesicles is of short duration, probably not more than twenty-
four hours, and is therefore very apt to be overlooked. When there
has been marked initiatory fever, acuminated vesicles, with turbid
contents, on the face, on the fourth or fifth day of the eruption,
with desiccation on the fifth or sixth, and at the same time (fifth or
sixth day) acuminated vesicles on the trunk and extremities, there
should be no hesitation in regarding the case as modified small-
pox — not varicella.

Treatment. — In the mild distinct small-pox with a moderate
eruption we may look for recovery ; and, with the exception of
mitigating the febrile disturbance by diaphoretics, aperients, if
necessary, and attention to purity of air and cleanliness, further
medical interference is unnecessary.

In the confluent form we have another illustration of the speedy
prostration of vital actions from the sedative influence of the
morbific cause, often aggravated by complicating derangement of
important organs.

All that can be attempted under these circumstances is to endea-
vour, by stimulants, nourishment, and opiates, to sustain the sys-
tem till the natural course and processes of poison elimination have
been gone through. It need hardly be added that attention to purity
of air and cleanliness are most important parts of these arrangements.
Finally, in respect to the initiatory fever the treatment should
always be very guarded, and conducted in recollection that the
dangers of prostration are likely soon to arise.

SMALL-POX — PREVALENCE, PREVENTION. 187

Prevalence and Prevention of Small-pox. — The best means of
prevention of this still very prevalent and fatal disease continue to
engage the attention of the Indian Grovernment. In the report of
the Small-pox Commissioners apppointed by the Grovernment oi
Bengal in 1850; in Mr. Bedford's Statistical Notes on Small-pox,
Vaccination, and Inoculation in India*, and in Dr. Mackinnon's
paper on the Epidemics of the Bengal and North- West Presidenciesf,
we have the latest and fullest consideration of this subject in rela-
tion to Bengal and the North- Western Provinces,

In the following remarks, however, I shall confine myself in a
great measure to the island of Bombay ; for I believe that in the
published mortuary registers of Bombay, prepared since the year
1848 with so much care and ability by Mr. Leith, we have data
far more trustworthy than are to be obtained of any other part of
India.

From these we learn that during the five years from 1st Febru-
ary 1848, to 31st January 1853, 4,038 deaths took place from
small-pox in Bombay, and of these 3,203 occurred in children under
seven years of age. The proportion of deaths from this disease
to the total deaths was, for the five years, 5*83 per cent., the
highest being 7-80, in the year 1848, and the lowest 2*70, in 1849.

The observation made by me in 1846 J — founded on hospital
records, and on Dr. Stewart's report of the small-pox epidemics in
Calcutta of 1833, 1838, 1843 — that small-pox prevailed more in
some months of the year than in others, is amply confirmed by
Mr. Leith's registers, for in these we find that the deaths from
small-pox bear, in the different quarters of the year, the following
proportions to the total deaths : —

1st Quarter from 1st February to 30th April 11*15 per cent.

2nd „ 1st May to 31st July 6-24

3rd „ 1st August to 31st October 1-19

4th „ 1st November to 31st January 1-36 „

The tables enable us to enter into still further details, and to
allot the proportion of deaths from small-pox to the different
months of the year. Thus — still taking the average of the five
years — the proportion in different months is —

January ..... 4'18

February ..... 11*17

March ...... 20*34

April ...... 24*24

* " Indian Annals of Medical Science," No. 2, 1853.

t Ibid. No. 3, 1854.

\ " Transactions, Medical and Physical Society of Bombay," No. 8, p. 28.

188

ERUPTIVE FEVERS.

May
June

17-47
11-36

July

August .
September
October

4-51

2-20

1-21

•51

November

•90

December

1-84

Total .

99-93

The tabular statement of small -pox in the Jamsetjee Jejeebhoy
Hospital (p. 183) illustrates this feature of small-pox, viz. that it
prevails most in Bombay in the first half of the year, and more in
March and April than in other months. The same general law is also
true of Calcutta.* A similar characteristic, but much less marked,
may probably be observed of small -pox epidemics in Europe.
Sydenham distinctly states that the season about the vernal equinox
is that most favourable to epidemic small-pox ; and the same fact
may be traced more or less through Huxham's *^ Observations on
Air and Epijdemics." In the Second Annual Report by the Regis-
trar-Greneral of births, deaths, and marriages in England, there is an
account of an epidemic small-pox in England in the years 1838,
1839, in which this law may be traced, but not so clearly as in the
Bombay and Calcutta records. For example, from 1st January to
1st July of 1838, there were 8,631 deaths from small-pox ; from
1st July to 1st January 7,536 deaths, being a decrease of 1,095
in the last half year. , From January to July 1839, there were
5,487 deaths ; but from July to January 1840, there were 3,263,
being a decrease in the summer and autumn of 2,224.f

* Eeport of the Small-pox Commissioners, Calcutta, 1850, table A. page 9; also the
following abstract, taken from p. 24 of the same Eeport.

Table showing the Total Monthly Mortality by Small-pox during Eighteen succes-
sive Years, from 1st May 1832, to 1st May 1850, inclusive : —

November

. 120

December

. 512

January

. 1,316

February

. 2,372

March

. 3,689

July .

. 651

April

. 2,846

August

. 189

May

. 1,419

September

. 181

June

. 761

October .

. 134

t This observation, written in 1846 and published (Transactions, Medical and
Physical Society of Bombay, No. 8, p. 29) in 1847, does not altogether accord with
the statement made by Mr. Bedford at page 192 of the able and interesting paper
abeady referred to ; nor with that of the SmaU-pox Commissioners of Calcutta at page
24 of their Eeport. I have not at present the opportunity nor the time to mak
another and more extensive reference to the Eeport of the Eegistrar Greneral.

In 1846 (Transactions, Bombay, Medical Society, No. 8, p. 29), adverting to these
facts, which seem to show that the prevalence of small-pox in particular seasons, so

SMALL-POX — PREYALENCE, PREVE^^TION. 189

The question of the degree to which the prevalence of small-
l)ox may be attributed to the practice of inoculation, has been dis-
cussed in the Bengal reports ; but as respects the island of Bombay
it need not be entertained. The practice of inoculation is not, it
is believed, followed by any of the classes of the native community
of Bombay ; but a greater mortality from small-pox in some years
than in others is very observable in Mr. Leith's reports : for
example, —

In 1848. 1849. 1850. 1851. 1852.
7-80 2-70 7-635 3-57 7-45

We gather, then, from Mr. Leith's registers, that the mortality
from small-pox in the island of Bombay is very nearly 60 in 1000.

Small-pox inoculation is not practised in the island, but it is so
to some extent in the adjoining Concans; therefore, though the
native population of Bombay is not in general protected by inocu-
lation, still, from its fluctuating character, a proportion of it pro-
bably is so.

I am unable to state precisely the number of annual vaccinations
in Bombay, but the proportion which it bears to the total native
population is very small indeed. The mortality from small-pox in

remarkable in India, may also be traced in European countries, I remarked," Though,
then, this law of epidemic small-pox is not peculiar hut only more marked in tropical
countries, it is only, as far as I am aware, in this country, that a similar law has been
observed in a remarkable way to influence the propagation of the vaccine disease.

" Now that there is not any longer doubt in regard to the identity of small -pox and
cow-pox, the difficulty of propagating the latter in some parts of India during the hot
months may be considered as in accordance with the epidemic law, and as additional
evidence of the identity of the two diseases. The difficulty which has attended the
propagation of the vaccine disease in some months, in some of the Bengal provinces,
has been the subject of much discussion, and too much weight has in all probability
been attached to it, as an impediment in the way of the diffiision of the protective in-
fluence of vaccination in India. While the law of preference of certain seasons has
been so much dwelt on with reference to the cow-pox, it has been too much lost sight
of in regard to the small-pox. For what is the practical inference ? It is this : if, in
the seasons in which there is difficulty, if not impracticability, in propagating the
vaccine disease in its perfect form, there is also very seldom prevalence of epidemic
small-pox — does it not follow that this obstacle to the diffiision of the vaccine is a
matter of no great regret, and speaking generally, the absence of vaccination in these
seasons no great evil, because there is no great demand for the exercise of its protec-
tive influence ? While, on the contrary, if the seasons, to which epidemic small-pox is
almost exclusively confined, are those, or immediately succeed those, in which there is
no difficulty in keeping up the vaccine disease, — then, does it not follow that vaccina-
tion, assiduously and carefully practised in those seasons, will affi)rd to the people almost
the full measure of its protection ? "

Mr. Bedford, at page 194 of his " Notes," shows, that in the Upper Provinces of
India, successful vaccinations in July amount only to 10 per cent, and in October to
7 per cent.

190 ERUPTIVE FEVERS.

Bombay represents that of a* very partially protected community.
But when we direct our attention to the European residents
of Bombay, whose number, according to the census of 1850*, was
5,088, we find that, during the five years from 1848 to 1852
inclusive, 1,177 deaths are registered, and of these 12 were from
small-pox. This is a fraction more than 10 deaths in 1000 ;
double that of the average of European countries in which vacci-
nation is compulsory, but not half that of England and Wales,
and not more than one-fifth of that of the native population of
Bombay. There can be no doubt that the instances, if any, must
be few of inoculated Europeans in Bombay, and that therefore tlije
smaller proportion of mortality from small pox jn them can only
be attributed to the protective power of vaccination.

The results deducible from my notes of the fatal cases of Euro-
pean officers do not seem so favourable to vaccination. Of 311
deaths 7 were from small-pox, which is at about the rate of 22 in
1000. The fatal cases f occurred in the years 1834, 1848, 1849,
1850, 1851.

Though the attention of the Indian Grovernment was called to
the subject of vaccination very shortly after Jenner's discovery,
and notwithstanding the exertions which have been made, it is to
be feared that as yet little influence has been exercised on the
health of the civil population of India by the systems of vacci-
nation which have been adopted. The tabular returns, from the
impossibility, owing to the prejudices or fears of the people, of
verifying the success of the operation in a large proportion of cases,
and from the ignorance, dishonesty, and unskilfulness of much of
the native agency employed, are unworthy of being received as
evidence for or against a question so important as the prophylactic
power of vaccination.

Nor can it be said that vaccination in the Native army and fol-
lowers has been attended with that degree of success which might
fairly have been anticipated from the more effective agency of
military system. It was, I believe, never enforced in the Bengal
Native army ; but the rule both in Madras and Bombay has been
to vaccinate all unprotected recruits.

The prevalence of small-pox at several of the military stations

* I have not alluded to this census (which make the total population of the island
566,119), relative to the native population, because it is considered untrustworthy.
But in respect to Europeans there is no reason for questioning its accuracy.

t One at each of the following stations : Seroor, Nassick, Poona, Mooltan, Mahu-
bideshwur. Of two the station is not mentioned in my notes.

SMALL-POX — PKEYALENCE, PRETENTION.

191

in the Poena division of the Bombay army, in the early part of
1858, led to the system of vaccination and its results being sub-
mitted to close scrutiny. The returns of all kinds were communi-
cated to me, as Superintending Surgeon of the division, by Major-
Greneral Michel, who at that time commanded ; and the report which
was prepared by me from these documents was afterwards published
by the Commander-in-chief in the general orders of the army.
From this report the following extracts are taken : —

"1. The tables exhibit a total of 7,189 natives; that is, 58*2 per cent, of the
strength who have at some time or other suiFered from small-pox. As the returns do
not separate those who have been inoculated for small-pox from those who have had
the natural disease*, it is impossible to estimate correctly the mortality represented
by this number of attacks. If these had been all instances of natural small-pox, and
if the average rate of mortality in European countries, viz. 1 in 4, obtains also in
India, then 7,189 attacks represents about 1,797 deaths. If, however, the impression
entertained by some, though as yet unsubstantiated by statistical data, that small-pox
is a less fatal disease in India be correct, and 1 in 7 be assumed as the rate of mor-
tality, then the number of attacks in question will have been attended by about 1,027
deaths in the communities of which the individuals were members.

" 2. Ths same tables show the numbers vaccinated to be 4,299 — that is, 34-8 per
cent, of the strength ; and the numbers unprotected to be 855 — that is, 7 per cent, of
the strength. Of the unprotected, 539 are children under 10 years of age, which gives
a per-centage 20*3 of unprotected children.

" 3. This proportion of small-pox and unprotection, viz. 65-2 per cent., and of vac-
cinated 34-8, exists in a native army in which " every recruit is to be vaccinated, if
requisite, on enlistment," and in respect to which medical officers are told " that it is
particularly imperative on those serving in the army to fulfil this duty (vaccination)
in their respective regiments or other charges, as well as among the women, children,
and camp followers belonging to the same."

"4. Of adult male sepoys and followers the following are the general per-centages :

Small-pox.

Vaccinated.

Unprotected.

Sepoys
Followers .

61-8
68-8

34-5
27-1

3-5

3-4

" If these be alone regarded, then it may be inferred that the per-centage of small-
pox shows the proportion existing at the period of enlistment, and merely indicates
the degree in which vaccination is neglected in the communities of which the indi-
viduals in question were originally members. But when the difference exhibited in
the several regiments is considered, then the following range becomes apparent : —

Small-pox.

Vaccinated.

Unprotected.

Sepoys
Followers .

23- to 86-3 7-1 to 72-9
13-8tolOO' 0- to 86.2

0- to 13-6
0- to 20-

* On this question it may be stated that inoculation is not practised in the upper
provinces of India, is so in a very limited degree in the Deccan, but in greater degree
in the Concan.

192

ERUPTIVE FEVERS.

" It may be advanced, in explanation of this difference in the proportion of small-
pox, that inoculation is probably more practised in the communities from which some
regiments are chiefly recruited than in those from which others are ; and to account
for the greater proportion of vaccination in some, it may be that it is practised in
these more indiscriminately than in others — that is, without regard to the fact of
previous small-pox ; and that such operations, though unsuccessful, have been errone-
ously recorded as vaccinations. Still, making every allowance for these explanations
in abatement of the difference in the number of adult males vaccinated in different
regiments, it is impossible to avoid the conclusion that vaccination, as respects this
class, is more carefully conducted in some regiments than in others.

"6. Of the wives of sepoys and followers the general per-centages are —

Small Pox.

Vaccinated.

Unprotected.

Sepoys' "Wives
Followers' ditto .

69-7
73-7

29-3
21-3

0-9
5-7

The range is as follows : —

Small Pox.

Vaccinated.

Unprotected.

Sepoys' Wives
Followers' ditto .

40-4 to 97-3
16-6 to 100-

2-7 to 55-
0- to 85-3

0- to 4-4
0- to 17-5

'* The several remarks made in the preceding paragraph on the different proportions
of small-pox and vaccinated among the males in different regiments, are, to some
extent, also applicable to females. But this further observation may be hazarded —
that the differences in the number vaccinated show that scruples and prejudices are
more readily overcome in some regiments than in others.

" 6. Of the children of sepoys and followers the general per-centages are —

Small Pox.

Vaccinated.

Unprotected.

Sepoys' Children
Followers' ditto .

27-
40-6

57-3
34-3

15-5

2o-l

The following is the range ;

Small Pox.

Vaccinated.

Unprotected.

Sepoys' Children
Followers' ditto .

17-9 to 54-3
4- to 100-

22-5 to 77-7
4-4 to 96-

0- to 50-
0- to 71-2

*' The difficulty in determining the number of adults, male and female, affected with
small-pox before coming under regimental' observation, renders the returns of these
classes an imperfect test of the degree of observance or neglect of vaccination. But
in respect to children, this uncertainty does not exist ; for it may be fairly assumed
that a large proportion of them have been born and reared in the regimental lines,
and that 27 +40-6 = 67-6-j-2 = 38-8 per cent, small-pox, and 15-5 + 25-l = 40-6-^2 =
20-3 per cent, unprotected prove a very defective state of vaccination in the commu-
nity in which they exist.

"7. The number returned 'vaccinated' is showTi in the 2nd paragraph to be
4,299 ; that is, 34-8 per cent, of the strength. But even this emaU proportion of
'vaccinated' is in excess of the nominally 'vaccinated' under ordinary circumstances,
and very considerably in excess of the truly protected by vaccination, (rt.) On the

VACCINATION — NATIVE ARMY.

193

prevalence of small-pox at Poona being reported, the acting superintending surgeon
called the attention of the medical officers in charge of native troops in the division
to the subject of vaccination by circular, dated 10th March, and required not only a
return of the numbers vaccinated monthly, but also of those who remained unpro-
tected. From the 1st March to the 30th June 1,138 vaccinations were returned from
native regiments, which is 26-4 per cent, of the total vaccinated shown in the 2nd
paragraph. It is therefore a just conclusion that the proportion of vaccinated shown
on the 30th June had been raised above the usual standard by a temporary impulse.
(b.) The native regimental vaccinations for the official year 1857-58 (from 1st April
1857, to 31st March 1858) amounted to 1,627, viz.: — Men, regiments, 460 ; men,
followers, 2 ; woman, 1 ; children, sepoys, 713 ; children, followers, 451 : total, 1,627.
Of these the proportion returned as failed or doubtful is : — ^Men, regiments, 273 ;
men, followers, 2 or 59*3 per cent, this class ; children, sepoys, 202 ; children, fol-
lowers, 126 or 28-1 per cent, this class. The total of vaccinations in 1857-58, not
affijrding the certainty of protection, was 602, or 37 per cent, of the whole number
vaccinated. It may be reasonably assumed, that of the total vaccinations given in
the 2nd paragraph, 37 per cent, were failures or doubtful ; and that, in consequence,
the proportion of real protection from vaccination is not 34*8 per cent, of the strength,
but only 22'1.

" 8. It is of importance to determine the cause of the large proportion of unsuc-
cessful vaccinations in the native army. They may be stated as follows : — 1st. The
want of general and systematic vaccination leaves the medical officer too often depen-
dent on lymph, preserved on glasses, — often sent from a distance, and perhaps care-
lessly taken and transmitted. 2nd. Vaccination is too much left to hospital assistants,
who, from want of practice, are unskilled in the operation, and, from defective know-
ledge, are not well acquainted with the conditions of its success. 3rd. A portion of
the failures in adults is due to protection by previous smaU-pox.

" 9. Another table shows the number of European soldiers, with their wives and
children, who have had small-pox, been vaccinated, or are unprotected. The per-
centage to strength is as follows : —

Small Pox.

Vaccinated.

Unprotected.

Soldiers
Ditto Wives
Ditto Childi-en .

13-5

11-6

2-8

83-5
86-2
93-0

3-4
0-5
4-1

" The contrast between the proportions of vaccinated here shown and that in
natives, in paragraphs 4, 5, 6, is striking. Still the proportion of those who have
had small-pox illustrates the well-known fact, that in the classes in Grreat Britain and
Ireland, from which recruits for the army are drawn, vaccination is also imperfectly
conducted.

"10. The information communicated in these returns, relative to the proportion of
protected and unprotected in cantonment military bazaars, is quite inadequate for the
object in view. The facts recorded amount to this : that the estimated population is, in

Poona Bazaar .

. 35,000

Kirkee .

5,000

Ahmednuggur .

6,405

Malligaum

3,949

Sattara

2,142

Dapoolie

3,615

Total

66,111

194 ERUPTIVE FEVERS.

*' The number protected in the Poona, Kirkee, and Malligaum bazaars is unknown.
In the other, the residents are supposed to bo all protected, with the following
exceptions : —

Ahmednuggiir ..... 236

Sattara . . . . . .11

Dapoolie ...... Ill

" If the ratio of the successfully vaccinated in the native army, under the more
favourable circumstances of smaller numbers, greater control, and professional agency,
is only 22 per cent, of the strength, it may be fairly assumed that the ratio of annual
vaccinations in large military bazaars as that of Poona, does not, under ordinary cir-
cumstances, exceed that of the general civil population of the Bombay Presidency,
which, estimating the population at 15,578,992*, and the successful vaccinations at
202,535t, is 1'3| per cent.

" Though the quarterly returns, from which the several statements in this memo-
randum have been deduced, cannot be regarded as statistical data, on which full reli-
ance may be placed, yet they safely justify the following conclusions. 1st. Vaccination
is very insufficiently carried on in the general communities from which the recruits of
the native army are drawn. 2nd. Vaccination is unequally practised in native regi-
ments, and though this may in part be explained, as respects adults, by circumstances
antecedent to enlistment, yet the great degree of difference, and the facts relative to
small-pox and to vaccination in children, prove that this important sanitary measure,
inadequate in all regiments, receives much greater attention in some than in others.

"12. The representations which led to the issue of the Division Order wovild seem
to be amply confirmed by the analysis of these returns, and it is not to be doubted
that the imperfect practice of vaccination, thus mad^ apparent, calls for active and
sxistained eiforts on the part of the military and medical officers connected with the
native army and with military bazaars. This subject, though of great importance to
the interests of the native military population, also involves the welfare, in some
degree, of a large body of European troops brought into constant association with the
Sepoys of the native army and the residents in the military bazaars. Though it is
true that Europeans in India enjoy, for the most part, the advantage of protection
from small-pox through a well-organised system of vaccination, still occasional in-
stances occur when, from some cause or other, this protection has ceased, and lives, of
the highest value to the State, may thus fall a sacrifice to that extensive diffusion of
small-pox which the neglect of vaccination permits to exist." §

Section III. — On Measles in Bombay and the Deccan.

My clinical knowledge of measles has been chiefly obtained in
the sick wards of the Central Schools at Byculla.|| This institution
is for the maintenance and education of children of the European
soldiers of the Bombay Presidency. The children are partly of
unmixed European extraction, and partly Indo-Britons. During

* "Thornton's Gazetteer."

t "Eeport on Vaccination, Bopabay Presidency, for 1854-55," p. 53.

\ In Agra and Delhi, 0-054 per cent. In Bengal, where inoculation is practised,
the annual vaccinations are 0-98 per thousand. — Indian Annals Medical Science, vol. i.
{Bedford.)

§ This memorandvim was written shortly after the lamented death of Sir William
Peel, by confiuent small-pox, at Cawnpore, in April 1858.

II In the Island of Bombay.

MEAgiLES. 195

the last twenty years, their numbers, both sexes included, have
ranged from 235 to 355, and their ages from 3 to 16.'

There are two buildings, one for boys, the other for girls ; both
situated in the same grounds, with an interval of about 100 yards.
About eight years ago, a separate hospital was added to the
institution ; for before this period, the sick wards were in the
school buildings.

Measles prevailed in the schools in October 1832*; but no
record has been preserved of this visitation. The next occurrence
of the disease was in December 1838; it commenced on the 21st
of that month, and continued till the 2nd of April 1839. At this
time I held medical charge of the institution. The schools, with
the exception of a single case in January 1840, remained free of
measles till December 1846, when it commenced on the 21st of
the month and ceased on the 10th March 1847. It reappeared
on the 13th March 1852, and prevailed till the 22nd of May.
It was again absent till the 10th March 1857, when it returned
and continued till the 14th of April. No further notice wall be
taken of the visitation of 1832; and in the subsequent remarks,
I shall designate the remaining four the first, second, third, and
fourth epidemics.

The disease commenced in the girls' school in the three first,
and in the boys' in the last epidemic, and in the second and third
the importation of the infection was traced to a fresh arrival.
The period that elapsed between the commencement of the disease
in the one school and its appearance in the other was in the first
epidemic twenty-six days, in the second twenty-seven, in the third
twenty-four, and in the fourth eleven. During the first and second
epidemics there was no separate hospital building. During the
first epidemic the healthy children were removed to a building at
some distance!, and the school -rooms were converted into sick
wards. This course was adopted because, in the months of February
and March 1837, 74 cases of mumps occurred in the girls' school,
but not a single case in the boys' school ; and in the months of
March and April 1838, 29 cases of varicella occurred in the boys'
school, but not a single case in the girls' school. I had therefore,
on the outbreak of measles in the girls' school, some expectation

* Measles was very prevalent at Calcutta and the vicinity in March, April, and
May 1832, as stated by Mr. Corbyn. — Transactions, Medical and Physical Society of
Calcutta, vol. vi. p. 477.

t The imperfect accommodation for the sick was also a r^son for the adoption of
this measure.

o 2

196 ERUPTIVE FEVETIS.

that it would not extend to the boys' school, and in consequence
did not recommend in the first instance any measures of prevention
in addition to those already afforded by the school buildings.

But the removal of the healthy children, after the disease had
shown itself also in the boys' school, had no effect in checking the
further spread of the epidemic.

There have been, in the course of twenty-two years, four visi-
tations of measles in these schools, with intervals of five and eight
years. The first and second commenced on the 21st December,
and the third and fourth on the 13th and 10th of March, and none
of them continued later than the 22nd of May. Epidemic measles
then, in Bombay, shows a preference for the same months as small-
pox and (as has just been shown) mumps and varicella are simi-
larly characterised.

The following is a note of the admissions and deaths in the four
epidemics ; —

1838-39

Admissions.
100

Deaths.
5

Mortality

per cent.

1846-47

144

3-4

1852

107

5-4

1857

117

8-5

These four epidemics have been described in the Transactions of
the Medical and Physical Society of Bombay. The first t by myself,
the second J by Dr. Coles, and the third and fourth § by Mr. Carter.

But my information relative to measles is not confined to this
single institution or to the island of Bombay. In 1857 it prevailed
among the general native population in Bombay. Mr. Moreshwur
Junardhun, in a report addressed to the Grrant College Medical
Society mentions that between January and May of that year he
treated 83 cases, of which 15 died — a mortality of 18 per cent.
In March and April of the same year the disease visited the infant
branch of the Byculla Schools, located at Poona; 31 children were
affected and 7 died, — a mortality of 22-5 per cent.

The children of the 1st battalion of Artillery at Ahmednuggur
suffered from measles in May, June, and July of 1857, with this
result : —

Admitted. Died.

Indo-Britons . . . .12 4

Europeans . . . . " . 52 14

64 18

This high mortality — 28 per cent. — may in part be accounted

* The number is not distinctly stated in tlie Keport.

t 2nd No. + 9th No. § 1st No. and 4th No. New Series.

MEASLES.

197

for by the children having come off a long and fatiguing journey
from Nusseerabad, and their accommodation at Ahmednuggur
being overcrowded.

Again, as regards the general population of the island of Bom-
bay, it appears from Mr. Leith's Eegister that during the five years
from 1st February 1848, to 31st January 1852, 323 deaths from
measles are recorded; and of these 212 occurred in children under
seven years of age. In the following classification of these deaths,
made with reference to the months of their occurrence, the prefe-
rence shown by the disease for the first six months of the year is
again well illustrated : — *

January-
February
March .
April
May
June

. 32

July .

. 48

August

. 47

September .

. 63

October

. 57

November .

. 41

December .

288

4
1
7
4
4

Among the children of the better classes of Europeans at Bombay,
I do not recollect an instance of its epidemic prevalence. But spo-
radic cases have been met with from time to time. 1 remember,
however, only two as coming under my pei'sonal observation. They
occurred in the month of June 1853.

In the fatal cases of European officers, from 1829 to 1848, I find
only one case of measles. It occurred at Belgaum in February
1832, in an officer of the staff. The initiatory febrile symptoms
were congestive in character ; they continued from the 9th to the
13th, when the eruption came out on the 14th. This officer impru-
dently sat up, exposed to cold, and attended to some of the duties
of his office. On the evening of that day he complained of sore
throat, which had increased on the following day with addition of
oppression of the chest and delirium; symptoms of collapse came on,
and he died on the 15th.

It is unnecessary for me to describe the symptoms and treatment
of a disease so well known to medical observers in all countries ;
but there is one circumstance in the character of the symptoms,
as it has been observed in the BycuUa schools, which it is of
importance to note. In the accounts of measles as occurring in
European countries, paleness of the eruption is stated to be of un-
favourable import. This doubtless is true of the more sthenic chil-
dren of these countries, and equally so of well- conditioned European
children in India. But in all Indian epidemics we may expect
frequently to meet with the disease in children more or less

o 3

198 ERUPTIVE FEVERS.

ansemic ; and in them the eruption will be found occasionally to
present a faintness of tint, which in a sthenic child might excite
apprehension, but which in the asthenic is quite compatible with a
mild and favourable course.

In respect to treatment, I would only observe that it is of much
importance in the feeble children of India to be very careful not
to debilitate, but to watch for a failing pulse and other symptoms
of asthenia, and then to give chicken broth or beef tea freely,
and wine if necessary ; to omit all depressant medicines, and use
squills and carbonate of ammonia with camphor mixture. I am
satisfied that several livei^'were saved in the first epidemic from
observance of this principle, and if errors were committed in the
general management they were on the side of too much depression.

Measles in the Byculla schools has been usually followed by
troublesome catarrhal ophthalmia.

The fatal cases which I had an opportunity of examining were
those of the first epidemic. They were five in number. In all
there was pneumonia, which in four had passed on to hepatization,
with, in one, gangrenous excavations. In two the pneumonia
was general, in two lobular, and in one vesicular. In all there
had been muco-enteritis, which in two had led to granular exudation
on the mucous lining of the lower part of the ileum and of the
colon ; in one to turgescence and ulceration of Peyer's agminated
glands ; in one to redness of the mucous membrane of the lower
part of the ileum and turgescence of Peyer's glands ; and in one
merely to vascularity of the end of the ileum.

When we compare the history of measles in India with that of
the disease in colder climates, we find the mortality to be much
higher in the former. The rates of mortality stand thus : —

European countries * . . .3* per cent.
Byculla Schools, Eombay, — 1st Epidemic 5-

„ 2nd „ 3-4

3rd „ 5-4

4th „ 8-5

Moreshwur Junardhun's cases . .18* „

Infant Schools, Poona . . . 22*5 „

1st Battalion, Artillery, Nuggur . 28* „

Bengal and N.W. Proyinces f . .8. „

Nor is it difficult to understand how this should be. The prone-

* " Lectures on Diseases of Infancy and Childhood," by Dr. West. 4th edition, p.
712.

t Dr. Mackinnon, in his remarks on the Epidemics of Bengal and the North-
western Provinces, states the mortality from measles in the children of European
soldiers to be eight per cent. — Indian Annals of Medicine, No. 3, p. 171.

SCAELATINA. 199

ness of the asthenic constitution in India to become affected
with pneumonia has been already alluded to, and will be more
fully illustrated in a subsequent part of this work. It has been
also shown that January, February, March are months in which
measles is apt to prevail. Though the absolute temperature of
these months in India is high compared with that of European
countries, yet the daily range is great relatively to other seasons of
the year ; and the more or less prevalence of north-easterly winds
in these months also increases the heat-abstracting property of the
atmosphere. When these facts are considered with the additional
one, that the heat-generating power of the animal system has rela-
tion to temperature of season and climate, we can be at no loss in
understanding how the predisposed become affected with pneumo-
nia in India and how cold is an exciting cause.

There is probably moreover greater danger in measles from
gastro-intestinal inflammation in India than in the same disease
in more temperate climates. And as an additional cause of
high mortality, the greater obscurity of pneumonia in asthenic
states, and the less control over its course, are deserving of notice.

Section IV. — Scarlatina. — Erysipelas. — Varicella. — Hoop^
ing Cough. — Cynanche Parotidea.

Scarlatina. — We have not any satisfactory account * of the
occurrence in India of the scarlatina simplex, anginosa, and maligna
of European countries.

A fever, remittent in character and attended with scarlet erup-
tion, has prevailed epidemically on several occasions, since 1824 to
1853, in Bengal and the North-western Provinces. In some in-
stances the mucous membrane of the mouth and fauces has been
inflamed ; but in others this feature has not been observed. In
the earlier epidemics rheumatic pain of the joints was frequently
noticed ; but this has not been the case in the later visitations of
the disease.

I am not acquainted with the occurrence of a similar epidemic
in any part of the Bombay Presidency.f I have however met with
an occasional case of remittent fever in natives attended with an
eruption resembhng roseola. The same kind of eruption has also

* The single case entered in the Madras return at the commencettient of this chapter
cannot be received. The fact of a single case of an infectious disease returned of an
unprotected community, is of itself proof of inaccurate diagnosis.

t Dr. Peet reports that it has prevailed at Bombay andPoonain 1859. "Trans-
actions, Medical and Physical Society," New Series, No. 5, p. 211.

O 4

200 EKUPTIVE FEVERS.

been observed by me in a few instances in the secondary fever of
cholera, and I have already stated that it was present in some of
the cases of febricula in the D troop, Koyal Artillery, at Poona
in the hot season of 1858.

The Bengal epidemics have been described by Drs. Mellis,
Twining, Cavell, Mouat, and H. H. Groodeve * ; also by Dr. Edward
Goodevef, and by Dr. Mackinnon.J None of these authors have
considered the disease described by them as identical with Euro-
pean scarlatina. It is, however, similar to the Dengue of America
and the West Indies.

Erysipelas, — The remark made by Dr. Mackinnon, that
" idiopathic erysipelas, as it appears on the face and lower extre-
mities unconnected with wounds, is a rare affection in India," § is
fully confirmed by observation in Bombay. I have met with very
few cases either in Europeans or in natives.

But traumatic erysipelas is of more common occurrence, and at
times evinces almost an epidemic tendency. It was common in
the Jamsetjee Jejeebhoy Hospital in November and December
1851, after wounds of the scalp and lower extremities, but was
easily subdued. It did not in all cases originate in the hospital,
but in some was present on the admission of the patient; thus
showing that it was not, at least in all cases, due to the air of the
hospital. On one or two occasions I have also noticed the lia-
bility to erysipelas after the application of blisters so well marked
as to render it expedient to discontinue, for the time, the use of
this remedy.

Varicella. — In my observations on measles, allusion has already
been made to the occurrence of twenty-nine cases of varicella in the
boys' school at Byculla in March and April 1838, but notes of this
epidemic have not been preserved by me. Since then, however,
cases of this disease have come under my observation, and I am
satisfied that the term varicella has not been applied by me
to an affection varioloid in character. The diagnosis of the two
diseases has been already explained in the remarks on small-pox.

Mr. Carter states that, in the year 1849, a varioloid form of vari-
cella affected twenty-four boys in the school, but only one girl, in

* " Transactions, Medical and Physical Society, Calcutta," vols. i. ii. ix.

t " Indian Annals of Medical Science, No. 2."

X " Treatise on Public Health. Indian Annals of Medical Science," No. 3.

§ '* Indian Annals of Medicine," No, 3, p. 177. It may be well to bear in mind im-
munity from scarlatina and erysipelas in India, in reference to the question raised by
some pathologists of relation between these affections.

HOOPING-COUGH. 201

the months of March, April, and May. I am unable to say whe-
ther this epidemic differed from that of 1838, or whether the term
varioloid used by Mr. Carter merely indicates a difference of opinion
on the part of the observers.

Hooping-Cough. — In Dr. Coles' Eeport on Measles in the
Byculla schools, allusion is made to the presence of three cases of
hooping-cough at the same time. I do not find any account of
the epidemic prevalence of this disease in these schools ; but my
impression is that it has occurred, from time to time, during the
last twenty years.

Cynanche Parotidea attacked the girls' school in February and
March 1837. Seventy-four girls were affected, not a single boy.
Mr. Carter reports that it broke out among the boys in October
and November 1851. Seventy-five boys were affected, but only
two girls.

202

EriDEMIC CHOLEHA.

CHAP. XIII.

ON EPIDEMIC CHOLERA.

Section I. — Remarks on the Seasons of Prevalence and on the
Causes of Cholera,

The leading statistical facts of cholera amongst European and
native troops in India are * : —

Pbesidenoy .

EUROPEANS.

NATIVES.

S>2 .

Ill

Per-centage
of Deaths to
Admissions.

Ill

11!

<v o

III

til
III

Bengal .
Bombay .
Madras .

2-87
2-64
1-98

0-97
0-86
0-69

33-70
32-53
34-83

0-53
0-96
1-35

0-16
0-32
0-58

30-54
33-06
42-91

In the European Greneral Hospital 234 cases of cholera, and in
the Jamsetjee Jejeebhoy Hospital 1259, were treated during my
periods of service in these institutions. I have also had the oppor-
tunity of investigating this disease in other parts of the presidency
as well as among the better classes of the community, both Euro-
pean and Native, in the island of Bombay.f

The following remarks on cholera combine the results of my
own experience, and of a careful consideration of much that has
been written on the subject, both by Indian and European writers.

My connexion with hospitals in Bombay extends from June

* *' Vital Statistics of tlie European and Native Armies in India," by Joseph Ewart,
M.D., pp. 147, 160.

t It may be stated here, that during my service in India, from August 1856 to
September 1859, subsequent to the publication of the first edition of this work, I have
again had extensive opportunities of observing cholera, both in the Jamsetjee Jejeebhoy
Hospital, and the Hospitals of the 61stEegiment and the German Legion, at Poona.
Notwithstanding, the text is left very much as originally written, for this further ex-
perience has in no respect modified my opinions.

SEASONS OF PREVALENCE. 203

1838 to May 1854; and from these sources I learn, that in
the years 1841, 1847, and 1848, there was very little cholera
in the island. It, however, prevailed extensively in the years
1842, 1846, 1849, 1850, 1851, 1853, and 1854. But the partial
character of the visitations of cholera is shown by the returns from
the BycuUa schools, in which 1840, 1844, and 1845 were the
years of greatest prevalence, and 1848, 1850, 1852, and 1853 were
those of exemption.

The greater prevalence of cholera in some years than in others
in Bombay is also apparent in Mr. Leith's Mortuary Eegister.
There we learn that the proportion which the deaths from cholera
bore to the total deaths in the island in different years, was as
follows : —

1848 .

•63 per cent.

1851 .

. 2775 per cent.

1849 .

. 17-40

1852 .

. 8-40

1850 .

. 27-850

The greater prevalence of cholera in the warmer months of the
year in European countries, has been supposed to depend on ele-
vated temperature favouring an impure state of the atmosphere by
increasing decomposition.* But as the heat of an Indian climate
must always be sufficient to cause atmospheric impurity in this
manner, it may be inferred, if the view stated in respect to Euro-
pean countries be correct, that cholera in India will not show a
preference for particular seasons. The admissions into the Euro-
pean General Hospital at Bombay, from 1838 to 1853, are, for the
half year from April to September, 234, and for that from October
to March, 1 14 : those into the Hospital of the Byculla schools,
from 1837 to 1853, are, for the first period, 68, and for the second
21. Cholera prevailed extensively in many places in the southern
Mahratta coimtry and Deccan from April to June 1859; and the
Artillery, the 61st Regiment, and the German Legion at Poona
suffered considerably from the 24th May to the 7th June.

This statement seems to countenance the relation of the disease
to the hot and rainy months of the year ; but then this inference is
corrected by a reference to the Jamsetjee Jejeebhoy Hospital,
in which (from 1848 to 1853) 417 admissions took place in the
first half year, and 637 in the second. Mr. Leith's Mortuary Ee-
turns, from 1848 to 1852, also give the greatest number of cholera
deaths in the half year which includes the cold season, viz. 7,112
for the half year, from October to March, and 5,110 from April to
September.

* " Eeport on the Cause and Mode of Diffusion of .Epidemic Cholera." By Wni.
Baly, M.D. 1854.

204 EriDEMIC CHOLERA.

But it may be supposed from these statements, considered in
connexion with remarks in Mr. Webb's report on the medical
statistics of European troops in the Bombay presidency*, that
cholera affects Europeans in greatest degree in the hot and rainy
months, but Natives in the cold season. This conclusion is, how-
ever, corrected by tabular statements before me, relative to the
disease in Calcutta. The first f refers to the general population of
the city, from 1832 to 1838, and shows, for the half year from
April to September, 9,560 deaths, and for that from October to
March, 8,555. The second J relates to the European General
Hospital at Calcutta from 1842 to 1853, and gives from April to
September 358 admissions, and from October to March 383.

I conclude, then, that though partial data may suggest that
cholera has also in India its seasons of preference, the conclusion is
not as yet sustained by general and extensive inquiry.

The cause of cholera — that is, the nature of the poison — is as
yet undetermined. If we regard the various opinions which have
been put forth on this subject, the want of precision and complete-
ness in many of the statements and the hypothetical character of
much of the reasoning on which the opinions rest, it is impossible
to avoid the conclusion, that at the present time the records of
medical science are inadequate for the solution of this question.

In the course of three epidemics of cholera in Bombay (from
1849 to 1854), 158 inmates of the Jamsetjee Jejeebhoy Hospital,
while under treatment for other diseases, have been attacked
with cholera, and 73 of them died. At the time of these events,
a record was kept, showing the date of the attack, the bed of the
patient, the date of admission into hospital, and the disease for
which he was under treatment. § I entertained the hope that
these facts might throw some light on the etiology of cholera ; but
their careful consideration has brought me to this conclusion, —
that though a considerable part of them are trustworthy, so far as
they go, yet they are defective in so many particulars, necessary to
justify positive inferences, in an inquiry so difficult and important,
that their detailed statement is not here submitted. This course

* " Transactions, Medical and Physical Society of Bombay," New Series, No. 1, p. 104.

t Mr. Martin, " Influence of Tropical Climates," &c. p. 346. Edition of 1854.

X "Notes on Cholera," by John Macpherson, M.D. "Indian Annals of Medical
Science, "No. 1, p. 111.

§ This unsatisfactory state of matters continues. Dm*ing my absence from India,
and also subsequent to my return: viz. from July 1854 to April 1857, there were 84
seizures from cholera in Hospital, with 79 deaths, and yet the explanation is no fur-
ther adyanced.

CAUSES OF CHOLERA. 205

is adopted, because I am satisfied that nothing so surely impedes
the progress of medical science as the irrelevant use made by some
inquirers of the observations and statements of others.

The occurrence, however, of so many attacks of cholera in one
institution have seemed to point to the following general in-
ferences : —

1. Cholera prevailed in the divisions of the town adjacent to the
hospital, so that the cause may be assumed to have been operative
on the residents of both.

2. A considerable proportion of the seizures was of individuals
only a few days resident in the hospital, and who may therefore
have been infected before admission.

3. A considerable proportion was simultaneous with an increase
of the disease in the island generally, and therefore justified the
inference that a general cause was in operation.

4. They occurred more or less in all the fourteen wards of the
hospital, but in considerably greater number in those in which
from position, nature of disease, or number of inmates, atmospheric
impurity was most likely, at times, to be present.

5. The greater number of attacks was in cachectic or debilitated
individuals : the influence of predisposition was very apparent.

6. The cholera sick in the hospital, whether admissions or
seizures, were treated in the verandahs of certain wards, and were
so arranged as to be widely apart from each other. The ward
which adjoined the verandah in which cholera patients were most
constantly present, was that in which, in one epidemic, the fewest
cholera seizures took place ; and in which, in another epidemic,
the seizures were fewer than in several other wards.

These statements seem to indicate a relation between the cause
of cholera and an atmospheric state, external to, as well as in, the
hospital ; also a relation to impure conditions of the atmosphere
and states of individual predisposition.

The portable or contagious property of the cholera poison is not
supported by these statements ; and it is chiefly with reference to
this question that facts more complete, precise, and detailed than
these, or than any as yet observed and recorded, are required.*

* In the "Lancet" of the 4th and 11th December 1858, circumstances relative to
the arrival of two coolie ships at Mauritius are narrated by Dr. Ayres, the superin-
tendent of quarantine at Mauritius, which appear to him convincing proof of the con-
veyance of cholera, its communicability, and the value of strict quarantine. The
narrative is very interesting, but the conclusions appear to me in part questionable.
The following is a summary of the leading facts. The quarantine station at Mauritius
is on two small islands, Gabriol and Flat Islands, separated from each other by a

206

EPIDEMIC CHOLERA.

My present impression on this point is, that if any of the spread of
cholera be due to human intercourse, the degree is very limited ;
but my practice with reference to it has always been to pay great
attention to scrupulous cleanliness and ventilation around cholera
patients, and to place them widely apart from each other ; for set-
ting aside the suspicion of communicability, nothing is so likely,

coral reef. Flat Island is about one mile in diameter, and it had been inhabited for
many months by about 150 persons, Exiropeans and coolie workmen, and sen-^ants of
the quarantine establishment. On the 16th October 1857 a coolie ship arrived from
Madras, after twenty-six days' voyage; thirty-six cases of cholera, with eighteen
deaths, the last five days before arrival, had occurred. Shortly afterwards, another
coolie ship, in which there had been cases of cholera during the voyage, arrived from
Calcutta. The coolies of both ships numbered between six and seven hundred. Those
of the Madras ship were landed on 16th October, and accommodated in Flat Island;
and those of the Calcutta ship on the 26th, and placed in huts on Gabriol Island.
There had been no trace of cholera in Mauritius or the adjacent islands for upward? of
a year. The Madras coolies were in a much better physical condition than those from
Calcutta.

The following cases of cholera, or choleraic diarrhoea, occurred in Flat and Gabriol
Islands : —

Date.

Madras

Calcutta

Quarantine

Coolies.

Servants.

October 26 . . .

27 .

November 1

••

Consequent on the greater number of cases in Gabriol island, the Calcutta coolies'
were removed to Flat Island on the 5th November, and the disease entirely disap-
peared after the 20th.

From these facts. Dr. Ayres concludes : — 1. That cholera was conveyed from India
to Mauritius. 2. That the quarantine servants were infected. 3. That the disease
would have been introduced into Maxiritius, which it was not, had rigid quarantine
not been enforced.

I woidd rather substitute for these conclusions the following suggestions : —
1. That the probably tainted with cholera poison, on departure from India, were with
the others, placed, from crowding and other defective sanitary conditions on board ship,
in circumstances favourable for the development of the disease. 2. That, congregated
together in huts on two small islands, the unfavourable conditions of the ship were
continued after arrival ; the disease was therefore kept up, and extended to others,
who had also become exposed to the same adverse local sanitary state. 3. That liad the
coolies on arrival, instead of being collected together, been distributed, well housed,
clothed, washed, and fed, the probabilities are that cholera would not have reappeared
amongst them, and would not have affected others.

CAUSES OF CIIOLEHA. 207

as exhalation from the discharges and bodies of the sick, to pro-
duce that impure state of the atmosphere, which is undoubtedly
an efficient condition in favouring the spread of the disease.

There were circumstances connected with the outbreak of cholera
at Aden, in October 1858, and in part of the troops at Poona, in
May 1859, which bear evidence on questions involved in the
etiology of cholera, and which it may be useful briefly to state.

In the summer of 1858 *, cholera prevailed to a great degree
along the Arabian coast, at Jedda, Loheia, Hodeida, Mocha, and
Musawa. Native vessels from these ports were in constant com-
munication with Aden ; and in a ship with pilgrims from Mecca it
was said that two deaths from cholera occurred as they approached
Aden, but none were reported after the vessel came to anchor;
but the date of arrival is not stated in the report. Aden had
been exempt from cholera, with the exception of an occasional
spasmodic case, from the period of its occupation in 1839 to the
29th of September 1858, when the first case occurred among the
labourers on the public works. The temperature ranged from 80
to 98, and dew fell in the early morning. Between the 29th Sep-
tember and the 13th October, when it ceased, 136 individuals,
partly labourers, partly Sepoys and others, were seized, and 85
deaths occurred, a mortality of 62-5. The mortality among
the Sepoys was less than amongst the labourers : it was 52*6 in
the former and 65'6 in the latter ; and the difference was attri-
buted to the Sepoys being in better condition, and nearer to their
hospitals. The disease became more amenable to treatment after
the 8th October.

Of the number attacked, 108 resided in the Koosaff Valley, in
one side of which there was an open privy ground near to the huts,
and a source of foul emanations.

After ceasing at Aden, the disease appeared at Lahadge, a short
distance inland, and also at Berbera, on the opposite Somauli
coast. Both these places were in free communication with Aden,
but the date on which cholera appeared in them is not stated in
the report.

Mr. Hormuzjee was of opinion that the outbreak was caused by
the poison imported from affected places acting on people generally
predisposed by debility, and favoured by a privy atmosphere and ele-
vated temperature ; but the evidence of importation is incomplete.

In May 1859, cholera, though prevailing in different places of

* Keport by Mr. Ruttonjee Hormuzjee. "Transactions, Medical and Physical
Society, Bombay ; " New Series, No. 5.

208 EriDEMIC CHOLERA.

the Deccan, was, in the military cantonment of Poona, confined to
the Artillery, the 61st Eegiment, and the Grerman Legion. These
troops occupied a consecutive line of barracks, in a direction from
east to west. The buildings, with the exception of one block, were
the oldest and worst constructed at the station, and had long
before been condemned. They were, moreover, overcrowded, but
the exigency of the times had continued to render their occupation
an unavoidable measure. The 61st Eegiment, after distinguished
services before Delhi and Lucknow. were marched to Bombay for
embarkation to Europe, but an unlooked-for contingency led to their
temporary detention, and with this view they were sent to Poona,
where they arrived in May, disappointed and depressed. The
condition of the Germans, on arrival from the Cape, and their
subsequent sickness in March and April, from febricula, have
already been described (p. 163).

The regiments exempt from cholera were the 31st Infantry, and
the 6th and 14th Dragoons, situated at considerable distances from
the others, in more open positions, and in better barracks.

The 31st and 6th Dragoons had been healthy throughout the
cold and hot seasons, and though the 14th Dragoons had, as the
61st, been marched to Bombay for embarkation, and also tem-
porarily detained, the circumstances were very different. The
14th returned from service to their families and to a favourite sta-
tion, which had for many years of their Indian service been their
home. The 61st had served exclusively in the Bengal Presidency,
and found themselves in a new place and among strangers.

Before concluding my remarks on the causes of cholera, I would
observe, that the occurrence of the disease after exposure to cold or
wet, has been occasionally noticed ; and it may be presumed that
the relation which subsists between these ordinary exciting causes
of disease and the special cause of cholera, is the same as that
which obtains between them and malaria in respect to occasional
attacks of intermittent fever. They are determinining causes.

Section II. — Symptoms considered in reference to their degrees
of severity. — Diagnosis from. Bilious Cholera, Irritant Poison^
ing, and Collapse of Remittent Fever.

It is assumed that the student of clinical medicine is already
familiar with the leading features of epidemic cholera — that the
disease frequently comes on in the night, often without previous
warning, but, at other times, preceded by diarrhoea of longer or

SYMPTOMS. 209

sliorter duration — that the characteristic symptoms are the rice-
water-like alvine discharges, the vomiting of watery fluid, spasms
of the extremities or muscles of the abdomen, restlessness and
anxiety, skin cold, damp and clammy, sunken eyes and shrunken
features, a quickly failing, and finally imperceptible pulse, much
thirst, suspended secretions, a whispering voice, intelligence lan-
guid but not deranged.

There is considerable range in the degree and rapidity of the
collapse ; and neglect of this fact has led to much inaccurate state-
ment on the value of different remedial means.

The characteristic alvine discharges are the pathognomonic
symptom of cholera. They may be present in varying amount,
associated with more or less — sometimes hardly appreciable —
muscular spasm, and with different degrees of collapse. The fol-
lowing classification is convenient for practical purposes.

1. Cases in which, after three or four hours of the characteristic
vomiting and purging, with some amount of spasm, the countenance
becomes somewhat collapsed; but the tempe rature of the skin
remains still good, and the pulse of tolerable strength. There is
generally a varying proportion of this class of cases met with in
epidemic visitations in European regiments in India; and if they
are judiciously treated, a very considerable number may be ex-
pected to recover. This mildest form of the disease occurs very
seldom in natives, or in the classes of Europeans who resort to
general hospitals in India.

2. Cases in which, after six or seven hours of more or less
characteristic purging, vomiting, and spasm, the countenance
becomes sunken, the skin cold and damp ; but the pulse, though
small and feeble, is still distinct, and the respiration without hurry
or oppression. This degree of the disease is met with both in
natives and Europeans. It may be considered the mildest form in
natives as well as in Europeans in general hospitals. It does not
seem to be merely the first degree aggravated by longer duration ;
for it will be found that the greater collapse has been present from
the very outset, and little under the control of medical treatment.
Still, a considerable proportion of this form of the disease recovers,
probably more than one half.

3. Cases in which, after from one to* six hours of characteristic
vomiting and purging, with discharges often inconsiderable in quan-
tity, the skin becomes cold and clammy, the countenance sunken,
the voice almost gone, the restlessness great, the pulse impercep-
tible, and the respiration begins to be hurried and anxious. This

210 EPIDEMIC CHOLERA.

degree of the disease occurs both in Europeans and natives, and
recoveries, though occasional, are few in number. The very-
speedy collapse, unattended by the usual evacuations mentioned
by some writers, has not come under my observation ; bu^ I
should think it a very possible occurrence, for the scanty watery
secretion may take place into, and be retained in, the intestinal
canal.

The two last degrees of the disease are by far the most common,
at the present time, in India, and have been so during the whole
period of my service in that country. The first degree would seem
to have been met with more frequently in the epidemics between
1818 and 1824, as suggested by Mr. Martin, and many of the cases
detailed by Sir James Annesley confirm this opinion.

I have not thought it necessary to notice particularly a train of
symptoms described as occurring in sthenic Europeans in India, and
consisting of urgent cramps, a warm skin, a flushed countenance,
and a pulse full and firm. This must be a rare form of disease, for
I can bring to my recollection only one instance, and that was in
the year 1830, in a soldier of her Majesty's 40th Regiment, at
Vingorla; yet it has been erroneously classed with epidemic
cholera, and its successful treatment by general blood-letting
was one of the circumstances which led to the adoption of that
remedy in the very dififerent form of disease now under consi-
deration.

In following the course of the three degrees under which the
symptoms of epidemic cholera have here been classed, we find
that in the first, recoveries are numerous, derangements pass
away, and the saveral functions are gradually restored to their
normal state ; and that when cases prove fatal this result is brought
about by increasing collapse, or by consecutive fever with or with-
out the complication of secondary inflammations. I do not, how-
ever, enlarge on these milder instances of the disease, because my
clinical experience has been chiefly of the severer forms.

In a large proportion of the second and third degrees, the pulse-
less collapse, which has taken place in periods longer or shorter,
persists, though the serous discharges from the bowels may have
ceased, and the cramps have abated; the respiration becomes
hurried, and death follows* in from four to thirty-six hours, dating
from the commencement of the symptoms. When, however, a
fatal result has not occurred in the stage of collapse, then the
disease may pursue one of the following courses : —

1. There is gradual and slow improvement of the pulse; the

SYMPTOMS. 211

skin loses its dampness, and its heat slowly returns ; the alvine
discharges become less frequent and watery, assume first a turbid
and milky appearance, then become coloured, and gradually
restored to their normal state ; and the secretion of urine, which
had been suspended during the stage of collapse, is slowly es-
tablished. It is when the collapse has not been of long duration
— not exceeding seven or eight hours — that we may hope for
this favourable course of the disease. It is, on the other hand,
when the collapse has endured eighteen hours or upwards (though
recoveries may still take place in the manner just described), that
we may apprehend one or other of the remaining more unfavour-
able terminations.

2. The restoration of function, and final recovery, may be re-
tarded by gastro-enteric irritation, or inflammation, characterised
by a florid tongue with central yellow fur, uneasiness at the epigas-
trium, vomiting of ingesta, yellow watery, or greenish gelatinous
dejections, associated with a dry skin, and often some degree of
febrile heat and frequency of pulse.

3. Whilst the pulse and the heat of the skin have been gra-
dually restored, the alvine and renal excretions may continue
suppressed, the conjunctivae become gradually injected, and the
manner sluggish ; then distinct drowsiness may come on and pass
into coma. In these cases the stupor is occasionally preceded by low
delirium ; and a preternatural slowness of the pulse is sometimes
the first symptom to direct attention to the cerebral functions. This
train of symptoms, if not passing beyond the state of drowsiness, is
sometimes recovered from.

4. The stage of collapse may be immediately succeeded by febrile
reaction, adynamic in character, sometimes complicated with gas-
tro-enteritis, cerebral or pulmonic symptoms, or suppressed alvine
and renal excretion.

5. In asthenic individuals there may be restoration of function,
and yet death from secondary exhaustion, without any very evident
local complication.

Though the favourable import of restored urine and coloured
alvine discharges in the course of cholera is not to be doubted, yet,*
I am certain, that needless alarm is often experienced from their
absence, as well as too much hope sometimes entertained from their
reappearance.

So long as the skin continues cold and the pulse imperceptible
or very feeble, it is not in accordance with isound physiology to
look for restoration of the biliary or urinary secretions. Again :

P 2

212 EPIDEMIC CHOLERA.

if the collapse has not exceeded eight or ten hours, the non-
appearance of the excretions during the succeeding twelve or
eighteen hours of the gradual return of the circulation and of
animal heat need not occasion apprehension.

But if the collapse has endured for eighteen hours and more,
then, as already explained, with the return of the circulation and of
animal heat, all secondary dangers — those arising from defective
excretion included — are increased. The more completely and
speedily the circulation becomes restored after this long collapse,
the greater is the risk incurred by the continued suppression of
urine.

These statements, derived from clinical observation, are in strict
accordance with physiology. While the processes in which the
capillary circulation is concerned are suspended during the stage of
collapse, metamorphoses of tissue and the formation of products of
excretion are necessarily in abeyance ; but the longer the collapse has
endured and the more completely it has been removed, the more
surely and quickly will effete products be formed and the necessity
for their elimination created.

Though we may admit that there is a probable relation between
urasmia and cerebral disturbance, and perhaps other local derange-
ments, yet we shall be disappointed if we always expect to find head
symptoms removed on the return of the urinary secretion.

Again, in attributing the cessation of drowsiness to the restoration
of the renal secretion, care is necessary in order that the stupor
occasionally present in the stage of collapse may not be mistaken
for that which is secondary, which occurs after reaction, and which
alone can be related to uraemia.

There is still another clinical remark to be made with reference
to the urine. The early observers of cholera confounded sup-
pression with retention of urine, and used the catheter ; but there
is now an occasional risk of retention being mistaken for a continu-
ance of suppression and the use of the catheter being neglected.

It has been already mentioned that as the profuse watery alvine
discharges cease, they become less thin, and assume a milky ap-
pearance ; there is, in fact, less of water and more of epithelial
debris. This change, in favourable cases, is a state intermediate
between the clear watery and the coloured discharges, and
may continue for twelve hours and more after reaction has taken
place. Nor are we to assume from the continuance of these scanty
milk-like discharges that the case is progressing unfavourably.
They were present in the intestinal canal as the residue of the

SYMPTOMS — DIAGNOSIS. 213

transudations of the stage of collapse, antecedent to the commence-
ment of reaction, and must necessarily be evacuated before more
normal excretions can reappear. Moreover, if during the period of
transudation much of the intestinal epithelium has been thrown off,
it is reasonable to suppose that its restoration will be amongst the
earliest actions of returning health, and one desirable to accomplish
before biliary secretions are brought into relation with the lining
membrane. Then, just as in respect to the urine, clinical observa-
tion and physiology lead to the practical conclusion that for twelve
or eighteen hours after the commencement of reaction, more parti-
cularly when the collapse has been of short duration, we need not
attach any importance to the alvine discharges not becoming of
normal colour.

In occasional instances dejections during the collapse are of
pinkish tint; they may be so, and not profuse, from the com-
mencement, or they may present this appearance at a later period
when they have ceased to be very watery. Discharges of this kind,
caused, no doubt, by partial transudation of the colouring matter
of the blood, have been observed by me only in natives. They are
of most unfavourable import, for I have never met with an in-
stance of recovery.

Dr. Macpherson* cites two interesting cases of haematemesis in
the course of cholera, which occurred to him in the Greneral Hos-
pital at Calcutta ; and it is not improbable, though I am not
aware that the observation has been made, that the pink-coloured
discharges are of more frequent occurrence in Bengal than in
Bombay, because haemorrhage from the bowels is more common in
that province.

The remark, in the report on cholera by the Madras Medical
Board, that hiccup is not the unfavourable prognostic in this disease
which it is in many others, accords with what I have myself noticed.
It occurs generally in cases in which the collapse has been long,
and the reaction slowly established, is coincident with the latter
state, and though often, is not necessarily, associated with gastric
irritation.

The diagnosis of epidemic cholera is well marked when the
disease is fully formed. The cramps and the prostration co-exist-
ing with the peculiar discharges, are sufficiently characteristic to
distinguish it from bilious cholera, with its bile-tinged discharges,
coated tongue, transient prostration, and occasional cramps. If a

* " Notes on Cholera. Indian Annals of Medical Science," vol. i. p. 120.

P 3

214 EPIDEMIC CHOLERA.

conclusion may be drawn from my own field of inquiry, I would
say that bilious cholera is a rare form of disease in Indian hospitals,
particularly in those for native sick. On referring to the returns
of the European Greneral Hospital at Bombay, I find, that of 20,147
admissions in fifteen years, only 74 were from bilious cholera, and 52
of those were during the six years of my service in that hospital.
The deaths recorded under this head were 3, occurring from 1845 to
1847 ; and as during this period the admissions amounted only to 4,
we have a mortality from bilious cholera of 75 per cent. — a result
so contrary to all experience, leads to the conclusion that these were
cases of epidemic cholera, and the record therefore further shows
that an error in diagnosis is a possible contingency. Then in
respect to the Jamsetjee Jejeebhoy Hospital, it appears that out
of 25,190 admissions in six years, there were only 2 of bilious
cholera.

These facts justify the statement that bilious cholera is not a
common disease in India in numerous classes of the community.

It is not denied that in sthenic Europeans in India bilious
vomiting, a flushed countenance, a coated tongue, and more or less
derangement of the bowels after debauch, are sufiiciently common ;
but this form of disease, even if correctly designated bilious cho-
lera, cannot possibly be mistaken for epidemic cholera.

But another and very important question of diagnosis may present
itself in India.

In one * of the reports of the Bengal charitable dispensaries, it
is stated that advantage is sometimes taken of the prevalence of
cholera for the perpetration of acts of criminal poisoning, in con-
sequence of the lessened chance of detection which exists under
such circumstances of the public health. This remark is just ; for
my own observation in Bombay enables me to say, that criminal
poisoning, chiefly by arsenic, is, unfortunately, not rare, and that
the great collapse which speedily comes on after a large quantity
of this poison has been taken, sufficiently resembles that of cholera
as to render the mistake in cholera seasons, when suspicion has not
been aroused, by no means improbable. If we have the oppor-
tunity of examining the vomited and dejected matters during life,
there should be no difficulty in determining the question. The
florid tongue and tender epigastrium of gastritis, will also assist in
the diagnosis ; but if in fatal cases doubt still remains, a post mor-
tem examination will at once remove it.

^ I regret my inability at the present time to refer particularly to the Eeport and
its author.

EATD OF MORTALITY.

215

At a time when cholera prevailed, two children, a brother and
sister, were brought to the European Greneral Hospital ill with
vomiting and purging. They died shortly afterwards, and there
had not been any opportunity, subsequent to their admission into
hospital, of observing the character of the evacuations. There were
circumstances connected with the commencement of the illness of
these children which raised the suspicion that something deleterious
had been exhibited. An inquest was held. The parents were un-
willing that the jpost mortem examination should be more minute
than was sufficient to remove the doubt. The stomach and the end
of the ileum were opened, and in both cases the mucous coat of the
former was pale, that of the latter was studded with prominent
Peyer's glands. On these appearances, coupled with the circum-
stance that cholera was prevalent, I grounded the opinion that death
had been caused by cholera, and not by an irritant poison.

When treating of remittent fever it was explained that the
paroxysm sometimes terminates with unlooked-for prostration,
thready pulse, cold skin, and death by syncope. I have known
such an event viewed as an attack of cholera coming on in the
course of fever ; but we must be on our guard against an error of
this kind. Cholera may doubtless occur in the course of fever, and
lead to a fatal issue ; but there can be no difficulty in distinguishing
such cases from prostration at the close of a febrile paroxysm. The
diagnosis will turn upon the relation of the prostration to alvine
discharges, to the period of the paroxysm, and to the general course
of the disease.

Section III. — The general rate of mortality* — Its relation to
age, period of epidemic, and duration before admission con-

sidered. — General pathology shortly noticed,
tomy described.

Morbid ana-

The following statement,'with that at p. 202, illustrates the well-
known mortality occasioned by this disease : —

Proportion of Mortality from
Cholera to total Mortality.

In European troops, Bombay Presidency ,
European officers, ditto .... *

In Population, Bombay, for four years
European G-eneral Hospital, Bombay
Jamsetjee Jejeebhoy Hospital * . < .

10- per cent.
77
20 '35 J,
14-5
13-9 „

If 4

216

EPIDEMIC CHOLERA.

In regard to the rate of mortality there is a good deal of dis-
crepancy in published statements. But this is easily understood,
when we recollect that the severity of the disease varies in different
epidemics, and at different periods of the same epidemic, and in
different classes of individuals.

As an approximate statement, we may estimate the mortality in
India at from 30 to 45 per cent, in regimental hospitals, 50 to 55 in
European general hospitals, and 60 to 65 in general hospitals for
the civil native population of large towns, as the Jamsetjee Jejee-
bhoy Hospital in Bombay.*

The only investigations which I have made on the variation of
the ratio from age f, the period of the epidemic, and duration
of attack, refer to 159 individuals admitted into the Jamsetjee
Jejeebhoy Hospital from the 17th August to the 31st December,
1849; of these, 94 died, and 5 remained under treatment
on the 1st of January. The results are shown in the following
tables : —

Ages noted.

Numbers.

Rate of Mortality.

Under 10 years

Between 10 and 20 .... .

20 and 40 .... .

Above 50

112

69 per cent.
63 „
58 „
50 „

These numbers are too limited to be of much value on the
question of age. The high mortality shown in the tables in very
early life probably accords with the results of the epidemic
cholera in England in 1849.^ But in that epidemic the lowest
mortality was from five to fifteen years of age : this does not appear
to be a feature of cholera in India, judging from the above table
and one in Dr. Macpherson's notes. § The low mortality above the
age of fifty, in my statement, is opposed to the results obtained by
Dr. Grull and Dr. Macpherson, and illustrates the errors into which
we may be led by partial statistics.

* This is a considerably higher rate than appears in the appended return of this
hospital for six years, and I so state it because the mortality has been higher in
other years and patients occasionally are removed in a precarious state by their
friends, but entered discharged in the returns, and rated as recoveries.

t The rate of mortality in the BycuUa Schools may also be considered — it has been
48-2.

I "Eeport on the Morbid Anatomy, Pathology, and Treatment of Epidemic
Cholera." By William W. Gull, M.D. &c. p. 147.

§ " Annals of Indian Medical Science." No. 1, p. 113.

KATE OF MORTALITY.

217

The varying ratio at different periods of the epidemic is clearly
exhibited in the following table : —

Dates of Admission,

Rate of Mortality.

17tli August to 3rd September

84-6 per cent.

4th September to 17th September

72-0

18th September to 1st October.

75-0

2nd October to 15th October .

47-0

16th October to 29th October .

28-0

30th October to 12th November

500

13th November to 26th November

500

27th November to 10th December .

55-5

11th December to 31st December

43-3

With the view of endeavouring to determine to what extent the
mortality was influenced by admission into hospital at early or ad-
vanced periods of the attack, I made the following note in respect
to 157 cases: —

Duration of Disease on Admission.

Numbers.

Rate of Mortality.

Under 5 hours

„ 5 to 12 hours

„ 12 to 24 hours

Above 24 hours

38
49
48
22

63-3
61-3
45-9
59-0

That the highest mortality should be in those admitted at the
earliest period of the disease, and the lowest in those in whom it
had been present for upwards of twelve hours, may seem an unex-
pected result ; but it is easily explained by those who are acquainted
with the habits of the individuals represented by these figures, —
with their unwillingness to resort for hospital relief in the early
stages of illness. The conclusion to be drawn from the statement
is, that the admissions under five hours were cases of great severity,
enforcing an early application for relief, hence the high mortalit}^
On the other hand, those between twelve and twenty-four hours
were milder, and had not yet entered on the risks of reaction. In
the admissions above twenty-four hours there is again a rise in the
mortality, depending, no doubt, on the fact that a proportion of
these cases had been neglected, and that the secondary dangers
had been incurred before admission.

To determine the proportion of deaths in the stage of collapse,
and in that of reaction, is a question of interest, for it probably

218 EriDEMIC CnOLEKA.

differs in India and in European countries ; I have no data bearing
on this point. Dr. GruU * estimates the proportion of death from
consecutive fever in England at one-tenth. Though the opinion
generally entertained, that the proportion of deaths in the stage
of collapse in India preponderates over that of the same stage in
England, is probably correct ; yet it is an error to suppose that the
practitioner in India is not perfectly familiar with all the secondary
phenomena and dangers of cholera.

Pathology. — In considering the pathology of cholera, the first
circumstance on which to fix the attention is, that the general and
capillary circulation of the blood, and all their dependent actions,
are more or less arrested. That this arrest is favoured, but not mainly
caused, by the copious watery discharges, is shown by the facts that
not unfrequently the collapse is great, and the discharge is small ;
and that occasionally the prostration is moderate, and the discharges
copious and long continued.

WTiether the morbific cause acts first on the blood or on the
ganglionic nervous system, is a question which physiological and
pathological science are, in their present state, unequal to deter-
mine, and the discussion of which does not come within the scope
of a clinical treatise.

I proceed to notice the morbid anatomy of the disease. Of
17 fatal cases now before me, 15 occurred in the stage of collapse,
and 2 with secondary complication — one of the head, the other of
the lungs and pericardium. These cases show that the morbid ap-
pearances which chiefly attract attention after death, in the col-
lapsed stage of cholera, are the following : —

Head. — The vessels of the membranes are congested with dark-
coloured blood, and the substance of the brain, when incised,
shows numerous bloody points. There is generally increased
effusion of serum in the cavity of the cranium, but this state is not
necessarily an evidence of drowsiness or other head symptoms
having been present during life.

Chest. — The lungs are usually well collapsed ; the anterior
surface is pale, with sometimes an inflated, or emphysematous state
of their edges. There is, for the most part, a reddened colour
at their posterior aspect, with moderate congestion. The heart
is sometimes flaccid, at others not so. The left ventricle is
almost invariably empty ; but the right one is more or less filled
with blood, dark-coloured, generally quite fluid, sometimes with
co-existing fibrinous coagula.

^ Keport, p. 142.

PATHOLOGY. 219

Abdomen, — Very commonly there is a blush of redness on the
visceral peritoneum. The stomach is frequently distended, and its
mucous surface, commonly pale, sometimes presents dotted or
marbled red patches. The small intestines usually contain some
amount of watery or milk -like contents similar to the cholera dis-
charges; and their mucous surface is, for the most part, pale,
with the villi very distinct. The isolated and agminated glands
of Peyer are very generally prominent ; this has been chiefly ob-
served at the lower part of the ileum, where the surface is often
studded with pale solitary glands, enlarged to about the size of a
mustard seed. The large intestines are often contracted, and the
mucous membrane of the colon is pale, and the solitary glands
prominent : the mucous follicles, with their dark depressed centres,
are frequently distinctly seen. The mesenteric glands are usually
enlarged, but pale in colour. There is commonly little to notice in
the appearance of the liver; sometimes, when incised, it bleeds more
freely than usual. A distended state of the gall-bladder was observed
in only one of the cases, and from this it may be inferred that there
has not been usually anything in the state ofthis viscus to arrest
my attention. In my cases little notice is taken of the condi-
tion of the spleen, from which it may be concluded that it was
not enlarged ; the free evacuations must tend to cause this organ
to shrink, and, indeed, I have had evidence of this in the great
decrease of a much enlarged spleen in an individual who became
affected with cholera. The kidneys are sometimes healthy in
external apppearance, sometimes they are congested. In one
case, that of an individual (with abdominal pleuritic effusion,
with commencing Bright's disease and old tubercular peritonitis),
attacked with cholera, the collapse was incomplete, and the disease
protracted for four days — evidently in consequence of the drop-
sical effusions, which gradually disappeared, supplying to the blood
the water which was being lost by the discharges. In this case
absorption took place because the pulse continued distinct till
shortly before death.

In cases of cholera fatal in the secondary stage, the mor-
bid appearances found after death are the results of inflam-
mation of the structures which have been chiefly affected during
life.

Such is a summary of the morbid appearances in the collapsed
stage of cholera, drawn from my own observation, and I am not
aware that any important addition can be n^ade to it from the
writings of the latest observers, with exception of a minuter de-

220 EriDEMIC CHOLERA.

scription of the condition of the kidneys.* I allude to the epithelial
debris found in the uriniferous tubes and pelvis of the kidney as
explanatory of the albuminous state of the urine f on its re-appear-
ance after reaction.

The chemistry of the alvine discharges and of the blood in
cholera has also been investigated ; but as yet the inquiry has
done little more than confirm and give precision to inferences
already fairly deducible from clinical observation and morbid
anatomy.

According to Dr. ParkesJ, there are in 1000 parts of cholera
evacuations: water, 987*95 ; organic matter and insoluble salts
(earthy phosphates), 3-9; soluble salts (chlorides, phosphates, and
sulphates of soda and potash), 8-1. The same careful inquirer has
particularly noted the small amount of organic extractives in the
discharges of cholera, and he believes that this circumstance indi-
cates the suspension during the collapsed stage of cholera of the
proper excreting functions of the intestinal mucous membrane. I
need hardly remark that this belief is quite in accordance with
clinical inferences relative to the general state of the vital actions
of the system in this stage of the disease.

The density of the blood is necessarily much increased in conse-
quence of the transudation from the capillaries and discharge from
the bowels of so much of its watery constituent. The degree of in-
crease of density will have relation to the duration of the attack, the
amount of transudation, and the absence of replacement of water.
It need hardly be observed, that the loss of the water of the blood
does not merely affect the constitution of the liquor sanguinis, but
must also, in accordance with the laws of endosmosis and exosmosis,
influence that of the contents of the blood corpuscles. The propor-
tion of the inorganic salts of the blood would seem to be increased
in the early stages of the disease in consequence of the greater pro-
portional transudation of the water. But in the more advanced
periods the salts gradually sink below their normal ratio. §

Dr. Grarrod || thus states the conclusion which may be drawn
from his experiments on m-ea in the blood in cholera : " That
urea usually exists in increased quantities in cholera blood,

* Dr. Gull's Eeport, p. 32.

t Of this condition of the urine I am unable to say much from my own observation ;
in the few cases in which the urine was tested it was found albuminous.

I " Report on the Morbid Anatomy and Pathology of Cholera," pp. 25 and 26, by
Dr. GuU.

§ Dr. Gull's Eeport, p. 45.

II Dr. Gull's Report, p. 53.

TREATMENT. 221

but that the amount differs considerably in the different stages of
the disease ; being but small in quantity in the intense stage of col-
lapse, increasing during re-action, and in excess when consecutive
febrile symptoms occur."

This statement — that urea is present in the blood in small
quantity in the intense stage of collapse, increased with reaction,
and is in excess when consecutive febrile symptoms occur — quite
accords with the general tenour of the remarks, based on clinical
observation alone, which I have already made relative to the
importance attributable to the absence of the urinary secretion in
cholera (pp. 211, 212).

Section IV. — Treatment in the different degrees and stages of

the disease.

My remarks on the treatment of cholera will be restricted to a
statement of the conclusions to which I have been led by reflection,
and the clinical observation of cases not only immediately under my
own care, but also of those treated by others in the same or different
hospitals. I place the more confidence in the opinions thus formed,
— many years ago in part elsewhere expressed, — because they
rest on principles very similar to those entertained by the latest
and best writers * on this disease.

Extensive clinical experience of epidemic cholera leads the
unbiassed mind to this conclusion. That there are degrees and
stages of cholera, as of other zymotic diseases, beyond the direct
resources of medical art, and that in the management of these the
physician best consults the interests of humanity and the character
of his profession, when he abstains from rash and restless empiri-
cism, and is satisfied with placing the patient in the circumstances
most favourable for the revival of vital actions, under the influence
of their ordinary stimuli. That, on the other hand, there are de-
grees and stages of the disease which are frequently readily con-
trolled by medicine, and that these demand careful study and
attention. Gruided by these principles, I proceed to the considera-
tion of the treatment of cholera.

The prevalence of diarrhoea in seasons of epidemic cholera,
obtains in India as well as in European countries ; but this event
is more common in the latter than in the former. The relation,
however, which these two affections bear to each other is the same

* Chapter on Treatment in Dr. Parkes' " Kesearches into the Pathology and Treat-
ment of Cholera ; " also Dr. Gull's "Keport on the Treatment of Cholera."

222 EPIDEMIC CHOLERA.

in both countries. The diarrhoea, if neglected, is very apt to pass
into cholera; and, on the other hand, is amenable to ordinary
treatment in a large proportion of cases. We may state these facts
in other words by saying that cholera is not nnfrequently preceded
by a premonitory, and often readily curable, diarrhoea. The prac-
tical rule of carefully regarding and treating all cases of diarrhoea,
and of being very cautious in the use of purgatives, antimonials, or
other intestinal irritants, in the general treatment of disease, in
cholera seasons, is very familiar to the experienced practitioner in
India ; and there can be no doubt that its observance has led to
much saving of life. It has for many years been the judicious
practice of the authorities in Bombay, in seasons when cholera is
epidemic, to station qualified individuals, with suitable remedies, in
the different divisions of the native town; and to encourage chose
affected with diarrhoea to apply for relief.

The medicines which have been used for this premonitory diar-
rhoea are numerous ; but in natives or Europeans who have been
long resident in India, a simple opiate is the best means we can
adopt. One or two grains of solid opium, or twenty to forty minims
of the tincture with peppermint water, and two or three drachms
of brandy, may be given. If the diarrhoea has been early noticed,
and if at the same time diet and the temperature of the surface of
the body have been carefully attended to, a single dose of opium
will very generally suffice. Should, however, it prove otherwise,
then after a suitable interval a smaller dose may be repeated.

In sthenic Europeans in India, in whom this premonitory diar-
rhoea frequently co-exists with a coated tongue, it is advisable to
combine the opium with calomel, in the proportion of two grains
of the former to ten of the latter. This course is followed, not so
much on account of any direct expected benefit from the calomel,
as on the supposition that it modifies or prevents the astringing
effect of the opium on the biliary excretion.

In cases in which the diarrhoea has been neglected, and allowed
to continue for some time unchecked, in which the discharges are
becoming very watery, and the pulse and countenance beginning to
change, then attention to such adjuvants as confinement to bed in
the recumbent posture, and warmth by suitable clothing to the sur-
face of the body, must at once be enforced ; while at the same time
the opiate remedies are given and repeated, combined with a larger
proportion of alcoholic or ammoniated stimulant.

Should such means, however, used under these circumstances,
fail in speedily checking the diarrhoea, and should the true cholera

TREATMENT. 223

discharges not as yet have been established, then we are no longer
to trust to opium alone, for it will prove inefficacious in small doses,
and injurious in large ones frequently repeated. Kecourse must be
had to astringent remedies given more or less frequently, either
alone or combined with small doses of opium. Acetate of lead,
diluted sulphuric acid, preparations of kino or catechu, gallic acid,
with many others, may be named. The first * is the astringent of
which my experience has been the greatest, but I have no great bias
in its favour, and would prefer any of the others, if, as is very pro-
bable, they should prove of equal efficacy.

But should the symptoms still continue, and the diarrhoea pass
into cholera, and collapse be more or less established, then the
principles for the treatment of this stage of cholera, presently to be
explained, ought to be applied.

After these few remarks on the treatment of, and the importance
of attending to, the diarrhoea prevalent at cholera seasons, I next
consider the management of the disease after it has become fairly
developed. And here it is necessary, in the first instance, to state
certain principles which seem to me to be true, and to rest on
clinical observation.

* I have always used the formula recomTnended by Dr. Graves, from whose writings
I adopted this system of treatment, viz. : " A scruple of acetate of lead combined with a
grain of opium, and six grains of powdered liquorice made into a mass with mucilage,
divided into twelve pills."

In the year 1839, I published in the second number of the " Transactions of the
Medical and Physical Society of Bombay " cases of cholera treated with acetate of lead,
after the manner recommended by Dr. Graves. They seemed to me favourable.
Further experience led me, in the seventh number of the Transactions of the Society,
in 1845, to write in a more qualified manner. Again, after my experience in the
Jamsetjee Jejeebhoy Hospital, I expressed myself in the tenth number of the Trans-
actions, p. 323, in 1850, to the following effect : —

" In the "Transactions of the Medical and Physical Society" I have expressed my
opinion on the efficacy of the acetate of lead, if given while the pidse is of tolerable
strength, also of its inapplicability to those extreme cases of the disease in which
great collapse follows trifling discharges ; and I would now add, as the result of my
experience in this epidemic, that the acetate of lead has proved altogether powerless
in restraining the serous discharges occurring after collapse has fully set in.
Whether an attempt to restrain these discharges after fully formed collapse has taken ^
place is an indication to be kept in view, is probably an open question in the patho-
logy of the disease, which need not be discussed here. The acetate of lead, however,
has been inefficacious for the purpose, and I shoxild be indisposed again to have
recourse to it under the same circumstances of the disease ; the more so, as it is pos-
sible enough that the drug lying inert in the alimentary canal during the period of
collapse may have an injurious influence by its rapid absorption on the occurrence of
reaction." My present opinion, then, is not corroborative of the estimate entertained
by Dr. Graves of the value of this medicine in cholera, ai^d the above statement will
show that it has not been hastily formed, but is the result of upwards of fifteen years'
attention to the question.

224 EPIDEMIC CHOLERA.

1. In the collapsed stage of cholera, the capillary circulation,
and the processes in which it is concerned, are in a great measure
suspended ; hence there cannot be absorption or action of medicinal
agents.

2. In cases in which the collapse is recovered from, the re-
turn of the general and capillary circulation, and consequent vital
processes, is gradual and slow, and more likely to be disturbed than
aided by medicines ; while, at the same time, the gastro-intestinal
mucous membrane is very predisposed, from defective epithelium,
to take on inflammatory action.

3. Medicinal agents given in the stage of collapse and not at
that time absorbed, are liable to accumulate in the intestinal canal,
to become absorbed as reaction is re-established, and then to inter-
fere with the restoration of secretion and other functions ; or they
may, by their mere presence, act as irritants on the predisposed
mucous surface, and excite gastro-enteritis.

In the first and milder degree, described at page 209, — in
which, though the cholera discharges are present, the pulse is
still of moderate strength, — it is not improbable that absorption
still may be carried on at the intestinal surface, and that there-
fore there may be indication for the use of medicines. It is
right to act cautiously on this probability ; but, with every allow-
ance for it, my belief still is, that when cholera discharges are
fairly established, they are, whatever the state of the circulation
may be, very little under the control of astringent or other
remedies.

In my further remarks on treatment, it is assumed that the
reader bears in mind not only the statement of principles which has
just been made, but also the degrees of the disease as already ex-
plained in connection with the symptoms.

When cases of cholera come under treatment with the" pulse dis-
tinct, then the remedies recommended for the treatment of the
preliminary diarrhoea may be used. We must be careful, however,
not to give more than one or two * full doses of opium ; for this
will be test sufficient of its efficacy, and more will be likely to prove
injurious. If the collapse increases and the pulse becomes indis-
tinct, or if, after four or six hours of the use of astringents, the
discharges persist unchecked, the discontinuance of these remedies,
even though the pulse is still distinct, will be advisable, for under
both circumstances a fair trial of them will have been made. The
want of success justifies the inference that the state of the system

* I assume, of course, that opiates have not been previously given at earlier stages.

TREATMENT. 225

has not been compatible with the action of the medicines, and that
their further use may lead to the subsequent risks attendant on
their accumulation.

A considerable proportion of the cases of the first degi-ee of the
disease, — those in which, after three or four hours of characteristic
vomiting and purging, the temperature of the skin remains still
good and the pulse of tolerable strength, — will do well under this
treatment without any material augmentation of the collapse.
It was in this form of the disease — common in the early epi-
demics in India, but rare in later years — that general blood-
letting and repeated doses of calomel and opium acquired a thera-
peutic fame, which subsequent and more general experience has
not confirmed. The truth is simply this, — that when the degree
of the disease is such as to stop short of any considerable amount of
collapse, then attention to the recumbent posture, to warmth of the
surface of the body by suitable coverings, and the exhibition of a
full opiate with or without calomel, according to the state of the
tongue, are means sufficient for the cure. That more than this is
in general not only unnecessary, but likely to be injurious rather
than beneficial.

But, as already stated, a large proportion of the cases in Indian
epidemics are of those degrees in which collapse, complete or great,
comes on more or less quickly. In these the skin is cold and damp,
the pulse thready or imperceptible, and the features shrunken.
When these symptoms are present — it matters not whether they
have come on quickly or slowly, or whether treatment has been
previously followed or neglected, or whether the discharges con-
tinue or have ceased — the period for the exhibition of opiates
or alteratives or astringents has passed ; the condition of the
system is incompatible with their action. This state of the
disease is best managed by directing attention to those ordinary
stimuli necessary to the maintenance of vital actions in health,
and to their restoration when depressed. The patient should
be placed in a well-ventilated room ; the surface of the body
should be wiped from time to time, lightly covered with two or
three blankets, over which warm bricks, or other similar means
of imparting external heat, may be applied. Water should be
given frequently in small quantities, according to the desire of
the patient, if he is alert ; or it should be offered to him if he is
sluggish and apathetic. It has been my practice, in addition to
these means, to give a drachm of aromatic spirit of ammonia every
hour or second hour, and a little wine with thin sago every third

226 EPIDEMIC CHOLERA.

hour ; for it is well to assume the possibility of some degree of ab-
sorption, and to regard it to this extent. A recumbent postui-e
should also be strictly observed. The cramps and restlessness, if
distressing, may be palliated by gentle rubbing and shampooing.

The proportion of recoveries from the stage of complete or great
collapse is considerable, certainly not less than 40 per cent. : but I
believe that if the attention of the practitioner were more generally
confined to assiduously enforcing the simple indications just ex-
plained, and not distracted with the vain hope of benefit from rash
empirical experiments, the mortality in this stage would be still
further reduced. Of the cases in India, which recover from the
collapse, the larger proportion is restored to health by a gradual
return of the functions to their normal condition ; but the re-
mainder is more or less exposed to the risks of secondary fevf r or
inflammation, and a portion of them die. Though my impression,
— that by treating the stage of collapse in the manner just recom-
mended, an increase in the number of recoveries from that state is
probable, — may admit of doubt, still I am very confident that, by
abstaining from the use of opiates, astringents, alteratives, and
excessive stimulants, we materially lessen the proportion of sub-
sequent secondary risks, and, consequently, diminish the absolute
mortality of the disease.

Let us now follow the treatment when collapse is passing
away and reaction is taking place, noticirkg, first, those cases in
which there is gradual restoration of function without febrile ex-
citement or secondary inflammation. When writing on the treat-
ment of cholera in the European Greneral Hospital in 1845, I made
the following observations * : —

" The most satisfactory recoveries which I have witnessed from states of extreme
and almost hopeless collapse — the purging having in great measure ceased — have been
under the use of camphor and blue pill, in doses of three grains of the former and two
of the latter, given every second or third hour, with effervescing draughts, light
nourishment, and occasional stimulants.

"In successful cases, when the collapse is passing off, and the indication of cure is
to restore the secretory functions which have been paralysed, I am clearly of opinion
that this, in most cases, can be most satisfactorily eiFeeted by combinations of
camphor, or quinine, and blue pill ; perhaps calomel in small doses, with or without
a small addition of opium, according to circumstances, and accompanied with the occa-
sional exhibition of effervescing draughts, or small doses of castor oil. This course
seems to me safer than to attempt the same indication by calomel in large doses and
purgatives ; it being probably more in accordance with the operations of nature. For
it seems a fair assumption that functions after having been completely checked, will
be more likely to recover their natural course by degrees ; and that, consequently, the
indication seems rather gently to guide, than attempt by strong measures to propel."

" Transactions of Medical and Physical Society of Bombay," No. 7, p. 192.

TREATMENT. 227

In the fifteen years whicli have elapsed since these remarks were
written, my opportunities of treating cholera, and of witnessing the
treatment by others, have been extensive ; but my principles have
undergone very little change. On considering the diaries of re-
covered cases now before me, I observe that not unfrequently
twenty-four hours, after return of pulse and warmth of the
surface, have elapsed before the urine has been restored, or the
alvine discharges become coloured: such facts prove that these
processes are restored to their normal condition slowly and gradually,
and that, if active alteratives and eliminants are used, harm rather
than good is likely to result. Again, some cases show that calomel
may, under these circumstances, be given in considerable doses,
and yet not exercise any perceptible effect on the biliary secretion ;
while, at the same time, its irritant action on the gastro-intestinal
surface may be suspected : from these events we may draw the
inference, that for some time after the commencement of reaction
the secretory processes are not readily susceptible of influence
from alteratives or eliminants, and that, therefore, when these re-
medies are used, the hazard of gastro-enteric irritation without the
counter-balancing advantage of more quickly restored secretions,
is incurred. It follows, then, that, in my remarks of 1845, an
importance was accorded to the combination of blue pill with
camphor and quinine to which it was in all probability not
entitled. My present opinion is, that the recoveries would have
taken place equally well under the use of occasional effervescing
draughts and diluents, light nourishment and occasional stimu-
lants ; and that, by the needless use of mercurials and purgatives,
restoration is delayed, and gastro-enteric irritation is apt to be
excited. In individuals asthenic before the attack, it will some-
times be of advantage to give small doses of quinine every third
or fourth hour; and it will be very necessary in such cases to
pay much attention to frequent and appropriate nourishment,
for asthenic individuals recovered from collapse are liable to
sink unexpectedly from subsequent exhaustion. Occasionally,
after reaction has been established, the alvine discharges continue
so frequent as to indicate the expediency of restraining them by
small opiates or astringents ; but I believe that this seldom occurs,
unless secondary enteric irritation is present, and is chiefly ob-
served when irritant remedies have formed a part of the previous
treatment.

Next we have to notice the treatment 'of cases recovered
from collapse, but in which the restoration to health has been

Q 2

228 EPIDEMIC CnOLERA.

delayed, and risk to life occasioned, by secondary fever or in-
flammation.

The secondary febrile and inflammatory states are more or less
adynamic. In India the febrile state is seldom simple, but gene-
rally accompanied with gastro-enteric, cerebral, pulmonic, or other
inflammation ; but when it does occur in its uncomplicated form, it
must be treated on the general principles applicable to adynamic
fever, however arising.

When the injected conjunctivae, delirium, or drowsiness, and slow
pulse, indicate cerebral disturbance, and threatening secondary
meningitis ; or the florid tongue, the tender epigastrium, the
vomiting, the diarrhoea, indicate gastro-enteritis, then general prin-
ciples of treatment, by leeches and blisters according to the state of
constitution, must be adopted, and cases before me show that
success may attend the use of these means.

But an important practical question remains to be considered.
It is the tendency of current pathological theory to relate these
secondary inflammations, more particularly the cerebral, to the re-
tention of excretions in the blood, and to point to elimination by
the usual channels, as an indication in their treatment. Clinical
observation is sufficiently in accordance with this theory to justify
our acceptance of the therapeutic principle ; but it requires to be
carried into effect with much caution.

Whenever the collapse has been of such duration as to render it
probable that secondary dangers may arise, then, with the return-
ing pulse and warmth of the surface, we may commence the use
of a saline diuretic, and give it every third or fourth hour : the
acetate or nitrate of potass in combination with spiritus setheris
nitrici, answers very well, and, at the same time, simple diluents
should be given. Should cerebral complication threaten, and there
be no symptoms of gastro-enteric irritation present, then recourse
may be had to one or two ten-grain doses of calomel, followed, if
necessary, by two or three drachms each of castor and turpentine
oil. These means, however, must be very cautiously used, because,
as already shown, under this state of the secretions calomel is slow
to take effect on them, but quick to excite gastro-enteric inflam-
mation. When, however, the threatening of cerebral complication
co-exists with gastro-enteric irritation, we must abstain from the
use of mercurial or other purgatives, for the excitement of gastro-
enteritis will more certainly aggravate the head symptoms and
endanger life than the eliminatory action of the mercury effect
good.

TREATMENT. 229

On the whole, there is more scope for the use of mercurial and
other purgatives in cerebral complication after cholera in sthenic
individuals, than in those debilitated before the attack, because
in asthenic constitutions cerebral complication with gastro-enteritis
is more common than the simple form, and when this coincidence
occurs, the remedial means are restricted to local depletion, counter-
irritation, diuretics, and diluents.

Still, however, another practical question may be asked : May
we not endeavour to control the secondary inflammations of cholera,
more especially the cerebral, by constitutional mercurial action ?
My opinion is distinctly opposed to this proceeding, both because
the adynamic state of the system generally contra-indicates it, and
the risk of gastro-enteric irritation, from the internal use of mercury,
more than counterbalances any advantage likely to arise from its
theoretic adoption.

Before concluding the treatment of cholera, it is desirable that I
should state the estimate entertained by me of remedies which at
times have been much used, but which, as yet, have not been
alluded to in these remarks.

General Blood-letting, at one time so much used in India in the
treatment of cholera, is now nearly abandoned. In the few in-
stances in which I have myself adopted it, no good effect was appa-
rent, and the recoveries which took place under its use in the early
epidemics, were probably generally of the mild form of the disease
now seldom seen, and for the cure of which rest and an opiate
usually suffice.

My estimate of opium, calomel, astringents, and stimulants, may
be gathered from the observations which have already been made
on the general treatment of the disease.

The Hot hath, with the view of restoring the heat of the body
and thus lessening the collapse, has been had recourse to. On
this means of treatment Dr. Parkes * thus expresses his opinion :
*' The depressing effects of the warm bath were sometimes marked
and unmistakeable. I have seen a man walk firmly to the bath,
with a pulse of tolerable volume, and a cool but not cold surface,
and in five or ten minutes have seen the same man carried from the
bath with a pulse almost imperceptible, and a cold and clammy
skin. I cannot find in my notes a single case in which the warm
bath appeared beneficial." In the second number of the " Trans-
actions of the Bombay Medical and Physical Society," in 1839, I
thus stated the result of my own observatidh on the effect of the

^' " Treatise on Cholera.)" p. 209.
q3

230 EriDEMIC CHOLERA.

hot bath in cholera patients. " I used the hot bath in this case,
and watched the effect, that I might have an opportunity of satis-
fying myself on this point of practice. The bath was plainly
injurious." *

Further, it may be asserted that a reference to the works of
authors on Indian cholera will show a very general condemnation
of the hot bath in the stage of collapse. This important fact
would seem to have been disregarded in the treatment of
cholera in London in the epidemic of 1854, for I find f in the
metropolitan hospitals it was used in nearly 37 per cent, of the
cases treated.

Emetics have been given in the collapse of cholera in expec-
tation that the act of vomiting might favour reaction. In the
cholera epidemic of 1849, in Bombay, a Cholera Infirmary was
temporarily established by Dr. Mosgrove, for the treatment
of the disease chiefly by the plentiful imbibition of cold water
and the application of external heat. When this institution
passed under the care of the late Dr. Larkworthy, I visited,
through his kind permission, the patients almost daily, and some-
times twice a day, for the period of a month. One of the objects
in giving large draughts of water was, that the act of vomiting,
and its assumed stimulant action on the pulse, might be from
time to time induced. As I had never exhibited emetics in my
own practice, I gladly availed myself of the opportunity of testing
the accuracy of the principle on which they have been recom-
mended ; and the result of my observation was, that in a
large majority of cases in which collapse was fairly present, the
draughts of water and the vomiting were not followed by any sen-
sible effect on the pulse. I witnessed many cases of ultimate re-
covery, in which the state of pulseless collapse continued from six
to twenty-four hours after the commencement of the exhibition of
the cold water ; and it may be further remarked, that in some in-
stances the frequent imbibition of water in large quantity seemed to
keep up an irritable state of the stomach, which it was afterwards
troublesome to subdue. J

Hot Saline Enemata were used by me in the European General

* " Transactions of Medical and Physical Society of Bombay," No. 2, p. 240.

t " Eeport on the Results of the DiiFerent Methods of Treatment pursued in Epidemic
Cholera, addressed to the President of the General Board of Health." By the Treat-
ment Committee of the Medical Council.

X At p. 321, No. 10, •' Transactions, Medical and Physical Society of Bombay," there
will be found a letter on the treatment followed in the Cholera Infirmary, addressed
by me to the Superintending Surgeon.

TREATMENT. 231

Hospital, but without any effect in lessening the state of
collapse.

Rubefacient Liniments, Turpeiitine, and Sinapisms have been
generally applied in the stage of collapse, but I have no faith in
their utility ; and there is a disadvantage in the disagreeable odours
which arise from some of them, and in their probable interference
with the functions of the skin.

Of Saline Injections into the Veins I have no experience ; but it
may be taken for granted that the experiments which have been
already recorded are conclusive against them.

The Inhalation of Vapours seems to be a therapeutic means to
which some still incline with hope. I have not had any oppor-
tunity of witnessing this mode of treatment, nor am I of those
who see in it the prospect of good. If it be that the pulmonary
is obstructed as well as the general capillary circulation, then
the pulmonary channel of absorption into the blood is as much
closed as the intestinal one: and when it begins to be re-esta-
blished, can there be a doubt that pure atmospheric air will
more surely minister to the restoration of depressed vital actions
than medicated vapours ?

Galvanism has been applied with the view of exciting the action
of the heart and the respiratory function in the stage of collapse,
but without any results calculated to inspire hope. The coil
machine has also, to my knowledge, been used after reaction with
the view of re-exciting the secretory function of the kidney. In
this therapeutic theory I have no belief. The statements which
have been made to me of urine having been passed shortly after
the transmission of the electric currentin the course of the kidneys
and ureters are not called in question ; but it may be suggested
that the action has been on the muscular fibre of the bladder, into
which the urine for hours previously had been slowly trickling, and
not on the secretory structure of the kidney.

Cold Affusion and Wet Sheet — Of these I cannot speak from
personal knowledge ; but I quote * Dr. Grull's summary : —

*' On the continent, in the former and in the last epidemic, cold aiFusion was highly-
spoken of as a means of producing reaction. The patient was placed in a warm hip
bath, and cold water poured or thrown over the head, back, and chest. This was done
quickly, and the patient then placed between warm blankets. If the first appKcation
was followed by any improvement, the operation was repeated every three or four
hours. The results appear to have been on the whole more satisfactory than from the
hot bath.

" The ' wet-sheet envelope ' was more commonly used^in this country. The effects

* Report, p. 206.
Q 4

232 EPIDEMIC CHOLEEA.

varied according to the state of the patient ; in the milder cases it favoured reaction,
but when the disease was severe it was useless or injurious. The sweating caused by
it added to the exhaustion, and had no influence in arresting the intestinal discharges.
In none of the cases, which were many, in which we saw it tried, did it produce any
good effect."

Kesults such as these are surely sufficient to induce medical men
henceforth to abstain from a restless and too often injurious em-
piricism in the management of this disease.

KECAPITULATION.

My practical conclusions may be shortly re-stated under the
following heads ; —

1. In cholera epidemics there is a proportion of cases ushered in
by premonitory diarrhcea, which if early treated by simple means
are frequently cm-able, and the cholera attack is prevented. In
some instances, however, the diarrhoea is not checked by treatment,
and cholera becomes developed.

2. Cases of cholera occur — common in the early Indian
epidemics, but rare in the later ones — in which the state of col-
lapse is moderate in degree. In these the tendency is to recovery,
not to death ; but restoration is materially favoured by judicious
moderate medical treatment.

3. When collapse is considerable, then we have a condition
somewhat analogous to the cold stage of ague, or the initiatory
fever of small-pox, — a state which cannot be checked, but which
must run on a certain course, varying in intensity and duration
in different instances — in which all that we can pretend to
attempt, is to place the patient in circumstances as favourable as
possible for enabling the system to outlive this stage of the disease
while we at the same time carefully abstain from the use of means
which may be injurious, not only then, but in subsequent stages of
the attack.

5. When reaction from collapse is taking place, the restoration
of the various functions is a slow process requiring careful watching,
mild assistance, and avoidance of officious interference. This
expectant course is more certainly correct when the stage of col-
lapse has not exceeded eight hours; but when it has been
longer, the probability of secondary danger is increased; and
when this arises it must be met, or when it threatens it may be
modified, by cautious judicious medical treatment, directed with
the fact constantly before us, that in this state of the disease gastro-
enteritis is readily excited.

STATISTICS.

233

5. The secondary dangers of cholera are to be treated, on gene-
ral principles, with that care and caution which it is always neces-
sary to observe^in all forms of disease present in states of constitution
which tend to be adynamic.

6. In a disease amenable in its milder degrees to ordinary medi-
cal treatment — and in its severer ones, though beyond the influence
of medicines, still often recovered from — the value of remedies can-
not be tested by statistical data as hitherto recorded. Therapeutic
principles drawn from this source are very likely to be erroneous.

7. It is to be feared that cholera — as some other zymotic dis-
eases in their severer forms, for example, plague, yellow fever,
small-pox — will, in its severer forms, always prove little under
the control of medical treatment; and that therefore in it, as in
these others, the chief hope of lessening the mortality rests on our
being able to understand its causes, and to prevent their action.
To these important objects the attention of the medical profession
should be earnestly given.

Section V. — Statistical Tables relative to Epidemic Cholera in
the European General Hospital, the Jamsetjee Jejeehhoy Hos-
pital and the Byculla Schools at Bombay,

Table XIX. — Admissions and Deaths, with Per-centage, from Epidemic
Cholera in the European General Hospital at Bombay, for the Six years
from 1838 to 1843.

1838 to 1843.

Monthly Average.

Deaths on
Admissions.

Admissions

Deaths on

Admissions.

Deaths.

on total Ad-
missions.

total
Deaths.

January

100-0

0-18

2-3

February

—

March .

30-8

2-5

12-1

April .

81-8

1-8

21-9

May .

50-0

6-5

35-0

June .

56-5

2-9

25-5

July .

47-4

2-6

24-3

August .

45-5

1-8

14-3

September

35-7

2-5

9-6

October

60-0

1-3

22-2

November

57-1

2-04

17-02

December

58-06

5-05

27-3

Total

203

106

52.2

2-7

19-5

234

EPIDEMIC CHOLERA.

Table XX. — Admissions and Deaths, with Pcr-centage, from Epidemic
Cholera, in the European General Hospital at Bombay, for the Five years
from 1844 to 1848.

1844 to 1848.

Monthly Average.

Admissions.

Deaths.

Deaths on
Admissions.

Admissions

on total
Admissions.

Deaths on

total
Deaths.

January
February
March.
April .
May .
June .
July .
August
September
October
November
December

4
6
5
3
11
29
7
1
1

4
3
4
4
8
12
5

100-0
50-9
80-0

133-3
72-5
41-4
71-4

0-6

1-1

1-03

0-5

1-9

4-6

1-03

0-18

2-2

8-7
8-6
13-3
12-8
26-6
36-7
13- J

Total

59-6

0-98

10-3

Table XXI. — Admissions and Deaths, with Per-centage, from Epidemic
Cholera, in the European General Hospital at Bombay, for the Five yearSj
from 1849 to 1853.

1849 to 1853.

Monthly Average.

Admissions.

Deaths.

Deaths on

Admissions.

Admissions

on total
Admissions.

Deaths on

total

Deaths.

January

Februar

March

April

May

June

July

August

Septeml

October

Novemb

Decemb

)er

er
er

7
2
4
3
5
9
5
16
10
1
7
9

6
1
2
2
3
7
5
9
7

3
5

85-7
50-0
50-6
60-6
60-0
77-7
100-0
56-2
70-0

42-8
55-5

1-5

0-5

0-9

0-5

0-9-

1-5

0-9

3-2

2-8

0-25

1-3

1-5

15-4

5-9

8-3

12-5

241

15-1

23-7

28-0

10-0
12-5

Total .

64-1

1-3

13-9

STATISTICS.

235

Table XXII. — Admissions and Deaths, with Fer-centage, from Epidemic
Cholera, in the Jamsetjee Jejeehhoy Hospital at Bomhaij, for the Six years,
from 1848 to 1853.

1848 to 1853.

Monthly Average.

Deaths on

Admissions

Deaths on

Admissions.

Deaths.

on total

total

Admissions.

Deaths.

January-

158

60-2

7-5

February

52-2

3-7

11-3

March .

141

50-3

6-6

18-4

April .

138

52-9

6-5

21-3

May .

48-8

3-8

14-3

June .

60-0

2-4

9-8

July .

54-1

1-8

6-5

August .

65-9

2-05

8-2

September

65-1

3-3

13-8

October

47-7

3-04

9-1

November

47-8

4-3

13-6

December

110

56-3

4-7

15-6

Total

1053

574

54-5

4-1

13-9

Table XXIII. — Admissions and Deaths, with Per-centage, from Epidemic
Cholera in the Byculla Schools, at Bombay, for the Seventeen years from
1837 to 1853.

1837 to 1853.

Monthly Average.

Admissions.

Deaths.

Deaths per

cent, of
.Admissions.

January
February
March .

2
3

1
6

50-0
33-3

42-8

April .
May
June .

6
15
31

66-6
33-3
54-8

July .
August .
September
October

14
2

8
1

571

50-0

November

—

December.

—

Total

48-2

236

DYSENTERY

CHAP. XIV,

ON DYSENTERY.

Section I. — The Importance of Dysentery in India
which the subject will be treated.

Order in

The following facts relative to the sickness and mortality, from
dysentery and diarrhoea, amongst European and Native troops in
India, are extracted from Dr. Ewart's very instructive work : — *

EUROPEANS.

NATIVES.

lii

Per-centage
ofDeaths
to strength.

m
II

&§5

III
III

Bengal .
Bombay
Madras .

30-41
27-13
23-43

2-02

1-71
1-24

6-65
6-30
5-30

6-18
6-57
3-08

-173
•196
-190

2-80
2-98
6-17

During the six years of my service in the European Greneral
Hospital, 736 cases of dysentery were treated ; and during nine of
the years of my charge of the Jamsetjee Jejeebhoy Hospital, 1642
cases were admitted. To these latter may be added f 1470 cases of
diarrhoea treated during the same period ; making an aggregate of
3112 affections of the bowels.

This disease also came under my observation in its severest form
in the hospital of Her Majesty's 40th Kegiment at Belgaum, in
1830 ; al^o in Her Majesty's 4th Light Dragoons at Kirkee, in
1832, as well as more or less in all the other fields of practice in
which I have been engaged in India.

* " Vital Statistics of the European and Native Armies in India," pp. 86, 121.
t My reason for classing diarrhoea with dysentery will appear in the seqnel of this
chapter.

ITS PREVALENCE.

237

The importance of this disease is at once shown by the facts just
quoted from Dr. Ewart's work, as well as by those exhibited in the
following tabular statement :

Per-centage

of Deaths from

Dysentery and

Diarrhoea on

treated.

Per-centage
of Deaths from
Dysentery and
Diarrhoea on
aggregate Mor-
tality.

European General Hospital, Bombay (Dysentery)
^ Do. Officers, Bombay Presidency
Jamsetjee Jejeebhoy Hospital ....
t General Population of Bombay

18-3
38-9*

24-1

5-7

21-8

13-50

The ratio of deaths to treated varies according to the class of
the sick, and the stage of the disease when submitted to treatment :
it is therefore less in regimental than in general hospitals. It is
very high in the Jamsetjee Jejeebhoy Hospital, because, as has
been explained in respect to other forms of disease, the admissions
often take place in hopeless states and stages of disease. The rate
of mortality from these affections would seem to be greater in
native than in European troops, more particularly those of the
Madras Presidency ; but the reason is not apparent.

My remarks on dysentery will be arranged in the following
order: 1st. Pathology; 2nd. Causes; 3rd. Symptoms; 4th. Treat-
ment.

Section II. — Pathology.

— Detailed Statement of the Morbid
Anatomy.

Dysentery is inflammation of varying extent and degree, of
more or less of the constituent parts of the mucous membrane,
— sometimes also of the other tissues, — of the large intestine.^

* My own Notes.

t Mr. Leitli's Deaths in Bombay.

I When we consider the structural analogy of cutaneous and mucous tissue, it
is reasonable to anticipate more or less resemblance in their pathological phenomena,
which future research may establish.

Inflammation of the skin exists in various forms, (a.) General redness with or
without desquamation of the cuticle — the orders exanthemata and papulcB. (b.)
The cutis may become thickened in patches of greater or less extent, with an exco-
riated surface, and excessive development and shedding of epidermal scales — the
order squama, {c.) The upper layer of the cutis, inflamed at points more or less
numerous, more or less aggregated together, may lead to serous or puriform eifusion,
confined by the superimposed epidermis, in collections of various size, and termi-

238 DYSENTERY.

In describing the morbid anatomy of the disease, I sliall,
though occasionally referring to the writings of others, chiefly
follow my own observations.

The subject may be appropriately arranged under the following
heads : —

I. The morbid appearances presented by the mucous membrane
of the large intestine.

II. The complication of inflammation, or its results, of the
mucous membrane of the large intestine, with peritonitis, general
or partial.

III. Tumefaction in the region of the coecum, or sigmoid flexure
of the colon.

IV. Displacements of the colon.

V. Complication of ulceration of the mucous lining of the large
intestine, with abscess in the liver.

VI. Complication of dysentery with morbid lesions of the sto-
mach or small intestine.

VII. The co-existence of enlargement of the mesenteric glands.

I. — The morbid appearances of the Mucous Membrane of the
LARGE Intestine may be classed under the following heads : — 1.
Changes of colour and texture of the membrane ; 2. Exudation on
the free surface and into the interstices of the membrane ; 3. Impli-
cation of the ordinary mucous follicles, or of the solitary glands ;
4. Different forms of ulceration of the mucous membrane ; 5. The

nating in desiccation, incrustation, and desquamation — the orders vesiculce, bullcB, and
fustulcB. (d.) Inflammation of the skin may extend to the subcutaneous tissue, and
end in serous or puriform effusion, or gangrene and sloughing — erysipelas, carbuncle,
furunculus. Consequent on these various forms of inflammation, there may be
solution of continuity — destruction — of portions of the skin, more or less extensive,
by processes of ulceration or sloughing.

The several orders of cutaneous inflammations have been further subdivided into
genera and species. The opportunity of observing inflammation of the skin from its
earliest appearance to its close has enabled us to determine these facts of its patho-
logy. Similar processes may fairly be assumed to occur in some degree in the mucous
membrane of the large intestine ; but, for very evident reasons, they are, and must
always be, insusceptible of proof, except in a very limited degree.

If the skin during life were removed from the cognizance of our senses, and all that
we know of its inflammations were derived from symptoms caused by deranged
function or constitutional sympathy, desquamated products, and post mortem appear-
ances, we should be, in respect to the pathology of the skin, in a position analogous to
that in which we now stand in respect to the pathology of the mucous membrane of
the large intestine. In this hypothetical state of ignorance of cutaneous inflammation,
our positive knowledge would probably be fully expressed by a single term — as
dermitis — just as our present positive knowledge of inflammation of the mucous mem-
brane of the large intestine is expressed by the single term — dysentery.

PATHOLOGY — DISCOLOEATION. 239

cicatrisation of ulcers ; 6. The separation of parts of the mucous
coat in patches, shreds, or tubular portions.

1. Changes of Colour and Texture of the Membrane. — A
bright red and turgid state of the mucous membrane must be the
earliest change produced by acute inflammation ; but death takes
place so seldom in this stage that the appearance is very rarely
observed. Occasionally in cases of disease which have proved fatal
with the symptoms of chronic dysentery, the only morbid appear-
ance found after death is dark red or grey, sometimes black
(melanosis), discoloration of the mucous coat of the large intes-
tine. This state may be attended with softening, thinning, or
thickening of the tissue. Hypertrophy is more common than the
other alterations of texture, and sometimes in consequence of its
having taken place unequally, the surface of the membrane pre-
sents an irregular mammillated or tubercular appearance. I have
not satisfied myself that there are any particular symptoms
which enable us to determine during life, that these only, and not
other morbid changes, have taken place. It is not improbable
that they exist most generally in cases in which dysentery has
alternated with other diseases — as rheumatism — and in which it
is reasonable to infer that there may be something special in the
character of the inflammatory action.

The following three cases are illustrative : —

46. Under treatment nine months. — Dysentery alternating with rheumatism, probably

syphilitic ; terminating in general cachexia with febrile symptoms. — Charles ,

aged twenty-eight, after ten days' ilhiess with dysentery, was admitted into the Grene-
ral Hospital on the 3rd November, 1841. The symptoms were for some time urgent,
and considerable abdominal tenderness was complained of. He remained under treat-
ment with alternation of dysentery, swelling and pain of joints, with thickening in the
com'se of the tibiae and increasing cachexia, and died on the 1st August, 1842.

Inspection fourteen hours after death made and reported by Mr. J. Peet. — Body
emaciated, crude tubercles interspersed through the substance of both lungs. Eather
more fluid than usual in the pericardium ; heart healthy. Abdomen. — The stomach
and duodenum contained a quantity of dark chocolate-looking fluid, and the mucous
membrane of both presented distinct patches of injected vessels ; these were most
distinctly seen near the pyloric extremity of the stomach. The mucous membrane of
coecum of a dark, nearly approaching to a black, colour, but without thickening or
ulceration. The transverse portion of the colon upon its inner surface was in a state
of excessive congestion, but there were no distinct ulcers, although in some parts
the mucous membrane was soft and pulpy ; the mucous surface of sigmoid flexure
healthy. Coats of the ileum at its termination in the colon thickened, in other re-
spects, as well as the jejunum, healthy. Other viscera presented no abnormal ap-
pearance.— Head not examined.

47. Chronic dysentery, discoloration with thickening of parts of the mncoics mem-
brane of the large intestines. — Antone de Cost, of African extraction, but brought up
at Goa, of twenty years of age, and following the occupation of cook on board a ship.
For about two months before his admission, on the 28th June, 1849, he had been

240 DYSENTEEY.

affected with bowel complaint." He was mucli emaciated, and the pulse was very-
feeble. The tongue was moist and florid. lie was purged from six to ten times in the
twenty-four hours. The discharges were of slimy feculence, sometimes pale, at others
of various tints of gray. He improved somewhat from the 2nd to the 10th July, then
the purging increased, the discharges being more copious and watery. He died on
the 21st.

Inspection. — Chest. — The lower part of the second lobe of the left lung was in a
state of red hepatisation, the upper lobe was somewhat cedematous. The right lung
adhered by old adhesions to the costal pleura, but was crepitating in its structure.
Abdomen. — The liver was undiseased ; the small intestine was somewhat attenuated.
About three feet of the lower end of the ileum were laid open, but no morbid changes
of the mucous membrane were observed. The mucous lining of the ccecum, colon, and
rectum was in many places discoloured, of dark red, of brownish and of greyish tints,
and in parts seemed somewhat thickened ; in the sigmoid flexure and at the upper
part of the rectum there were well-marked cicatrices of former ulcers. Kidneys, — In
the central part of both there was commencement of yellow degeneration.

48. Melanosis of the colon. — No ulceration. — Tubercles in the liver. — Private P. L.,
aged forty-five, of the Bombay European Regiment. Had frequently been a patient
in hospital, with symptoms of dyspepsia. He was admitted for the last time at
Bombay on the 13th April, 1829. He then complained principally of flatulence and
debility. Seldom had pain of abdomen, but when present it was generally removed by
carminatives and remedies of that description. He gradually became emaciated,
without the symptoms becoming more distinct. Finally diarrhoea came on, and thei
dejections were of dark colour. He sunk slowly, and died October 29th, 1829.

Inspection. — The transverse colon was much distended, except at the middle portion,
where it was a good deal contracted. The peritoneal surface was of dark colour.
The coats of the large intestine throughout its whole course were much thickened and
indurated. The mucous membrane was of dark colour, in some places almost black,
and presented a very irregular surface, which v/as caused by numerous small globular
bodies, each about the size of a pea, apparently situated in the sub-mucous tissue.
There were not any traces of tdceration throughout the whole course of the large
intestine. The stomach was small, and owing to the distension of the colon, was
forced upwards ; but its coats were free from disease. The small intestine was healthy.
The liver was of light colour externally, with tubercles the size of cherry stones in the
substance of the left lobe. With the exception of old costal adhesions the thoracic
viscera were healthy.

2. Exudation on the Free Surface and into the Tissue of the
Membrane. — The uniform effusion of lymph for some extent over
the surface of the mucous coat, in such manner as to lead to its
separation in shreds or tubular portions, as obtains in the croupous
forms of inflammation of the mucous membrane of the air passages,
has been noticed by several writers on this disease. The occasional
occurrence of this exudation in tropical dysentery may probably be
admitted, but the following is the only instance of this morbid
state which has come under my own observation, and it was not a
case of dysentery : —

49. Membranous miwous exudation on the inner surface of the large intestine. — ^Private
William Todd, aged 29, admitted into the hospital of the Bombay European Regiment,
October 28th, 1829, ill with fever. There was much headache, with full and frequent
pulse. He became drowsy, the skin assumed a yellow tint ; he sunk and died Novem-
ber 1st. On the 29th he shrunk on the abdomen being pressed ; but there was no

rATIIOLOGY — EXUDATION. 241

purging except from the use of medicine. About one hundred grains of calomel were
given during the three days preceding death.

Inspection. — Vascularity of the membranes of the brain and effusion of patches of
lymph. The greater part of the mucous surface of the large intestine was covered
with a dark red effusion, in some places loosely attached to the membrane, and having
the appearance of red currant jelly ; in other places the effusion was firmer in consis-
tence, and could be peeled from the mucous tunic in an almost membranous form. In
the ccecum the effusion was evidently of longer standing from its firmer consistence,
and from its being connected with the subjacent mucous tissue, through the medium
of what appeared to be small capillary vessels. The mucous membrane underneath
the effusion was vascular.

A yellow or greyish granular exudation — sometimes small, like
grains of sand, at others larger and thicker — not unfrequently
occurs on the mucous surface of some part of the colon or rectum,
as well as of the ileum in cases of disease which have proved
fatal with symptoms of chronic dysentery. It presents itself in
patches more or less extensive, frequently coursing round the in-
testine in transverse bands, and preferring the elevated part of the
rugae of the membrane. The granules are generally found adherent
to the surface of the membrane, which is commonly of a red tint
more or less dark. The mucous membrane and the sub-mucous
tissue are also usually thickened, sometimes to a considerable de-
gree, and when cut, the edges of the incision present a fleshy
appearance.

The granular exudation and the thickening are, however, dis-
tinctly preceded by a state of simply increased redness ; whence it
follows that the appearance adverted to under the first head —
discoloration — may be merely the earlier stage of that now
under consideration.

This granular deposit, which probably consists partly of modified
epithelial debris, and partly of amorphous lymph exudation, is
noticed by Eokitansky, Baly*, and other pathologists.

It has been observed by me most commonly in dysentery in
persons whose constitutions have been in some degree cachectic,
and an analogy between it and the squamous order of cutaneous
inflammation may be suggested. The two cases which follow are
instances of this appearance : — f

50. Chronic dysentery in an opium eater. — ThemuLcous coat of the colon covered with
a firm granular layer. — The lungs tubercular. — Cartilaginous contraction of the
pyloric orifice of the stomach. — "Wm, C, aged about thirty-five, of dissipated habits, an
acknowledged opium eater, of spare habit, with narrow chest, came to Bombay as the
surgeon of a ship from Austral^ and was under treatment in the General Hospital for
delirium tremens. He was discharged cured, and remained out of hospital for about
. — . ■ ' •

* Gulstonian Lectures, Medical Gazette.

t Also 34, 36, 42, 95, 98, 99.
R

242 DYSENTERY.

a fortnight or three weeks, when he was again admitted on the 10th of July, 1840, with
dysentery, which had attacked him four or five days previously. It became chronic,
and he gradually sunk and died on the 3rd September. The treatment consisted of
free opiates with bismuth, quinine and blue pill, wine and brandy.

Inspection seven hours after death. — Body much emaciated. Head. — There was a
veil of serum below the arachnoid membrane on the convex surface of the brain.
Chest. — The lungs partially collapsed, adhered here and there to the costal pleura. A
considerable part of the upper lobe of the left lung was condensed from tubercular
infiltration, and at its apex there was a cavity the size of an almond. In the lower
lobe of the left lung there were many scattered miliary tubercles. There were numer-
ous miliary tubercles in the right lung, but nowhere condensation of any considerable
portion of the pulmonary tissue. Abdomen. — The intestines were collapsed. The liver
was of dark red colour. The mesenteric glands were not enlarged. Four feet of the
end of the ileum and the large intestine were laid open. The contents of the end of
the ileum were mucous and tenacious. The lining membrane was of dark red colour
without alteration of texture. The mucous coat of the coecum was dark red, the surface
slightly roughened, as if sprinkled with sand, but the texture was natural. The
inner surface of the colon was of dark red colour throughout, and granular. But
in the rectum the granular exudation was greatest, and most firmly adherent to
the mucous coat, which was somewhat thickened, and when cut, had a fleshy ap-
pearance. There was one ulcer in the colon. The mucous coat of the stomach was
of dark brown colour towards the cardiac end. The pylorus was much contracted
from a cartilaginous ring in the sub-mucous tissue. The mucous coat of the
duodenum was dark red in colour, but healthy in texture. The kidneys were healthy.

51, Diarrhoea tedious. — Granular yellow exudation on the mucous surface of the
large intestine with thickening of the tunic. — James Grady, aged twenty-three, private
in Her Majesty's 15th Hussars, admitted on the 12th October, 1839, with febrile
symptoms. Diarrhoea followed and continued troublesome. The dejections were
generally of pale yellow colour and thin. There was frequently irritability of stomach,
with ftdness and tenseness of the abdomen, and florid tongue. Under these symptoms
he became much emaciated and sallow, and died on the 13th January.
^ Inspection. — Abdomen. — The chief disease was a yellow warty granular layer on the
mucous coat of the large intestine, closely adherent to, and attended with thickening,
and a thickened state of the mucous, and subjacent tunics. Where this granular
exudation was still thin and only formed here and there, the mucous coat had not
become thickened ; thus proving that the granular state preceded the thickening of
the tissue.

3. Implication of the Mucous Follicles and of the Solitary
Glands of the Colon. — In the normal state of the lining mem-
brane of the colon, the mucous follicles are hardly apparent to the
naked eye, but on the occurrence of increased secretion consequent
on active or passive congestion, they become more or less prominent,
and their orifices — dark coloured, slightly depressed points — are
very distinct. This condition of these follicles is very generally
observed in the examination of fatal cases of cholera ; also oc-
casionally after death from remittent fever (26) ; and it is very
probable that it always occurs in cases of transient diarrhoea, as
well as during and immediately after the action of an active ca-
thartic: it merely indicates an excess of the ordinary secretion
of the mucous crypts.

PATHOLOGY — FOLLICLES. 243

The enlargement of the follicles in these several circumstances
has as yet been unaccompanied by inflammatory action ; but there
is reason to believe that inflammation very readily takes place, and
that its early stage is marked by general redness of the mucous
membrane, or merely by a circle of vascularity around the orifice
of the follicle, associated in some cases with thickening of the
tissue, in others with ulceration. These conditions of the ordinary
follicles of the colon, though not frequently noticed in fatal cases
of dysentery, are very important with reference to that disease,
because they are the early stages of morbid changes, which, in
their advanced states, are often observed.

The solitary glands of the colon are also often implicated in this
disease. In cholera, they, as well as the ordinary follicles of the
colon, and Peyer's solitary and agminated glands of the ileum
become distinct, pale in colour, about the size of a mustard seed,
and are scattered here and there over the inner surface of the
bowel. Under continued irritation, these glandular structures are
liable, consequent on an increase of their secretion, to become
larger and more elevated, sometimes attaining the size of a split
pea. On the occurrence of inflammation of the mucous mem-
brane, that part of it which is placed over the swollen solitary
glands must, consequent on the pressure from within, readily
give way, partly by an ulcerative process, partly by simple rupture.
So frequently are these glands engaged in dysentery, that some
observers, as Dr. Parkes, are of opinion that the disease always
originates in them ; but it seems to me that the utmost that can
be said is, that they share with the other constituent tissues of the
bowel in the morbid action. There has been much obscurity in
the descriptions of the morbid appearances presented by the glan-
dular structures of the large intestine, partly in consequence of the
ordinary follicles and the solitary glands being confounded, and
partly from the terms used by some observers. It may be useful
to explain this statement more fully. Eokitansky uses the term
mucous follicles, and it is not always clear, whether in his descrip-
tions he speaks of the ordinary crypts or of the solitary glands.
Pringle*, in describing the morbid appearances in dysentery, men-
tions certain protuberances of light colour, roundish, the twelfth of
an inch in elevation, closely set, and resembling the small-pox at
the height of the disease. Dr. Murray, of the Bengal Service,
many years agoj drew attention to appearances similar to those

* "Diseases of the Army," p. 245.

t " Transactions, Medical and Physical Society of Calcutta," 7th volume.

B 2

244 DYSENTERY.

attributed by me to enlarged follicles ; but he uses the term vesicles,
and loses sight of the fact that they were probably more related to
the cholera of which his patients died, than to the dysenteric
symptoms under which they had previously suffered : he hence
conceived — on erroneous grounds, as seems to me — an analogy
between dysentery and small-pox. Whether it is the follicular
development, or the enlargement of solitary glands, which Dr.
Bleeker describes under the term "Lenticular exudation*," I am
unable to determine.

Eokitansky also alludes to vesicles formed by the epithelium
raised by clear serum, and this in connection with the granular
deposit of which I have already treated. Eokitansky implies that
both appearances are different stages of the same process ; that,
after the discharge of the serum the epithelium subsides in the
form of branny scales. It does not, however, clearly appear whether
this statement refers to what has been actually observed, or to a
hypothetical explanation of the commencement of morbid changes
witnessed only in their after stages. The elevation of the epithe-
lium in the form of vesicles by small collections of clear serum, has
never been seen by me ; and yet I have had the opportunity of
frequently observing the different stages of the process connected
with this granular exudation: 1, as reddened mucous membrane
without thickening or exudation ; 2, some slight degree of thick-
ening and sandy-looking deposit ; 3, increased thickening of the
membrane and increased exudation — morbid processes more re-
lated, it seems to me, to the order Squamae than Vesiculse.

The term pustular appearance has been used by Mr. Twining in
reference to the early stages of dysentery ; but he does not explain
to what altered anatomical condition of the membrane it is applied:
small puriform collections in the sub-mucous tissue, not elevations
of the mere epithelium, are probably referred to. Though in-
flammation of the mucovis membrane of the large intestine, analo-
gous to vesiculse and pustulse of the skin, is a reasonable hjrpothesis,

*■ " Indian Annals of Medical Science," No. 1, p. 4. I have read Dr. Bleeker's very able
paper with much interest and care, but I cannot satisfy myself that I rightly under-
stand his description of the morbid appearances of dysentery. When I compare it
with my own observations I find a sufficient resemblance to give me the impression
that we have both looked upon the same objects ; but I cannot avoid the suspicion
that Mr. Bleeker has marred the distinctness of his pictures by a too exclusive gene-
ralisation and by the unappreciated influence of a preconceived theory. This remark
I make with great diffidence, being very sensible that the error may be with myself
and not with the acute Batavian pathologist, whose co-operation I, equally with the
able editors of the " Indian Annals of Medical Science," have hailed with much and
sincere pleasure.

PATHOLOGY — ULCERATION. 245

yet, in determining its probability, we must not forget tlie physical
difference of the epithelium in the two situations.*

4. Different Forms of Ulcer of the Mucous Membrane.— lih.Q
term ulcer is here used to express destruction, more or less exten-
sive, of the mucous membrane, irrespective of whether it has been
caused by a true process of ulceration, or by one of more rapid
fusion of tissue, or by a process of gangrene and sloughing.

Ulcers of the mucous membrane of the large intestine may be
conveniently classed under the heads transverse, and circular, as
elementary types. These two forms, however, though often dis-
tinct, are not unfrequently combined ; and in their advanced stages
they may coalesce, and thus form extensive irregular surfaces of
ulceration. The transverse form, — either in separate bands, or in
several bands coalescing and occupying a greater or less extent of
the inner surface of the large intestine, — is generally found after
acute attacks of dysentery, and is most commonly associated with
more or less thickening of the walls of the intestine. The appear-
ance of the ulcer varies according to its stage, and the state of the
contiguous tissues. Its bed may be occupied by a greyish slough ;
or the slough having been thrown off, the muscular coat may be
exposed, and the edges of the ulcer may be irregular and thick-
ened, or thinner and more rounded, with commencing cicatrisa-
tion. On the mucous membrane surrounding the ulcer granular
exudation is sometimes observed.

In regard to the manner of formation of these transverse ulcers,
it may in the first place be remarked, that one of the early effects
of inflammation of the mucous lining of the large intestine is to
stimulate the muscular coat to increased contraction ; and, in con-
sequence, to dispose part of the free mucous surface to arrange
itself in transverse folds, as well as in rugae in other directions.
This fact has, I am satisfied, not been sufficiently taken into ac-
count in the explanation of the irregularity of surface frequently
presented by the mucous membrane in its morbid conditions, f

* Since this passage, was written the transhition of the Eudiments of Pathological
Histology, by Carl. Wedl, M.D. by the Sydenham Society, has come into my hands,
and I obserA^e at page 213 the following observation : —

" When the delicacy of the epithelial layer of the mucous membranes in general,
except in the mouth, (xsophagus, vagina, and palpebra, is considered, it is easy to
comprehend that exudations poured out from the corium cannot produce any vesicular
elevation of the epithelium. The single layer of epithelial cells is easily detached by
the exudation collected beneath it ; and the elements newly formed from the exuda-
tion, are seen upon the exposed surface of the mucous membrane, and often become
the subject of observation when eliminated from the living -organism."

t I called attention to this in a paper published in the 7th volume of the " Transac-
tions of the Medical anU Physical Society of Calcutta," in 1835.

R 3

246 DYSENTERY.

It has been stated that the granular exudation is frequently-
found on the summit of the transverse folds of the membrane.
This is true of the ileum as well as of the large intestine. Why
inflammatory action should show this preference for these situa-
tions I do not pretend to explain ; but the fact is undoubted.

Let it be further remembered that, in the advanced stages of the
granular exudation, there is always considerable thickening of the
mucous membrane and sub-mucous tissue ; and that the transverse
ulcers are most commonly associated with thickening of the intes-
tinal coats.

These facts justify the inference that transverse ulcers, co-exist-
ing with thickening, are merely the last stage of that morbid pro-
cess which, commencing with redness, terminates, in its chronic
form, in thickening and granular exudation; but which, u^ider
acuter inflammatory action, either original or superadded, passes
on to gangrene and sloughing, and the formation of the kind of
ulcer of which I now treat, as well as of others of different forms,
also associated with thickening of tissue.

Under this view, then, it is assumed that when the morbid pro-
cess — which going on slowly, gives rise to the symptoms of chronic
dysentery, and does not pass beyond a state of thickening of the
mucous membrane with granular exudation on the free surface —
runs a more rapid course, it gives rise to the symptoms of acute
dysentery, and ends in gangrene and sloughing. This view also
explains how it is that we not unfrequently meet with cases of
dysentery in which, after two or three days of apparently a simple
diarrhoea, acute symptoms rapidly evolve themselves. In such we
may suppose that the first stage — that of redness — of the process
has gone on mildly, but that, from some cause or other, exacerba-
tion has arisen, and that then the morbid action has rapidly gone
through its full course.

But there is still further evidence of this relation between trans-
verse ulcers and granular exudation in the fact, that cases of
dysentery are not unfrequently met with in which we find sloughy
ulceration of the mucous membrane, and granular exudation on the
free sm-face immediately adjoining.

The following thirteen cases illustrate this last statement ; —

52. Dysentery with adynamic febrile symptoms. — Granular exudation on the mucous
coat at the end of the ileum. — Sloughy ulceration of the large intestine. — John Thomp-
son, aged thirteen, of the Garrison Band, a delicate boy, frequently in hospital with
intermittent fever, was admitted on the 27th November, 1840, stating that he had
suffered from bowel complaint for two or three days. The tongue was without fur, the
abdomen supple, dejections yellowish, thin, and the iliac regions tender. He was
freely leeched and treated with ipecacuanha, gentian, and blue pill without purgatives.

PATHOLOGY — ULCERATION. 247

On the 29th pyrexial symptoms came on. The dejections thin and partly feculent.
Abdomen tender. He was again leeched and the ipecacuanha and blue pill treatment
continued. The purging became more urgent, the pulse rose to 120, the skin became
dry and the tongue brownish. He lost flesh and continued to pass light yellow dejec-
tions sometimes with streaks of blood. Enemata, opiates, a blister, &c. were used. He
died on the 10th December.

Inspection twelve hours after death. — Body considerably emaciated. Head. — The
membranes of the brain rather vascular and there were more bloody points than usual
on incising the brain. There was an ounce of serum at the base of tlie skull. Chest,
— The lungs collapsed and were healthy. Heart healthy. Abdomen. — Liver healthy.
The omentum was matted over the transverse colon and the coecum, and adhered to
folds of the small intestine. The descending colon adhered to the lateral parietes, and
the sigmoid flexure, by tender bands, to the walls of the pelvis. The mesenteric glands
were enlarged, and reddened. The small intestine contained much thin yellow adhesive
feculence. For three feet of the end of the ileum a layer of granular lymph adhered
closely to the mucous coat, in transverse bands, following the summit of the valvulse
conniventes. There was little of the mucous coat of the large intestines left except
in the form of sloughy transverse patches ; the muscular coat was distinct and denuded.
The stomach was healthy.

53. G-ranidar exudation on mucous surface of ileum and colon, with irregular ulcera-
tion of the latter. — No disease of the liver. — Displacement of the colon. — Henry Green,
aged thirty-six, private 4th Light Dragoons, ten years resident in India, suffered from
fever twice at Kaira, but never from hepatitis, was admitted into the hospital at
Kirkee, on the 21st April, 1832, with diarrhoea, was discharged on April the 25th. Ke-
admitted on June 1st, with mild dysentery, and was discharged on the 26th.
Ee-admitted on the 15th July, aiFected with frequent purging. The evacuations
contained blood and mucus and were passed with griping and straining. There was
constant pain around the umbilicus increased by pressure. The disease progressed,
and by the 21st the discharges were reddish brown, watery, with clots of blood and
shreddy matter. The pulse was frequent and small, the countenance collapsed, and
hiccup present. He died on the 30th July.

Inspection five hours after death. — The omentum- was vascular, and adhered firmly
to the surface of the transverse colon, to the left side of the pelvis, and to the sigmoid
flexure of the colon. The large intestine throughout was thickened. The upper portion
of the ascending colon adhered to the under surface of the liver. The commencement
of the transverse portion doubled down towards the umbilicus, thence ascended
obliquely upwards towards the left side, passed to the left of the great arch of the
stomach to which it was closely united, reached the diaphragm, and thence, after an
acute duplicature, descended closely adherent to the left side of the abdominal parietes.
The mucous coat of the ileum for about three inches from its termination was of dark
red colour, and covered with granular lymph. The inner coat of the large intestine
was irregular, and in many places fungus-like from granxdar l^nnph. There were many
large transverse ulcers, some covered with thick pus, and others with black sloughs in
the centre. Surrounding the ulcers, and in most part of the inner coat not occupied
by ulceration, there was tenacious red transparent mucus effiised ; and here and there
on its surface there was granular lymph. The stomach was displaced to accom-
modate itself to the displacement of the transverse colon ; its inner surface was not
examined. Liver healthy. GaU-bladder not distended. Lungs healthy. Heart healthy.
There were one or two small points of deposit at the commencement of the aorta.

54. Dysentery alternating with febrile accessions. — Bands of granular deposit at the
end of the ileum. — Sloughy ulceration of the colon. — Goolab Poorie, a Hindoo beggar, of
twenty-seven years of age, was admitted into hospital on the 17th June, 1851. He had
suifered for about two months from quotidian fever, which commenced with chills in

R 4

248 DYSENTEKY.

the evening. For fifteen days he had been affected with dian*hoea. From the time
of admission to tlie 1st July, frequent thin feculent evacuations were passed with
griping and straining. The tongue was florid and glazed, and there was occasional
vomiting. The pulse was feeble, but febrile accessions were absent. He was treated
with astringents, opium, diluted hydrocyanic acid, opiate enemata, and small blisters.
From the 1st to the 16th July, the bowels were composed, the vomiting ceased, the
tongue lost its florid appearance, but the febrile accessions recurred and were tertian
in type. He was now treated with hydrocyanic • acid and quinine in small doses.
From the 14th to his death on the 20th July, dysenteric symptoms recurred and the
discharges contained blood-tinged mucus, and the febrile accessions ceased.

Inspection jive hours after death. — The body generally was much emaciated, but
there was a thick layer of fat in the parietes of the abdomen as well as in the omentum.
The peritoneal covering of the small intestine was in some places slightly vascular,
and some of the convolutions adhered to each other by tender lymph. A part of the
great omentum (that covering the ascending and the transverse colon) was fleshy
looking and of rose-red colour. Intestines. — The mucous lining at the end of the
ileum presented red transverse streaks, the surface of which was studded with granu-
lar deposit. The ascending and the transverse colon were much thickened through-
out, and presented internally almost a continuous surface of iilceration covered with
greyish sloughs. In the mucous membrane of the descending colon and of the sigmoid
flexure the ulcers were not so continuous. They were circular in character, each
about the size of quarter of a rupee. The liver was of natural size and texture,
but of pale yellow colour, both externally and internally. The mucous membrane
of the stomach was pale-looking and soft, chiefly towards the cardiac end. Both
the kidneys were healthy but ex-sanguine. Chest. — The lungs collapsed, were of
spongy textxire and free from adhesion. The heart was of natural size, and its surface
covered with fat, chiefly towards the margin of the right ventricle.

55. Dysentery. — Sloughy ulceration of large intestine. — Granular deposit in trans-
verse bands in the ileum. — Peritonitis and matting of the omentum. — An opium eater.
— Dhyam, a Mussulman water-carrier, of forty years of age, emaciated and addicted to
the habitual use of opium, a native of Delhi, and not long resident in Bombay, was
admitted into hospital on the 10th December, 1848. He had been ill with bowel com-
plaint and febrile symptoms for twenty days. On admission, the abdomen was soft
and collapsed, but uneasy on pressure at the umbilical region. During his stay in
hospital the alvine discharges were frequent, consisted of slimy mucus tinged with
blood, and were passed with griping, tenesmus, and occasional prolapsus. Febrile
heat was frequently observed, and the pulse was feeble ; the tongue was moist and
without fur. He died on the 24th December. He was treated first with ij)ecacuanha
and full opiates ; then acetate of lead or sulphate of copper or trisnitrate of bismuth
were substituted for the ipecacuanha. A small blister was applied to the pained part
of the abdomen.

Inspection six hours after death. — Chest. — Lungs extremely collapsed, crepitating
and healthy. Pericardium and heart healthy. Abdomen. — The liver was healthy.
The great omentum, red, and thickened, was matted over the transverse colon, and
adhered by friable lymph to folds of intestine (small and great) and to parts of the
abdominal parietes. The convolutions of the intestines adhered by flakes of lymph to
one another, to the viscera of the pelvis, and the parietes of the abdomen ; and there
was a blush of redness over them. The ccecum, the ascending colon, and the right half
of the transverse colon were internally in a state of sloughy ulceration, and all the
coats were tender, of greyish colour, and pultaceous consistence, and tore readily on
separating the adhesions ; the contents of the gut were thin and of greyish colour.
The sigmoid flexure of the colon was in a similar sloughy condition. The rest
of the colon was somewhat thickened with the mucous lining softened, but without
any distinct ulceration. The ileum was laid open for about three feet of its length;

PATHOLOGY — ULCERATION. 249

there was general redness of the mucous coat ranged in transverse streaks, correspond-
ing to -the valvulfe conniventes ; and at the lo\yer part of the intestine, the reddened
surface was covered with a layer of firm, granular lymph, and the mucous coat under-
neath was thickened. This effusion of granular lymph lessened as the ccecum was
receded from, and ceased two and a half feet from the ccecum, but the redness in
transverse streaks without the granular deposit extended somewhat higher. The
kidneys appeared tolerably healthy. Head not examined.

56. Probable scorbutic taint. — DarJc, irregular, ragged, internal surface of the colon^
with thickening. — Granular deposit on mucous membrane of ileum, with thickening. —
Dhondoo Essew, a Maratha labourer, twenty-one years of age, recently returned
from Aden, where he had been employed for two years, was admitted into hospital on
the 16th October, 1848, after ten days' illness from diarrhoea and febrile symptoms.
He was reduced in strength. He died on the 8th of November. The symptoms ob-
served were frequent alvine discharges, scanty, passed with griping, and consisting of
adhesive pasty or slimy feculence of palish colour, and frequently streaked with blood.
There was no fulness or induration of abdomen, and seldom uneasiness on pressure.
The tongue was sometimes coated in the centre, but was not florid. There was frequently
an evening febrile exacerbation noted. The skin was always dry ; the pulse feeble, some-
times irritable, and it ranged from 80 to 94. There was no spcJnginess of the gums, yet
residence at Aden is well known to engender a scorbutic taint. The urine showed no traces
of albumen. He was treated first with acetate of lead and opium, then with quinine and
full opiates, and a small blister was applied to the abdomen. Diet, milk, sago, port wine.

Inspection thirteen hours after death. — The body much emaciated. Chest. — The
lungs collapsed freely. Abdomen. — The intestines collapsed. No peritoneal adhesions.
The large intestine was rather contracted, and very much thickened. The inner
surface presented a dark green, very irregular and ragged surface, and the dark tint
extended into the interstices of the tissues, and gave the cut edges of the thickened
walls an almost black colour, in places. The inner surface of the ileum, for about two
feet above the ileo-colic valve, was diseased ; the mucous membrane red, thickened, and
covered with a layer, more or less thick, of granular, closely adherent lymph. The
kidneys were healthy. The liver was healthy.

57. Thickening and sloughy ulceration of large intestine, with here and there a small
encysted abscess in the thickened tissue. — Granular deposit on inner surface of ileum. —
Peritonitis. — Old pericarditis and heart disease. — Corporal C. W., aged thirty-one, of
Her Majesty's 40th Eegiment, after four days' illness, was admitted into the hospital
at Belgaum, on the 8th July, 1830. There was tenderness of abdomen, and frequent
purging, attended with tenesmus. The skin was hot and dry. The tenderness of
abdomen, never entirely removed, was much aggravated on the 14th. The purging
continued frequent, and he died July 16th. No ptyalism induced.

Inspection. — The peritoneal covering of all the intestines and of the convex surface
of the liver was vascular and covered with flakes of effused lymph. The caput ccecum
had formed firm adhesions, and in endeavouring to separate it from the iliac fossa, its
coats readily gave way. The disease of the mucous membrane commenced at the
termination of the ileum, where there where several vascular patches covered with a
slight effusion of granular lymph, but unattended mth ulceration. In the ccecum and
ascending colon the whole mucous coat was ulcerated and broken down, and the
subjacent coats were much thickened, with here and there a small encysted secretion
of pus in their tissue. In the transverse and descending colon the ulcers were large,
but circumscribed, of an olive green colour in their centre, surrounded by a blush of
redness, and uniformly attended with thickening of the other tunics. The paren-
chyma of the liver was of lighter colour than natural. The gall-bladder contained little
bile. Chest.~The pericardium adhered firmly to the whole surface of the heart,
from which it could not be separated without the knife. The heart was natural in
size, but of darker colour. The mitral valve was thickened and cartilaginous ; the

250 DYSENTERY.

aortic valves were in a similar state, and instead of being applied to the sides of the
vessel projected into its cavity, leaving dilated pouches behind them,

58. Dysentery. — Sloughy ulceration in transverse bands, and the follicles of the colon in
different stages of disease. — Insensibility for an hour before death. — Two ounces of serum
at the base of the skull. — Edward Clark, aged twenty -four, a seaman of slight frame and
dark complexion, was under treatment in the General Hospital from May 26th to 31st,
1839, ill with rheumatism, chiefly marked by rigidity of the muscles of the back of the
neck, and of the masseter muscles. He was discharged well, and joined the Indian Navy.
On the 6th June he was re-admitted into the hospital, ill with dysentery. It was tlie fifth
day of the disease. There was considerable fulness and pain of the abdomen, with tenes-
mus and pain at the anus. The countenance was anxious, the pulse frequent, and feeble,
the tongue white, but not coated, and the evacuations were yellow, slimy, and streaked
with blood. Five dozen leeches were applied to the abdomen, a warm bath used at bed-
time, and pills of calomel seven grains, ipecacuanha and opium, each one grain and a half,
were given, and followed on the succeeding morning by fouj drachms of castor oil. During
the night he was several times disturbed; the evacuations were watery, and tinged red.
On the morning of the 17th, the abdomen continued full, and was somewhat tense and
tender at the umbilicus. There was also considerable pain at the anus ; the countenance
was anxious ; the pulse ll6, of moderate strength, and the tongue pretty clean. Five
dozen leeches were again applied to the abdomen, and fomentations directed to be used
every second hour, and an anodyne enema to be exhibited at noon. The evacuations
continued frequent, watery, and tinged with blood. The tenderness and fulness of the
abdomen persisted, the skin was above natural temperature, the pulse 120, and
irritable.. At the evening visit the fomentations were continued, and calomel six
grains, with opium and ipecacuanha two grains, given at bed-time. The purging con-
tinued during the night, and on the morning of the 18th tlie skin was dampish, pulse
92, and feeble. There was less fulness of the abdomen, and less straining. A large blister
was applied to the abdomen, and the anodyne enema was repeated, and three ounces
of port wine ordered. At the evening visit the blister was found to have act^d well ;
the purging, however, persisted, and the evacuations consisted of bloody serum with
flocculi of blood. Pulse frequent and small, skin hot, much thirst, but the tongue not
furred. There had also been frequent vomiting. Calomel and opium each two grains and
ipecacuanha one grain, in the form of a pill, were ordered every four hours. The purging
was unchecked, and he died at 7 p.m., having become comatose half an hour before death.
Inspection twelve hours after death. — The abdomen was moderately distended.
Head. — There was about two ounces of serum in the cavity, chiefly at the base of the
skuU. Chest. — The lungs were emphysematous and not coUasped ; but the thoracic
viscera were otherwise healthy. — Abdomen. The omentum adhered to the ccecum,
and to the colon ; and many of the mesenteric glands were enlarged. At the hepatic
flexure of the colon, an ulcer was patched by the opposing side of the angle. The
whole of the inner surface of the large intestine was more or less diseased. There
were sloughly ulcerations and elevated transverse ridges coated with a layer of
granular lymph. The mucous follicles were also in different stages of disease ; in
some the oriflce was merely apparent, in others it was enlarged by ulceration, and
ranged from a mustard seed to the size of a sixpence. The mucous coat of the
stomach was mammillated. The liver was pale in texture, and in the left lobe there
was a small abscess, the size of a walnut. The kidneys were healthy.

59. Dysentery neglected for thirteen days, attended with abscess in the liver. — ■
Sloughy ulceration of the mucous coat of the colon, with fringe of granular exudation.
— Charles Mitchell, aged twenty-four, of stout habit, four years resident in India.
After thirteen days' illness, was admitted into the General Hospital on the 14th
December, ill with dysentery. There was a good deal of uneasiness of the abdomen,
and much tenesmus, and the dejections contained much blood mixed with mucus or
serum. He died on the 3rd January,

PATHOLOGY — ULCERATION. 251

Inspection. — Abdomen. — In the right lobe of the liver there was an abscess the size
of an orange, and in the left lobe there was one the size of a walnut. The large
intestine was thickened, and there were large patches of sloughy ulceration of the
mucous surface fringed with a layer of granular lymph. This layer of lymph was
plainly secreted by the inflamed surrounding mucous coat, and not by the surface of
the ulcer.

60. — Acute dysentery. — The large intestine ulcerated in transverse ridges. —
The mucous follicles enlarged. — Considerable effusion of serum in the head without
symptoms. — John Billing, aged twenty-three, a stout muscular man, a seaman of Her
Majesty's ship Volage was admitted into the European G-eneral Hospital, on the 28th
December, 1838. On the 22nd he had been affected with slight diarrhoea, from which
it was stated he had recovered. He was allowed to go on shore on leave, and re-
turned to the ship complaining of inability to void his urine, and of pain and tender-
ness of the hypogastrium. A catheter was introduced, and the bladder was found
empty. Subsequently, after the exhibition of diiu-etics, the mine was voided
naturally. On the morning of the 28th there was griping and purging, pain and ten-
derness of the abdomen on pressure, a small and rapid pulse, cold perspii'ation, and a
dark brown fur on the tongue. He was bled to twenty ounces, a blister was applied
to the abdomen, some castor oil exhibited, and he was sent to the European General
Hospital. On admission, at 5 p.m., the pulse was very feeble, the skin was cold, the
respiration was somewhat hurried, the tongue had a tliin brown coat in its centre,
and the chief complaint was of debility, faintness, and frequent ineffectual calls to
stool. The blister on the abdomen had risen well. An ounce of camphor mixture,
with a drachm of aromatic spirit of ammonia and five grains of the sesquicarbonate
of ammonia, was given on admission, and ten grains of calomel and two of opium at
bed-time. The respiration became more hurried, the pulse thready, the skin cold and
damp. Mulled wine was given every hour. He died at 2 a.m. of the 29th.

Inspection eleven hours after death. — Head. — The vessels of the pia mater were moder-
ately congested. On the convex surface of the brain between the pia mater and the
arachnoid membrane, there was considerable effusion of serum, and the latter mem-
brane was somewhat thickened and opaque. There were about six drachms of serum
in each lateral ventricle, and about two oimces at the base of the skull. Chest. — The
lungs with exception of emphysema of the upper lobes were healthy. Abdomen. — The
omentum adhered by fleshy points to the coecum, the iliac fossa, and different parts of
the ascending and descending colon. The sigmoid flexure of the colon was doubled
down, and adhered to the fundus of the bladder, and to the rectum. The inner
surface of the coecum and colon was much ulcerated, under the form of closely set
transverse elevated indurated ridges, with an ulcerated suface fringed by a layer of
granular gritty yellow lymph, or red gelatinous mucus. In many places, when the
layer of lymph was removed, the ulcer was found in process of cicatrisation. Many
of the mucous, follicles in the colon were enlarged, and some were ulcerated. Through-
out the greater part of the large intestine, the sub-mucous tissue was thickened.
The liver was healthy, and the gall-bladder full of bile. The small intestine was
healthy. The mucous membrane of the stomach was somewhat softened, with
marbled dark redness at its cardiac end, and in some places it was mammillated and
thickened. The spleen, the kidneys, and bladder, were healthy.

61. Acute dysentery. — The ulceration in transverse ridges. — Considerable effusion of
serum in the head, without symptoms. — John Gale, aged fifty-two, a tall man of
sallow complexion, who had served for forty-two years in India, had generally en-
joyed good health, but had led an intemperate life. After six days' illness, he was
admitted into the European General Hospital on the 12th December, affected with
frequent purging and pain of the abdomen. He described the evacuations to have
been of various appearance, and frequently to have contained much blood. On the

252 DYSENTEIiy.

night before • admission he had been constantly purged, and much blood had been
dejected. There was acute tenderness in the course of the colon and over the coicum.
Pulse 120, feeble. Skin of natural temperature ; tongue furred. He was ordered
four grains of acetate of lead with two grains of opium, at bed-time, and to be repeated
the following morning ; port wine was also given in small quantities. During the
night there was much purging, the evacuations being red and watery, and on the
morning of the 13th the pulse was almost imperceptible. The purging continued, the
sinking increased, and he died at midnight.

Inspection eight hours after death. — Head. — The vessels of the pia mater were turgid.
There was considerable effusion of serum between the arachnoid tunic and the pia
mater on the convex surface of the brain, and there was also considerable effusion at
the base of the skull. Chest. — The lungs were of dark colour and emphysematous, but
otherwise healthy. The heart was healthy. Abdomen. — The liver was of natural
size, externally of pale colour, with an irregular surface. When incised the texture
was found to be indurated, was of a pale buff colour, and mottled. The mucous lining
of the middle of the great arch of the stomach was mammillated ; at the cardiac end it
was thin, and in places almost removed. The end of the ileum was natural. The
£olon from beginning to end presented internally an irregular surface of sloughy
ulceration, chiefly ranged in dark red fungous, closely set transverse ridges, some of
which were half an inch thick, and fleshy when cut across. The free surface of these
ridges presented either a foul ulceration or a granular gritty surface from eflPused
lymph. The small intestine was contracted. In the right kidney there was a serous
cyst of the size of a walnut, and the parenchyma of the organ was congested. The
spleen was healthy.

62. Dysentery in an advanced state obscured by secondary peritonitis. — Granular
deposit on the mucous surface of the large intestine. — Shawah, a Hindoo washerman,
of thii'ty years of age, was admitted into the Jamsetjee Jejeebhoy Hospital on the 2oth
December, 1851. He was emaciated, had been ill for a month, and could not give a
connected history of his iUness. He complained chiefly of uneasiness of abdomen,
which was somewhat full and resisting. The bowels were open sometimes two or
three times in the day, and the evacuations were thin and feculent ; at other times
they were not opened. The pulse was feeble. The case was looked upon as one of
subacute peritonitis, and was treated with leeches, opium, ipecacuanha, and castor and
turpentine oils in small doses. He died on 1st January.

Inspection. — The small intestine was fuU of air, and its convolutions were adherent
to each other by bands of friable lymph. The transverse colon was displaced down-
wards at its central part. The omentum was matted over it, and was also closely
adherent to the larger curvatiire of the stomach. There was a pouch-like dilatation of
the upper part of the ascending colon. The coats of the large intestine were generally
thickened ; the mucous coat was pulpy, and generally softened, and studded over
with large patches of ulceration and granular deposit. The other viscera were
healthy, with the exception of slight encroachment on the tubular part of the kidney.

63. Several attacks. — Colon thickened. — Sloughy idceration, with granular deposit
on other parts of the mucous surfuce of the colon. — Slight peritonitis. — Private J. A.,
aged thirty-five, of Her Majesty's 40th Eegiment, was admitted into hospital at
Belgaum, on the 8th July, 1830, ill with dysentery. The attack was acute, but he
was discharged well on the 31st July. Ee-admitted 10th August with tender abdomen,
and other dysenteric symptoms. Ptyalism not induced. He was discharged on
the 18th September, after having been in hospital a long time convalescent. Re-
admitted September 23rd with tender abdomen and frequent purging. He complained
for the first time of pain of the right hypochondrium. Was subjected to the usual
treatment. No ptyalism. Died on the 1st October.

Inspiction. — There was much fat in the omentum and about the mesentery. The

PATHOLOGY — ULCERATION. 253

omentum adhered slightly to the intestmes. The small intestine had a blush of
redness on its peritoneal surface. The caput ccecum was drawn upwards from its usual
situation in the iliac fossa. The colon was thickened, covered witli fat, and firmly-
adherent to the fundus of the gall-bladder, which latter organ adhered also to the
pyloric portion of the duodenum. The transverse arch was closely connected to the
stomach. The sigmoid flexure formed several folds in the hypogastrium, and the
sides of the folds adhered to each other. The mucous membrane of the large intestine
was discoloured and ulcerated, and when floated in water exhibited a flocculent
surface. "Where less diseased there was a granular white effusion on the vascular
mucous surface. The liver was rather enlarged, and of lighter colour than natural ;
no adhesion. The viscera of the chest were healthy.

64. Dysentery admitted in the last stage. — Peritonitic inflammation. — Sloughy ulcera-
tion of the mucous coat of the colon. — Robert Hunter, aged thirty-eight, a seaman of
Her Majesty's ship Endymion, was admitted into the European General Hospital
on the 21st August, 1841. He stated that he had suffered from dysenteric symptoms
for five weeks, but had not reported himself sick till ten days previously. On admis-
sion the countenance was sallow, reduced, and anxious. The skin dry, and above
the natural temperature. The pulse 116, feeble and easily compressed. The abdomen
was rather full and tender on pressure at the right iliac region. The tongue was
florid at the tip, dryish in the centre, and without fur. He had been frequently
purged during the previous night, but the straining, formerly great, had considerably
decreased. Thirty-six leeches were applied to the right iliac region, a warm bath was
used, and the ipecacuanha pills with opium given. During the night, there were
frequent dejections of ochreous red colour, with intermixed sloughy shreds.^ On the
morning of the 22nd pulse 88 feeble. The other symptoms as on the previous day.
Two grains of opium, with an eqiial quantity of blue pill and ipecacuanha, were given
every four hours. On the 23rd, the frequent purging continued, the dejections being
of claret-red colour, attended -with hiccup and sinking pulse. Acetate of lead and
opium were given every four hours, two grains of each. The purging continued
unchecked, and on the 24th, the opium was combined with sulphate of copper, instead
of the acetate of lead, without benefit. He died on the morning of the 25th.

Inspection six hours after death. — The omentum, vascular and fieshy, extended over
the intestines, adhered to the ccecum and to the abdominal parietes. There was dark
vascularity, with exudation of lymph and tender adhesions of the peritoneal surface
of the small intestine. The ccecum, ascending and transverse colon were thickened and
tender, tearing readily and showing an inner surface of irregular ulceration, covered
with dark-coloured adhesive secretion. Liver healthy. Thoracic viscera healthy.

Transverse ulceration may also exist with thickening of the
coats of the intestine, but without granular exudation. It may-
occur also, though rarely, without thickening, and then the morbid
process is of a different nature — it is one of serous and lymph
exudation and suppuration in the sub-mucous tissue of the trans-
verse fold, followed by gangrene and sloughing of the mucous
layer. But this lesion will be more fully considered in connection
with the second form of ulcer — the circular.

Circular ulcers are generally found in dysentery of long duration,
in. which the symptoms have never at any time been very acute.

According to Drs. Parkes and Baly they originate in the solitary
glands. The latter author has described well the process of

254 DYSENTERY.

sloughing by which the gland is thrown off and the circular ulcer
is formed. That some circular ulcers of the large intestine are
formed in this manner is not to be disputed. They, however, con-
stitute, probably, but a small proportion of the circular ulcers
which are met with in that situation; for many of them have
seemed to me to originate in the ordinary follicles. It has been
already explained that when these structures are irritated to
increased secretion the}^ become turgid and their orifices distinct ;
then a vascular ring surrounds them and exudation of serum and
lymph in small quantity takes place into the mucous membrane
of the follicle and the areolar tissue around it, soon to be fol-
lowed by destruction of these tissues, through a process of fusion
or sloughing.

Circular ulcers may probably also be formed by the same proc3ss
as transverse ones, viz. by thickening of and granular exudation
on circular patches of the membrane followed by grangrene and
sloughing. But this mode is suggested rather hypothetically than
stated as an observed fact.

Circular and other forms of ulcer may originate in circumscribed
sub-mucous suppuration, of greater or less extent, followed by
sloughing of the superimposed mucous layer ; or, to express it
otherwise, exudation of circumscribed portions of lymph takes
place into the sub-mucous tissue, degenerates into pus, and is
succeeded by gangrene and sloughing of the mucous coat which
covers it. This manner of ulceration in dysentery has been
described by Haspel* ; and if I comprehend Dr. Bleekerf rightly,
it is the explanation of destruction of tissue in dysentery,
which he exclusively adopts. That ulcers are thus formed does
not admit of doubt. The process is analogous to that by which
some kinds of cutaneous ulcer are caused, viz. by small circum-
scribed sub-cutaneous abscesses with sloughing or ulceration of the
superimposed cutis. But in the writings of Haspel and Bleeker it
does not distinctly appear whether these observers have met with
the small sub-mucous abscesses frequently or only very occasionally.
If the latter, — which would be in accordance with my own ex-
perience,— -then their opinion that intestinal ulcers are frequently
formed in this way is in great measure hypothetical. If, however,
on the other hand, they have frequently observed this morbid pro-
cess in the stage of sub-mucous abscess, then the inference is,
either that this process is rare in India compared with Algeria and

* "Maladies de I'Algerie," tome ii. p. 71.
t ."Indian Annals of Medical Science," No. 1.

rATIIOLOGY ULCERATION. 255

Batavia, or that death in these latter countries takes place more
frequently at an earlier period of the disease.

I have met with only one instance of sub-mucous abscess in my
own researches ; for this state is not to be confounded with that of
intestinal thickening from lymph deposit with subsequent de-
struction, partly by sloughing, partly by suppuration.*

The following is my only case of sub-mucous abscess : —

65. Patches of suh-mucous puriform infiltration in colon. — A Hindoo, with febrile
symptoms, abnormal dulness of the lower part of right chest, with crepitus, was con-
sidered to be affected with pneumonia, and was treated in part with tartar emetic.
He died, and a large abscess was found in the upper and central part of the right lobe
of the liver, approaching the diaphragm ; its walls were ragged and shreddy. On the
inner surface of the ccecum, ascending and transverse colon, there were sloughy ele-
vated dark grey patches, of the size of a rupee, not separating, but pulpy, and chiefly
remarkable for the distinct puriform infiltration into the sub-mucous tissue beneath.
The kidneys were in a state of granular degeneration. Diarrhoea had not been present
as a prominent symptom.

Circular ulcers of the mucous membrane in cachectic individuals
may be caused in still another manner — by gangrenous patches con-
sequent on sub-mucous oedema, just as in similar states of constitu-
tion cutaneous ulcers may be formed by a like process.

The following is an illustrative case : —

&Q. Sloughy patches of mucous membrane of colon, with suh-mucous adema. — Earn
Dial, treated in the clinical ward, in February 1852, for emphysema, dropsy, and
dysentery. The surface of the mucous membrane of the large intestine was elevated
from sub-mucous oedema. The elevated patches were grey, circular, and gangrenous in
the centre, and ranged in size from a rupee to a quarter of a rupee. In none had
separation of the slough taken place.

There is then, it seems to me, still considerable uncertainty, in
regard to the precise mode of formation of ulcers in dysentery,
more particularly of those which are circular in form.

Pathologists in India will do well to direct their attention to this
subject, and to pursue it with minuteness and care. The questions
to be determined are, — the relative proportion of these ulcers which
originate: 1, in the solitary glands; 2, in the ordinary mucous
follicles ; 3, in patches of mucous membrane thickened by exu-
dation process ; 4, in sub-mucous abscess ; and perhaps, we may
add, in vesicular and pustular processes of the superficial parts of
the membrane. The circumstance of surrounding thickening of
the mucous membrane, or sub-mucous tissue, or of both, should
also be carefully noted. My expectation is that it will be found
.that circular ulcers are associated with surrounding thickening,
chiefly when they are formed in the third manner.

I now quote four cases illustrative of circular ulceration: —
* Cases 57 and 75.

256 DYSENTERY.

67. Numerous small circular ulcerations of the colon. — Kunecm Khajee, a Mussul-
man pilgrim, of twenty years of age, on his way from Lahore to Bombay, with the
view of proceeding to Mecca, was exposed to vicissitudes of weather, and three months
before admission into hospital, on the 28th September, 1852, became affected with
bowel complaint. When he came under observation, he was a good deal emaciated.
The face was puffed, the feet were ocdematous, and the abdomen full, with indistinct
sense of fluctuation and uneasiness in the course of the transverse colon. The bowels
were opened eight or ten times in the twenty-four hours, and the evacuations, passed
with griping and straining, were thin, slimy, and sometimes streaked with blood. The
urine not scanty, had generally a specific gravity of 1020, and showed no traces of
albumen. He died on the 4th October.

Inspection five hours after death. — The body was much emaciated. Chest. — There
were about six ounces of serous fluid in the sac of the left pleura. Both lungs were
pale, crepitating, and without adhesion. The sac of the pericardium contained about
four ounces of serous fluid. The heart was of natural size, and the valves healthy ;
but there was more than usual quantity of adipose tissue, both over the base and
apex of the organ. Abdomen. — The sac of the peritoneum contained about ten ounces
of clear serum. The liver was smaller than natxiral, and the external surface and sub-
stance were of pale yellow colour. The gall-bladder and the gall-ducts were quite
pervious. Stomach and small intestines collapsed, their peritoneal surface was pale.
The large intestine was not collapsed; its coats were thickened apparently from
oedema ; the mucous membrane was mottled red and white, and numerous small cir-
cular ulcers — some about the size of a pin's head, and others that of a split-pea —
were seen scattered throughout the whole inner surface. They were most numerous
about the sigmoid flexure of the colon, and many of them presented an appearance of
cicatrisation. The mucous membrane of the ileum was healthy, except close to the
ileo-colic valve, where several circular tdcers were also observed. The kidneys were
healthy.

68. Chronic dysentery in a person of hroJcen constitution. Numerous circular ulcers
in the large intestine, many of them cicatrising. Serous effusion in the head without
symptoms. — Henry Heming, aged forty-seven, an Indo-Briton, broken in constitution,
feeble in mind, and subject to dysentery for many months, was admitted into hospital
on the 2nd November, 1840. Both legs were cedematous, and the surface of the right
one was of dark red colour. The diarrhoea continued notwithstanding the different
remedies used, which were chiefly bismuth, sulphate of copper, and quinine in combi-
nation with opium. The dejections were generally pale in colour and thin. He died
on the 14th November.

Inspection thirteen hours after death. — Head. — There was a thin veil of serum be-
tween the arachnoid and pia mater on the convex svirface of the brain, and about an
ounce at the base of the skull. Chest. — The lungs were fully collapsed. The right
auricle of the heart was distended with blood. Abdomen. — The liver, not enlarged,
was mottled red and white, and blood flowed from it when incised. The sigmoid
flexure of the colon was much dilated, and filled the space between the pelvis and um-
bilicus, and overlaid the ccecum. The end of the ileum and the large intestine were
laid open. The mucous coat of the end of the ileum was of natural appearance, and
contained light yellow formed feculence. The coats of the colon were not thickened,
except, in places, the mucous coat itself. The inner surface tliroughout was very
closely studded with circular ulcers ranging from a silver penny to a small split pea in
size. In some places the ulcers ran together, and formed irregular longitudinal vertical
bands. For the most part the edges of the ulcers were rounded and cicatrised, and the
bed of the ulcers presented a dark grey cicatrised surface somewhat fleshy when incised.
The surface generally had very much the appearance of deep small-pox pits, shortly
after desquamation. The mucous coat between the ulcers presented generally a dark
reddish tint, but was not softened. The ulcers were most crowded in that part of the

PATHOLOaY — ULCERATION. 257

sigmoid flexure which was dilated. The mucous coat of the stomach, the kidneys,
spleen, and mesenteric glands were healthy.

69. Bark grey discoloration^ with some degree of thicJcening of mucous membrane of
colon, with numerous circular ulcers. — Luximan, a Hindoo T^eggar, of twenty-five years
of age, after eighteen days' illness, was admitted into hospital on the 30th November,
1850. He was frequently purged ; the evacuations consisted partly of thin feculence,
blood, and mucus, and were passed with much griping and tenesmus. The abdomen
was full, and tender on pressure, chiefly at the iliac regions. He suffered from febrile
disturbance also. The symptoms continued with occasional alleviation, but at times
hiccup was present with a gradually failing pulse, till 23rd December, when he died.
Leeches were used at the commencement, followed by small blisters. Quinine and
opium and then acetate of lead were given, and towards the end opium alone. Milk,
sago, wine, and chicken-broth as diet.

Inspection eleven hours after death. — Chest. — The lungs did not collapse readily, and
adhered closely to the costal pleura. The upper lobe of the right lung was crepitating, ,
the middle and inferior lobes were cedematous, as was also the inferior lobe of the left
lung. The heart was healthy. Abdomen. — The cavity contained about three pints of
clear serum. The mucous membrane of the large intestine was of dark grey colour,
was somewhat thickened, and did not move freely on the subjacent tissue. There were
many round superficial ulcers, several of which were in process of cicatrisation. The
ulceration, in its most active state, was in the ccecum and ascending colon. The
glands at the end of the ileum were more developed than natural. The mucous mem-
brane of the small intestine was healthy. The mesenteric glands were somewhat
enlarged, but free from tubercular deposit. The liver somewhat congested. Kidneys
normal.

70. Circular and transverse ulcers of the large intestine. — Matting of the omentum,
over the colon, with displacement. — Liver healthy. — Distention of the urinary bladder . —
Antonio Ignatio, of twenty-two years of age, and of spare habit, a native of Lisbon, a
sailor by occupation, and once the subject of yellow fever at Eio de Janeiro, was
admitted into hospital on the 25th July, 1851. He suffered from tertian fever for
eigliteen days, and some degree of enlargement of the spleen was noted. Dysenteric
symptoms had been present for five days before admission, and there was pain of the
abdomen on pressure at the umbilicus. While under treatment, the alvine discharges
— from six to twelve in the twenty-four hours — are described as thin and feculent,
passed with tenesmus, and occasionally with prolapsus. The tongue was coated, and
latterly florid at the top. The febrile accessions occasionally recurred. He died on
the 10th August. He was treated with opium and ipecacuanha, anodyne enemata,
and the application of a small blister to the pained part of the abdomen.

Inspection ten hours after death. — Chest.— 'Both, lungs collapsed freely. They were
soft and crepitating, but pale, and adhered firmly to the walls of the chest. The
pericardium contained about two ounces of clear serum. The valves and structure of
the heart were natural. Abdomen. — The liver was of normal size ; its structure healthy.
The spleen was somewhat enlarged. A small portion of the omentum matted over the
coecum, dragged the transverse colon downwards, to the right side. The coecum ad-
hered to the anterior parietes of the abdomen by tolerably firm bands. The whole of
the colon was distended by flatus. The mucous membrane of the large intestine
throughout presented numerous ulcers of various sizes. The smallest was the size of a
split pea, others — the largest — that of a dollar. Some were circular, others oval or
transverse, and others were rendered very large and irregular, by the coalescence of
several smaller ones. The base of all these ulcers was formed by the muscular coat.
The mucous coat presented here and there a blush of redness chiefly around the mar-
gins of the ulcers. The sub-mucous coat of the ccecum was swollen by serous infiltra-
tion. The kidneys were slightly enlarged, but their structure was healthy. The bladder

258 DYSENTERT.

was much distended by urine, and reached above the pelvis.* The ureters were also
distended up to the kidneys. The mucous membrane of the anterior wall of the stomach
presented a blush of redness.

5. The separation of Farts of the Mucous Goat in Shreds
and Tubular Portions. — The description of the processes by
which destruction and sloughing of the intestinal mucous mem-
brane are effected in dysentery is not yet completed. The mucous
membrane of the large intestine is liable to be affected with a form
of inflammation, acute and generally extensive, which, from the
course it follows, and the appearances it presents after death, may
reasonably be regarded as analogous in character to erysipela-
tous inflammation of the skin. It is commonly, but not exclusively,
met with in Europeans who have not been long resident in India,
and whose constitutions have been deteriorated by debauch and
climatic influences. The mucous membrane is discoloured and
swollen from exudation of serum and badly plastic lymph, which, also
diffusively infiltrated into the sub-mucous tissue, quickly degenerates
into sero-pus, and leads to gangrene of this tissue as well as of the
mucous membrane itself. Hence the separation of patches and
shreds of sloughy mucous tissue — often seen in the dejections
during life, and found after death in various states and stages of
separation. Cases 71 to 76 illustrate this condition of the intes-
tinal structures.

71. Dysentery. — Death in early stage hy cholera. — Gangrenous patches of mucous
mcmhrane of large intestine, hut no se'paration. — A soldier of the German Legion atPoona,
imder treatment for aifection of the bowels with bloody discharges, mistaken for haemor-
rhoids, was seized on the 4th June, 1859, with cholera, at the time prevailing, and died.

Lispection. — The mucous membrane of the colon and rectum was somewhat (Edema-
tous ; there were numerous large, grey -black, tumid, chiefly transverse, patches ; none
had separated, but some were very easily lacerable and gave out sero-pus, others were
firmer. The intervening mucous membrane was pale, with enlarged solitary glands
and follicles.

72. Dysentery. — Sloughs of the mucous coat passed before death. — Mu^h displacement
of the colon to the left side. Abscess in the Liver. — Joseph Slayman, aged thirty-two,
a seaman, was admitted into hospital on the 20th August, ] 840. He had been iU with
dysentery for fourteen days. On admission the abdomen was tender, the skin and
tongue were dry, and the pulse moderately full. On the 22nd there was tenderness of
the left iliac region, with perceptible hardness. Throughout his illness there was a
good deal of tenesmus. The abdomen was moderately full, and there was more or less
dysuria. Dejections watery, brown, and with dysenteric foetor. On the 4th, 5th, and
6th September, considerable patches of sloughed mucous coat were passed. There
were no peritonitic symptoms during the last days. He died on the 10th September.
Treatment. — He was once bled at the arm, was leeched several times on the abdo-

*■ The distention of the bladder would seem not to have been detected before death.
This is an oversight which ought never to occur in the treatment of dj'^sentery, as
attention to the state of this viscus should be a rule of practice.

PATHOLOGY— SLOUGtHINC}. 259

men, and around the anus. The abdomen was blistered. At first two or tliree doses
of calomel with opium and ipecacuanha were given, then ipecacuanha, gentian, and
blue pill, without pui'gatives ; aftei'wards free opiates frequently repeated in combina-
tion with blue pill and ipecacuanha, or quinine and bismuth, according to the state of
the pulse and skin. For two or three days acetate of lead and opium were freely used
with partial alleviation of the symptoms. Light nourishment and wine.

Inspection eight hours after death. Body emaciated.^ — Chest. — Old adhesions of the
right pleiu'a; no emphysema. Viscera healthy. Abdomen. — The omentum adhered
to the left lateral parietes, and had so dragged the colon from its natural situation
that the ccecum was lodged in the pelvis and adhered to the bladder. The right iliac
fossa and all the right side of the abdominal region were occupied by the small intes-
tine. The ascending and transverse portions of the colon passed vertically in the
mesial line, extended under the stomach, and formed various turns before passing into
the descending colon ; these duplicatures adhered to each other, and the intestine was
lacerated in many places, in separating them. The mucous coat of the end of the
ileum was healthy. In the coecum there were hanging loose dark sloughed patches of
the mucous tunic. Lower down the mucous coat had separated and been thro\vTi oflF,
and a pearly glistening surface was left, with here and there bands and isolated
patches of the mucous coat tolerably healthy, and standing out in relief. The liver
was enlarged, and extended into the left hypochondrium. It was mottled red and
white ; and in the right lobe towards the diaphragm there was an abscess about the
size of a large orange, and about half an inch from the surface. The pyloric end of
the mucous coat of the stomach was mammlllated. The kidneys were healthy.

73. Acute Dysentery. — Extensive sloughy ulceration of the inner surface of the large
intestine. — Dark red grumous discharges. — Charles Thompson, aged forty-two, a sailor
of intemperate habits, who had been five years in the Indian Navy, and who had
made frequent voyages to China dm-ing the twelve previous years, was admitted into
the European General Hospital on the 17th July, 1838, after he had been ill with
dysentery for five days. On admission the symptoms were not urgent. The skin,
pulse, and tongue were natural. There was no distention or pain of the abdomen, or
straining, when he was purged. The discharges varied in frequency ; they were gene-
rally tinged deeply with bile, and contained mucus. As the disease advanced, the
purging became more urgent, and tenesmus more complained of. The dejections were
more mucous and scanty; latterly they became dark red and serous, and contained
clots of blood. The pulse became frequent and feeble, and the skin damp. He died
on the 11th August, It would be tedious to detail the varied and ineffective treat-
ment that was pursued.

Inspection five hours after death. — Body not very emaciated. Abdomen. — The
omentum extended over all the intestines, and in the hypogastrium and iliac regions
adhered to the walls of the pelvis by fleshy vascular fringes. The intestines generally
were of dark grey colour, and more distended than natural. The coecum adhered by tender
dark-coloured layers of lymph to the lateral parietes, and in these places the coats of
the bowel were black, and tore readily. The tunics of the ascending and transverse
portions of the colon were also tender, and the latter part of the gut passed the left
side of the stomach, was applied to the diaphragm, and united by adhesions to the
spleen. The descending colon adhered to the left lateral parietes, and, on attempting
to separate it, the coats readily gave way, and dark grumous blood escaped. The sig-
moid flexure of the colon, before turning to reach the top of the sacrum, had dipped
more into the pelvis than is natural ; it adhered to the peritoneal lining of the peh-is,
and its coats also tore readily. The same lacerable condition characterised the tissues
of the rectum ; so much so that it was only separable in fragments. The whole of
the large intestine was filled with dark grumous blood. The inner surface of the last
two feet of the ileum was dark and red, vascular and softened. The coats of the
ccecum were much thickened, and the lining membrane completely disorganised, was

s 2

260 DYSENTERY.

replaced by large dark purple sloughy shreds. In the transyerse colon the ulcers were
more defined, and where there was no ulceration, tliere the mucous coat was dark red,
and softened. Tlie condition of part of the internal surface of the descending colon,
the sigmoid flexure and rectum, was sindlar to that of the coecum. The lining mem-
brane along the small curvature of the stomach presented marbled, red, extravasated
patches, and was softer than natural. The liver was healthy. The kidneys were
paler than natural. The thoracic viscera were healthy.

74. Dysentery. — General 'peritonitis before the fatal termination. — Berous effusion
in the head ; no head symptoms. — The mucous coat of the colon in process of separation
from the other tunics. — William Anderson, aged twenty-one, stout, seaman of the ship
Lord Auckland, after ailing more or less with dysentery for a fortnight, but much
aggravated during the last two or three days before admission into the Greneral Hos-
pital on the 25th July, 1840, when the abdomen was full, tender, and resisting; pulse
frequent and slightly sharp, but compressible. He was once bled from the arm, and
leeches in considerable numbers were applied to the abdomen, so long as any tender-
ness remained. He was also blistered twice. Calomel in free doses with opium and
ipecacuanha was given at the commencement at bed-time, followed during the day
with pills of ipecacuanha blue pill and extract of gentian. The dejections were, for
the most part, of light yellow colour streaked with blood, and generally passed without
much tenesmus. The disease not yielding, mercury was exhibited, partly by the
mouth, partly by inunction, with the view of affecting the system. On the 17th August
he was under the influence of mercury, and an abscess formed at the right angle of the
lower jaw. The purging, however, continued. Free opiates, in combination with bis-
muth, sulphate of copper, or acetate of lead, were given, and opiate enemata were used.
On the 29th August the abdomen became tender, continued so, and became full and
somewhat tense. The sinking increased rapidly, the purging continued, and he died
on the 1st September.

Inspection five hours after death. — Head. — The vessels of the membranes were defi-
cient in blood, and the substance of the brain was pale. Between the arachnoid mem-
brane and pia mater, at the posterior part of the hemisphere, there was a thin veil of
serum, and there was also about an ounce at the base of the skull. Chest. — The viscera
were healthy. Abdomen. — The omentum thickened was spread over the intestines and
adliered to them, and to parts of the abdominal parietes by a red-coloured fringe. The
convolutions of the intestines, great and small, adhered to each other by flakes of
lymph, and, on separating these, sero-purulent effusion oozed from among them. The
end of the ileum and the large intestine were laid open. The mucous coat of the end
of the ileum was healthy, and its contents were feculent and partly formed. The
mucous coat of the large intestine was of dark grey colour and pulpy aspect, and
throughout almost the entire extent of the bowel large patches were detached from
the muscular coat. Between the mucous and muscular coats there was a yellow lymph-
like lacerable layer. The stomach was healthy. The kidneys were healthy. Blood
flowed from the liver where it was incised, and the substance of the viscus was in
part mottled buff.

75. Sloughy state of mucous membrane of the colon. — Suh-mucous puriform infiltra-
tion forming little cavities. — General peritonitis. — Matting of omentum.— Ectention of
urine. — Mahdoo Suggujee, a Hindoo labourer, aged fifty years of age, and of feeble
constitution, was admitted into hospital on the 2nd July, 1848. There was retention
of urine, the abdomen was painful, and the pain was increased by pressure. He had
also frequent calls to stool, and the discharges consisted of blood-tinged serum ; he
had been ill four days; he died on the 11th July. During the time he was under
treatment the alvine discharges were frequent, consisted of blood-tinged mucus or
serum, mixed with more or less feculence. The abdomen was full, doughy, or tense,
with some degree of hardness in the right iliac region ; was tender on pressure, and a

PATHOLOGY— SLOUGHING. 261

sense of burning was at times complained of. The catheter had frequently to be used.
From the 4th the countenance was anxious, and dysenteric foetor was observed.
The tongue was more or less coated, the pulse was never above 92, at first well
developed, latterly becoming small. Leeches were several times applied. The treat-
ment was commenced with grains ten of calomel and two of opium, followed by castor
oil ; then ipecacuanha and blue pill were given at intervals, latterly combined with
quinine. Turpentine stupes were applied to the abdomen.

Inspection twelve hours after death. — The abdomen distended, the body emaciated.
Abdomen. — The small intestine was much distended from the duodenum downwards,
and adhered to the abdominal parietes, and the convolutions to each other by flakes
of lymph. The chief adhesions were to the pelvic walls and pelvic viscera, and over
the descending colon. In the pelvis and in the lumbar regions there was a good deal
of pus effused. The peritoneal surface under the flakes of lymph had a dotted red
appearance. The large intestine was contracted. The omentum was matted over the
transverse colon. The inner surface of the large intestine, throughout its entire
extent, was of a grey black colour, pulpy, thickened, softened from disorganisation ;
and here and there apparently in the sub-mucous tissue were little cavities with ragged
sides, containing grey foetid, sero-puriform fluid.

76. Mucous membrane of colon sloughy and separating in shreds. — General perito-
nitis and matting of the omentum. — Enam Khan, a Mussulman water-carrier, of
twenty -five years of age, was admitted into hospital on the 6th August, 1850. He
was reduced in fiesh. The abdomen was tense and generally tender on pressure, but
more particularly so in the right iliac, epigastric, and left iliac regions. There was no
dulness or induration. The skin was above the natural temperature. The pulse was
frequent and somewhat irritable. The tongue was coated with a thin dark brown fur,
and was florid at the tip and edges, but moist. The lungs and heart showed no signs
of disease. He stated that he had been ill for a month with relaxed bowels, that at
first the evacuations were thin and feculent, but after a few days consisted chiefly of
scanty discharges of blood and mucus, passed with griping and straining ; that for
fifteen days there had been febrile symptoms, with tender abdomen. At the time of
admission he was purged from fifteen to twenty times daily, and the urine was scanty
and high coloured. On the 7th the scanty bloody mucus discharges continued, the
pulse became more irritable, and there was hiccup. On the 8th the abdomen was
more tense, full, and tympanitic, and he died at noon of that day. He was treated
with quinine, opium, and ipecacuanha.

Inspection twenty-one hours after death. — Chest. — There were firm adhesions between
the greater part of the pleural surfaces of both lungs. The substance of the lungs was
soft and crepitating. The heart was healthy. Abdomen tense and tympanitic. On
opening the cavity of the peritoneum, some gas escaped. The great omentum was
contracted, and matted over the colon, and was also attached by tender lymph to the
adjoining convolutions of the small intestine. The small intestines were somewhat
distended, and at points of their contact with one another there were continuous stripes
of redness, about one-third of an inch broad. There was also slight eflfusion of lymph
between the uppermost convolutions of the small intestine and the transverse colon
and stomach. There were five or six ounces of sero-puriform effusion in the pelvic
cavity. The mucous membrane, throughout the whole extent of the large intestine,
was in a sloughy state. It was detached from the subjacent tunic, and in some places
hung in loose shreds. There was some mottled redness of the mucous membrane near
the pyloric extremity of the stomach, but this tissue was otherwise healthy. Head. —
The vessels of the membranes of the brain were a good deal congested. The substance
of the brain was apparently healthy.

There is one form in which these sloughs of mucous membrane

s 3

262 DYSENTERY.

are separated, which has given rise to some discussion among
pathologists, and which therefore calls for more particular notice,
viz. : the separation of tubular portions of several inches in extent.
Of this lesion eight cases have come under my observation : — 1.
In a soldier of the 15th Hussars in the European Greneral Hospital
in 1839. The slough, of about one foot in length, was perfectly
tubular, and evidently consisted of the mucous coat of part of the
intestine. Eecovery took place. 2. Four in the Jamsetjee Jejee-
bhoy Hospital, with one death, and the result in the other three not
known. 3. A gentleman, at Poena, in August 1859. The slough
was tubular, nine inches in length, and death took place by
haemorrhage eighteen hours after its separation. 4. One in the
practice of Mr. Sebastian Carvalho, the wife of a European pen-
sioner, fatal ; one with Mr. Bhawoo Dhajee, a Parsee female, pr<3g-
nant four months. She miscarried, but ultimately recovered.
Dr. Stovell * thus records his experience : —

" In four cases there was separation and expulsion per anum of some portion of
the mucous lining of the large intestines. In each of these cases the portion was
about six inches in length, and in one of them it retained its tubular form. It occurred
in the case of a seaman belonging to the ship Euterpe. He died two days afterwards.
In a second case, the patient, a sergeant in the Ordnance Department, lived three months
after the separated portion came away. The third case recovered. The fourth case
was more remarkable. It occurred in a boatswain of the Indian Navy. The separated
portion was twenty inches in length, the greater part retaining its tubular form. The
membrane was passed on the 29th January, 1852; yet he lived till June 28th — five
months. This was the largest portion of membrane which was ever passed in my care."

Of the twelve cases observed by Dr. Stovell and myself, there
have been three recoveries, six deaths, and of three the result
was unknown. In two of the fatal cases the result was postponed
for three and five months after the separation of the slough. In
only one haemorrhage was present, and caused death.

The nature of the sloughs has been considered at great length
by Haspel.f He adopts the view that they consist of mucous
tissue, and quotes confirmatory cases strengthened by microscopic
observation. Annesley was acquainted with this morbid process,
but Twining would seem not to have been familiar with it ; indeed,
he almost doubts its occurrence.

Intus-susception, — strangulation, sloughing, and discharge — of
part of the end of the ileum, consequent, probably, on previous
destruction of the ileo-colic valve, may be confounded with the
morbid lesion which has just been described. I have never seen
an instance of it. Twining, in the course of eight years, met with

* " Transactions, Medical and Physical Society, Bombay." New Series, No. 3, p. 29.
t " Maladies de I'Alg^rie," tome ii. p. 78.

PATHOLOGY— CICATRISATION OF ULCEES. 263

five cases ; and in two of them recovery took place. Dr. Stovell *
reports an interesting case of intus-susception in its early stage.

6. The cicatrisation of ulcers. — The cicatrisation of intestinal
ulcers has been mentioned, by several late writers, as a process with
which Indian pathologists are not well acquainted, but I cannot
bring to my recollection the time when it was not as familiar to
me as any other fact of the morbid anatomy of dysentery. It is
distinctly noticed by me in papers published in 1832 f, 1833 |, and
1845.§

The stage of the disease when this healthy action may be expected
to commence, and its duration, are points which it is impossible
to foretell in any given case, because they are dependent more or
less on coincident circumstances — as the state of constitution, the
degree in which the process of repair has been promoted by judi-
cious management, or counteracted by too active interference. It
doubtless may be assumed that the less the constitution has
been impaired, the more kindly cicatrisation will progress after
it has commenced. Moreover, it is evident from some of the cases
to which reference will presently be made — and it is a satisfactory
fact, — that the repair of intestinal ulcers may go on under very
adverse circumstances, such as the co-existence of abscess in the
liver. The process of cicatrisation has been minutely and well
described by Drs. Parkes and Baly. It consists of exudation and
organisation of lymph with contraction of the edges of the ulcer.
The appearances which it presents are illustrated by the following
cases, 77 to 79. Also in 80, 81.

77. Dysentery attended by general 'peritonitis. — The ulcers in different stages of
progress, some cicatrised, one perforating, hut patched up, — John Murphy, aged eight,
■was admitted into the sick ward of the Byculla Schools on the 25th September, 1837,
ill with dysentery. After ten days he had recovered, the gums having become aiFected
from the moderate use of hydrargyrum c. creta. Shortly afterwards, however, the
dysenteric symptoms recurred, but were slight. On the 17th November they had
increased, and were attended with tenderness to the left of the umbilicus. The gums
were still affected with mercury. From this time to the period of his death, on the
28th November, the symptoms were more or less urgent. There were frequent calls to
stool, attended by tenesmus, and scanty discharges of blood-tinged mucus or serum.
There was more or less tenderness of the abdomen, though never very acute ; it was
sometimes of the right iliac region, at others of the left, and unattended at any time
with much distention. The skin was often hot and dry. The pulse ranged from 120
to 130, and was occasionally sharp and irritable. The tongue was generally clean and
moist, but towards the end of his illness it became florid at the edges and tip. The

* " Transactions, Medical andPhysical Society of Bombay." No. 10, p. 312, FirstSeries.
t "Edinburgh Medical and Surgical Journal," April, 1832.
:j: " Transactions, Medical and Physical Society of Calcutta," vol. vii.
§ " Transactions, Medical and Physical Society of Bombay." No. 7.

8 4

264 DYSENTERY.

treatment consisted of leeching and blistering, opiate enemata, opium combined with
ipecacuanha, and with acetate of lead, &c.

Inspection six hours after death. — Abdomen. — There were three or four ounces of
sero-punilent fluid in the cavity. The omentum was vascular, spread over the small
intestines, and adherent to them. The peritoneal surface of the anterior parietes,
that of the ileum, the sigmoid flexure of the colon, and the rectum, was dotted red,
and the convolutions of the ileum adhered to each other by flakes of lymph. The
sigmoid flexure of the colon and the rectum adhered in a similar manner to their
opposing serous surfaces. The coecum was thickened, and perforated by a small idcer-
ation, which had been patched up by one of the convolutions of the ileum. On the
inner surface of the coecum there were large sloughy ulcerations, with much thick-
ening of the subjacent coat, except where the perforating ulcer existed ; and its bed
was a portion of sloughy -looking lymph, lying immediately upon the peritoneal coat.
The perforation existed at one corner of the ulcer. On the inner surface of the trans-
verse colon there were puckered dark grey cicatrices, and also others, round, depressed,
the size of a sixpence. Cicatrisation had commenced at the edges and the centre, but
the mucous layer had not been replaced in these situations. About two inches above
the sphincter of the anus there was thickening of the mucous coat; and for about an
inch in breadth, and throughout the whole circumference of the gut, a portion of that
tuiiic had been removed, and the muscular coat was exposed, and presented a shreddy
surface. There was no ulceration of the ileum.. The other abdominal and the thoracic
viscera were healthy.

78. Chronic dysentery. — 'Enlarged Tnesenteric glands. — Mucous coat of the colon
firm and thickened. The cicatrices of ulcers. — Abraham Johnson, aged twenty-eight, a
seaman of the ship Triumph, suifered from chronic dysentery from July 12th to
January 22nd, when he died, much emaciated.

Inspection.— Ahdomen. — Many of the mesenteric glands were as large as an almond
without the shell. The intestines were generally contracted. At the end of the ileum
there was vascularity in transverse streaks, but the tunics were sound. The colon was
in many places contracted; the mucous surface was in parts white, in others dark
grey, and slightly roughened ; it was firm, and adhered closely to the sub-mucous
tissue. There were the cicatrices of several ulcers in the upper part of the colon.

79. Pleuritis cured, succeeded by hydrocele radically cured ; followed by rheumatism,
succeeded by dysentery, cachexia, and recurrence of dysentery. — Colon ulcerated. —
Phillip Steer, aged twenty-five, a marine on board Her Majesty's ship Endymion.
On the 25th June, 1841, sniFered from an attack of pleuritis, for which he was bled
largely. On the 22nd July he was admitted into the European General Hospital with
swelling of the left testicle and hydrocele of the same side of ten days' standing. On
the 2nd August the hydrocele was tapped and port wine injection was used. On the
23rd August the testicle was nearly well, and the fluid had not re-accumulated ; but
swelling, pain, and heat of the left knee (to which he had formerly been subject) came
on and continued at times very acute, and with much febrile excitement ; treated with
leeching, colchicum, and mercurials. After a few days' steady improvement, on the
21st September dysenteric symptoms came on, and the knee-joint improved more
rapidly; and he was discharged, free of complaint, though weak, on the 11th October.
On board the Hastings he became affected with dysentery on the 2oth October,
and continued under treatment there till the 30th, when he was sent again to the
General Hospital. He was reduced in flesh and strength, pulse 120 and very feeble.
The tongue aphthous at the edges and coated in the centre ; the abdomen collapsed,
but without tenderness. There had been no return of the pain or swelling of the knee-
joint. Sago and port wine were ordered, and an anodyne enema at bed-time. During
the night he was purged frequently, the dejections being feculent and lumpy, and
passed without griping or straining. Subnitrate of bismuth, four grains, opium one grain,

PATHOLOGY — COMPLICATIONS. 265

were ordered every four hours. On the morning of the 31st the purging continued;
drowsiness came on with a febrile evening accession. The quantity of opium in each
dose of the piUs was reduced to half a grain, but the drowsiness increased to coma,
and he died at 8 p. m. of the 31st.

Inspection twelve hours after death. — The body was much emaciated. The left knee
in every respect similar to the right. The left testicle much wasted ; no effusion into
the tunica vaginalis of that side. Chest. — There were firm adhesions of the right lung
to the costal pleura. The serous covering of the heart presented a general pearly ap-
pearance, with here and there opaque spots very slightly thickened ; no enlargement of
the heart. Abdomen. — The liver was pale and bound to the side by partial peritonitic
adhesions. The intestines generally pale and washy-looking ; and there were a few
ounces of serous effusion in the cavity of the abdomen. The colon presented on its
inner surface numerous puckered ulcerations, many of them in process of cicatrisation.

In cases of frequently recurring attacks of dysentery, appearances
are sometimes observed which are best explained on the supposition
that under the fatal recurrence the cicatrices of former ulcers have
lost their vitality, and assumed the appearance of dark-coloured thin
pellicles, some attached, some separating, and some detached, and
exhibiting underneath a dark red or black, moist, infiltrated surface,
with a layer of pale condensed areolar tissue interposed between
it and the muscular tissue.

II. The Complication of Inflammation, ok its Results, of the
Mucous Membrane of the Large Intestine, with Peritonitic In-
flammation, GENERAL OR PARTIAL. — Under this head are included,
1st, those cases of general peritonitis terminating in vascularity of
the membrane, deposit of flakes of lymph on its suface, or sero-
purulent effusion, traceable, perhaps, in some cases, though cer-
tainly only in a small proportion, to rupture of an ulcer and
consequent escape of part of the contents of the intestine into the
sac of the peritoneum. It is remarkable how very generally per-
foration of the intestinal wall, from sloughy or other ulceration, is
patched by adhesions, and effusion in this manner prevented.*

2nd. Those very frequent instances of partial peritonitis which
cause adhesions of the omentum over the transverse colon or the
coecum, to the margin of the liver or to different parts of the peri-
toneal lining of the abdominal walls, — the most common being over
the transverse colon and in the neighbourhood of the coecum.f

The first complication, when not dependent on effusion into the
peritoneal sac, will be found generally to occur in persons who have
suffered for some time from dysentery, have been previously in
indifferent health, or who, not having had the advantage of appro-
priate treatment at its commencement, have experienced an exacer-

* Cases 58, 72, 73, 77, 80, 81, 82, 87, 96, -135, 178, 179.
t Do. 52, 54, 55, 60, 72, 96.

266 DYSENTERY.

bation of inflammatory action terminating in gangrene of the
mucous membrane. The second complication most frequently
takes place in acute attacks, and is generally associated with
thickening of the walls of the intestine, and sloughy ulceration of
the mucous coat in transverse bands. Sometimes, as a result of
omental adhesion, a tight band passing over the coecum, and ad-
herent to the iliac fossa, is found calculated by its pressure to
obstruct the passage through the gut.

The following cases from 80 to 86 illustrate these observa-
tions ; as do also 52, 54, 55, 60, 72.

80. Slough?/ ulceration of colon. — General peritonitis and matting of the oinentum. —
Shaik Abdoolla, a Mussulman sailor of twenty-two years of age, using spirituous
liquors moderately, but not opium, was, after four months' illness with bowel com-
plaint, admitted into hospital on the 23rd August, 1850. He was much reduced. The
abdomen was full and soft, and painful on pressure at the umbilicus. The tongue was
moist and slightly florid. The pulse was 76, small, and easily compressed. He con-
tinued under observation till the 21st September, when he died. During that time
the bowels were opened from six to ten times in the twenty-four hours. The evacu-
ations were scanty, thin, yellowish, greyish, or greenish feculence tinged with mucus
and blood, and passed with griping and straining. There was occasional evening
febrile exacerbation. The countenance became pinched, the feet cedematous. The
urine was of low density, but showed no traces of albumen. He was treated with
opiates, astringents, and the application of small blisters, sago, milk, and wine.

Inspection seven hours after death.— Chest. — On opening the chest, both lungs were
found fully collapsed. No effusion into the sacs of the pleura, nor any adhesion ob-
served. There was some degree of emphysema of both lungs at their thin edges. The
lungs were spongy in every part. Some degree of redness of the mucous membrane of
the bronchial tubes was observed, but no dilatation. Heart. — There were opaque
points of deposit on the inner surfiice of the aorta ; also on the aortic valves, but not
to the extent of injuring their pliability. Ahdomen. — ^About eight or ten ounces of
serum were effused into the cavity of the abdomen. There was a blush of dotted red-
ness on the peritoneal surface of several of the convolutions of the small intestine,
with effusion of flakes of lymph. The omentum, vascular and matted over the trans-
verse colon, had a sloughy appearance at one part — that over the hepatic flexure of
the colon ; and under this sloughy part there was an ulcerated opening into the intes-
tine. About the omentum, and also over part of the mesentery, there were greyish
flakes of lymph deposited. Pelvis. — There were five or six ounces of serum in the
cavity of the pelvis. Its peritoneal lining, including that covering the fundus of the
bladder, was covered with thick yellowish flakes of lymph. The mucous membrane of
the large intestine presented numerous ulcerations, some of them with soft and gra-
nular surfaces, in others more or less cicatrisation had taken place. The opening at
the hepatic flexure of the colon was about the size of half a rupee. The kidneys were
healthy. Liver of natural consistence and structure, but rather pale. The spleen was
not enlarged. The brain was healthy.

81. Sloughy ulceration of large intestine without thicJcening. — Commencing abscesses
in liver. Peritonitis. — Private W. H., aged thirty-eight, of Her Majesty's 40th Eegi-
ment, after two days' illness, was admitted into hospital at Belgaum, on the 14th July,
1830. There was purging, with much pain and tenderness in the course of the colon.
Pulse full, frequent, and sharp. He was freely bled and leeched, and was free of pain
for some days ; but the purging continued, attended with tenesmus. The dejections

PATHOLOGY — COMPLICATIONS. 267

contained neither mucus nor blood, but were watery, light-coloured, foetid, and filmy.
On the 23rd there was again tenderness of abdomen. The symptoms continued un-
altered. He died July 27th. No ptyalism induced.

Inspection. — The omentum adhered to both iliac fossae. The peritoneal covering of
all the intestines was vascular, and in some places covered with effused lymph. The
ascending colon and commencement of the transverse arch adhered to the concave
surface of the liver. The mucous membrane of the large intestine was ulcerated in
many places. In the coecum one ulcer had perforated the coats of the bowel, but
effusion was prevented by adhesion to the abdominal parietes. Some of the ulcers
had the appearance of commencing cicatrisation, and were covered with firmly adher-
ing yellowish shreds. In no situation were the coats of the intestine thickened ; on
the contrary, they were generally thinner than natural. The liver, more compact and
tougher than in the healthy state, was externally of olive colour, and in its substance
some points of purulent effusion were observed. The gall-bladder was shrivelled and
nearly empty.

82. Sloughy ulceration and thickening of large intestine. — Matting of omentum.
Bysuria. — Peritonitis of bladder. — Private J. T., of Her Majesty's 40th Regiment,
twenty-six years of age, and of slight make, was, after two days' illness, admitted into
the hospital at Belgaum on the 30th May, 1830. He complained of tenesmus, and
passed frequent scanty dejections, which contained blood and mucus. There was not
any febrile excitement or tenderness of abdomen. He gradually improved, and was
discharged free of complaint on the 14th June. He was readmitted on the 18th Jime
with a return of his former symptoms. Still neither pain nor tenderness of abdomen.
On the 22nd, however, slight tenderness of the right iliac region was present, but it
was removed by the application of a few leeches. On the 26th he complained of dy-
suria. On the 27th the dejections were brown and watery. He gradually sank with-
out return of pain of abdomen, and died on the 30th June. Ptyalism had not been
induced.

Inspection. — There was evidence that extensive inflammation of the peritoneum had
existed. The colon and rectum adhered to every organ in contact with them, the
former to the under surface of the right lobe of the liver, the latter by more recent
adhesions to the urinary bladder, and to the pelvic wall at the symphysis pubis. The
large intestine throughout its whole course was thickened. The mucous membrane
was much ulcerated, and in many places gangrenous. The omentum was drawn down
like a cord of small vessels, and adhered firmly to the coecum.

83. Mn^h sloughy destruction of the colon. — Peritonitis and matting of the omentum.
Former attack of hepatitis. — Puckered fibrous bands m liver. — Private B. M., aged
twenty-seven, of Her Majesty's 40th Eegiment, was admitted into hospital at Bel-
gaum on the 22nd July, 1830. He had been ill in hospital with hepatitis from January
16th to January 24th. Had been well ever since, till three or four days before admis-
sion, when he became affected with purging of mucous and bloody dejections, and
with tender abdomen. He died on the 6th August. No ptyalism. Tender gums.

Inspection. — The whole omentum, vascular, thick, and fleshy, embraced firmly the
colon from the coecum to the sigmoid flexure ; and on attempts being made to separate
it, the contents of the bowel escaped. In some places, where covered by the omentum,
the natural coats of the intestine were entirely destroyed. All the intestines, great
and small, were connected together in one mass, and adhered to the parietes of the
abdomen. The liver was smaller than natural. Its whole surface, both convex and
concave, was covered with depressed and puckered cicatrices, which, when cut into,
were found to be firm and membranous. The liver adhered slightly to the diaphragm.

84. Thickening of the colon. — Numerous deep idcers. — Matting of the omentum.
Liver with fibrous puckered bands. — Private J. P., aged thirty-one, of leuco-phlegmatic
habit, was admitted into hospital at Belgaum, on the 27th June, 1830, with ophthal-

268'

DYSENTERY.

mia, which terminated in ohstinate opacity of the cornea with interstitial ulceration.
While under treatment for ophtlialmia, he complained for the first time of dysentery on
the 9th October ; but it was ascertained that he had been ill during the two days
preceding. The symptoms were urgent. The dejections very frequent, mucous, and
bloody, were passed with griping and tenesmus, and there was tenderness in the
course of the colon. The skin was hot and dry, and the pulse frequent. He was
treated in the usual way. Ptyalism was not induced. He died on the 15th October.
Inspection. — The omentum spread over the intestines adhered firmly to the coecum,
where that intestine was united by unnatural adhesions to the iliac fossa. At the
points of adhesion the coats of the ccecum were black and tender. The walls of the
large intestine, which were in general thickened, were at the upper portion of the
ascending colon quite cartilaginous. The mucous membrane was idcerated. The
ulcers were numerous, defined, and deep. The liver was natural in size, but hard and
much mottled ; there were few adhesions, but the peritoneal covering of the organ
was thickened and of pearly colour. Old firm adhesions attached the gall-bladder to
the colon. Around the situation of the gall-bladder and elsewhere the liver had a
puckered depressed appearance, as if from the adhesion of the surfaces of the cyst of
an abscess. In these situations the structure of the liver was almost cartilaginous.
The gall-bladder contained numerous concretions. In the chest the costal and pul-
monary pleurae were connected by old adhesions.

85. Thickening and sloughy ulceration of large intestine. — Matting of omentum.
Congestion of the liver. — Private M. C, Her Majesty's 40th Eegiment, aged twenty-
eight, after suffering for thirteen days from pain in the epigastrium and right h;y'po-
chondrium, on motion and pressure, was admitted into hospital at Belgaum on the
26th June, 1830. His bowels had generally been confined, but he had been purged
the day before admission. The purging became more frequent. The dejections con-
tained mucus and blood, then finally became watery and of a reddish brown colour.
He sunk and died July 5th. No ptyalism induced.

Inspection. — The colon was distended, and its peritoneal covering was vascular, and
had contracted adhesions. Those between the ccecum and right iliac fossa were pale
and firmly organised. The omentum was very vascular, and adhered by one corner
to the caput coecum and right iliac fossa, so that the commencement of the transverse
arch of the colon was drawn down towards the right iliac region, and a bend was pro-
duced in the course of that intestine. The ascending colon was more diseased than
the rest of the intestine, and it adhered to the gall-bladder. The mucous membrane
of the coecum, ascending colon, and transverse arch, was not vascular, but thickened,
and presented an irregular and softened surface, resembling the walls of a tubercular
excavation. The liver was much enlarged, and contained much blood, but was free
from adhesion or abscess. The gall-bladder was full of bile.

86. Habitual constipation. — Colon contracted in parts and strictured by a band of
the omentum. — Tubercular infiltration of the lungs. — Ulceration of the ileum and coecum,
probably from softening of tubercles. — A lady of strumous habit and feeble conforma-
tion, aged about twenty-two, had whilst in England, for some years before her depar-
ture for India, suffered habitually from constipation, sometimes urgent, attended with
fulness and pain in the right iliac region, supposed to be caused by foecal accumula-
tions. In January 1834, after a year's residence in Bombay, in the enjoyment of
comparatively good health, this lady became the subject of a severe attack of dysen-
tery, for which, about the end of February, she was sent to the Mahubuleshwur Hills.
She was pale, weak, and very much reduced ; the bowels acted irregularly, sometimes
loose and irritable, the dejections being watery and containing mucus, — at other times
confined for two or three days in succession, and then relieved by sudden and copious
evacuation. The monsoon was passed at Poena, where her bowels were more irritable
and relaxed, and where she latterly experienced frequent attacks of dyspnoea. Much

PATHOLOGY — COMPLICATIONS. 269

emaciated, she returned to the Mahiibuleshwiir Hills on the 31st October, and died
on the 24th November.

Inspection seven hours after death. — The body was much emaciated and the abdo-
men collapsed. Abdomen. — The stomach was small and contracted. A band of the
omentum reached from the first third of the transverse colon, passed across the cce-
cum, and adhered to the hollow of the os ilium. Underneath the peritoneal coat of
the end of the ilium there were small miliary tubercles, and underneath that of the
ccecum the tubercles were numerous, and of the size of a pea. The coats of the ccecum
were much thickened, and there was adhesion to the hollow of the os ilium. At the
hepatic flexure the colon was contracted, and formed a double angle ; it then passed
obliquely upwards to the left, became applied to the cardiac end of the stomach, and
to the diaphragm ; thence it doubled acutely downwards, and formed the descending
colon, considerably contracted, but without thickening. The rectum and the sigmoid
flexure of the colon were dilated. On the inner surface of the ileum, close to the ileo-
colic valve, there was a ragged ulceration the size of half a crown, with edges dark red,
elevated, rounded, and centre irregular. The inner surface of the ccecum presented
an irregular hard fungoid surface, the elevated parts coursing in transverse bands
with an occasional intersection of longitudinal ones ; their colour was dark red, grey
black, in parts ink black; the colouring matter infiltrating deeply the thickened
tissues. The mucous coat of the ascending colon was of dark red colour, and much
softened. The mesenteric glands were enlarged, and had undergone tubercular de-
generation. Chest. — Both lungs contained tubercular masses in a crude state, and
adliered to the costal pleura at the points of tubercular deposition. Around the tuber-
cles the substance of the lung was quite healthy, and collapsed, so that the tubercles
stood in relief from the surface of the lung.

III. Tumefaction in the Eegion of the Ccecum or Sigmoid
Flexuee of the Colon. — The first is the more common, and is
caused by matting of the omentum over the coecum, with more or
less thickening of the coats of the latter, or by thickening of the
coats of the coecum without adhesions of the omentum.* It may
be caused also by intus-susception of the ileum. In case 88, per-
foration of the coecum and effusion of its contents into the cellular
tissue surrounding the gut, followed by gangrene of the abdominal
walls, took place.

The opinion that the tumefaction is frequently caused by foecal
accumulation does not accord with my experience in India ; and
belief in the frequent occurrence of this morbid condition has, to
my knowledge, led to serious errors in practice.

87. Chronic dysentery. — A jpaljpahle twnour of the coecum. — The lungs studded with
tubercles not suspected during life. — Considerable effusion of serum in the head. — ■
Patrick Fox, aged forty-two, a pensioner, emaciated and of broken constitution, was
admitted into the European General Hospital on the 8th March, 1839. He had
served twenty -three years in India^ had been pensioned two years and a half, and
had, he said, generally enjoyed good health. On admission he stated that since the
10th of January he had been affected with purging; that at first the evacuations
were scanty and slimy, but that latterly they had become watery ; and that he had
not used any remedies. The abdomen was not distended, but it was somewhat tense ;

* Cases 87, 133.

270 DYSENTERY.

and on pressure in the course of the colon there was tenderness, and over the
coecum a distinct defined hardness. The pnlse was 92 and small ; the skin cool ; the
tongue, coated yellow, was rough in the centre and florid at the edges and tip. There
were in general eight or ten pale, yellow, watery, sometimes frothy, evacuations passed
in the twenty -four hours, with dysenteric fcetor, but unattended by either griping or
straining. At no time was there cough or other pectoral symptoms complained of.
He died on the 22nd.

Inspection sixteen hours after death. Head. — About three ounces of serum in the
cavity. Chest. — The lungs collapsed partially. There were old adhesions of the
upper lobes of both sides, and a good deal of puckered irregularity of the external
surface of the lung at the site of these adhesions. Both lungs and all the lobes were
more or less studded with small grey tubercles, the size of a mustard-seed. At the
posterior part of both lungs, these tubercles had become so numerous and aggregated
that the tissue was almost impermeable. On the anterior part of the lungs they were
scattered with considerable intervals. Here and there there was a small cavity, the
size of a pea ; and there were one or two nodules which, when cut, presented a pearly
cartilaginous appearance. Abdomen. — The coats of the ccecum were about half an
inch thick, firm and cartilaginous, with round tubercular deposition, intermixed ■ the
inner surface ragged and ulcerated, and a perforation on the anterior aspect was
patched up by the omentum. The rest of the colon was little diseased. The liver
was pale, mottled, and softened. The stomach was healthy ; so were the kidneys.

88. Dysentery. —Perforation of the ccBcum, with consequent formation of a circum-
scribed sac, with gangrene of the muscles and integuments. Walker, private of

Her Majesty's 6th Regiment, aged 28, after six days' illness, was admitted into hos-
pital with dysentery, and died after a month. The bowels were generally very loose,
and the dejections frequently contained clots of blood with dysenteric fcetor. The
pulse was feeble and the skin damp. Latterly there was much defined fulness over
the coecum.

Inspection. — There was fulness of the right iliac region, with a dark gangrenous
patch of the integuments about three inches in diameter ; and underneath the muscles
were found in a gangrenous state. Over the ccecum there was a circumscribed sac,
about the size of an ostrich egg ; the inner surface dark olive green, foetid, and sloughy.
The contents of the sac were dark olive green, watery, foetid,— the evident contents of
the ccecum which communicated with the sac by an opening of an inch and a half in
diameter,

IV. Displacements of the Colon — are, 1st, of the commencement
of the transverse arch. This is very frequent, and is produced by
adhesion of the omentum to the coecum or iliac fossa, causing that
portion of the intestine to double down parallel to the ascending
colon. 2nd. The transverse colon passing in the line of the great
arch of the stomach, adherent to the left side of the diaphragm, and
then doubling acutely down to form the descending colon, is a form
of displacement occasionally observed, but not nearly so frequently
as the one first described. I have witnessed it in four cases. 3rd.
Tlie sigmoid flexure dragged to the right, and adherent to the brim
of the pelvis or to the bladder, is a displacement, also caused by
adhesions, but it is not very common.

I would refer to cases 53, 60, 63, 68, 70, 72, 178, 179, as afford-
ing illustrations of various displacements of the colon.

PATHOLOGY — COMPLICATIONS. 271

V. Complication of Ulceration of the Mucous Lining of tee
liAEGE Intestine, with Abscess in the Liter. — This is very com-
mon; but the subject will be more appropriately considered in a sub-
sequent chapter in connection with hepatitis and hepatic abscess.

VL Complication of Dysentery, with Morbid Lesions of the
Small Intestine or of the Stomach. — When the small intestine
is affected, the morbid changes will be generally found at the end
of the ileum. They consist of ulcers more or less circular, originat-
ing in Peyer's glands ; or in increased redness, with granular exuda-
tion, as already stated.*

In the following cases circular ulcers of the stomach were
associated with similar ulcers of the colon : —

89. Circular ulcers with sloughs in mucous membrane of colon and stomach. — No
thickening. — Mahadoo Mallee, a Hindoo flower-seller, of thirtj-five years of age, of
feeble constitution, in destitute circumstances, and often exposed to vicissitudes of
weather, and occasionally indulging in the moderate use of spirits, was, after twelve
days' illness, admitted into hospital on the 22nd June, 1850. During that time he
had siiffered from relaxed bowels ; the evacuations at first had been thin and feculent,
but latterly had shown traces of blood and mucus, and were attended with tenesmus
and sometimes with prolapsus. Siich continued to be their character during the time
the patient was under observation. On admission, the lungs and heart were found to
be healthy. There was some fulness of abdomen, but no induration. There was no
febrile disturbance. The pulse was small, feeble, and easily compressed. The tongue
was clean, moist, and pale. These symptoms continued with little change till the
25th, when the bowels became more relaxed ; he sank rapidly, and died at 9 p. m. of
that day. He was treated with quinine, in three-grain doses, combined with a grain
each of ipecacuanha and blue pill, and latterly half a grain of opium, every fourth
hour ; and had milk, sago, and wine as diet.

Inspection seventeen hours after death. — Chest. — The lungs M^ere collapsed and cre-
pitating, but in parts old adhesions united the costal and pulmonary pleurse of both
sides. The heart was of healthy size and structure. Abdomen. — There was a small
quantity of serous fluid in the peritoneal cavity. The liver was healthy in size and
structure. The spleen was healthy. There were five or six patches of ulceration in
the mucous membrane of the stomach ; one or two of them were quite circular, with
dark yellow or brownish sloughs in the centre ; the others were larger, and more or
less irregular, but also had central sloughs attached to them. The mucous membrane
at the cardiac extremity of the stomach had a dark brown marbled appearance, but its
substance was not soft. The mucous membrane of the large intestine, from the rectum
to the ccecum, was studded with ulcers, with dark grey sloughy surfaces of different
sizes, — the smallest being circular, and the larger irregular. There was no thickening
of the coats of the intestine, and the mucous membrane was not more firmly adherent
to the subjacent coat than natural. No ulceration of the mucous membrane of the end
of the ileum. The kidneys were apparently healthy.

90. Gray softening, with a few ulcers of the mucous lining of the stomach and colon.
— Cicatrices of idcers in the former. — JohnKnapp, a private of the 4th Light Dragoons,
aged twenty-two, who had suffered twice from dysentery in the year 1830, was, after
two days' illness, admitted into the Hospital at Kirkee, on the 17th April, 1832. The
evacuations were scanty, frequent, of light colour, tinged with blood, and passed with

— _ . 1

* Cases 46, 52, bb, and 56.

272 DYSENTERY.

griping and tenesmus. The iliac regions were tender on pressure. The tongue was
coated in the centre and florid at the edges. There was occasional retching and
vomiting, and frequency of pulse. He died on the 22nd. He had been bled ; a
blister was applied to the epigastrium ; mercury with opiates was given. The mouth
was sore, but there was no salivation.

Inspection. — There were not any traces of peritoneal inflammation, and no disten-
tion of the bowels. The mucous membrane at the end of the ileum was somewhat
vascular, perhaps thinner, and peeled easily oflP with the nail. There was one ulcer in
the ccecum about the size of a silver penny, not deep, and unsurrounded by thickening
or vascularity. The mucous lining of the great intestine throughout, perhaps thicker
than natural, of a light ash-grey colour, was here and there dotted red, and peeled oiF
readily with the nail in shreds. The contents of the large intestine were green and
feculent. The mucous membrane of the stomach, thickened and somewhat softened,
presented there and here an ash-gTcy dotted red appearance, with the marks of one or
two small cicatrising ulcers. The small intestine was not opened, with exception of
the end of the ileum. The liver was healthy. The gall-bladder was full of bile. The
thoracic viscera were healthy,

VII. Co-existence of Enlargement of the Mesenteric G-lands
WITH Dysentery. — An enlarged, reddened, and somewhat sero-
infiltrated state of the mesenteric glands is not unusual in dysen-
tery, depending, it may be supposed, on the increased flow of
blood through the mesenteric arteries, which is probably present
in this disease. These glands were enlarged in cases 52, 69, 101.

Part of the intestine chiefly affected. — On this point observers
have somewhat differed in their statements. The tendency of
the inflammation is to affect the entire mucous surface of the
large intestine. In some cases it is general ; in others present in
greater degree in one portion than another, but very seldom ex-
clusively limited to a particular part. The situation of the disease
is noticed distinctly in forty-six of my fatal cases. Of these it is
described as general in twenty-four ; as predominant in the coecum
and ascending colon in fifteen; in the coecum and transverse colon
in three ; in the coecum and rectum in one ; in the coecum and
sigmoid flexure in one ; and in the transverse colon in two.

Concluding reTriarhs. — My observations on the morbid ana-
tomy of this important disease do not include any results of
microscopic inquiry, for I have not any information from this source
to communicate. A careful use of the microscope will, doubtless,
give precision to descriptions of the discharges and of the exudation
matter on the surface and in the interstices of the membrane, and
serve to distinguish the tissues and structures affected in different
forms of the disease. Still, mal^ng full allowance for this,
and not estimating lightly the addition of positive facts to our
knowledge, however unimportant they at first sight may appear, I
must frankly avow that I do not anticipate much increase to our

CAUSES — EXCITING. ^7^

practical acquaintance with dysentery from this method of investiga-
tion ; and I would venture to caution the young pathologist, when
engaged with microscopic details, to take care tliat his mind does
not lose the grasp of large principles of Pathology, Etiology, and
Therapeutics.

Section III. — Etiology of Dysentery. — Importance of distin-
guishing exciting and predisposing Causes. — Exciting Causes.
— Cold, Food. — ^ Predisposing Causes. — Cachectic States. —
Action of MalaHa discussed.

In explaining the etiology of dysentery it is necessary carefally
to distinguish between exciting and predisposing causes, for neglect
of this distinction has led to much of the confusion which exists in
the descriptions of this disease. I shall treat first of the exciting,
then of the predisposing causes ; and lastly state my reasons for
dissenting from the common opinion that malaria is an exciting
cause, and for believing that the important influence which it
undoubtedly exercises in the causation of dysentery, is predis-
posing.*

Exciting causes. — The atmospheric states which unduly or
suddenly depress the temperature of the surface of the body are
the most common exciting cause. They consist of absolute lowness
of temperature, of considerable diurnal ranges, of much atmospheric
moisture, and of currents of dry or humid air. The action of these
conditions is often favoured by imprudent exposure of the body
deficient in resisting power in consequence of that lowered capa-
city of generating animal heat which is its physiological state in
tropical climates.

My hospital experience shows that the proportion of admissions

* In a note on the'pathology of dysentery, p. 237, reference is made to certain
theoretic analogies between inflammation of the skin and that of the intestinal mucous
membrane ; and, in considering the causes of dysentery, these analogies are again
suggested to the mind. Some inflammations of the skin — the eruptions of measles,
scarlatina, small-pox — are caused by the reception of specific poisons into the blood.
To apply a similar principle of causation to some forms of dysentery, and to suspect
contagious or infectious properties, is within the limits of rational speculation. But
it may be safely affirmed that such conclusions are as yet altogether without proof.

Again, it is sufficiently probable that the blood, vitiated by a specific poison, or by
retained or altered excretions, may give rise to other forms of cutaneous inflammation—
as erysipelas — or some of the squamous, vesicular, and pustular eruptions ; and that
this theory may also be reasonably applied to some forms of dysentery.

But, as it is not pretended that every inflammation of the skin is caused by the
blood being vitiated in one or other of these ways, it is contrary to analogy to propose
an etiological theory of this kind in respect to all forms of dysentery.

274

DYSENTERY.

from dysentery is greatest in those months of the year in which the
atmospheric state is most likely to be one or other of those which
have just been mentioned ; and in this category I am careful to in-
clude June and November, — months in which marked atmospheric
changes occur in Bombay. In June the hot season terminates, the
rains begin to fall, and damp winds to blow. In November the
sultry heat of October ends, and north-easterly winds set in.

The following statement gives the proportion of admissions from
dysentery per cent, of the total admissions in the European
Greneral Hospital, and the Jamsetjee Jejeebhoy Hospital at
Bombay, in different seasons of the year : —

European General
Hospital.

Jamsetjee Jejeeb-
Hospital*

Cold months. — November, December, January
Wet months. — June, July, August .
Transition from cold months. — February,

March

Transition from rains. — September, October .

Hot months. — April and May

Annual proportion

10-8
7-0

6-3
5-4
51
7-4

10-2
10-7

6-4
8-9

7-2
9-1

The same result is shown by the per-centage of monthly admis-
sions, from dysentery and diarrhoea, to the total annual admissions
from these diseases in the European Greneral Hospital for the ten
years from 1846 to 1856, and in the Bycalla Schools for the seven-
teen years from 1837 to 1853. Thus : — f

January
February-
March .
April .
May
June
July .
August .
September
October
November
December

European General Hospital.

Dysentery.

12-470
5-827
6-177
7-266
7-266
7-342

10-839
7-459
5-827
5-447
9-440

14-685

Diarrhoea.

8-172
5-836
8-300
7-652
6-485
9-597

12-840
9-987
5-966
6-255
8-819

10-116

Byculla Schools.

Dysentery

and
Diarrhoea.

5-634

6-933

8-422

7-769

8-956

12-633

16-903

11-565

5-753

4-922

5-634

4-863

* This column gives the proportion of dysentery and diarrhoea combined.

t The figures relative to the European General Hospital, are taken from Dr.

CAUSES — PREDISPOSINGf. 275

Unsuitable food— impure water included — may excite dysen-
tery ; but it is not a common cause.

Fsecal accumulation, and what are usually termed vitiated ex-
cretions, in tbe large intestine, may act as exciting causes of
dysentery; but my experience on this point is not confirmatory
of the doctrines of Annesley and others on the frequency and
importance of these conditions : it is more in accordance with the
opinion of Dr. Mackinnon, that fsecal accumulation is not a
common pathological state in India.* The question is practically
important, from its evident bearing on the use of calomel and
purgatives, not only in the treatment of dysentery, but of disease
in general.

Predisposing causes. — The exciting causes of dysentery cannot
be justly appreciated unless we carefully note those predisposing
states of the system which very generally determine their action.
Therefore, in order to discover the causes of dysentery, it is not
sufficient merely to regard the atmospheric states to which the
affected have just been exposed, or the food, clothing, and houses
with which they have been supplied. It is fully as necessary that
we should be informed whether or not, and in what degree, they
have heeii previously subjected to those various well-known influ-
ences designated predisposing causes, which are as essential to the
development of the disease as the application of the exciting cause
itself.

The chief predisposing conditions of dysentery may be thus
briefly stated.

The European lately arrived in India, consequent on the exhaust-
ing effects of elevated temperature, or on the want of adaptation of
food and habits to the altered assimilation and elimination induced
by climate, has a state of constitution engendered favourable to
the occurrence of dysentery, under the influence of exciting atmo-
spheric conditions, and which is often still further favoured by
imprudent exposure of the perspiring surface of the body. It is in

Stovell's report. " Transactions, Medical and Physical Society," No. 3, New Series,
pp. 22 — 34. Those of the ByeuUa Schools, from my own notes, Table XXIX., p. 322.
There is a striking contrast in the ratios of the General Hospital and of the Schools for
December and January ; but as respects the schools, tlie necessary data are incomplete.
It is not improbable that a " strength," greatly reduced by absence in the Christmas
holidays, may explain the low ratio in December and January. When we compare
the column diarrhoea of the hospital with the conjoint column of the schools, the in-
ference may be drawn that the high ratio of June, July, August, in the latter — is due
to diarrhoea rather than dysentery.

* Treatise on Public Health, by Dr. Mackinnon, p. 314.

T 2

2T6 DYSENTERY.

these circumstances that the erysipelatous form of dysentery is
usually produced in Europeans in India.

All cachectic states of the system, however developed, are very
predisponent of dysentery. So much so, that when they are pre-
sent in considerable degree, a very slight exciting cause is suf-
ficient; and when present in great degree, inflammation of the
intestinal mucous lining is apt to arise, almost without appreciable
exciting cause, — being, as it were, the closing act of the cachexia.
Let me point to some illustrations of this position.

1. There is no more common cause of cachexia in India than
malaria, and recurrences of malarious fever. It consequently
happens that whenever persons cachectic from malaria are exposed
to atmospheric states, which depress the temperature of the sur-
face of the body, dysentery becomes prevalent and very fatal.
Evidences of this etiological law, which have passed under my own
observation, have been already brought forward in reference to the
mortality from intermittent fever (p. 24), and it would be easy to
add to their number. For example, the experience of the Hima-
layan Hill Sanitaria, as set forth by Mr. Grrant and Mr. G-reen in
their papers * on Hill Diarrhoea and Dysentery may be instanced.

2. Again, continued elevation of temperature, habitual residence
in an atmosphere vitiated by excess of carbonic acid, or emana-
tions from decaying vegetable or animal matter, or too nmch
moisture, will induce cachexia ; so will the habitual use of food
defective in quantity or quality (scurvy), intemperance of all kinds,
too much bodily fatigue, and the influence of depressing passions,
as anxiety, fear, &c. A cachectic state may also arise from long-
continued disease, from injudicious and too-prolonged antiphlo-
gistic medical treatment, from mercury, and the poison of
syphilis, &c.

3. The occurrence of dysentery in crowded barracks, transport
ships, jails, standing camps, besieged garrisons, beaten and retreat-
ing armies, are illustrations of the importance of considering
cachectic conditions in explaining the causes of dysentery. And, if
the history of events of this kind be rightly investigated, the in-
fluence of cold or wet, from undue exposure, defective clothing, and
houses, or of unsuitable food, or impure water, will always be
evident, and prove the preventible character of both the predispos-
ing and exciting causes.

The opinion that malaria is an exciting cause of dysentery may
now be considered. I do not pretend to name all the able writers

^ " Indian Annals of Medical Science," Nos. 1 and 2.

MALARIA NOT AN EXCITINa CAUSE. 277

wlio have advocated this doctrine ; but, amongst later authors,
Dr. E. Williams, Dr. Baly, Haspel, Mr. Hare, and Mr. Grant
may be mentioned.

The circumstances in which dysentery have occurred in my own
field of observation have never justified the supposition that
malaria was the exciting cause * ; and the facts usually ad-
duced in support of the contrary opinion have seemed to me to
admit of a more ready explanation, either in the predisposing
influence of malaria, or the exciting influence of the cold, damp
air, which in marshy tracts frequently co-exists with malaria.
It was to the cold, damp condition of the atmosphere that Pringle
attributed both remittent fever and dysentery. He does not allude
to malaria, to which since his time both fever and dysentery have
been referred. When intermittent and remittent fever co-exist
with dysentery, it will probably always appear that the conditions
of malaria co-exist with a damp and variable atmosphere. But
according to my belief malaria causes the fever f, and the cold damp
air the dysentery ; hence we can understand why the two affec-
tions may sometimes be associated, but also be frequently distinct.

It would be foreign to the objects of this work to enter into a
critical examination of the arguments of those who consider malaria
to be an exciting cause of dysentery. Indeed, the assumed facts
are so generally wanting in precision, that it may be doubted
whether practical profit could arise from engaging in the in-
quiry. Yet allusion may be made to some points which fail to
make that impression upon me which they seem to effect upon
others.

1. The fact that fevers and dysentery prevail in the same divisions
of the Indian army, is not necessarily confirmatory of identity of
cause. They who think otherwise forget that a " division " may
refer to an extensive tract of country, and may present in different
localities considerable variety of climate and of physical feature.

* On the contrary, the 4th Dragoons, who suffered much at Kaira from malarious
fever, were little affected with dysentery there. At Belgaum, dysentery is a frequent
and fatal disease ; malarious fevers not so. Of the dockyard peons, so frequently
under treatment in my clinical ward with malarious fevers, only two were received ill
with dysentery.

t To prevent misapprehension, I would suggest a reference to Section I., and that
part of Section II. which refers to mortality — of the Chapter on Intermittent Fever.
It will there appear that full importance is attached to cold and wet as a determining
cause of re-attacks in the previously tainted with malaria. My present observation
relates to the previously healthy, and exiwesses the belief* that in these malaria alone
excites the fever, but that the co-existing cold and wet, not the malaria, excite the
dysentery.

T 3

278 DYSENTERt.

Moreover, in the kind of statements now referred to, mention is
not generally made of the months or seasons of the year in which
the two diseases have respectively prevailed ; hence we are left in
ignorance whether the occurrence has been in the same or in a dif-
ferent season. Again, the character of the fever is frequently not
stated; for example, Dr. E. Williams, in his work on Morbid
Poisons*, places the Presidency division of the Madras army
first in his list of instances of the prevalence and identity of cause
of paludal fever and dysentery in the same district. Whereas, the
fact is, that this division of the Madras army is singularly free from
malaria ; and of the fevers registered in it, the larger proportion is
febricula, and not paludal.

2. Complication of intermittent or remittent fever with dysen-
tery, has been of rare occurrence in my own experience, bat it
would seem not unfrequently to exist in other provinces of India
and in other countries, and is then accepted as evidence that
idiopathic dysentery is caused by malaria. In this conclusion, how-
ever, I am unable to concur. Elsewhere in this work it will be
shown that remittent fever in the natives of Bombay is often com-
plicated with pneumonia, but it has never on this account been
inferred that malaria is an exciting cause of idiopathic pneumonia ;
yet the conclusion would be quite as logical as that which
has been drawn with reference to dysentery from analogous
premises.

3. When a person, tainted with malaria, becomes affected with
dysentery, sometimes the symptomatic febrile phenomena evince a
periodic character, and occasionally the dysenteric symptoms show a
similar tendency ; but in this we have no proof that malaria has been
the exciting cause of the dysentery. A similar order of events has
been observed in other inflammations, as well as in injuries, in
the same kind of constitution. Though a staunch advocate might
still insist that malaria may be the exciting cause of these other
inflammations also, yet he will hardly maintain that the contused
wound or fractured limb — which, equally with dysentery, may be
accompanied by symptomatic fever of periodic character — can be
thus accounted for.

4. Nor does the alternation of febrile accessions with symptoms
of dysentery or diarrhoea — occasionally observed in persons tainted
with malaria, and previously affected with intermittent fever —
imply that malaria has been the exciting cause of the dysentery.
The alternation of dysenteric symptoms with those of chronic

* Volume ii. p. 540,

MALAEIA NOT AN EXCITINa CAUSE. 279

laryngitis, of pulmonary affections, and of rheumatism, has from
time to time come under my observation ; but such facts have not
been held necessarily to indicate identity of cause of these several
affections.

5. Mr. Grrant, in his interesting report * on the prevalence of
dysentery and diarrhoea in the Himalayan Hill Sanitaria, while he
attributes much to the cold moist atmosphere of these stations, yet
believes that malaria is also influential as an exciting cause. The
chief argument which he adduces in favour of this opinion is, that
in other hill stations possessing analogous climates, as regards tem-
perature and moisture, this tendency to dysentery has not been
observed. Nainee Tal, Murree, Darjeeling, the Neilgherries, and
Mahubuleshwur, are instanced as hill localities which enjoy this
immunity. In respect to the four first stations I am not aware
whether the experiment has been made of exposing cachectic per-
sons to the influence of their cold, moist atmosphere ; but in respect
to Mahubuleswhur I know that the result has been similar to that
so ably detailed by Mr. Grrant, relating to Kussowlie, Subathoo,
Simla, and Dugshai.

The sanitary station on the Mahubuleshwur hills was established
with the view of benefiting the health of the sick European soldiers
of Poona and Bombay. The experiment was made in 1829.
Badly selected invalids were sent to the hills at the end of
October, or commencement of November, with the following
result : — The tendency of dysenteric and hepatic affections to
relapse, and of soldiers cachectic from fever, mercury, syphilis,
rheumatism, to become affected with dysentery or hepatitis, was so
well marked that the scheme was very properly speedily abandoned
and has not since been revived.

These facts were necessarily unknown to Mr. Grrant, because they
are not stated in Mr. Murray's interesting Eeports f on the climate
of Mahubuleshwur. These reports relate to an after period and to
other sanitary objects. My information has been derived from Mr.
Walker's official reports, or rather, I should say, that such are the
deductions to be drawn from these reports. Mr. Walker was at the
time medical officer in charge of the station. When myself acting
in that situation from 1833 to 1835, I had an opportunity of con-
sulting the records of the station, and have again very recently en-
joyed this privilege through the courtesy of the Medical Board.
It is not improbable that my conclusions may be met by statements

* " Indian Annals of Medical Science," No. 1, p. 311f

t " Transactions, Medical and Physical Society of Bombay," Nos. 1, 2, 5, and 7.

T 4

280 DYSENTERY.

of an opposite tendency, but ^on this point I venture to suggest a
caution. It is often forgotten that the characteristics of hill cli-
mates vary much at different seasons. The results which I have
stated to have occurred at Mahubuleshwur, in November, Decem-
ber, and January, would no doubt have been observed in much less
degree in March, April, and May.

In thus venturing to differ m part from the opinions expressed
by Mr, Orant, I have not overlooked his remark, that attacks of
dysentery or diarrhoea were not confined to persons in broken-down
health ; but this is merely to say that the exciting cause was
adequate to produce the disease, irrespective of peculiar predis-
position.

This discussion has been prolonged further than I at first intended
or than its practical importance may seem to require. For it may
be objected that when so much importance has been attached to
malaria as a predisposing cause, the difference is rather of words
than of facts. But there is surely more than this. The opinion
that malaria, in common with many other causes, induces cachexia,
and that this state gives a susceptibility to dysentery, enforces the
importance, with the view of preventing the disease, of protection
from the influence of such predisposing causes. While, on the
other hand, the opinion that conditions of the atmosphere which
abstract heat are the common exciting cause, enforces the import-
ance of protection from their influence by avoiding exposure to
them, and by attention to clothing, houses, &c., and this the more
especially when we have to deal with cachectic individuals. To
state the difference in still more practical terms, the just infer-
ence from the principles which have been here advocated is, that
the cold season of all hill climates in India is liable to excite dysen-
tery in cachectic individuals irrespective of the presence of the con-
ditions of malaria ; whereas the view that malaria is itself the
exciting cause of the dysentery must tend to condemn only those
hill climates in which the conditions of malaria are apparent.

Section IV. — Symptoms of Dysentery,

The division of dysentery into several varieties, the allotment of
a particular name to each, and the attempt to distinguish the one
from the other by symptoms, are not calculated to advance our
clinical knowledge of this disease, or to strengthen our hands in its
treatment. It is sufficient that, in respect to each case of dysentery,
we propose to ourselves the following questions: — ^^Is it recent or

SYMPTOMS. 281

advanced ? Does it engage much or little, and what part of the
mucous membrane of the large intestine? Is it idiopathic, or
co-existing with remittent fever ? Is it simple, or combined with
hepatitis, peritonitis, or other disease ? What is the state of con-
stitution ; is it sthenic, or likely to be the subject of erysipelatous
inflammation ; is it asthenic from former disease, deficient fodd, or
elevated temperature ; or is it tainted with malaria, scorbutus,
struma, syphilis, mercury, or retained excretions? What is the
condition of the mucous membrane, — simply reddened, or thick-
ened, or ulcerated, or sloughing ?

I must assume that the clinical student of dysentery understands
how, by inquiry into the history and by observation, he is to make
himself acquainted with the diathesis of his patient ; and I shall,
therefore, in my description of the symptoms, keep in view chiefly
the other practical points to which his attention has just been
directed.

Variation in Sym/ptoms. — The severity of the disease in a
measure depends on the extent of surface of the mucous membrane
of the large intestine, which is involved. The symptoms will also
somewhat vary, according as the inflammation is in one part or
other of the intestine. It may be chiefly in the coecum or ascend-
ing colon, in the transverse colon, in the descending colon, or in the
sigmoid flexure and the rectum. But in the severer acute forms of
the disease the greater part of the surface is generally implicated.

Acute form in sthenic Europeans, — The symptoms of acute
dysentery as it occurs in sthenic European troops shortly after their
arrival in India will first be noticed. The disease in them fre-
quently commences with a relaxed state of the bowels ; thin fecu-
lent evacuations being passed with some degree of griping and
general uneas'iness of abdomen. The fact that serious dysentery
in India may begin with symptoms differing little from those of an
ordinary feculent diarrhoea is practically most important. It incul-
cates both on patient and physician the lesson of carefully watching
such cases, with a view to the prevention of the disease *, or the
detection of its earliest symptoms. Not a few instances have come
to my knowledge of fatal dysentery having been permitted to
develop itself from oversight of this simple rule.

It is probable that at this early stage there is merely increased
vascularity of a limited portion of the mucous surface ; and that as
this extends, and passes into the more advanced stages of thick-

*■ The importance of watching these symptoms of diarrlioea with reference to cholera
has been enforced elsewhere, p. 221.

282 DYSENTERY.

ening, exudation, and sloughing, the characteristic symptoms of
acute dysentery gradually evolve themselves. Thus the feculent
diarrhoea may continue for two or three days ; then the discharges
become more scanty, but the calls to evacuate are more frequent, and
attended with more griping pain and some degree of tenesmus. Now
the dejections consist sometimes merely of portions of clear mucus
more or less tinged with blood ; at other times there is mixed with
these bloody mucous discharges more or less feculence, generally thin,
of various colours, sometimes natural in appearance, at others green-
ish and gelatinous. Or, instead of clear blood-tinged mucus alone
or intermixed with feculence, the evacuations may have a slimy
appearance like oil paint of various colours, yellowish, greenish,
streaked, or speckled with little patches of blood : such evacuations
are in general passed without much tenesmus.

In regard to the diagnostic value of these different kinds of dis-
charges, they all indicate that the inflammation has not passed on to
its advanced stages. When the evacuations consist of mucus clear
or tinged with blood, passed unmixed, in small quantity, and with
much tenesmus, it may be inferred that the secretions proceed from
the inflamed mucous lining of the rectum and lower part of the
colon, and are uncombined with those of the liver and small intes-
tine ; and that probably the disease is as yet chiefly confined to the
lower part of the bowel.

When, however, the evacuations are more copious, partly of
mucus tinged or not with blood, and intermixed with more or less
thin feculence, — generally passed with some degree of tenesmus,
— the case differs from the first, inasmuch as the secretions from
the inflamed mucous lining of the large intestine are accompanied
by more or less of the natural contents of the small intestine ; and
all — in consequence of the increased peristaltic action resulting from
the more extensive inflammation of the mucous membrane of the
large intestine — are passed rapidly through with tormina, and dis-
charged. We may infer, then, that when the evacuations are of
this latter character, a greater extent of the colon has become
involved; and if such discharges take place with little or no
tenesmus, we may further conclude that as yet the lower part of
the bowel is little enofaged.

But in applying these suggestions to clinical diagnosis it is neces-
sary to caution the practitioner not to lose sight of the nature of
the remedies which have been previously used. It is very evident
that in the first supposed case — that in which the disease is
chiefly confined to the lower part of the bowel — the action of a

SYMPTOMS. ' 283

purgative will give to the discharges the character related to the
second supposed case — that in which the disease has affected a
more extensive and higher part of the large intestine. Again, a
too free use of opium may give to the discharges of the second the
character of those of the first.

In reference to the diagnostic value of the intestinal excreta, one
general remark may be prefaced, viz., that I entertain a strong
suspicion that much of the dark green, gelatinous, and other varie-
ties of discharges which have been described by various authors,
and to which much pathological importance has been attached, are
the products of the excessive use of calomel and purgatives and not
true symptoms of the disease.

Dysentery in Bombay and Bengal very generally commences
with diarrhoea in the manner which has just been described, but
sometimes it is otherwise. In the disease, as observed by me in
Her Majesty's 40th Eegiment, at Belgaum, the bowels were often
rather constipated at the commencement, than relaxed, and there
was a sense of fulness and uneasiness experienced in the course of
the colon, followed after a time by mucous and scanty dejec-
tions. It is when the disease originates in this manner that the
intermixed feculence may occasionally exhibit a scybalous cha-
racter.

The further description of the symptoms will equally apply,
whether the disease has commenced with diarrhoea or in the man-
ner last alluded to.

Abdominal pain, — Associated with the frequent and morbid dis-
charges, the tormina and tenesmus, there is a sense of uneasiness
experienced in some part of the colon ; and therefore in all cases
of dysentery the abdomen should be carefully examined with the
view of ascertaining in what situation this uneasiness is chiefly
present. We must not expect to find the acute tenderness of
idiopathic peritonitis, but rather a sense of soreness which is how-
ever distinctly aggravated by pressure. The extent and situation
of this discomfort will indicate the extent and parts of the intestine
affected. The degree of the pain will suggest the complication, or
not, of general or partial peritonitis, and our suspicion of this will
receive confirmation from the co-existence of tenseness or indura-
tion* in the neighbourhood of some part of the large intestine.

* In respect to a feeling of induration in some part of the course of the colon, it is
necessary to offer this caution. If the abdominal parietes be thin, we may frequently
feel the intestine indurated merely from being in a state of contraction. We must be
careful not to confound this with induration depending on thickening or other organic

284 DYSENTERY.

The clinical observer will readily appreciate the importance of
symptoms of peritonitis appearing in the course of dysentery when
he recollects that this serious complication attends only the
worst forms and the advanced stages of this disease, — those in
which there is sloughy ulceration t)f the mucous membrane with
threatened perforation of the intestine. (P. 265.)

But in respect to the import of tenderness in the course of the
colon as a symptom of dysentery, I must guard myself against being
misunderstood. That degree of tenderness, tenseness, and indura-
tion related to peritonitis is a condition of an advanced and gene-
rally hopeless stage of the disease. In those early stages, however,
when precise diagnosis is practically so important, a careful
observer will be able to discover some uneasy part of the large
intestine — caused by inflammation of the other tissues — to which
his remedial means may be more particularly applied ; but should
he fail in detecting this symptom, he is not on that account to
attach the less importance to the evidence of presence or severity
of the inflammatory action derivable from the character and man-
ner of the discharges alone.

Bysuria and retention of urine are occasional occurrences in
the course of acute dysentery. They have been generally attributed
to extension of irritation from the rectum to the neck of the bladder.
Without denying that this may be the explanation of these sym-
ptoms (more particularly of mere irritability of the bladder), in
occasional cases, yet the tendency of my own observation has been
to regard them in a much more serious light. Eetention of urine
will very frequently be found co-existing with inflammation of the
peritoneal covering of the bladder, — to be, in fact, an illustration
of paralysis of the muscular fibre of a hollow organ, consequent on
inflammation of its serous covering. (Cases 60, 82.)

Tenesmus. — In the account of the symptoms of dysentery
usually given in systematic works, the straining, the frequent calls
to evacuate, and the scanty mucous, blood-tinged discharges, are
dwelt upon as the very characteristic phenomena of the disease.
It is true that when the sigmoid flexure and rectum are the parts
chiefly affected these are prominent symptoms. But in Indian
dysentery the inflammation is very often principally in parts of
the large intestine above the sigmoid flexure, and then, as
already explained, the discharges may be more copious, and

change. The state to which I now allude is not morbid, and with careful examina-
tion and under this caution ought not to be mistaken for disease. I have observed it
most frequently in the left iliac region.

SYMPTOMS. 285

scantiness and tenesmus be symptoms which attract little atten-
tion. All the best writers on tropical dysentery confirm this truth,
and yet it often fails to correct the contrary erroneous general im-
pression. It is because the fact that inflamn:kation of the mucous
membrane of the large intestine — dysentery — may be present
without tenesmus or scanty mucous discharges, is so constantly
overlooked, that cases of dysentery are very frequently returned
as diarrhoea, and thus our statistical data vitiated at their very
source.

General symptoms do not assist much in the diagnosis of this
disease. The tongue is often white at the commencement, but it
exhibits no characteristic appearance and is seldom much coated
except in sthenic lately arrived Europeans in whom biliary derange-
ment is also present. In the advanced stages it may become florid
and glazed, or present other features related to the state and degree
of constitutional disturbance. Symptomatic fever is generally
absent at the outset of dysentery, and is often very slight even
when a considerable degree of inflammation is present. The
co-existence of well-marked febrile phenomena with the early stage
of dysentery should always suggest the suspicion that the disease is
not simple, but a complication of remittent fever. Then the course
of the affection should be very carefully watched with the view of
determining this question — a most important one as respects the
system of treatment.

Symptoms of advanced stages. — Hitherto in my remarks on
the symptoms — with exception of those relating to a co-existing
peritonitis — I have had in view those periods of the disease in
which the inflammation has not as yet passed on to ulceration or
sloughing. The course of dysentery to these more advanced stages
and to a fatal issue has now to be traced.

The frequent discharges continue, but they become more watery,
brown in colour, streaked with blood, or they contain small floating
clots of blood, or white shreddy-looking films, or patches of sloughy
tissue. Then the watery fluid becomes still more tinged red, and
the fcetor peculiar and very offensive. Febrile exacerbations now
become distinct — the skin may be hot and dry, and the pulse
irritable, or the skin may be covered with perspiration, and the
pulse small and compressible. The tongue becomes coated in the
centre and dry, the abdomen not unfrequently full and tense, and
before the fatal issue some degree of muttering delirium is some-
times present.

When the dejections are serous, more or less tinged red, contain

286 DYSENTERY.

floating clots and shreds, and possess a strong dj^senteric foetor, we
may infer that they have proceeded from an ulcerated and sloughy
surface of the mucous coat of the large intestine : they also may
be more or less intermixed with the secretions from the mucous
lining of the small intestine and the liver.

The disease, as just described, may run its fatal course in from
nine to fifteen days. In those cases in which death takes place
most quickly it may be assumed that the inflammation has been
erysipelatous in character, and has led to extensive gangrene of the
mucous membrane. While, on the other hand, in those in which
the several stages have been passed through more slowly, we
may infer that the morbid state has been thickening, exudation,
gangrene, and sloughing of transverse or other shaped patches of
the membrane.

Hcemiorrhage. — There are still, in relation to the severer and
frequently fatal forms of dysentery, other symptoms to allude to.
The discharges may contain dark-coloured blood in considerable
quantity, constituting that form of the disease to which the name
hsemorrhagic has been given. A reference to the detailed cases
will show that in some (73, 128,) a considerable quantity of
blood has been found in the intestine after death, associated with
a state of sloughy ulceration. But the occurrence of considerable
haemorrhage from the bowels in dysentery, is a rare event in
Bombay compared with what the experience of Mr. Twining, Dr.
Ealeigh, Dr. Mouat, and Mr. Hare shows it to be in Bengal. In
some cases it would seem to be related to a state of ulceration, to
the diathesis, — scorbutic or other, — perhaps to the co-existence
of hepatic disease, as cirrhosis ; but in others, the haemorrhage
would appear to present itself in the early stages before the advent
of ulceration, and to be a transudation dependent on congestion
of the mucous membrane, and an altered state of the blood:
this state, I apprehend, generally complicates forms of remittent
fever, caused by intense malaria, and is probably pathologically
distinct from dysentery. It is not an inflammation, but passive
congestion tending to haemorrhage. This distinction is clini-
cally important, for cases with red-tinged serous discharges (that is
discharges which in dysentery proceed from a sloughy ulcerated
surface, and are of most unfavourable prognosis), are sometimes
unexpectedly recovered from. Close inquiry will, however, gene-
rally prove that these have not been of dysentery, but simply
of congestion ; and the diagnosis will chiefly rest on the fact,
that in the latter the discharges occur early in the illness, and

SYMPTOMS. 287

are associated with more or less of the symptoms of congestive
fever.

The dangers of dysentery may further be enhanced by a compli-
cation of hepatic disease. But this subject, as already observed,
will be treated of, with more advantage, in connection with
He-patitis.

I have traced the course of acute dysentery in its more formida-
ble aspects, and must now follow that of the great majority of
cases, to their more favourable termination.

The frequent calls to stool, the blood-tinged mucus intermixed
with feculence, passed with griping and more or less tenesmus, and
attended with abdominal uneasiness, may, under appropriate treat-
ment, progressively decline, and health be restored. Under these
circumstances we may infer that the inflammation of the mucous
membrane had not advanced beyond the state of redness and tur-
gescence, and that its texture had escaped uninjured.

Chronic form. — Instead of progressive recovery in this manner,
the symptoms may continue with, perhaps, alternations of allevia-
tion and exacerbation. The discharges, still frequent, may become
gradually more copious, and consist of thin feculence, frequently of
pale colour, and frothy, streaked with mucus and blood, or reddish
serum, or speckled with small blood clots, films, and shreds, and be
passed with some degree of griping, but very generally with little
tenesmus. This change is attended with increasing emaciation, and
the tongue becomes florid at the tip and edges, with sometimes a
glazed appearance. The acute dysentery has passed into a chronic
state. Or this chronic condition may take place without having
been preceded by the symptoms of the acute degree — the diarrhoea
with which I have said dysentery frequently commences, may con-
tinue and gradually merge into this chronic form. The reader,
with these facts before him, will at once understand that long-
standing diarrhoea and chronic dysentery are generally one patho-
logical condition ; and that, therefore, a large proportion of hos -
pital disease, returned under the head diarrhoea, is in fact dysentery.

The pathological condition of the mucous membrane in chronic
dysentery may consist merely of a state of increased redness of the
membrane ; or the tissue may also be thickened, and have granular
exudation on its free surface. There may be various states and
stages of ulceration, more generally, however, of the circular form,
and with cicatrisation in different degrees of progress.

It is observed by an able writer *, " The second stage is said to
* " Elements of Medicine." By E. Williams, M.D., vol. ii. p. 553.

288 DYSENTERY.

commence when pus appears in the stools, but it must be admitted
there are cases in which the disease pursues a chronic course, and
terminates fatally without any such appearance." When we con-
sider the morbid changes that have taken place in chronic dysen-
tery, the probability of the presence of pus in the intestinal canal,
and its ready detection by the microscope, in the evacuations,
may be admitted. But that the presence of pus in the discharges
of Indian chronic dysentery is frequently suggested to the naked
eye of the clinical observer, is at variance with my experience.
Indeed, I am certain that in the numerous diaries of dysenteric
cases written by me in Bombay hospitals, European and native,
such terms as pus, puriform, purulent, applied to the intestinal
excreta, will seldom be found.

In Natives, — In describing the symptoms of dysentery, I have
not thought it necessary to distinguish the disease as occurring in
natives of India from that of Europeans. Cases 54, 55, 5Q, 67,
69, 70, 75, 76, 80, 89, show that it occurs in the former in forms
as severe as in the latter. The general description is equally ap-
plicable to both.

Section V. — Treatment. — General Principles and Indications,
— Detailed Remarks on Blood-letting, general and local, Calo-
mel, Mercurial Influence, Ipecacuanha, Purgatives, Diapho-
retics, Opium, Chloroform, Astringents, Tonics, Fomentations,
Blisters, Enemata, Diet, and Change of Climate in Dysentery,

General Principles. — ■ The treatment of dysentery must neces-
sarily vary, according to the stage of the inflammation, and the
state of the constitution ; and neglect of this simple therapeutic
principle, has led to needless confusion and uncertainty. Success
in the treatment of dysentery depends on the recency of the attack,
and the judgment displayed in adjusting the remedies to the state
of the constitution.

Early stage. — The indication in the early stage is to prev^ent
the simply reddened and swollen membrane from passing into a
state of thickening, ulceration, or gangrene. In effecting this it
must be remembered that the amount of antiphlogistic means,
which in some states of constitution may be required to prevent
disorganisation, will in others be the most certain method of en-
suring it. Nor are we to expect in inflammation of the intestinal
mucous membrane the speedy and marked effects from remedies
which sometimes occur at the commencement of the inflammation

TREATMENT — GENEHAL PHINCIPLES. 289

of other tissues, but must rest satisfied with steady, progressive
amendment; for the contrary expectation is apt to lead to fre-
quent change, and to the continuance of medicines after benefit
from them has ceased and injury begun.

Advanced Stages. — After the early stage has passed, and dis-
organisation of tissue has taken place, it must be borne in mind
that restoration to health can only be effected by processes of
repair ; and that the indication with this view is simply to place
and to maintain the affected part, and the system generally, in the
conditions most favourable for growth and nutrition. The means
used for this purpose differ from those which it is often necessary to
adopt at the commencement of the attack, in order to prevent lesion.
Hence we cannot safely enter on the treatment of dysentery, unless
we regard the period of the disease, and determine whether dis-
organisation has to be prevented or repaired. But these two con-
ditions do not comprise all the contingencies of practice ; for there
is a transition stage, in which disorganisation, though in progress,
has not yet been completed, and the period of repair has consequently
not yet arrived. In this the treatment must partake of the transi-
tion character of the morbid action, and consist of a gradual change
from the principles of the early to those of the more advanced
period of the disease.

In my remarks on the causes of dysentery, much importance was
attached to predisposing states of the constitution. It has also
been stated that we may not hope to conduct the treatment of the
early stages successfully unless we rightly appreciate these conditions
of the system ; and now I would advert to their importance in that
period of the disease when recovery can only be effected through
processes of repair. With a view to the restoration of disorganised
structures generally, two leading principles command our attention ;
— 1. Asthenic or cachectic states of the system are to be cor-
rected; 2. The parts must not be unduly disturbed. It is true
that in the instance of the external surface of the body various local
appliances may also be used, but these are of trivial consequence,
compared with the two leading indications ; and in respect to parts
removed from the sphere of our senses, the accurate application of
local means becomes impracticable, and the attempt to use them
is often of questionable expediency.

These considerations lead to the conclusion that the successful
treatment of dysentery must always depend on a just discrimination
of its stage, and of the sta,te of the constitution. In the early stage
the remedies for inflammation are regulated with reference to the

290 DYSENTERY.

diathesis. In the advanced stage the means conducive to repair are
also selected with reference to the diathesis, and in recollection
that the time required for effecting restoration — generally con-
siderable — will vary according to the reparative power of the
general system.*

When we reflect on the details involved in applying these* prin-
ciples, we can be at no loss in understanding how the treatment of
dysentery is often complicated and confused, how it must always be
unsatisfactory, and frequently injurious, unless these principles are
kept steadily before us, and unless the further doctrine be admitted
that in all inflammations of mucous tissue and in all chronic dis-
eases time is a necessary condition of restoration to health.

What are the remedies which, if used with discrimination in the
early periods of dysentery, are efficacious, but most of which, if
used in the stage of repair, are injurious ? Blood-letting, general
and local ; mercury ; purgatives ; ipecacuanha ; opium.

What are the remedies which, if used with discrimination in the
stage of repair, are more or less efficacious, but most f of which, if
used at the outset of the disease, are injurious? Astringents;
tonics ; alteratives ; opium.

Then what are the states of constitution which demand consider-
ation, and modification of the details of treatment? The constitu-
tion may be sthenic, or in that condition favourable to erysipelatous
inflammation ; it may be asthenic or cachectic from malaria, scor-

* On tlie pathology and etiologj^ of dysentery, pp. 237, 273, allusion has been made
to a theoretic analogy between inflammation of the skin and of the mucous membrane
of the large intestine. The question may be put in respect to treatment. Should
future research demonstrate that inflammation of the intestinal mucous lining is
various as regards its coiirse and causes — as inflammation of the skin — will it not
follow that the principles of treatment now inculcated for dysentery will become in-
applicable and require complete revision? The true answer to this question will
be found in a reference to the treatment of diseases of the skin. What are the prin-
ciples applied to these ? (a.) The prevention of disorganisation in the early stages by
sedative means, (b.) The favouring of processes of repair in the advanced stages, (c.)
Above all, the correction of the diathesis on general principles ; for it is but in very
few instances that we can pretend to a knowledge of means special to particular aflPec-
tions. True, local applications are of subsidiary use, and generally had recourse to
with more or less advantage. But it is evident that whatever advances may be made
in the pathology of intestinal inflammation, the safe and efFective use of local remedies
must always be very limited, for the simple reason that the great extent of the struc-
ture must always be hid from our sense of sight. The statement of such self-evident
propositions would call for some apology to the reader were it not that I am desirous
of guarding the practice of medicine in India on all sides from the rash and dreamy
therapeutics of which I have seen much and read more.

t I use this qualifying term in reference to opium and ipecacuanha, which may be
used under both circumstances.

TEEATMENT— GENERAL PRINCIPLES. 291

butus, vitiated atmosphere, struma, syphilis, &c. Asthenic and
cachectic states — always difficult to correct — are necessarily more
so when an important part of the intestinal canal is the seat of
disease ; but in order to effect good and to avoid injury in medical
practice, we must always keep before the mind a clear view of the
whole subject, with all its attendant difficulties.

Having premised these observations on the principles of treat-
ment in dysentery, I proceed to explain the clinical details.

The leading indications of cure may be stated as follows : —

1. To subdue increased general and local vascular action by
blood-letting, general and local. To sustain vascular action, when
too depressed, by tonics and stimulants.

2. To favour — by preserving unembarrassed the capillary
circulation of all the organs included in the portal circle — the free
circulation of the blood in the mucous membrane of the large in-
testine, with the view of maintaining the integrity of that tissue
before inflammatory action has led to organic change ; or of favour-
ing the repair of lesions when they have taken place. This is to
be chiefly effected by rest * ; also by, in the early stages and in
robust subjects, increasing the secretions from the liver and the
entire tract of the mucous lining of the small intestine ; and by,
in the advanced stages, checking these very secretions when too
profuse.

3. After ulceration or other organic change has resulted, to
favour the processes of repair by attention to the state of the
tissues implicated, and of the general constitution of the individual
affected.

The first question which arises in the treatment of a case of dysen-
tery is, whether the inflammation has terminated in disorganisation,
and if so, whether the disorganisation has ceased to extend, and
left recovery, if practicable, to be effected only by repair of tissue.
In deciding this question, we must, in a great measure, be guided
by the duration of the attack, and the character of the symptoms
and of the diathesis.

If the disease be of a few days' duration, and the constitution of
the patient not broken by previous disease, or long residence in
India ; if the abdomen be full, but not tense, the dejections frequent
and scanty, consisting of mucus more or less tinged with blood and
passed with tenesmus ; if the tenderness of abdomen be not acute,
the tongue white but not much coated, and little, if any, febrile

* The importance of tlie recumbent position in the treati&ent of dysentery cannot be
too strongly inculcated.

V 2

292 DYSENTERY.

excitement present, then we may hope that disorganisation has not
taken place, and may be prevented, and that a cure may soon be
effected by appropriate antiphlogistic remedies. In the application
of these means, however, we must remember that inflammatory
action, once established in a mucous membrane, does not admit of
being checked in the speedy manner of which it is susceptible in
serous and other tissues.

If, on the other hand, the disease has existed for some time*, it
is probable that ulceration or other organic change has taken place,
and that recovery cannot be effected unless time be allowed, and
the patient be placed in the circumstances most favourable to
reparative action. In the treatment of these cases there is much
room for discrimination, because there is often difficulty in deter-
mining the precise pathological condition, and, consequently, the
indication of cure.

I shall attempt to point out the leading distinctive features.

(a.) Cases in which the abdomen is distended, tender, and tense ;
the dejections frequent, scanty, passed with little tenesmus, and
consisting of turbid serous fluid, more or less tinged red and of
offensive foetor ; the skin coldish and washy, the pulse frequent and
compressible ; or the skin hot and pungent, the pulse thrilling and
irritable, but still compressible, with the tongue moist or dry accord-
ing as the first or second state of the skin and pulse is present.
In such cases, generally of from ten to twenty days' duration, the
disease will be found to have already occupied the greater extent
of the mucous lining of the large intestine, and to have terminated
in sloughing, extensive ulceration, and matting of the omentum
over the colon and caecum. Persons admitted into the' European
Greneral Hospital in this stage and condition of the disease, have
generally been sailors or others of dissipated habits, the residents
in low taverns, either altogether neglecting the disease, or still
more frequently adopting the vain and delusive course of attempt-
ing to check its symptoms by the use of ardent spirits. Cases such
as these must, I fear, generally be regarded as hopeless. But
though we may regret our inability of being permanently useful,
we ought to recollect our ability to do harm. The kind of treat-
ment — antiphlogistic — which, at an earlier stage, would have
been beneficial, will under these circumstances, be positively
injurious, and must expedite the fatal termination.

(6.) Under this head may be included all the variety of cases,

* It is impossible to be more definite because the state of the constitution influences
the result.

TREATMENT — USE OF BLOOD-LETTING. 293

usually classed as chronic dysentery, of duration from one to two
months and upwards, in which ulceration of varying character and
extent exists ; or, instead of ulceration, thickeniog of the tissue with
or without granular exudation, generally existing in states of con-
stitution more or less deteriorated. It may be that the tone of the
constitution has been sufficiently preserved, to make the chief indi-
cation of cure the mere removal of sources of irritation, and the
placing thereby the injured structures in circumstances most favour-
able to restoration by the natural actions of the system. In such
cases a tonic plan of treatment should be avoided, and a mild
antiphlogistic course pursued.

(c.) But when the ulceration or other organic change exists in
deteriorated states of the constitution, from whatever cause arising,
then the cachexia must be chiefly considered under the certainty
that, if it can be removed or lessened, the reparation of the dis-
organised tissues will thereby be most effectually advanced. Just
as in external ulcers in similar circumstances it is vain to attempt
to heal them by any other means than those which effect an
improvement in the general system. When the cachexia, how-
ever, has been brought about mainly by the long continuance of
the local disease, — the patient having been, in other respects,
situated favourably, — then the chances of recovery are small.
But in a great many instances other causes of general cachexia
will be found to have aided the influence of the disease. For
example, medical treatment may have been neglected, or too
depressing, the patient may have been badly clothed, housed, or
fed, or exposed to unsuitable air or climate : in these circum-
stances it is reasonable to expect benefit from treatment judiciously
tonic, and from the removal of the influences which have operated
injuriously.

The remedial means which have been chiefly used with the view
of effecting these several indications will now be noticed.

Blood-letting, general and local. — The degree to w^hich increased
vascular action, general and local, maybe subdued by blood-letting,
general and local, must be determined in each particular instance
by the judgment of the practitioner. The tone of the constitution,
the state of the skin and pulse, the degree of abdominal tenderness,
the duration of the attack, and the consequent probable condition
of the mucous coat, — whether ulcerated or not, and whether
complicated with peritonic inflammation, — must be carefully con-
sidered.

Greneral blood-letting may be used with advantage within the

294 DYSENTERY.

first two or three days of the attack in Europeans of good
constitution, not long resident in India, and unaffected by the
depressing influences of heat, moisture, or malaria, provided the
pulse be of good volume and strength, the skin without coldness
and moisture, the dejections frequent, scanty, and mucous, and
the abdomen more or less uneasy on pressure. The benefit thus
likely to result may be maintained and increased by the subsequent
application of leeches, and the use of the other means presently to
be noticed.

General blood-letting is seldom, if ever, expedient in the treat-
ment of dysentery in natives of India. When the disease occurs
in states of constitution asthenic or cachectic, whether in Euro-
peans or natives, and has existed for several days, the proceeding
is altogether inadmissible.

In cases in which, from the state of the system, general blood-
letting is contra-indicated at the commencement of the attack,
recourse may be had to the application of leeches, in numbers of
from two * to six dozen, repeated more or less frequently accord-
ing to circumstances. With the view of determining the part
of the abdomen f on w^hich they may be best applied, the situation
in which uneasiness on pressure is chiefly experienced should be
carefully ascertained. It has been already said that asthenic and
cachectic conditions of the system are contra-indications of general
blood-letting ; and when present in great degree they are equally
so of local blood-letting.

Though the benefit derived from the abstraction of blood will
generally be proportionate to the recency of the attack, and the
consequent probable absence of ulceration or other organic change,
still it is not to be inferred that the utility of the measure is ex-
clusively confined to these circumstances. Though, from the dura-
tion of the attack and the character of the dejections, there is reason
for suspecting the commencement of ulceration ; still, if there be
abdominal tenderness and much tenesmus, — the state of the pulse,
the skin, and general system not distinctly contra-indicating, — we
may have recourse to cautious local depletion in the belief, that

* These numbers relate to the Bombay leech, which is small ; one dozen not ab-
stracting more than about an ounce and a half of blood. The size of the leech varies
much in different parts of India, and must of course always be regarded by the practi-
tioner. In respect to proportioning the local abstraction of blood to stage of disease,
and state of constitution, clinical experience and observation can alone teach this.

t On the comparative efficacy of the application of leeches to the abdomen or to the
anus, I am unable to offer an opinion. I have been always sufficiently satisfied with
their efficacy when applied to the abdomen.

TREATMENT — USB OF BLOOD-LETTINa. 295

though lesion of the mucous coat exists, there is also present an
amount of vascular obstruction of the surrounding portions of the
tunic, incompatible with repair, and favom'able to an extension of
the ulcerative action.

Though important in suitable circumstances, it is not to be sup-
posed that blood-letting is always requisite in the early stage of
dysentery in persons of good constitution. Cases frequently occur
in which, from the recency of the attack and the mildness of the
symptoms, the disease may be readily cured by rest, the removal
of laedentia, a mild laxative, an opiate, and abstinence. These will
be met with more frequently in natives of India than in Europeans ;
and in respect to the latter, the caution of not permitting the
patient himself to be the judge of the mildness or severity of the
attack cannot be too earnestly inculcated. The symptoms should
invariably be carefully investigated, and the character of the alvine
discharges particularly noted. This is a most important rule of
practice, for the mortality from dysentery in India is increased by
the patient's ignorance often leading him to make light of his
illness, and by the physician's credulity favouring neglect of that
complete examination of the case, without which there can be no
safety in the management of this serious disease.

The second indication of cure, viz., to favour the free circulation
of blood in the mucous membrane of the large intestine, by main-
taining unembarrassed the capillary circulation of all the organs in-
cluded in the portal circle, is most important, and to be held in view
in succession to the abstraction of blood. It is the indication which
constitutes the chief object of treatment in the majority of cases.

It may be assumed that when the capillary vessels of any portion
of the portal vascular system are congested, and when in conse-
quence the blood does not pass readily through them, then an
important step in the removal of this state is to free the entire
portal circulation, by augmenting the secretions which proceed
from the arterial capillaries of the mucous coat of the whole
tract of the intestine, as well as those which depend on the
capillary terminations of the portal vein itself. In other words,
to increase the secretions from the small intestine and from
the liver, is the second indication of cure in the early stages of
dysentery.

This principle of treatment is observed in the management of
many affections of the lower part of the bowel, arising from de-
ranged circulation, as in haemorrhoids, and in fistula .u ano. It
is surely equally applicable in the treatment of dysentery — a

U 4

296 DYSENTEBY.

deranged state of the circulation of the tissues of a higher portion
of the same intestine.

How is this indication to be effected ? Many of the remedies
generally found efficacious in dysentery, as calomel, blue pill,
ipecacuanha, and pm-gatives, act in this manner ; but their influence
has often been otherwise explained. By some (Sydenham) they are
considered useful, because they eliminate a morbid material from
the blood ; by others because they assist the discharge of vitiated
and acrid intestinal contents. But whichever theory be preferred,
this practical fact remains, that the efficacy of these means is re-
lated to the recency of the attack and the state of the constitution,

— that is, to the inflammation being as yet in great part in the
stage of capillary stagnation, and to the quantity of blood in the
general system being still sufficient.

O71 the use of calomel, — In persons whose constitutions are un-
injured by former disease or other cause, it forms an important
part of the treatment of the early days of the attack, after adequate
general or local blood-letting, to give, at bed-time, a ten-grain dose
of calomel combined with a grain and a half or two grains of ipe-
cacuanha, and the same quantity of opium, with on the following
morning from four drachms to an ounce of castor oil. The state of
the tongue — whether coated or not; the character of the dejections

— whether scanty or free; and the condition of the abdomen —
whether full and resisting, or supple and soft — will indicate the
expediency of repeating these means, or abstaining from their
further use. When the abdomen is supple and soft, there seldom
can be any necessity for full doses of calomel.

Though calomel in these doses is generally only applicable to
the first few days of the attack, it occasionally happens that it
may be given with advantage in more advanced stages, when the
tongue is coated, the discharges pale and scanty, the abdomen full,
and the general condition and strength of the patient not much
impaired. In fact, in circumstances in which it is reasonable to
conclude that the excretions are not free, and the portal circulation
in consequence embarrassed.

The object in exhibiting calomel is to increase the secretion of
the liver and of the mucous lining of the small intestine, but at
the same time to be careful that it does not aggravate the existing
inflammation of the large intestine. This latter injurious effect is
to be guarded against by avoiding the frequent repetition of the
calomel, and by combining it, when used, with opium. This
caution is the more necessary when there is good reason for believ-

tREATMENT — USE OF MERCURY.

297

ing that ulceration has taken place ; because the irritant action
of the calomel is then more certain, and there is, moreover, in a
lesion requiring time for its restoration less necessity for attempt-
ing to influence the abnormal circulation of the large intestine by
a decided and speedy effect on the upper part of the portal circu-
lation.

The treatment of dysentery by large doses of calomel repeated
and continued for some time, on the supposition that they exercise
a sedative effect * on the inflamed mucous coat, is, I trust, now
obsolete in India. It may be assumed that this system, at one
time strongly advocated, and generally followed, would not have
fallen into universal disuse, unless it had signally failed of success.
My own conviction is, that as a general method of treatment it is
irrational and injurious.!

Calomel is seldom required in the treatment of dysentery in the
natives of India.

Mercurial influence. — Though not related to the indication
of cure now under discussion, yet the present is the most ap-
propriate place in which to notice the treatment of dysentery by
inducing the constitutional effect of mercury. The use of calomel,
with this view, must be kept distinct from the cholagogue action,
which has just been considered. It is unnecessary to discuss in
detail the mercurial treatment of dysentery, for as a rule of prac-
tice, it has been generally and justly abandoned in India.

In theory, perhaps, it may be admitted that deposits of lymph
in the sub-mucous tissue of sthenic individuals might be appro-
priately controlled by mercurial influence. Yet when we reflect,
that ulceration and sloughing, consecutive on thickening, are sure
to be aggravated by mercury, and further that the disease very
often exists in states of constitution in which mercury is hurtful, we
must acknowledge that the reasons for not applying this therapeutic
principle in dysentery are just and convincing. I can further state,
from repeated observation of the fact that individuals under the
influence of mercury are very predisposed to dysentery: this is
particularly true of the natives of India.

Doubtless the records of medicine abound with reports of dysen-
tery cured after salivation. My earliest clinical acquaintance with

* This question has been abeady alluded to in my remarks on the use of calomel in
remittent fever, p. 136.

t I regret to observe in Haspel's Diseases of Algeria, a distinct leaning to the
treatment of disease by scruple doses of calomel, which as a routine system has
proved so injurious in India, and in consequence fallen into general and complete
disuse.

298 DYSENTERY.

this disease was in the hospital of Her Majesty's 40th Regiment at
Belgaum in the year 1830. The chief means of cure were free
blood-letting and mercury. Many recoveries, of course, took place,
and, to my inexperience, the treatment seemed efficacious. But
the opportunities which have been afforded me, during the thirty
years which have since elapsed, have enabled me to correct these
erroneous early impressions, and to justify the adverse opinion
which I now entertain on the mercurial treatment of dysentery.

On the use of Ipecacuanha. — Of the various remedies recom-
mended in this disease, there is none so generally efficacious and
applicable as ipecacuanha alone or combined with blue pill, or, in
some cases, with opium, provided it be fairly tried and steadily
continued.

This medicine, brought from the Brazils by Piso *, towards the
end of the 17th century, was given by him in dysentery in drachm
doses in the form of infusion. It was in more or less use through-
out the 18th century, and about the middle of the century was
much esteemed by Sir John Pringle, who gave it sometimes in
scruple doses, at other times in five-grain doses, three or four times
at intervals of two or three hours. Mr. Mortimer and other medi-
cal officers of the Madras army, upwards of thirty years ago,
thought highly of it, and used it freely in scruple doses, combined
with powdered gum arabic. Still more lately Mr. Twining advo-
cated its use in doses similar to the smaller ones given by Sir John
Pringle. Haspel also combines ipecacuanha in full doses with
calomel in the early stages of the disease. f

The efficacy of ipecacuanha in dysentery has been attributed by
some to its nauseant action, by others to its diaphoretic effect,
and by others, among whom is Sir J. Pringle, to its laxative or
purgative effect. It is to this last property that its efficacy seems
to me to be due; and it is with this view that I have always
used it.

* Waring's Manual of Therapeutics, p. 298.

t Since the publication of the first edition of this work, the use of ipecacuanha, in
doses of from ten to ninety grains, has been advocated by Mr. Docker, surgeon of the
7th Fusiliers — {Lancet, July 31st, August 14th, 1858) — but he does not seem to have
been aware of the extent to which the remedy had been previously used in large doses,
both in India and elsewhere. Subsequent to the publication of IVIr. Docker's reports,
rumours used to reach me at Poona, from Central India, of the wonderful success
attending the new method of treating dysentery by large doses of ipecacuanha. After
what I have at diiferent times written on this subject, I cannot well be charged with
undervaluing ipecacuanha in dysentery, in doses related to the severity and stage of the
attack ; but I regret this returning cycle of indiscriminate use and praise which is sure to
lead to injurious reaction, — that invariable result of extreme opinions in medical practice.

TREATMENT — USE OF IPECACUANHA. 299

In the early stages of acute dysentery, after blood-letting general
or local, calomel, ipecacuanha, and opium with laxatives, have been
used on the principles already laid down, — then the most satis-
factory course is to give ipecacuanha in the doses and combinations
recommended by the late Mr. Twining, viz., from six to three
grains combined with blue pill from five to two grains, and extract
of gentian from four to two grains, every third, fourth, sixth, or
eighth hour, and to continue it steadily till amendment takes
place. The proportion of the ipecacuanha and the frequency of
its repetition must depend on the acuteness of the symptoms. The
duration of the treatment and the gradual diminution of the dose
and of the frequency of its repetition, must be contingent on the
rapidity and permanency of the amendment. It must also be kept
distinctly in view that, whilst the treatment by ipecacuanha is
being pursued, it is often necessary — according as the state of the
pulse, or the uneasiness of the abdomen on pressure, may indicate
the necessity — to apply leeches ; and also — according to the
character and scantiness of the evacuations, and the greater or less
fulness of the abdomen — to give castor oil, occasionally, in
moderate doses.

In dysentery in the natives of India, or in Europeans, when the
disease comes under treatment at a more advanced stage or in a
cachectic diathesis, it is often necessary at once to commence the
treatment in the manner just described, omitting the preliminary
exhibition of calomel and opium, and castor oil, as recommended
for the earlier stages in good constitutions. We must be careful
not to continue the blue pill, in combination, sufficiently long to
run any risk of inducing the constitutional effect of mercury ; in
determining this risk we must be chiefly guided by the state of
the constitution. In cachectic individuals the ipecacuanha and
extract of gentian should be used without the blue pill from the
commencement of the attack.

The addition of opium to the ipecacuanha, blue pill, and extract
of gentian, will be considered in my subsequent remarks on the
use of opium in this disease.

It is not often that it is necessary to omit the ipecacuanha in
consequence of nausea and vomiting. Whether this immunity
from the emetic action of the drug proceeds from the effect of the
extract of gentian, as supposed by Mr. Twining, or whether from
a tolerance induced by the disease, analogous to that of tartar
emetic in pneumonia and of opium in tetanus, is of little prac-
tical importance. My own impression is that it depends on the.

300 DYSENTERY.

latter cause, and that it will generally be found in practice, that
when ipecacuanha disagrees, it is either because the disease is
very mild — rather threatens than exists — or has been already
removed by treatment ; or because the dysentery is complicated
wdth, and secondary to, some other serious disease, as abscess in
the liver.

The principle on which the efficacy of ipecacuanha and blue
pill depends, is, I believe analogous, but less in degree to that
assumed of calomel and purgatives. They cause a moderately
free secretion from the liver and small intestine, and thus tend
to place the mucous coat of the large intestine in the state most
favourable for the return of its deranged capillary circulation to a
normal condition.

Though approving the use of ipecacuanha in these doses and
combinations, the practice here recommended differs in one very
essential feature from that advocated by Mr. Twining. I mean the
absence of the daily exhibition of a dose of compound powder of
jalap. My objection to this system of treatment will be more appro-
priately stated under the subsequent head.

On the use of 'purgatives. — To follow the exhibition of calomel
and opium, as already advised at the commencement of attacks of
acute dysentery, with a dose of from one ounce to six drachms of
castor oil, is a necessary part of the treatment ; and during the use
of ipecacuanha and blue pill, to give occasionally smaller doses of
castor oil, is also important. The chief indications, under both
circumstances, are a scantiness of the dejections, and at the same
time a full and puffy abdomen.

There is, however, room for the exercise of considerable discretion
in the use of laxatives and purgatives in the treatment of dysentery.
Given occasionally in moderate doses in suitable stages of the
disease and states of the constitution, they assist very materially —
perhaps are absolutely necessary — in keeping up a free exercise
of the secretory functions of the upper part of the portal circula-
tion. But, when carried beyond this limit, or when given in
advanced periods, or cachectic habits, they not unfrequently in-
crease the inflammation of the mucous coat of the large intestine,
and thereby prolong and aggravate the disease. This error is very
frequently committed.

At the same time it ought not to be forgotten that injury may
result from neglecting the use of purgatives when required, and
thereby allowing the contents of the small intestine to accumulate.
The following case is an illustration of this : —

TREATMENT — USE OF PURGATIVES. 301

91. Dysentery. — The use of purgatives too much abstained from. — The lower end of
the ileum distended from thin feculence. — John Smith, aged sixteen, admitted on the
23rd April, 1842, ill with dysentery of a few weeks' duration, tender abdomen and fre-
quent scanty stools. Treated by moderate leeching, blister, ipecacuanha, blue pill, and
gentian, and opiate enemata; no purgative. Pulse 120. For two days before death,
considerable distention of abdomen. Died on the night of the 30th.

Inspection. — Matting of the omentum, ulceration and friable state of the colon.
Small intestine distended with air, and the lower part of the ileum full of thin yellow
feculence, and somewhat distended thereby..

By regarding fulness of the abdomen in connection with the
character of the discharges, and taking care not to confound the
former with the state of tension and distention, not unfrequent
in the latter stages of bad attacks, and related to peritonitic in-
flammation or hepatic abscess, little difficulty will be experienced
in deciding on the expediency of giving or withholding purgatives
in dysentery.

These remarks have had reference chiefly to castor oil, for it is
the purgative best suited for the disease. Still, I believe, that the
course of treatment recommended by the late Mr. Twining, of a
daily dose of compound powder of jalap in association with ipecacu-
anha, blue pill, and gentian, is applicable during the three or four
first days, in some forms of acute dysentery ; but that its 'longer
continuance is under any circumstances a very doubtful measure,
and under some, as when the tenesmus is very urgent or the secre-
tions not scanty, an inj urious one.

This caution in respect to purgatives in dysentery is unques-
tionably necessary in Bombay, and I believe that it is equally appli-
cable to Bengal. Still it may be useful to remark that the treat-
ment by purgatives, in the manner advocated by Mr. Twining, has
appeared to me more useful in dysentery in European troops in
the monsoon season in the Deccan than in the island of Bombay.
I have also, in former times, used the same treatment with advan-
tage in well-conditioned native troops in the cold season in the
Deccan; and more recently (February 1844) at Grharra in Scinde.
The latter instance was the more instructive, because this method
had proved inapplicable to the disease in the same body of men at
Hydrabad in the previous month.

It is important to keep these facts in mind, because in all proba-
bility difference of season and of climate may call for modifications
in the treatment of dysentery, as in that of other forms of disease.
It is not improbable that purgatives ought to be given more freely
in drier and colder, than in moister and warmer, climates ; but the
state and amount of the excretions, and the habit of body ought

302 DYSENTERY.

always to suffice for determining this point of practice in individual
cases.

It should, moreover, be remembered that benefit from laxa-
tives is chiefly confined to the outset of the disease, and that
nothing can be more faulty than the too frequent system of giving
castor oil to every patient admitted with dysentery, as a matter
of course, irrespective of his state or the stage of the disease. This
routine practice is often hurtful and is altogether at variance with
rational therapeutics.

Diaphoretics. — The maintenance of sufficient warmth of the
surface of the body, and the avoidance of all risk of its depression,
must be carefully attended to in the management of dysentery.
But general diaphoresis either caused by internal remedies, or
external appliances, as the warm bath, does not, in my opinion,
constitute any part of the treatment of dysentery in India. Even
were a perspiring state of the skin a positive benefit in this disease,
which I very much doubt, still the practical disadvantage would
more than counteract the gain ; for free perspiration is apt to inter-
fere with the thorough ventilation of the sick room, and to increase
the chance of exposure to chills, when the patient is disturbed by
the frequent alvine discharges characteristic of the disease.

On the use of opium. — Opium in appropriate combinations and
doses is useful in almost every condition of the disease. It may be
given with advantage combined with calomel at the commencement,
with ipecacuanha, and blue pill in the more advanced stages, and
alone or in union with tonics and astringents after the disease has
become chronic.

The doubt in regard to the efficacy of opium in dysentery which
was partially entertained by Pringle, and more distinctly avowed
by Twining and Haspel, may be readily removed by attention to
combination and to other points of treatment, as Sydenham well
knew and explained.

The mode of action is probably the same under all the circum-
stances of the disease for which opium is suitable. It controls the
increased peristaltic action of the intestine, and allays the distress-
ing sensations caused by it and by the other effects of the inflam-
mation. But, it may be objected, that opium given frequently in
free doses represses secretion ; and that therefore its use is opposed
to an important indication of cure in the early and middle stages
of the disease — the maintenance of a moderately free secretion
from the small intestine and the liver. To the practice of giving
opium alone in these stages this objection is just ; but it may

TREATMENT — USE OF OPIUM. 303

be obviated by, in the early stages, combination with calomel, and,
afterwards with ipecacuanha and blue pill. Thus two important
objects are effected. The irritation of the large intestine is miti-
gated by opium, whilst secretion is favoured by calomel, ipecacuanha
and blue pill ; and we lean to one indication or the other by
varying the proportions of the ingredients according to the circum-
stances of particular cases. For example if, in the treatment with
ipecacuanha and blue pill, the discharges are free and frequent, the
tenesmus distressing, and the abdomen soft and supple, improve-
ment will follow the addition of a grain or a grain and a half of
opium to each dose. But, after a time, the adverse action of the
opium may begin to appear, the secretions may become scanty, the
abdomen rather full, and the tongue somewhat coated. Under
these circumstances it will generally be better to omit the opium
for a time and continue the ipecacuanha and blue pill, than to give
a purgative, and then immediately resume the opium. For the
better illustration of this principle extreme cases have been sup-
posed; but between these there are many degrees which must
be met by corresponding modifications in the treatment, such
as by lessening the quantity of opium rather than by omitting it
altogether.

When opium is given alone, or in union with tonics or astrin-
gents, in chronic dysentery, with the view of favouring the repara-
tion of ulcers, or repressing excessive secretion, then its efficacy is
still more evident, because both the sedative and astringent
actions assist in fulfilling the indications of cure. Under these
circumstances opium may be used in two or three-grain doses every
third, fourth, or sixth hour with great advantage. It alleviates
suffering and diminishes evacuation, and thus places the patient
in the condition most conducive to his cure. The following case
illustrates the good effects of full opiates : —

92. Good effects of opium in the treatment of some states of dysentery illustrated.
— Greorge PemLall, aged nineteen, of strumous habit, and slight frame, after eight days'
ilhiess with dysentery, was admitted into the General Hospital, on the 30th June,
1840, He was leeched two or three times, and blistered. Ipecacuanha, blue pill,
and gentian, and anodyne enemata were used. He improved for a few days, and then
fell off. About the 15th July he was in a very precarious state. There was much emacia-
tion, the pulse was frequent and small, the tongue was florid, sometimes dry, and
sometimes coated. The dejections were frequent and scanty, consisted of mucus and
blood, were sometimes yeasty and offensive, and were passed with much tenesmus.
From this time the treatment consisted of large opiates, combined with quinine, blue
pill, or trisnitrate of bismuth. On the 28th July he began to take three grains of
opium, with one each of quinine and blue pill, every third hour. The amendment was
now tolerably steady and progressive, and the quantity and frequency of the opiate

304 DYSENTERY.

was gradually reduced. On the 30th there was slight relapse, when four grains of
bismuth and one and a half of opium was used every fourth hour with excellent effect.
On 22nd August all medicine was omitted, and he left the hospital on the 24th in
tolerable flesh, and with regular bowels. From the 15th he had chicken for dinner.

My remarks on opium have had reference to its exhibition in
the form of pill, but I by no means undervalue its use by enema,
in the manner usually employed.

Chloroform. — Dr. Lownds * has pointed out the good effect of
chloroform, taken internally in a twenty-minim dose, in relieving
severe tenesmus in dysentery. Dr. Stovell f also bears testimony
to its utility. I have used it in several cases, and its power in
allaying the pain consequent on intestinal spasm is undoubted ;
but I have observed that when repeated several times it is apt to
create gastric irritation, indicated by a sense of heat at the epigas-
trium, and a florid tongue. Chloroform should, therefore, be only
used occasionally, to relieve tenesmus or other symptoms of spasm
of the muscular fibre of the intestine, when urgent, if

We have hitherto been engaged in considering the two first indi-
cations of cure (p. 291). The third remains to be noticed.

3. The third indication of cure has in view the repair of ulcers
of the mucous coat. This, after increased vascular action of the
mucous lining has been subdued, must be effected by tonic treat-
ment in its most extensive sense — medicinal, dietetic, climatic —
and by restraining the excessive discharges which are apt to exist
in old cases in reduced subjects.

On the use of astringents and tonics. — In the advanced stages
of dysentery, when ulceration exists, when recovery is only possible
by processes of repair, and when the lesion is attended with free
discharges from the bowels and a deteriorated state of the consti-
tution, then as already stated the efficacy of opium is very appa-
rent. Under the same circumstances, astringent and tonic reme-
dies are often very beneficial. Of these the most common are
acetate of lead, nitrate of bismuth, sulphate of quinine, sulphate
of copper, preparations of iron, nitrate of silver, catechu, kino

^ "Transactions Medical and Physical Society of Bombay," New Series, No. 3,
Appendix, p. iii.

t Ditto, p. 32.

\ The vapour of chloroform introduced into the rectum, is probably deserving of a
more extensive trial than it has yet had in the circumstances for M'hich opiate enemata
are usually employed. It might be conveniently applied by means of the simple caout-
chouc cylinder and tube, used by Dr. Simpson, for conveying the vapour to the os uteri.

If it be a therapeutic fact as stated by Dr. Simpson, that carbonic acid is anaesthetic
and curative of foul ulcers, then applied by the same simple means it may be worthy
of trial in chronic dysentery. •

TREATMENT— ASTKINaENTS AND TONICS. 305

hsematoxylon, pomegranate, Bael fruit, gallic and tannic acids.
The metallic salts are, in general given, with varying quantities of
opium, and on this combination much of the benefit doubtless
depends.

Astringents and tonics, however, have hitherto been used with
little discrimination, and further careful observation is necessary to
determine the circumstances of the disease for which they are re-
spectively applicable. All that I can attempt on this point is to
offer some suggestions on principles and then to state the result of
my own experience of particular agents.

Astringents are indicated only in chronic dysentery, and in the
hsemorrhagic form of the acute disease. In chronic dysentery,
ulcers or other lesions require to be repaired ; and, for this, some
degree of tone of constitution is favourable. Increased intesti-
nal discharges debilitate the system ; therefore we endeavour to
restrain them by astringents. This is the simplest and probably
the truest explanation of the action of this class of remedies in
chronic dysentery; and should the astringent principle be in
combination with a tonic principle, then the efficacy of the re-
medy will be enhanced.

A condition of the body fit for the reparation of lesions can only
be brought about and maintained by suitable arrangements of the
vital stimuli — food, air, &c. Medicines which favour the action
of these stimuli, are named tonics ; but they are very subsidiary
to the vital stimuli themselves, and must always be used with much
care, lest they operate adversely instead of favourably. This cau-
tion is especially necessary, in diseases of the alimentary canal;
hence in the treatment of chronic dysentery there is risk of
injury in unskilful hands from astringents and tonics.

The cachectic states associated with chronic dysentery are various.
The special means at our command for the correction of special
cachexise are limited, but they should be carefully studied with a
view to their increase ; for it is in this direction that the resources
of medical art are most susceptible of improvement in the treat-
ment of chronic dysentery. In illustration of this statement it
maybe observed that when dysentery is related to malarious cachexia,
^Ye may expect the greatest benefit from astringent and tonic pre-
parations of iron, from quinine, and from a combination of vege-
table bitter and astringent principles. When there is reason to
think that the cachexia is scorbutic, we may turn with confi-
dence to vegetable acids, and to astringent, tonic, and mucilaginous
l^rinciples in combination with them. It is in this diathesis

306 DYSENTERY.

that the Bael fruit, lately again favourably reported of in Bengal,
by Mr. Grant and others*, is probably useful.

My experience of the Bael fruit is limited, yet I may venture to
entertain the apprehension that unless the states of the disease for
which it is appropriate be carefully determined, the good which it
is doubtless capable of effecting in suitable cases will be lost to
medical practice. I do not suppose that physicians expect to find
in the Bael, or any other article of the Materia Medica, a
universal remedy for dysentery; but I have had opportunities of
learning something of the state of popular credulity in the instance
of the Bael, and of noting its tendency to exercise an injurious
influence on rational treatment.

Still another remark may be made on such remedies, as pome-
granate, Bael fruit, and others whose positive therapeutic proper-
ties cannot be great. There is reason to believe that sometimes
the benefit is negative. The fact may be lost sight pf that
these kind of remedies are usually had recourse to after many
others have been previously tried, and not unfrequently injuriously
continued ; and that, therefore, the benefit from the change may pro-
ceed from the removal of Isedentia, not the application of juvantia.
That this suggestion is not fanciful I know from experience. In
dysentery in children it often happens that if opiates be unduly
continued, the discharges become pasty and scanty, and the general
state of the child deteriorates. If under these circumstances the
opiates be omitted, and a weak decoction of pomegranate be substi-
tuted, speedy improvement may be anticipated. But in these facts,
there is not proof of the therapeutic virtue of the pomegranate,
but merely evidence of a want of skill in the previous use of the
opiates. It is well observed by Cullen that the physician shows as
much skill in determining when to leave off a remedy as when to
prescribe it. There can be no doubt that a want of appreciation of
the injurious effects of previous remedies is a great source of fallacy,
in judging the true effects of subsequent ones ; and to no disease
does this principle apply more forcibly than to dysentery.

Acetate of lead has been little used by me in the treatment of
dysentery, because the trials which I have from time to time made
have failed to inspire me with confidence. To improve the gene-
ral state of the constitution is an indication in chronic dysentery,
but this result is not to be looked for from a salt of lead, and
therefore the continued use of this agent must generally be inexpe-
dient. Acetate of lead has, with a sad want of discrimination, been

* " Indian Annals of Medical Science," No, 3.

TREATMENT — ASTRINaENTS AND TONICS. 307

occasionally given in the early stage of acute dysentery with inju-
rious consequences.*

Trisnitrate of bismuth, and quinine, have been frequently used
by me, and often with advantage. But sulphate of copper is the
remedy of this class which is most immediately and generally useful.
It has been given by me in doses of from a grain to two and a half
grains, with an equal quantity of opium, every sixth, fourth, or
third hour, according to the urgency of the symptoms. The
cases for which it has seemed most applicable, are those in which
the dejections are very frequent, copious, often frothy, showing
that the secretions from the small intestine are in excess, and not
retained, for any time, in the large intestine. In the advanced
stage of acute attacks with sanious blood-stained discharges — the.
evident exudation from an extensive, irritable, probably sloughy
ulcerated surface — it is very proper to try either the acetate of
lead or sulphate of copper, or any other astringent which may
hold out the prospect of benefit ; — but with a knowledge of
the existing pathological conditions, it is vain to expect much
advantage from their use.

Nitrate of silver, in doses of one to three grains, combined with
opium, has been occasionally tried by me, both in Europeans and
natives, but without evidence of its efficacy.

In respect both to the salts of copper and of silver, it may be
said that as we cannot point to any particular cachectic state for
the correction of which they are appropriate, their use must at
present be regarded as empirical, and attended with the occasional
risk of harm.

Of the preparations of iron, the solution of the persesquinitrate
has been the most efficacious in my hands. With the sulphate of
iron combined with opium I have been disappointed.

Of the vegetable astHngents, gallic and tannic acids are the most
deserving of confidence in chronic dysentery.

It is very doubtful whether any astringent can be used with much
prospect of advantage, unless the tongue be moist and tolerably
clean ; and though in cases in which the tongue is florid, chapped,
and dryish, it may be proper to give them cautiously, — because
no other course is open to us, — still it should be done with
much watching, and with no sanguine expectation of a good result.

* Opportunities of observation after my return to India have convinced me that this
error in practice is much more common than I supposed, when I first expressed
this opinion. It is difficult to understand how a system of treatment which evinces
both ignorance of the therapeutic action of acetate of lead and of the pathology of
acute dysentery can have originated.

X 2

o08 DYSENTERY.

In chronic dysentery the evacuations are often pale, sometimes
ahnost of chalky appearance ; but this is not an indication of the
expediency of mercury, and not a contra-indication of astringents ;
for it not unfrequently happens that as the dejections decrease in
frequency, their colour gradually assumes a more healthy aspect.

Should the bowels show a tendency to become confined under
the use of astringent remedies, it is always better to intermit them,
and thus avoid the exhibition of a laxative or purgative, which,
under these circumstances, is apt to aggravate the disease.

The astringents which have been used with the view of restrain-
ing haemorrhage in the hsemorrhagic form of dysentery, are chiefly
the acetate of lead and the vegetable astringents. The most strik-
ing effects of this kind which I have witnessed were in the practice
of Dr. Leith, from gallic acid and tincture of catechu — eight
grains of the former and two drachms of the latter were given every
hour and a half alternately, and port wine was at the same time
freely used. The case was one of hsemorrhagic dysentery, with ady-
namic phenomena, in a European officer, and recovery was complete.

Fomentations to the abdomen, carefully used, are often
useful in the early stages of acute dysentery, and materially aid
the more important measures. The wet compress of the hydro-
pathic system frequently proves a convenient mode of applying heat
and moisture to the surface of the abdomen. In chronic dysentery
the maintenance of an equable temperature of the surface of the
abdomen by appropriate clothing, flannel bandages, &c., is an
essential part of the treatment.

Blisters. — When symptoms of inflammation continue after local
detraction of blood has been sufficiently employed, a large blister
is not unfrequently applied to the abdomen ; but my belief is, that
blisters under these circumstances do little good, and, as they occa-
sion considerable discomfort, I am averse to their use.

When, however, the inflammatory action is limited to particular
parts of the intestine, as the csecum or sigmoid flexure, — indicated
by tenderness or induration, — and when, from the stage of the
disease, it is probable that ulceration is associated with that
inflammatory condition of the surrounding tissue which is favour-
able to disorganisation, and adverse to repair, — then a blister, of
two to three inches square, is often useful in succession to adequate
leeching. By this course the derivative advantages of the blister
are obtained without the risk of constitutional disturbance.

The liquor lyttse has seemed to me the most convenient epispastic.

Enemata. — When tenesmus is urgent, and pain at the lower

TREATMENT — USE OF ENEMATA.

309

part of the rectum distressing, the local application of opium by
enema, or suppository, often affords great relief. The addition of
acetate of lead has not in my experience seemed to increase the
efficacy of the opiate enema.

To these uses, and to the occasional exhibition of cold water
enemata, my experience of this class of remedies is restricted.

The exhibition of large enemata in the treatment of dysentery,
acute and chronic, has been lately urged upon the attention of the
profession by Mr. Hare *, of the Bengal Medical Service. In acute
dysentery a flexible tube is passed above the sigmoid flexure, and
warm water, without limit in quantity, is then slowly injected by
a powerful pump, till the patient complains of the distention, and
the abdomen becomes visibly enlarged.

In chronic dysentery large enemata (six or seven pints) are used
daily, with the view of removing acrid secretions, softly stretching
the strictured parts, and appljdng emollient, astringent, or stimulant
lotions to the diseased surface of the intestine.

Though unable to offer an opinion on this system of practice
from my own observation, still it is incumbent on me to state the
convictions left on my mind from a consideration of the subject.

In respect to large warm water enemata in acute dysentery, I
would remark : — 1 . That, should a case of dysentery present
itself in which there is good reason for believing that the large in-
testine is loaded with scybalous or other feculence, the advantage
of removing these contents by a sufficient enema of warm water
may not be called in question. But a case of dysentery answering
to this description I have never seen, and, if a possible occurrence,
it must be certainly so rare as not to call for notice in laying down
a method of treatment of this disease. 2. That many cases of
dysentery may recover well under rest, abstinence, and large
warm water enemata, is not to be doubted; but such cases
will recover equally well under rest, abstinence, three or four
drachms of castor oil and an opiate, or even without these latter
means. Therefore in such the enemata are unnecessary. 3.
That the treatment of the severer forms of dysentery, in which
thickening soon talies place, or the inflammation is erysipelatous —
passing on to gangrene and sloughing, and secondary peritonitis,
— can be much advanced by the application of fomentations to the
affected mucous surface, is to invest this remedy, in respect to the
intestinal tissues, with a therapeutic value which it certainly does

not possess, when used in the same degrees and kinds of inflamma-

*
* " Indian Annals of Medical Science," No. 2, p, 485 and 495.

X .3 '

310 DYSENTERY.

tion in other textures of the body. 4. That dysentery is caused
or kept up mainly by the acrid nature of the secretions is a patho-
logical doctrine from which I altogether dissent. Surely it is not
when the secretions from the small intestine are passing copiously
into the large intestine, and being discharged, that the symptoms
of the disease are most distressing. Is it not rather when the dis-
charges are scanty, and consist of little else than the mucous,
bloody, or serous exudations proceeding from the inflamed membrane
itself that we are chiefly called upon to palliate pain ? and though
it may be admitted, that under these circumstances the application
of warm water to the intestinal surface may have a soothing effect,
yet it cannot, on this account, be advanced to any other than a
very subsidiary and occasional place in the treatment of this serious
disease. 5. Under any circumstances of dysentery, to distend
the intestine, — thus alter the relation of the mucous to the other
coats, and do away with the advantage of rest, — is, I apprehend,
a proceeding of very doubtful expediency. But when we recollect
what pathology teaches us, that there comes a stage, often quickly,
and not marked by characteristic symptoms, in which the coats of
the intestine become friable, and sloughy apertures^ are closed up
by tender patches of^ lymph, I would ask, what is likely to be the
effect on such an intestine of water injected into it without limit by
a powerful pump, till the patient complains of distention and the
abdomen becomes visibly enlarged ?

In respect to the use of large enemata in chronic dysentery : —
1. All that has been said in relation to the acute form on the
removal of acrid secretions and the distention of the gut, applies
also to the chronic form. 2. In the treatment of cutaneous
ulcers, or those of visible mucous membranes, local applications are
undoubtedly useful ; yet they are subsidiary to general and consti-
tutional treatment, and to the rest, position, and support, by which
the local circulation of the part is favoured. Moreover, the degree
of utility accorded to topical remedies is contingent on the ulcera-
tion being visible, — that is, on our ability to vary the applications
according to circumstances, and to apply them with precision.
Keeping these facts in view, and recollecting that ulcers of the
large intestine are out of sight, I would ask whether the repeated
use of large injections of solutions of sulphate of copper, alum,
nitrate of silver, &c., are not as likely to be injurious as beneficial ?
It may not, I admit, be justifiable on these grounds, to dissuade al-
together from the use of these means in chronic dysentery, because
in the weakness of our art we must act at times on probabilities ;

TREATMENT — ON DIET. 311

but I can have no hesitation in recording my opinion that they
must at best be very subsidiary, always require to be used with
caution and discrimination, and under a full appreciation of the
leading importance of constitutional treatment and rest of the
affected structure in the management of chronic dysentery.*

On Diet, — The principles which direct the medical treatment of
dysentery must guide us in determining the diet appropriate in
particular cases and different stages.

So long as the indication of cure is, by antiphlogistic remedies,
to prevent disorganisation of the mucous coat, or to check its ex-
tension, the diet, as a matter of course, must be very restricted.
When, on the other hand, the indication of cure is to favour the
reparation of lesions, it must be recollected that the debilitated
or deteriorated system cannot effect this without suitable nutriment.
It must be supplied of that kind and in that quantity which the
digestive organs, in part impaired by disease, are capable of fit-
ting for assimilation. I need hardly observe that with neglect
of this essential part of treatment, medicine must be utterly
useless.

In arranging the diet for acute cases, in which antiphlogistic

* In medical writing I am most anxious to avoid the semblance of a controversial
spirit, from the tendency which it has to obstruct inquiry and true progress, yet I
cannot avoid noticing the subjoined passage with which Mr. Hare concludes his paper.
To use the vague statistical data of Indian or other hospitals for the determination of
questions in therapeutics, is an error which has exercised, and does stiU exercise, an
injurious influence on the practice of medicine. The statistics of disease adequate for
tliis important end do not as yet exist in India, or in any other country, except on a
most limited scale, and they will require to be of a nature very different from that of
ordinary hospital records.

To base on data altogether insufficient for the purpose an argument for returning to
the treatment of dysentery by salivation, is, I think, very much to be deplored. It is
advocating, on unsound reasoning, an injurious system of practice. JMr. Hare thus
writes : —

" I must remark, in conclusion, on malarious dysentery, that if the above treatment
by injections be not adopted, statistical facts of the most undoubted kind prove the
necessity of our returning without delay to the salivating system. For the returns of
the largest and longest established dysenteric hospital in the world, show, that since
mercury has been avoided, the mortality has been double, for many years' continuance,
what it was when salivation was sought for, as the first and only object of treatment ;
and to complete the remarkable proof of the importance of mercury (if ray system by
quinine and injections be not received), these statistics clearly show, that as mercury
has gradually been disused, so the mortality has correspondingly increased. If statis-
tics then, are, as they ought to be, our only guide to rational practice, our path is clear,
— we must return to salivation till some more successful method be discovered. But
the fact that in treating 346 cases in Calcutta, I had but 4f per cent, deaths, will, I
hope, induce a trial of large injections by others, and thus prevent the necessity of
resorting to the more injurious remedy — mercury."

X 4

312 DYSENTERY.

remedies are indicated by the stage of the disease and the state of
the constitution, there is no difficulty. Thin farinaceous solutions
in small quantity from time to time are the only food that is
necessary or safe : and as recovery advances, the change to more
nutritive food must be cautiously made.

But when the constitution is asthenic or cachectic, and organic
lesion exists, then the adjustment of the diet will require all the
judgment and skill of the physician ; and, in regulating it, he must
be guided by his knowledge of the principles of physiology and
pathology, and of the digestibility and nutritive value of different
articles of food. Those from which selection may be made are
farinaceous solutions and jellies, milk, animal broths and jellies,
solid farinacea and animal food. When a scorbutic diathesis is
suspected*, then the usual special modification of diet will be
necessary : it is in such states that ripe grapes have been given at
the Cape of Good Hope and elsewhere with advantage. In the use
of wine we must be also regulated by general principles : it will be
sometimes useful ; but, on the whole, the error of undue use is
more frequent than that of abstinence.

The affectation and empiricism of regarding particular articles
of food as of universal application must be avoided, and we should
keep always before us the golden rule, — when the indication is
to restore injured structures by nutrition, — not to overtask the
digestive and assimilating powers of the weakened system ; and
further we must recollect that, in dysentery it is a part of the
organs of digestion that is structurally impaired.

On Change of Air and of Climate. — In considering the causes
of dysentery, importance was attached to conditions of the atmo-
sphere as predisposing or exciting causes.

If an atmosphere, loaded with moisture, or vitiated by malaria or
emanations from decomposing vegetable and animal matter or
excess of carbonic acid, favours the onset of the disease, then re-
moval from these influences is essential to success in treatment.
But the physician, in applying this principle, will sometimes have
to exercise much judgment and discretion, in balancing the advan-
tages of rest and medical care and the disadvantages of local in-
fluences, against the evils of the excitement of motion and less
careful treatment. On the whole, however, this difficulty will not
often arise ; for the benefit from rest and careful medical treatment

* I use the term " suspected " because there can be no question that the scorbutic
diathesis exists long before its presence is made certain by spongy gums and subcu-
taneous extravasations.

TREATMENT — CHANGE OF AIE AND CLIMATE. 313

at the commencement of acute dysentery is so unquestionable,
that we are not justified in withholding it unless the evidence
of injurious conditions of the locality be very clear. This
remark applies to such change of air as involves a journey and
the interruption of medical treatment, — not to that merely from
one house or room to another ; for in this, as in all other diseases,
the removal of the sick from confined houses and ground-floor
apartments to those that are well ventilated and elevated, is an
advantage which should be secured whenever practicable.

It may be laid down, then, as a rule subject to very few excep-
tions, that, in the management of acute dysentery, rest and watch-
ful medical treatment are to be enjoined; and the excitement and
disturbance of travelling and the interruption of medical care
strongly dissuaded from.

But to what extent are we to expect benefit from change of
climate in chronic dysentery ? If the climate, in which the patient
resides, is adverse to processes of repair — is not tonic in its
general influence — but from malaria, moisture, or continued eleva-
tion of temperature, exercises a depressant influence on the vital
actions, then removal from such climate is a leading indication of
cure.

In selecting a climate suitable for such cases, we must be careful,
while we aim at securing a temperate and pure atmosphere, to
avoid considerable and sudden reductions of heat, by absolute
lowness of temperature, winds, or varying states of atmospheric
moisture. Eesort to the Hill Sanitaria in India, more particularly
in the cold season of the year, is, on these accounts, generally un-
suitable in this disease. In removing to other countries, the season
of the 3^ear and the character of their climate, in respect to these
atmospheric conditions, must be carefully considered ; and if they
cannot be altogether avoided, the risk of injury must, as far as
practicable, be obviated by great attention to clothing and avoid-
ance of exposure. A cold moist air is the most injurious.

The means by which the change is to be effected ai-e also very
important, for exposure to the excitement of motion, unsuitable
food, confined and vitiated air, in the passage from one country to
another, are injurious influences, often overlooked, but which the
physician must never neglect in recommending change of climate.
For example, the efficacy in chronic dysentery of a sea voyage in
temperate latitudes, in a comfortable roomy ship, is undoubted.
From the diminished alvine and urinary excretion, observed in
persons at sea, we may infer that there is a corresponding increase

314 DYSENTERY IN CHILDREN.

of pulmonary and cutaneous elimination; and that the benefit
derivable from a sea voyage, in affections of the bowels, is perhaps
in part to be explained by this altered relation of the eliminatory
processes, and the fuller influence of oxygen which is involved in
it. But this advantage of sea air is in a great measure neutralised
in the overland journey from India as now conducted. The invalid
has to contend with the adverse influences of the discomfort of the
coaling stations, the fatigue and excitement of the journey through
Egypt, the unsuitable dietaries, and the overcrowded and badly
ventilated cabins. These are all serious evils *, and are sure to
operate injuriously on those who journey from India by this route,
in any but a state of advanced convalescence.

Section VI. — Dysentery in Children in India,

My opportunities of studying the morbid anatomy of dysentery
in young children have been limited, and I am unable to say to
what extent the sloughy disorganisation, common in the adult,
occurs in the early periods of life.

The general description of the symptoms, and the principles laid
down in respect to the causes and the treatment, apply equally to
all ages.

In regard to the treatment, it may be further observed, that in
the child the abstraction of blood is inexpedient, and the necessity
of it is best obviated by early and careful watching, and by such
judicious use of other means as shall prevent the disease passing
to that degree of severity which may require the application of
leeches.

Caution in the use of calomel is as applicable to the child as to
the adult. It can only be requisite in sthenic children, and then
merely at the commencement of the attack, in small doses, com-
bined with ipecacuanha, and not repeated above two or three
times. Fomentations or the wet compress are very useful in the
acute dysentery of children. The indication for the use of castor
oil, in small doses, and the cautions against its abuse, are the same
as those laid down in respect to the adult ; with perhaps this modi-
fication, that a greater degree of alvine excretion is physiological

* I venture on this statement from having been a passenger in 1853, in three of the
vessels of the Peninsular and Oriental Company, on the Suez and Calcutta line, and in
two between Bombay and Ceylon. Also in 1854 from Bombay to Suez, in one of the
Hon. East India Company's vessels : in this the adverse influences complained of were
still more apparent. Again from Suez to Bombay in 1856, and Bombay to Suez in
1859, in the Peninsular and Oriental Company's vessels.

TREATMENT. 315

during the season of growth, and that this fact should not be lost
sight of in using laxatives.

Ipecacuanha, given in the manner already recommended, is fully
as valuable a remedy in the treatment of dysentery in the child as
in the adult. It may be combined with blue pill and extract of
gentian, and be given, rubbed up with a little aromatic water ; or
the extract of gentian may be dried, and chalk and mercury sub-
stituted for the blue pill, and the compound prescribed in the form
of powder. If opium be indicated, a suitable proportion of Dover's
powder may be added. For a child between two and three years
of age, two grains of ipecacuanha will be a suitable dose in the
acute disease. It may be increased or lessened according to the
constitution of the child, the acuteness of the symptoms, and the
tolerance of the remedy. The following case illustrates the effi-
cacy of the ipecacuanha in the treatment of dysentery in childhood : —

93. Acute dysentery in a child. — Treated with ipecacuanha and blue pill. — Charles
Bowen, a European child, of three years of age, after suffering from dysenteric sym-
ptoms for fifteen days, was received into hospital on the 9th December, 1851. The calls
to stool were very frequent ; the evacuations were scanty, consisted of blood-tinged
mucus, and were passed with straining and prolapsus. The skin was dry, and above
the natural temperature ; the tongue was white ; there was no fulness of abdomen,
and he did not acknowledge abdominal tenderness. Two grains of ipecacuanha
three of extract of gentian, Dover's powder, and blue pill, each one grain, were given
every third hour. The hip-bath and fomentations were used, and the diet consisted
chiefly of sago. The improvement was rapid : the stools became less frequent, more
copious, feculent ; passed with less straining and no prolapsus. The Dover's powder
was omitted and the medicine was continued at longer intervals. He was discharged
weU on the 15th.

Opium in the form of Dover's powder, or the compound chalk
powder with opium, is also beneficial in the treatment of dysentery
in children, and the principles laid down for its use in the adult
should be observed, with, however, this additional caution. The
astringent effect of opium in the adult is more likely to be adverse
in sthenic states of the system when excretion is most active. This
principle also applies to the child during the season of growth.
The continuous use of opiates is a more common practice in the
treatment of dysentery in the child than in the adult; whereas, if
the law just stated be correct, it ought to be less so, and to be
conducted with more caution.

When the disease becomes chronic in children, we must trust
chiefly to vegetable astringents and the preparations of iron, with
judicious adjustment of food and of climate, and attention to the
state of the skin.

316 GASTRO-ENTEIIITIS.

Section VII. — On Gastro-Fnteritis.

This disease — inflammation of the mucous coat of the stomach,
of the small intestine, and of the colon — is not uncommon in its
chronic form in cachectic individuals, both European and native.
It is characterised by some degree of irritability of stomach, chiefly
after taking food, accompanied with more or less diarrhoea. The
skin is dry, the body is emaciated, the abdomen retracted, and the
tongue florid, glazed, and sometimes aphthous at the tip and edges.
In fatal cases the mucous membrane of the stomach presents
patches of dark, marbled redness, and is often softer than natural.
The lower part of the ileum and the colon are the parts of the in-
testinal canal usually afl'ected. The morbid appearances are
vascular patches, sometimes with softening, at others with granular
exudation. The solitary glands are often enlarged and prominent,
and circular ulcers are occasionally found scattered here and
there.

In consequence of the general relation of chronic gastro-enteritis
to depraved states of constitution the treatment is perplexing and
unsatisfactory. It resolves itself into carefully-j-egulated diet,
attention to the functions of the skin by suitable clothing, the use
of opium in small doses, with alkalies, or (according to the dia-
rrhoea) vegetable astringents. Dilute hydrocyanic acid with bi-car-
bonate of soda, is often very useful in allaying the irritability both
of the stomach and of the bowels. An occasional small blister to
the epigastrium or right iliac region is also attended with benefit.
In selecting a surfcable climate, the extremes of heat and cold and
much moisture should be avoided.

The practical lesson inculcated by these brief remarks is the
great importance of preventing the cachectic states on which the
occurrence and intractable nature of gastro-enteritis mainly depend.

Section VIII. — On Diarrhoea.

The term diarrhoea occupies a prominent place in the hospital
returns of tropical climates, because it is often used in its etymolo-
gical, not its pathological sense. It is only correctly applied to in-
creased alvine discharges, dependent on active or passive congestion
of some part of the mucous lining of the intestinal canal. The
increased evacuations consequent on inflammation of the same
tissue, either in its early stages or after it has led to structural

DIAERIIO^A.

317

change, are inaccurately designated diarrhoea. Yet this name is
often given to chronic dysentery, muco-enteritis, and gastro-enteritis;
and the returns of disease are in consequence rendered incorrect
and untrustworthy. The diagnosis is not difficult ; it rests on a
careful consideration of the history of the case and of all the
attendant symptoms.

Let us now consider the varieties of true diarrhoea.

1. Transient increased feculent discharges, consequent on excess
or errors of diet, or exposure to cold, occur in India in the pre-
viously healthy, as in all countries, but not so frequently. This form
of diarrhoea requires, however, to be watched with care, because, as
already explained, both dysentery and cholera often commence with
very similar discharges (pp. 221, 281).

2. In Europeans recently arrived, increased discharges, tinged
with acrid bile, — bilious diarrhoea, — occasionally occur ; but this
is a rare form of disease in the seasoned European and in the
natives of India.

3. In asthenic or cachectic persons, Europeans or natives, diarrhoea
is apt to come on consequent on errors of diet, but much more
frequently from cold and wet. The discharges are watery, generally
pale, often chalky and yeasty in appearance. We have illustrations
of this form of disease in the cold and rainy seasons at hill stations
in India, or in the change to colder latitudes at unseasonable periods,
or imprudently conducted. In fatal cases, the mucous membrane
of the intestine is found pale and attenuated. It is an error to
suppose, as many do, that this diarrhoea is symptomatic of hepatic
derangement. No doubt the secretion of bile is deficient; but
can it be otherwise when the system is anaemic, and an active
derivation of the fluids to the intestinal surface is going on.

The indications of cure are a regulated diet, derivation to the skin
by a suitable climate and appropriate clothing, the use of astrin-
gents, and the kind of tonics best adapted to the particular constitu-
tional state. If there be a series of amendments and relapses, the
disease may continue as a diarrhoea for a considerable period, but its
tendency always is, under lengthened continuous persistence, to pass
into chronic dysentery, muco-enteritis, or gastro-enteritis: hence
the reason why in fatal cases the structural lesions of inflamma-
tion are often present.

318

DYSENTERY AND DIARIHIffiA.

Section IX. — Statistics of Dysentery in the European Hospital,
and of Dysentery and Diarrhoea in the Jamsetjee Jejeebhoy
Hospital and Byculla Schools at Bombay,'*

Table XXIV. — Admissions and Deaths^ with Per-centage, from Dysentery,
in the European General Hospital at Bombay, for the Five Years from
July 1838 to June 1853.

July 1838 to June 1843.

Monthly Average.

Deaths on

Admissions

Deaths

Admissions.

Deaths.

on total

Admissions.

Deaths.

January-

21-8

14-2

39-5

February

41-8

7-0

37-5

March .

11-6

8-3

151

April .

21-6

6-3

19 5

May .

26-4

4-0

11-2

June

18-3

6-2

17-6

July .

14-

7-9

21-6

August .

16-2

7-0

20-0

September

33-3

6-0

October

6-2

6-5

11-1

November

8-2

10-6

12-7

December

19-3

15-1

27-2

Total

616

113

18-3

8-1

20-7

Table XXV. — Admissions and Deaths, with Per-centage, from Dysen-
tery, in the European General Hospital at Bombay, for the Five Years,
from 1844 to 1848.

1844 to 1848.

Monthly Average.

Deaths on
Admissions.

Admissions

Deaths

Admissions.

Deaths.

on total
Admissions.

on total
Deaths.

January

23-5

8-2

26-1

February

31-03

2-6

25-6

March .

12-5

&■&

13-3

April .

28-6

4-1

19-3

May .

3-8

4-5

3-3

June

8-8

4-7

9-09

July .

10-3

8-5

16-7

August .

6-06

6-0

13-3

September

13-3

6-5

18-2

October

277

2-9

13-2

November

13-2

6-8

16-1

December

23-3

11-5

35-0

Total

430

16-5

6-3

18-4

* For further information on the statistics of dysentery and diarrhoea, the reader
referred to Sections I. and III. of this Chapter.

STATISTICS.

319

Table XXVI. — Admissions and Deaths, with Per-centage, from Dysen-
tery, in the European General Hospital at Bombay, for the Five Years
from 1849 to 1853.

1849 to 1853.

Monthly Average.

Deaths on
Admissions.

Admissions

Deaths

Admissions.

Deaths.

on total
Admissions.

on total
Deaths.

January

30-4

12-4

43-7

February-

17-4

6-2

22-2

March .

40-9

32-4

April .

16-3

7-2

24-0

May .

167

5-8

20-8

June .

16-3

6-4

20-7

July .

19-6

8-7

27-3

August .

19-5

8-3

21-6

September

22-9

6-2

200

October

29-7

6-8

34-8

November

19-2

8-9

30-0

December

27-8

10-03

42-5

Total

454

105

23-1

7-8

29-4

Table XXVII. — Admissions and Deaths, with Per-centage, from Dysen-
tery, in the Jamsetjee Jejeebhoy Hospital at Bombay, for the Six Years
from 1848 to 1853.

1848 t(

5 1853.

Monthly Average.

Deaths on
Admissions.

Admissions

Deaths

Admissions.

Deaths.

on total

Admissions.

total Deaths.

January

120

40-8

5-7

10-9

February

27-9

4-9

8-1

March .

52-3

3-02

8-8

April .

47-9

3-4

10-2

May .

21-9

4-1

6-9

June .

52-4

3-8

14-007

July .

129

42-6

6-3

14-7

August .

118

38-9

5-9

14-03

September

44-4

4-8

14-1

October

48-0

3-5

10-6

November

102

36-2

4-7

11-2

December

154

31-8

6-6

12-3

Total

1,201

474

39-4

4-7

11-5

320

DYSENTERY AND DIARWICEA.

Table XXVIII. — Admissions and Deaths^ with Per-centage^from Diarrhcea,
in the Jamsetjee Jejeehhoy Hospital at Bombay^ for the Six Years from
1848 to 1853.

1848 to 1853.

Monthly Average.

Deaths on
Admissions.

Admissions

Deaths

Admissions.

Deaths.

on total
Admissions.

on total
Deaths.

January

102

40-2

4-9

9-1

February

46-2

3-4

9-4

March .

68-4

2-6

10-1

April .

30-1

3-4

6-4

May .

28-9

3-8

8-4

June

26-8

4-5

8-1

July .

122

36-4

6-04

111

August .

110

55-5

5-5

18-6

September

36-2

4-4

10-6

October

111

36-04

5-2

10-03

November

32-1

4-3

9-07

December

104

34-6

4-5

9-08

Total

1,104

425

38-5

4-3

10-3

Table XXIX. — Admissions and Deaths, with Per-centage, from Diarrhoea
and Dysentery, in the Byculla Schools, for the Seventeen Years from
1837 to 1853.

1837 to 1853.

Monthly Average.

Admissions.

Deaths.

Deaths on
Admissions.

January
February
March .

95
117
142

1-05
2-56

2-8

April .

May

June

131
151
213

6
2
3

4-58
1-32
1-4

July .

August .

285
195

7
9

2-43
4-63

September
October

97
83

3
1

3-09
1-2

November

2-1

December

1-23

Total

1,686

2-49

321

CHAP. XV.

ON HEPATITIS.

Section I. — Comparative Prevalence of Hepatitis,

The following table shows the ratio of hepatitis to strength in
European and Native troops in the three Presidencies : —

^" Peesidency.

EUROPEANS.

NATIVES.

Per-centage
of Admissions
to strength.

9J O ^

tic— 2

aj o

III

Bengal .
Bombay .
Madras .

5-65

7-78
7-0

0-40
0-41

0-29

7-16
5-27
41

0-10
0-18
0-12

•007
•019
•013

7-54:

10^28
10-07

A judgment may be formed of the comparative prevalence of the
disease in India, by observing the ratio in other countries ; thus
the per-centage of admissions to strength is in — .f

Canada . ,

Nova Scotia

England .

Malta

Cape of Good Hope

•75 per cent.

•82
84
2^09 „
2^18

Though hepatitis is a more common disease in India than in
temperate climates, still it is rare compared with fevers and affec-
tions of the bo^vels, as is proved by the following tabular state-
ment : —

* "Ewarfs Vital Statistics," pp. 127, 137.

t lb. p. 125, where there are also further similar facts in respect to other countries,

HEPATITIS.

EUROPEAN TROOPS.

Pbesidency.

Fevers.

Dysentery and
Diarrhoea.

Hepatitis.

Ill

Per-centage

of Admissions

to strength.

V c ^

III

1?^

Bengal .
Bombay .
Madras .

72-64
61-93
31-62

1-99
1-37
0-37

30-41
27-13
23-43

2-02
1-71
1-24

5-65

7-78
7-0

0-40
0-41
0-29

NATIVE TROOPS.

Presidency.

Fevers.

Dysentery and
Diarrhoea.

Hepatitis.

S £ S^

Per-centage

of Deaths

to strength.

tit
is!

tit

1 - c

tit

&2 .
Ill

Bengal .

Bombay . . ,

Madras .

48-50
41-20
25-04

•528

•57

•30

6-18
6-57
3-08

•173
•196
•190

0-10
0-18
0-12

•007
•019
•013

A similar result also appears on examining the retm-ns of the
European Greneral Hospital and the Jamsetjee Jejeebhoy Hos-
pital, thus : —

Fevers.

Dysentery and
Diarrhoea.

Hepatitis.

Per-centage

of Admissions

on total

Admissions.

Per-centage

of Admissions

on total

Admissions

o s ^

ill

^2|

Per centage

of Admissions

on total

Admissions.

European General
Hospital. •

Jamsetjee Jejeebhoy
Hospital .

19^7
9-8

10-3
7-5

12-9*
9-0

28-9*
21-8

3-7
1-5

7-8
3-0

From these statements we learn that hepatitis, though a com-
mon disease in Europeans in India compared with temperate cli-
mates, does not nearly equal fever and affections of the bowels in
frequency or in the mortality which it occasions. Moreover I
believe that hospital returns in India very generally exaggerate

* As my own notes do not supply me with the return of diarrhoea in the European
General Hospital, I have incorporated the ratios of dysentery of my own tables with
those of diarrhoea of Dr. Stovell's Keport, for the ten years from 1846 to 1856.

PRELIMINARY REMARKS.

323

the proportion of hepatitis. A sense of fulness and weight in the
region of the liver from congestion and enlargement consequent on
recurring fever, are not unfrequently classed as hepatitis, partly
from inaccurate diagnosis, but chiefly because the nosological
classification in use has not kept pace with the progress of patho-
logy and does not provide for these distinctions.

Notwithstanding my belief that the frequency of hepatitis in
Europeans is over-estimated, I am certain that the statement made
by Twining, and generally concurred in by writers on tropical
disease, that " acute liver disease terminating in abscess is exceed-
ingly rare among Asiatics," * is erroneous. In six years the deaths,
from hepatitis in the Jamsetjee Jejeebhoy Hospital amounted
to 125, and the fifty-five cases of hepatic abscess in natives now
before me, and partly detailed in the sequel of this chapter, form
but a part of those which at different times have come under my
observation. The origin of this common error is easily explained.
The imperfect statistics of disease in the Indian army have been
applied to the general population of the country, which is equivalent
to judging of the forms of disease prevalent in England from the
hospital returns of the troops serving in that country.

Section II. — Pi-eliminary Remarks on the nature of the Symp-
toms of Hepatic Disease. — Arrangement of the Subject

In distinguishing the diseases of the liver, we are often un-
assisted by derangement of its function — that is, by altered condi-
tions of the biliary secretion. In many affections of this organ
there is no evidence that the secretion is modified ; and though it
has been customary to attribute various of the morbid appearances
presented by the alvine discharges to a changed state of the bile,
and to infer the existence of hepatic disease, yet the proof is
frequently insufficient, and the fact that the altered character of
the secretions may have been caused by the remedies used is often
lost sight of.

It is, therefore, very necessary that the clinical student should
avail himself of all other useful sources of information. Above all,
it is essential that he should bring to the inquiry a precise know-
ledge of the anatomical position and relations of the organ, and
that this should be constantly present to his mind while he inves-
tigates its morbid states.

* Twining, " Diseases of Bengal," yol. i. p. 388.
Y 2

B24 HEPATITIS.

It is since the practice of percussion has been added to our
•methods of diagnosis, that great accuracy in respect to the
position of the liver has acquired its full value; for by this
means we can ascertain during life the noriual limits of the
organ, and also their increase or decrease. In the normal state
there is dulness on percussion from the sixth right rib, downwards
to the costal margin. The degree of dulness between the sixth
and seventh rib varies according as observation is made under
expiration or inspiration. Percussion about the fifth, sixth, and
seventh ribs should always be gentle, because as the convex
part of the liver rises as high as the level of the fifth rib, strong
percussion will indicate dulness higher than the sixth rib, and will
prevent us from determining whether the liver is normally, or
otherwise, overlapped by the thin part of the lung.*

There are leading features of the intimate structure of the liver
which should also be held in remembrance. The arrangement of the
portal capillaries, the position of the portal vein, and its branches
in the portal canals. The origin of the radicles of the hepatic
vein in the lobules, and their relation there to the portal capillaries.
The distribution of the hepatic artery. The situation of the origin
of the hepatic ducts. The supposed function of the hepatic cells,
and their relation to the terminal parts of the ducts. Nor may we
forget that by far the larger proportion of the blood flows through
the portal vein to serve the purpose of secretion ; and that a much
smaller portion circulates in the hepatic artery to serve for the
nutrition of the solid tissues of the organ, and then to mix with
the portal blood, and thereby, also, assist in secretion. The liver is
moreover abundantly supplied with lymphatics, and with nerves,
chiefly derived from the sympathetic system.

In describing the inflammatory affections of the liver I shall
use the terms Hepatitis and Cirrhosis. Hepatitis signifies
inflammation of the peritoneal covering of the organ, of its sub-
stance, or of both combined. When occurring in the investing
membrane, it may be recovered from with, or without, exuda-
tion of lymph and consequent adhesion. When occurring in
the parenchyma it may be recovered from, and the organ be left

* Though the great importance of careful systematic percussion in the diagnosis of
iepatic disease, is undoubted, still I have reason to believe that it is often very imper-
fectly attended to. It has happened to me on not a few occasions to become cognisant
of cases, in which enlargement of the liver was undiscovered, though the exercise of
moderate skill in percussion could not have failed to detect it. And on the other
hand, I have known instances in which congestion or enlargement was erroneously
supposed to exist, simply because this means of diagnosis had been neglected.

PATHOLOGY — GENERAL REMARKS. 325

sound ; or exudation of l3^mph may take place, and abscess may-
result.

The symptoms will be distinct or obscure, and the morbid
processes will follow a quick or a slow course, and will tend to
recovery or structural lesion according to the part and extent of
the organ implicated, and the diathesis of the individual affected.

The term Cirrhosis is applied to that slow inflammatory action
which, invading the fibrous and areolar tissues of the portal canals,
and generally caused by spirit-drinking, injures the structure of the
liver.

I prefer these terms to " suppurative inflammation," and " adhe-
sive inflammation," because the former, as a substitute for " hepa-
titis," does not include the cases of peripheral inflammation, and
seems to imply that every inflammation of the substance of the
liver, not of the character of cirrhosis, necessarily ends in suppura-
tion — a conclusion to which the observer of disease in India is
unable to assent. My objection to the term '^ adhesive inflamma-
tion," as restricted to cirrhosis, is, that it would be more correctly
applied to those numerous inflammations, primary or secondary, of
the peritoneal covering of the liver which lead to exudation of
lymph and adhesion of surfaces.

In arranging my remarks on Hepatitis^ I shall consider— 1st, the
pathology ; 2nd, the causes ; 3rd, the symptoms ; 4th, the treat-
ment.

Section III. — Patliology. — Preliminary Remarks on the General
Pathology of Hepatitis. — Morbid Anatomy of Stage of Vascu-
lar Turgescence, of Exudation of Lymph, and Formation of
Abscess explained. — The several Courses and Situations of
Rupture of Hepatic Abscess. — Abscess Absorption. — Secon-
dai^ Peritonitis and Formation of circumscribed Purulent
Sacs. — Secondary Pleuritis, circumscribed and general
Empyema. — Secondai^j Pericarditis. — General Secondary
Peritonitis. — Colour of Pus in Hepatic Abscess.

Before proceeding to describe the morbid anatomy of hepatitis,
I would notice a preliminary pathological question of some interest
and importance, but which, so far as I know, has not engaged the
attention of previous writers. Which are the capillary vessels of
the liver concerned in inflammation ? If the pathology of inflam-
mation be correct, viz., that it is an altered state of the nutritive
processes of the affected part, depending upon something faulty in

326 IIEPATITIS.

one or other of the conditions of normal nutrition, — then the
capillaries concerned in inflammation must necessarily be those
which circulate, in their normal state, arterial blood for purposes
of nutrition. The capillaries of the hepatic artery are the nutrient
vessels of the solid structures of the liver, and consequently the
only ones which can be directly engaged in the inflammatory pro-
cesses of those structures.* On the other hand, the portal capil-
laries circulate venous blood for purposes of secretion, and are
not supposed to take any part in the nutrition of the liver;
they are therefore not directly engaged in inflammation. This
is not merely an unimportant speculation because — Firstly, if
we regard the small capacity of the capillaries of the hepatic artery
in comparison with those of the portal vein, we have, under the
view that the former are those concerned in inflammation, an expla-
nation of the fact that the bulk of the organ is little increased in
inflammation compared with congestion — a deranged state in
which the capacious portal capillaries are directly implicated.
Secondly, this view helps to explain how it happens that the secre-
tory function of the liver is often not deranged in hepatitis. Thirdly,
it tends to remove that difficulty which practical writers on hepati-
tis have experienced in reconciling the results of clinical observa-
tion with therapeutic theory. It has been urged that to give mercury
with a view to its cholagogue action in hepatitis is opposed to the
doctrine that the special stimulants of secreting organs are contra-
indicated in the active inflammations of these organs. But this
principle — - doubtless true when the secreting capillaries and the
inflamed capillaries are the same, and both carrying arterial blood,
— cannot correctly apply to the liver, if the secreting capillaries
and the inflamed capillaries are distinct from each other. Further,
if we hold that the capillaries of the hepatic artery finally pass into
the portal veins, then to quicken the portal capillary circulation by
increasing secretion seems, in theory, a rational method of lessening
stagnation in the capillaries of the hepatic artery. These observa-
tions are not now made with any view of advocating the mercurial
treatment of hepatitis, for this question will be discussed elsewhere ;
but simply with the object of showing that the question — which
are the capillary vessels engaged in the inflammation, is not an idle

* I am aware that it may be tirged that the hepatic cells must be classed with the
solid structures of the liver, and that (viewing the close analogy between secretion and
nutrition) in one sense it may be said that they are nourished by the portal capillaries.
But this is apart from the argument, and the usual meaning of nutrition, which,
speaking generally, is a process requiring as one of its conditions arterial blood and
arterial capillaries.

PATHOLOGY — STAGE OF TURGESCENCE. 327

one, but is intimately related to the therapeutics, as well as to the
physical signs, and the symptoms of hepatitis.

In considering the morbid anatomy of hepatitis, it is import-
ant to remember the great size of the liver, and the consequent
fact that inflammation will vary according as it involves a greater
or less extent, and one or several parts of the substance or surface.

That inflammation of the capsule of the liver, with but little
implication of the parenchyma, may really occur is not to be
questioned. We may believe that in some instances recovery
takes place and leaves behind no trace of disorder. In other in-
stances, however, adhesions between the opposing peritoneal surfaces,
or an opaque and thickened state of the membrane, without appre-
ciable change of the parenchyma, result. Appearances occasionally
found after death prove this ; but from their rarity we are justified
in concluding that inflammation, limited to the periphery of the
liver, is not a common form of disease in India. This is the com-
mon opinion, and a review of my own cases serves to confirm it.
Still the subject is one to which further attention should be
directed, for in recorded cases (my own as well as others)
positive information is often defective. It is hardly necessary
to observe that my present remarks do not apply to the almost
universal co-existence, at one period or other, of inflammation of
the peritoneal covering with that of the parenchyma : its absence
is exceptional, just as in the pleura and lung.

When the substance of the liver is the seat of inflammation, then
a period of vascular turgescence, analogous to the first stage of
pneumonia, is the first pathological condition. This may be resolved
by treatment, or may lead to interstitial exudation of lymph and
its ulterior changes. These morbid processes may affect portions
of the organ ranging from the size of a pea to that of an orange
and upwards ; and in number from one to many. It is seldom, if
ever, that inflammation of the entire substance of the liver occurs.

Opportunities of studying the post-mortem appearances of the
first stage of parenchymatous hepatitis are necessarily limited, for
death seldom occurs at this early period of the disease. Still occa-
sional instances of death from some other cause, the first stage of
hepatitis being present (Case 6), and the inspection of the parts of
the liver immediately surrounding exudations of lymph enable us
to ascertain the general appearance of vascular turgescence of the
liver. The structure is redder and softer than natural, and blood
oozes from it when cut. Eokitansky adds, that it is largely
granular.

328 iiErATiTis.

The large dark-red liver, easily lacerable into a bloody pulp, de-
scribed by the older writers on tropical disease, and by them re-
garded as evidence of inflammation, is not the state just described.
These were not appearances resulting from inflammation, but were
conditions of the organ found in fatal cases of congestive malarious
fever in full-blooded Europeans, and caused by accumulation of
deteriorated blood in the capacious hepatic venous systems.

Under the continuance of inflammation, however, the morbid
process will not long remain in the state of mere vascular turgescence.
Interstitial exudation of coagulable lymph of varjring extent will
soon follow. Still, so long as the lymph maintains the liquid form
in which it is first exuded, there is hope of complete recovery by
re-absorption and resolution. When, however, the lymph has
coagulated in the interstices of the parenchyma, then one of the
three following courses will result: —

1. The liquid parts of the exudation may be absorbed, and the
solid lymph become organised into fibrous tissue. This termination
presupposes a good diathesis, exudation of limited extent, and the
return of the surrounding parenchyma to its normal state of capil-
lary circulation. We have evidence, I believe, of this occurrence
in the fibrous nodules or patches that are sometimes found in the
liver after death. (Cases 83, 84.)

2. The exuded lymph, instead of becoming organised, may re-
liquefy, be absorbed, and disappear. This termination is likely to
occur only in a good diathesis, when the exudation has been of
limited extent, is recent, surrounded by tolerably normal structure,
has not been circumscribed by an organised layer, and has not been
so copious as materially to interfere with the vitality of the tissues
amid which it is placed.

3. The lymph changes into pus, the tissues amongst which it has
been deposited become softened, liquefy and disappear, and the
whole is more or less circumscribed by membrane of low organisation.
Hepatic abscess has formed. This termination is favorued by the
extent of the structure involved, the severity of the inflammatory
action, the copiousness of the exudation, and above all, by the
diathesis of the individual affected, and sometimes by the nature of
the cause.

This progress from vascular turgescence to the formation of
abscess may sometimes be distinctly traced, as I have been
enabled to verify in several instances. The following are the
appearances which have come under my notice : —

{a) A part of the substance of the liver is redder and softer.

PATHOLOGY — FORMATION OF ABSCESS. 329

than the surrounding structure. (6) Another portion exhibits
a similar appearance, but with the addition of a circumscribed
part of fawn yellow colour of moderate texture, caused by lymph
deposited in the centre of the inflamed tissues, (c) In another
part, a similar fawn-coloured circumscribed portion, but softer and
friable in the centre, indicating that the lymph has begun to
change into pus. {d) In a more advanced stage, the centre of
the deposit becomes broken down, and converted into pus; the
parts immediately adjacent to the pus being shreddy and flocculent,
those beyond fawn-coloured and firm, bounded by reddened paren-
chyma gradually passing into healthy structure, (e) In a still
more advanced stage, the outer layer of lymph becomes organised,
in varying degrees, into a membranous investment, and the central
parts — lymph and tissue — change more or less completely into pus,
varying in character according to the diathesis of the individual.
But even in this stage the inner surface of the investing membrane
is not unfrequently roughened and flocculent from portions of the
vascular or other tissues, which, remaining in a condition more or
less organised, form nuclei round which flakes of shreddy lymph
become attached.

But the history of the formation of the abscess is not yet com-
pleted. More lymph exudes from the inner surface of the investing
membrane, and changes into pus. The sac becomes distended, the
bulk of the liver increased, and tumefaction takes place in different
directions, according to the situation of the abscess. Adhesion of
opposing serous surfaces follows; then the circumscribing wall be-
comes thin on one side by interstitial absorption, and pointing a,nd
rupture succeed. Sometimes the tendency to point and to rupture
is counteracted by the sac becoming thickened and strengthened in
the following manner. The surrounding parenchyma becomes
compressed by the increasing sac, and, in consequence, the lobular
structure, for two or three lines around, is atrophied and disappears,
but the connecting tissue remains. (Case 99.)

The completion of these processes, that is, the formation of an
outer organised membrane, the change of the central lymph and
tissues into pus, the adhesions, interstitial absorption, and rupture
-^must depend on the constitution of the individual, the size and
number of the abscesses, and the judgment displayed in the medical
treatment. In the greater number of hepatic abscesses death takes
place while these processes are yet in progress.

In this description of the formation of hepatic abscess, sketched
from actual observation, we find nothing different from what occurs

330 HEPATITIS.

in the course of an ordinary phlegmonous abscess in a good con-
stitution: the parts of the lymph most remote from the living
tissues — the central — change into pus ; those adjacent to the living
tissues — the peripheral — become organised into membrane.

Without pretending to assert that this is the only way in which
abscesses of the liver are formed, I am very certain that it is the
most common. It readily explains why these abscesses are gene-
rally not single, and why, when several, they are often in various
stages of progress. Though it is no doubt true that large abscesses
are sometimes formed by the coalition of several adjoining small
ones, still I do not concur with Eokitansky in considering that this
is the only mode ; for I think there can be no question that a large
hepatic abscess has sometimes its origin in a single extensive lymph
exudation.

In these remarks reference has not been made to diffuse sup-
puration of the liver. In truth I have no knowledge of it. The
absence of circumscribing tissue may be observed in that stage
when, as yet the lymph has not all broken down ; but when the
change into pus has been nearly completed, there is, according to
my observation, always a limitary tissue of some kind.

The cases which follow (94 to 102) will be found to illustrate,
in some degree, the remarks which have now been made; also 125,
137, 140, 141, 172.

94. Abscess in the brain not suspected during life. — Abscess in the liver, with pneu-
monia of the lowest lobe of the right lung, revealed by symptoms. — Vascular turgescence
of liver. — Thomas Saunders, boiler-maker, aged thirty-six, of stout habit, was admitted
into the European Greneral Hospital on the 9th August, 1838. He had arrived lately
in India, and had suffered whilst in England from pain of his right side. He had been
ill for fiv^e days before admission with pain of head, side, and limbs. These symptoms
had lessened, but the pain of the right side had increased much the night before
admission ; it was at the margin of the ribs, was accompanied with cough and im-
peded full inspiration. After free leeching, the warm bath and purgatives, the side
became easy ; but the pain continued to recur from time to time, attended with head-
ache and frequent pulse, and hot skin towards evening. He was dull of hearing on
admission ; his manner was slow and undecided, and his hands tremulous ; his spirits
were depressed, and the pulse easily excited. The bowels were kept free by mercurial
and other medicines ; leeches and blisters were applied, and quinine was at different
times given. On the 1st September it was thus reported : Is still nervous, but makes
no complaint of pain ; the pulse is easily excited ; there is abnormal fulness of the right
hypochondrium. About two inches below the right nipple, laterally and posteriorly
below the inferior angle of the scapula, there is dulness on percussion ; the respiratory
murmur is obscure, with occasional sibilus and crepitation ; the latter, smaller behind
and rather subcrepitous laterally. On the left side of the chest there is occasionally
sibilus, and mucous rhonchus ; there is no cough. Subsequently the cough became
troublesome, and the pulse frequent, and on the 16th he became drowsy for the first
time, then insensible, and died at 7 p.m.

Inspection twelve hours after death. — Head. — In the anterior and middle lobe of the

PATHOLOGY — FORMATION OF ABSCESS. 331

right hemisphere there was an abscess of considerable size, the inner surface having
in parts a red fungous appearance ; and the surrounding substance of the brain was
softened. Abdomen. — The substance of the liver was red and softened, and adhered
to the ribs and the diaphragm ; on separating the latter adhesion a small abscess was
discovered, and opposed to it the lung adhered to the diaphragm. The lowest lobe of
the right lung was hepatised, and the left lung was congested with blood.

95. Hepatitis. — Several abscesses in the right lobe. — Nodules in the left lobe. —
The mucous coat of the colon ulcerated. — Serous effusion in the head without
symptoms. — John Eobinson, aged twenty-six, a seaman, tall and fair, was admitted
with symptoms of acute hepatitis on the 7th February, 1840. He stated that
he had been ill since the day before admission. He was freely bled at the arm,
and very freely leeched, mercury was used internally and externally without inducing
ptyalism. On the 12th there began to be evening febrile accessions, which continued.
On the 15th there was fulness at the margin of the right ribs with hepatic sound an
inch below them and to two inches fi'om the nipple. The fulness of the side increased,
he became sallow and emaciated. The dejections were generally light yellow and
thin. The breathing became oppressive, and he died on the 22nd.

Inspection. — Head. — There was a thin veil of serum on the convex surface of the
brain, and an ounce at the base of the skull. Chest. — The lungs were emphysematous,
and the liver encroached on the chest to the level of the fourth rib. Abdomen. — There
were no adhesions between the conca\dty of the diaphragm and the surface of the liver.
In the right lobe of the liver there were several abscesses, each the size of an orange.
There was one to the right of the mesial line and superficial ; two were at the concave
surface of the lobe, and their walls were in close adhesion with the hepatic flexure of
the colon. The inner surface of the walls of the abscesses was very flocculent when
floated in water. The left lobe filled the left hypochondrium, was of pale colour, and
presented whiter defined proportions the size of a pea, like tubercles in appearance, but
not so hard in texture. The colon was studded with closely set circular ulcers, some
of them sloughy ; where the adhesions to the liver were, there the ulcerations had
advanced farthest. At the end of the ileum there was granular yellow lymph effused.

96. Dysentery^ complicated with delirium tremens. — MilJciness of the arachnoid. —
Matting of the omentum over the colon. — Numerous sloughy ulcerations of the mucous coat
of the caecum. — Many abscesses in liver. — Cornelius Moriarty, aged forty-six, a serjeant
in the Grand Arsenal, of dissipated habits, and in hospital at different times with
delirium tremens. He was admitted on the 7th November, 1840, with symptoms of
hepatitis, complicated with delirium tremens. He died comatose on the 11th.

Inspection Jive hours after death. — The liver enlarged and mottled yellow, was
brittle and hard in texture, and seven or eight small abscesses were detected ; the
largest was the size of a walnut, the others the size of horse-beans. The smaller ones
were occupied with thick adhesive pus, the large one had the appearance of paren-
chyma infiltrated with purulent matter, but not yet broken down, and the sur-
rounding texture was mottled red and friable. The description of the other morbid
appearances is omitted.

97. Elustrates formation of abscess from breaking down of lymph deposit. — Pus
tinged with bile. — The corpuscles granular and broken down. — Surrounding turges-
cence. — The liver of a dysenteric patient with abscess was sent to me from the
European General Hospital. In the right side of the right lobe there was a part, the
size of a large orange, the centre pulpy and broken down ; around it, for quarter of an
inch, there was a thick layer of buff-coloured structure ; around that, for some dis-
tance, an engorged part. In one other place there was a yellow-buff portion the size
of a bean, without central pulpy state. The rest of the organ was healthy. Hepatic
cells were distinct under the microscope. In the central pulpy part the puriform fluid
was tinged yellow (bile) ; examined under the microscope, the biliary tinge was very

332 HEPATITIS.

marked, and the corpuscles in greater measure had separated into their constituent
granules.

98. — Ilcfatitis. — Abscesses : in one, hrcaJcing down of the parenchyma ; in the other,
the deposit in the interstitial tissue had not yet broken down into pus. — Mucous coat of
the colon dark red, and covered with firm granular exudation. — Richard Cox, aged
forty-six, a seaman of the ship Tweed, was admitted on February 4th, 1841. He
stated that he had ailed for a week with dry cough, increased during the ' two days
previous to admission, and attended with pain at the lower part of the chest
extending to the epigastrium, and attended with pain on pressure. Pulse freq\ient ;
skin dry. He was bled once and leeched frequently ; took calomel in ten-grain doses.
The pain never ceased, though it was relieved. The mouth did not become affected.
There was not much purging, but the skin became washy, pulse feeble, countenance
collapsed; and he died on the morning of the 12th.

Inspection six hours after death. — Chest. — There were old adhesions of the pulmo-
nary to the costal pleura on both sides. Abdomen. — On the lateral part of the riglit
lobe of the liver there was a superficial abscess, containing dark reddish serous fluid ;
the inner surface of the sac was yellow and flocculent. About the middle of tlie
anterior part of the right lobe there was a somewhat prominent part, which, when
incised, showed a yellow substance the size of a walnut, softened in the centre, firmer
beyond. The parenchyma of the liver was generally mottled buff. The mucous coat
of the colon presented a dark red surface throughout the greater part, covered with a
yellow granular firm exudation with frequent traces of ulceration. There was com-
mencement of yellow deposit in one of the kidneys.

99. Hepatitis. — An abscess lined by firm membrane in the right lobe. — Several
nodtdes in different places of the liver ; in some suppuration commencing at the centre.
— Traces of ulceration in the colon. — Granular exudation on the nmcous coat of the
rectum. — John Richard Pauper, aged twenty-six, an Indo-Briton, was admitted on
the 29th January, 1841. He stated that for three weeks he had suffered from pain of
the right hypocliondrium, increased much during the two days previous to admission.
The pain prevented full inspiration and decubitus on the right side. The pulse was
badly developed and frequent. He was leeched and blistered, and an attempt was
made to affect the system by the moderate exhibition of calomel and opium and
mercurial inu.nction. The pain was much relieved ; never, however, completely
removed. No fulness at the margin of the ribs occurred. The gums became swollen, but
he was never fully under the influence of mercury. On the 1st February dysenteric
symptoms appeared for the first time, following a seven-grain dose of calomel, and
attended with a good deal of tenesmus till about the 5th. After this, the bowels were
moved generally seven or eight times in the twenty-four hours, the dejections being
brown and watery. He lost flesh. From the 8 th the treatment was chiefly palliative,
anodynes with quinine and light nourishment. He died on the 17th. Rigors are not
noted as having occurred in any of the reports.

Inspection eighteen hours after death. — Body emaciated. Head. — There was a thin
veil of serum on the convex surface of the brain. Chest. — The right lung was emphy-
sematotis, and adhered by tender bands to the diaphragm. The left lung was closely
united to the costal pleura. There were no tubercles in the lungs. The heart was
healthy. Abdomen. — The liver did not extend beyond the ribs. The surface was of
buff colour, exteimally and internally. The lateral part of the right lobe adhered to
the concavity of the ribs ; and underneath the adhesions there was an abscess the size
of an ostrich egg, containing about twenty ounces of thick pus, and lined by a firm
cartilaginous membrane : beyond it, for three or four lines, the substance of the liver
was cartilaginous and condensed. From the inner surface of the sac loose flocculi
depended. Elsewhere, here and there, in both lobes, there were round buff-yellow
defined portions from the size of a tare to a horse-bean, some consistent throughout,
others with a drop of pus in the centre. The mucous coat of the colon was pale, with

PATHOLOGY — FORMATION OF A1?SCESS. 333

traces of ulcel^ in process of cicatrisation. In the rectum there was granular lymph.
The mucous coat of the pyloric end of the stomach was mammillated ; at the cardiac
end there were dark brown vascular ramifications, but the texture of the coat was
sound. The kidneys were healthy.

100. Hepatitis. — Two large abscesses from degeneration of lymph and tissue. — The
liver mottled buff. — The miLCous coat of the colon dark grey with red patches, and
several ulcers. — The kidneys malforincd. — James M'Martin, aged thirty-eight, of the
ship Ingleboroibgh, was admitted into hospital on the 2nd February, 1841. He stated
that for a fortnight previously he had suffered from dysentery, and had passed blood
for several days. There was much tenderness across the abdomen. Pulse 100, irri-
table. He was bled to sixteen ounces, and freely leeched. The blood was cupped and
sizy. During his stay in hospital, the pain was chiefly about the margin of the right
ribs, shooting downwards to the iliac region, or backwards, or towards the epigas-
trium. Latterly there was distinct fulness and tenseness at the margin of the ribs.
On the 4th there was a distinct febrile paroxysm with rigors. The dysenteric symp-
toms were little urgent till the 12th, when a considerable quantity of brick-red puri-
form matter was dejected, and continued till his death, on the 14th. At first the ease
was treated as one of dysentery, and ipecacuanha pills were given ; but they were
rejected, and in consequence omitted. Subsequently an attempt was made to induce
mercurial action, but irritation resulted, and it was not persisted in. Latterly wine
with quinine and opium were given.

Inspection twenty hours after death. — Chest. — The lungs were emphysematous, but
otherwise healthy; no costal or diaphragmatic adhesions. Abdomen. — There were
two large abscesses in the liver : one, to the right of the gall-bladder, had thin ante-
rior and lateral walls opposed to the abdominal parietes and the concavity of the false
ribs, and its lower wall adhered firmly to the hepatic flexure of the colon ; but there
was no communication with the gut. The other abscess, the size of a large orange,
was in the centre of the right lobe. There were no adhesions to the diaphragm. The
contents of both abscesses were dark brown, and quite serous. The inner surface of
the sacs was flocculent. The rest of the liver had a bright buff mottled appearance.
The walls of the colon were not thickened. The mucous coat was dark grey with
dark red patches and numerous extensive superficial ulcers. There was a malformation
of the kidneys. The two kidneys were connected, and in a horse-shoe form, the con-
vexity downwards, extended across the abdomen, before the vessels and behind the
mesentery, — the whole length about ten inches, — the transverse part about one inch
and a half broad. Throughout the whole extent the cortical and tubular parts might
be traced, but the texture was soft and yellow, and probably altered by disease.
There were two ureters following their usual course.

101. Abscess in the liver. — Sac smooth without floccuU. — Large intestine, with
sloughy ulceration of the mucous coat. — Complicated with intermittent fever, which at
the commencement was the prominent feature. — Several lymph nodules. — David Hop-
kirk, Indian Na^T", aged twenty-six, was admitted on the 15th December, 1840, under
the head of intermittent fever, and died on the 9th February. He had been ill for
thi-ee weeks before admission with regular febrile paroxysms. There was also pain,
increased on pressure, at the upper part of the abdomen. The chief symptoms during
his residence in hospital were the frequent recurrence of this abdominal pain with
occasional febrile paroxysms, with rigors at first — tendency to dysenteric symptoms —
marked during the last ten days by considerable purging and tenesmus, with gradual
loss of flesh. He was never brought fully under the influence of mercury, though
calomel was given freely with this intention. He was bled freely, leeched and blis-
tered. There was clavus hystericus at one time, the result probably of the depletory
measures.

Inspection eight hours after death. — Body emaciated. Kead. — Brain pale, with

334 HEPATITIS.

about four drachms of senim at the base of the skull. Chest. —The lungs were emphy-
sematous, and tlicre were old adhesions of the right lung to the costal pleura. The
heart was healthy. Abdomen. — The omentum spread over the intestines adhered to
the brim of the pelvis and to the ccecum. In many places the intestine, chiefly the
ccecum and sigmoid flexure, was black and friable. The inner surface of the gut
throughout presented a ragged sloughy appearance, with hardly a trace of the mucous
coat. The lateral part of the right lobe of the liver adhered to the parietes, and at
the point of adhesion there was a superficial abscess, the size of an ostrich egg ; the
sac lined with a firm, smooth membrane. In the parenchyma, and around the abscess,
there were several yellow points, the size of a pin's head ; and in the centre of the
right lobe there was one the size of a horse-bean. The liver was red and firmer than
natiiral. The mesenteric glands were generally enlarged, many of them being larger
than an almond. In the kidneys yellow degeneration had advanced considerably ; in
one it was uniform, in the other it was striated.

102. Large hematic abscess, with shreddy fiocculent walls and surrounding vascular
turgescence. — No intestinal ulceration. — Shaik Abdoo, forty-three years of age, a Mus-
sulman, servant in a grog-shop, using spirits freely, of somewhat emaciated frame,
after ten or twelve days' illness, with pain of right side, cough, and daily double
febrile accessions, was admitted into the clinical ward on the 29th November, 1848.
There was dry cough, hiccup, tenderness below the right ribs, a yellow coated tongue
with florid edges, high-coloured urine, relaxed bowels, and febrile disturbance. There
was a sense of indm'ation with didness in the epigastric region, and below the margin
of the right ribs to within about an inch of the umbilicus. These symptoms con-
tinued with aggravation of the diarrhoea, and he died on the 8th December. He was
treated with leeches over the tender part, followed by a blister, and calomel three
grains, ipecacuanha one grain, opium half a grain every fourth hour. Slight fulness
and tenderness of the gums on the 4th.

Inspection eleveti hours and a half after death. — Chest. — Both lungs collapsed, and
were crepitating. Right lung. — There were old adhesions between tlie upper lobe and
the costal pleura. The base of the lung adhered to the upper surface of the diaphragm,
by recently efiused lymph, and the lateral surface of the third lobe to the opposite
costal pleura. A portion of this lobe was cedematous. No adhesions of the left lung. The
heart and pericardium were healthy. Abdomen. — The liver was so much enlarged as
to reach on the right and left sides to the level of the tenth and eleventh ribs, and to
a point about two inches above the umbilicus. There were tender adhesions between
the right lobe and the diaphragm, also between the gall-bladder and the adjacent
border of the right lobe of the liver and the colon, as well as between the lower sur-
face of the liver and the duodenum. An abscess occupied the lower and posterior part
of the right lobe, and was very superficial at the lateral part, so that the walls, which
had contracted adhesions with the opposite parietal peritoneum, gave way and
remained adherent to the latter, and seemed to consist only of the visceral peritoneum
thickened. The abscess was large, about the size of a cocoa-nut, and contained pus
with abundant shreddy-looking flocculi. The portion of the substance of the liver
surrounding the abscess was red, and the rest was mottled white and red, and was
very firm under the knife. The ascending colon passed obliquely upwards and inwards
to the notch in the anterior border of the liver and to the gall-bladder, and thence
the transverse part stretched downwards towards the left iliac fossa, close to the
anterior superior spinous process of the os ileum, and thence it passed upwards, then
downwards, as the descending colon. No disease of the large intestine, except that
its mucous membrane was thinner than natural, and softer in parts : it was not ulce-
rated. The stomach was quite concealed by the liver, and pushed more towards the
left side than natural ; it was also very contracted, so much so that it appeared no
larger than the intestine. Kidneys healthy in structure. Cranium not opened.

PATHOLOGY — ABSCESS OPENINU INTO LUNG. 335

Courses followed by Hepatic Abscess. — Having traced the
manner in which abscess in the liver is formed, I shall
now describe the different directions in which it may point and
rupture.

1. Hepatic abscess may open into the lung or sac of the pleura.

2. Into the stomach, or some part of the intestinal canal,

3. Into the pericardium.

4. Into the biliary ducts.

5. Into the cavity of the peritoneum.

6. Externally on the surface.

I shall here notice the first five directions, and leave the sixth to
be <Jonsidered in connection with the question of puncturing hepatic
abscess as a part of treatment.

1. Into the Lung or Sac of the Pleura. — As the right lobe of
the liver is the most common seat, and as abscess is frequently
formed not far distant from the convex surface of the organ, a ten-
dency to point towards the diaphragm, and open through it, is not
an uncommon occurrence. This, according to my observation, is
the direction in which hepatic abscess most frequently opens ; more
so, even, than on the external surface, unless puncture is had re-
course to. Taking 140 cases of hepatic abscess, the notes of which
are before me, and which constitute only a part of my experience
in this form of disease, I find that 14 or ten per cent, opened into
the lung, or sac of the pleura. Dr. Stovell reports that of the
cases of hepatitis in the European General Hospital during ten
years, abscess opened into the lungs or pleura in 3*837 per cent.*
When the abscess has been small, single,' not deep, and the consti-
tution tolerably preserved, then there is a fair chance of recovery
after communication with the lung. On the other hand, when
the abscess is large or not single, and the constitution is either
originally bad, or much reduced by disease or injudicious treat-
ment, then a fatal issue, with exhausting hectic fever, is the
usual termination.

The most satisfactory results of hepatic abscess communicating
with the lung are those reported by Dr. Stovell f, viz., sixteen cases,
with nine recoveries. The symptoms presented by the successful
cases justify the inference, that the abscess in each had been small

* The reader will not fail to notice that Dr. Stovell's data diifer from mine. He
gives the ratio to the total admissions of hepatitis. I give the ratio of a certain
number of cases of hepatic abscess.

t " Transactions, Medical and Physical Society," No. Ij Second Series ; and again
No. 3, Second Series, p. 43.

336 HEPATITIS.

and single. My own notes do not supply an equal success ; for, of
the four following cases, the history of three, in which recovery
promised, is incomplete.

103. Abscess in the liver discharged by the lung, followed by convalescence. — Proceeded
to England, and died shortly after arrival. — No account of the post mortem appear-
ances.— Eobert , aged fifty-one, lieutenant, of the pension list, thirty-two years'

service in India, resident in Bombay, a free liver, and the subject of occasional hepatic
ailments, was admitted into the General Hospital on the 23rd Jujie, 1842. He com-
plained of occasional uneasiness of the right side, want of appetite, and in-egular
bowels. On the night of the 4th July he was seized with a fit of coughing, and
ejected about six ounces of frothy puriform -looking fiuid. He continued till the 17th
August expectorating puriform matter, at times of brick-red colour, and occasionally
to the extent of several ounces in the course of the day. After the 17th the puriform
expectoration ceased, but occasional scanty mucous sputa were ejected. He improved
in general health, left the hospital on the 6th September, and proceeded to England
by sea ; but died shortly after his arrival in that country on the 8th February, 1843 ;
under what circumstances is not known.

104. Hepatic abscess attributed to blows. — Opening into the lung. — Improvement. —
Becord as to the issue incomplete. — Syud Merim, a Mussulman labourer of forty years
of age, about two months before his admission into the clinical ward, on the 28tli
June, 1850, received several blows on the right side of the chest, in a quarrel. He
experienced no inconvenience till a month afterwards, when acute pain came on sud-
denly in the right hypochondrium, with difficulty of breathing. On admission, he
was a good deal reduced ; the respiration was short and hurried. The ensiform car-
tilage, the margins of the ribs, and a line drawn from the left tenth rib across the
abdomen above the umbilicus, formed the boundaries of a full, resistant, and dull
space. The dulness extended upwards to the fourth right rib, and there was bulging
below the fifth rib. The decubitus was dorsal, the pulse feeble, the bowels regular,
and he suffered from evening febrile accessions. On the 23rd June he expectorated
eight ounces of pink-coloured sero-puriform fluid, with some relief to the dyspncea.
There was now more or less expectoration daily, with less febrile disturbance. On
the 2nd July the bulging of the right false ribs had nearly disappeared. He con-
tinued to improve slowly, but, becoming discontented, he left the hospital on the 8th
July ; after which date there is no record of his case. He was treated with anodynes
and tonics.

105. Hepatic abscess opening through the lung. — Result of the case not recorded. — •
Luxuman Kagoo, a Hindoo blacksmith, of thirty-five years of age, using about three
ounces of spirits daily, was admitted into the clinical ward on the 22nd February,
1853. There was some degree of falness of the lower part of the right side of chest,
with sense of induration and dulness for three inches below the right false ribs. The
dulness reached upwards to the fifth rib. There was pain, on pressure, below the
right false ribs, and in the epigastrium. Decubitus easy on all sides. Had occasional
short dry cough. Suffered two months before from occasional febrile accessions. These
ceased ; but about ten days before admission, while engaged in his ordinary a^oca-
tions, he suddenly felt uneasiness of the right hypochondrium. For six days the
bowels had been relaxed. On the 26th he began to expectorate pinkish muco-puriform
sputa. This continued sometimes copiously, and on the 1st March all fulness below
the margin of the right ribs had ceased, and dulness did not reach above half an inch
below them. Subsequently the cough was still troublesome, but the sputa chiefly
consisted of frothy mucus. Throughout this time there was little constitutional dis-
turbance, and the diarrhoea had ceased. The diary of the case closes abruptly on the
6th of March, through carelessness of the clinical clerk, without record of the issue.

rATiroLoaY — aescess opening into lung. 337

106. Hepatic abscess communicating with the lung. (?) — Besult not known. — Isaac
Ibrahim, a Mussulman cart-driver, of forty years of age, was admitted into the clinical
ward on the 5th November, 1852. He was emaciated. The respiration was short and
hurried, and the right side did not move freely. There was complete dulness of the
right dorsal and lateral regions, with defective resonance of the scapular, interscapular
and mammary, with absence of vocal thrill and respiratory murmur in the two first.
There was no induration or dulness below the right ribs, but pain on pressure there.
On measurement, the right side of chest exceeded the left by half an inch. He was
troubled with cough and expectoration of muco-puriform red-tinged sputa. Bowels
relaxed. He said that he had suffered from intermittent fever five months before,
which ceased in fifteen days, and was followed by pain below the margin of the right
ribs, and of the right shoulder. The cough came on about six weeks before admission,
was mild for the first fifteen days, but then became troublesome, and the sputa tinged
red. The dysenteric symptoms had existed for a month. Admitted that he had used
spirituous liquors pretty freely. He remained in hospital till the 12th November,
when he was removed by his friends. During his stay he experienced evening febrile
accessions.

Remarks. — The physical signs and symptoms were hardly adequate to determine the
diagnosis of hepatic abscess, communicating with the lung ; but, coupled with the
history, they were probably sufficient.

The common expression, hepatic abscess has opened into the
bronchi, is not correct if it be meant to imply that direct com-
munication has taken place between the abscess and a large
bronchial tube. In fatal cases it will be generally found that
adhesions have formed between the diaphragm and the con-
cave base of the right lung on the one side, and the convex surface
of the liver on the other; and that a ragged excavation exists
in the lower part of the lung communicating with the abscess in
the liver. Occasionally an opening into the sac of the pleura is
observed, as well as into the lung ; and sometimes it is only into
the pleura, causing empyema.

Of ten cases before me, the six following are narrated in illustra-
tion of these remarks : —

107. Dysentery. — Secondary hepatic abscess forming obscurely. — Opening into the
lung. — No ulceration of the intestine. — Eustom Khan, a worker in tin, a Mussulman,
of thirty-five years of age, reduced in flesh, not using spirits, was, after twelve days'
illness, admitted into the clinical ward on the 21st December, 1851. He suffered from
dysenteric sjmiptoms, without abdominal fulness or induration, or febrile excitement.
After the 29th there were occasional accessions of fever, commencing with chills and
terminating with sweating. The dysenteric symptoms continued, but in less degree ; and
on the 29th January there was pain of the right shoulder for the first time, and on
the 30th, below the margin of the right ribs, on full inspiration, but without dulness.
There was apparent fulness of the right side of the chest, from the nipple to the margin
of the ribs, but dulness did not reach above the fifth rib. The right side of abdomen
was more resistant than the left, respiration was short and humed, the pain of
shoulder and side continued, and on the 5th February there was dulness and indura-
tion for half an inch below the ribs. On the 8th there was troublesome cough, and
extension of the dulness an inch below the ribs. The febrile accessions had become
less, and the dysenteric symptoms were almost gone. On th^ 18th the right side, at

338 HEPATITIS.

the nipple, measured an inch more than the left. On the 23rd Ave ounces of pinkish
puriform 8puta were expectorated ; this continued more or less with occasional recur-
rence of dysentery till the 19th April, when he died. The urine was frequently tested,
but showed no trace of albumen.

Inspection twenty hours after death. — Abdomen. — The cavity of the abdomen con-
tained a pint of limpid serous fluid. On removing the enlarged liver, with the right
lung which adhered firmly to the diaphragm, a large abscess, the size of an ostrich egg,
containing about a pint and a half of healthy pus, was found in the substance of the
right lobe. The walls lined by thin fibrous membrane were formed inferiorly, and on
the left side, by the parenchyma of the liver ; on the right, superiorly, by the dia-
phragm, but at the right edge of the superior wall, for the space of about two and a
half inches in circumference, the diaphragm was absorbed and destroyed, and the pus
lay in contact with the substance of the inferior lobe of the right lung, which was also
absorbed, forming a slight excavation, having a surface, red, soft, and irregular, but
not lined by adventitious membrane, nor communicating with a large bronchial tube.
The left lobe of the liver was healthy. Both kidneys were pale, but healthy. The
mucous lining of the large intestine presented here and there patches of redness ;
otherwise it, and the other coats were healthy. Peyer's glands, solitary and agminated,
were slightly enlarged, but not ulcerated. The coats of the small intestine were thin
and pale. The other viscera were healthy. Chest. — Both cavities of the chest con-
tained about a pint of clear serous fluid. The left lung was healthy. The two upper
lobes of the right limg were soft and crepitating ; but the inferior lobe which adhered
firmly posteriorly to the pericardium and to the diaphragm, though in its upper half
healthy, was towards its base red, dense, and very oedematous.

108. Large hepatic abscess with bric7c-red pus. — Smaller one opening into lung. —
Brick-red sputa. — iVo diarrhea till just before death. — Intestines not examined. — A
spirit drinker. — Kalloo, a Mussulman sailor, a native of Calcutta, twenty-six years of
age, in bad condition, was admitted, after twenty days' illness attributed to excessive
spirit-drinking, into the clinical ward on 18th April, 1849. The respiration was
thoracic, and chiefly with the left side. There was dulness of the right side of the
chest, from the fourth rib to the margin. The abdomen was generally soft, with ex-
ception of induration without prominence, for two and a half inches below the right ribs,
with pain on pressure, augmented by cough and full inspiration. There was febrile
heat, and frequent small pulse ; but the tongue was moist and nearly clean. He
stated that his illness commenced with fcA^er, ushered in with chills, and that after
seven days there was pain of the right hypochondriac region, with a marked evening
exacerbation of fever, sometimes terminating in sweating. Cough, pain of right side,
and hectic fever persisted, and on the 23rd there was crepitus anteriorly above the
third right rib, and below it dulness and absence of breath sounds. After the 27th
the mucous sputa became tinged of a brick-red colour, and were sometimes copious.
The urine, generally free, ranged from 1004 to 1016 in density, and showed no trace
of albumen. There was no diarrhoea till three days before death, on the 7th May.
He was treated with anodynes, quinine, and mineral acids, and a small blister was
applied above the right nipple when the crepitus was detected, sponging the side with
nitro-muriatic lotion having been previously used.

Inspection seven hours after death.— Abdomen. — A large abscess containing upwards
of two pints of reddish-coloured thick pus, occupied the outer side of the right lobe
of the liver. It projected from the concave surface towards the colon. The liver
adhered firmly to the lateral abdominal parietes and to the diaphragm, and these parts
formed the external lateral wall of the abscess. Another small abscess the size of a
hen's egg, occupied the upper convex surface of the right lobe, separated from the upper
wall of the large abscess by a layer of compressed parenchyma, about an inch in
thickness. This small abscess opened through the diaphragm, by a free orifice with

PATHOLOGY — ABSCESS OPENING INTO LUNG. 339

rounded edges, into a sac, the size of an orange, in the base of the third lobe of the right
lung. At the anterior and lateral part of this sac, about the level of the fifth and
sixth ribs, there was a gangrenous opening into the cavity of the pleura, which was
filled with grey serous, fetid pus ; and the pleura, in contact with the effusion, had a
greyish gangrenous look, and was covered with flakes of friable lymph. The upper
and middle lobes of the right lung were compressed against the mediastinum by the
pleuritic effusion. Both kidneys, when divested of their capsules, presented a red
and yellow mottled appearance.

109. Hepatic abscess opening through the lung. — Causing pleuritis and effusion. —

Also presenting externally, hut not opened. — Goohee , a Mussulman sailor of stout

frame, a native of Calcutta, thirty-eight years of age, and for twenty years engaged
in voyages to all parts of the world, and habitually using spirits freely, was after a
month's illness admitted into the clinical ward on the 6th August, 1850. The res-
piration was short and hurried, and the lower part of the right side of chest moved
imperfectly. Occasional crepitus was audible in the lower part of right mammary-
region, but there was no abnormal dulness. The abdomen was full, resistant below
the margin of the right ribs, with dulness, but no distinct induration, for three inches
below the ribs. He had dull pain of the right hypochondrium, increased by full inspira-
tion and pressure below the ribs, occasional coxigh, with frothy mucous sputa. The
bowels were rather slow. Morning and evening chills but no febrile heat were com-
plained of, and the tongue was moist and almost clean. While at sea he had been attacked
with fever, followed in three days with acute pain of right side, and attributed to wet.
The fever, he said, left him, but the pain persisted. After admission, evening febrile
accessions, with night sweats, were noticed, and the bowels began to be relaxed. On the
29th August there was indistinct fluctuation between the seventh and eighth right ribs,
an inch and a half external to a vertical line dropped from the nipple. The fluctuating
point became more distinct and prominent, and there was general bulging of the lower
right chest. The cough had persisted with mucous sputa, but on the 26th September the
sputa became more copious, pinkish, and muco-puriform ; on the 27th eighteen ounces
were expectorated. The fulness, tenseness, and fluctuation disappeared, and the hectic
fever lessened. From this to 10th October there was relation between the quantity of
the sputa and the uneasiness and tenseness of the side, and the absence or presence
of fluctuation. On the 10th October severe pain of the right side of chest was com-
plained of, and on the 14th that side ceased to move in respiration. The diarrhoea,
more or less present during his residence in hospital, increased. Exhaustion and
dyspnoea became aggrai^ated, and he died on 20th October.

The treatment previous to the 29th August consisted in the application of small
blisters to the right side, the \ise of quinine, combined with ipecacuanha and opium,
and occasionally blue pill. Afterwards anodynes, tonics, and stimulants, with suitable
nourishment, were the means used.

Inspection twelve hours after death. — Chest. — On removing the sternum, a fluctuating
sac was seen to the right of the mediastinum formed of partially organised lymph. It
was somewhat pyriform in shape, in contact, anteriorly, with the ribs and their carti-
lages, posteriorly, with the anterior siirface of the third lobe of the right lung, and
rested, inferiorly, upon the diaphragm which was here normal in structure. On laying
open the sac a large quantity of limpid serous fluid was found mixed with flakes of
fibrine ; and it was further divided into two or three sacculi by bands of friable
lymph. When traced upwards, this sac was found to be separated by a layer of
lymph from another large one from which, on being opened, a few bubbles of gas
escaped. This second sac contained a large collection of fluid (about a pint) sero-
purulent in character ; it involved almost the whole of the right pleura, compressed
the two upper lobes of the lung against the mediastinum, and. passed behind the third
lobe, as far as the diaphragm, — being, however, separated from the lateral, anterior,

z 2

340 HEPATITIS.

and inferior surfaces of this lobe by the Arm connections which these parts of the lobe
had formed with the costal pleura and diaphragm. On cutting into the third lobe,
a ragged and irregular cavity was seen, which, laterally, approached very nearly to
the surface, and was torn open on the lung being separated from its adhesions to
the costal pleura, and here it had probably communicated with the sac of the
pleura, and led to empyema. Inferiorly, this ca\'ity communicated through the
diaphragm with a circumscribed excavation, about the size of a large orange, situated
in the upper and lateral part of the right lobe of the liver, lined by a membrane with
irregular surface, and extending from the sixth to the tenth rib. The abscess in the
liver communicated externally, at the most prominent part of the swelling noticed in
the side during the lifetime of the patient, through the intercostal space between the
seventh and eighth ribs. The intercostal muscles were in this situation in a gangren-
ous state, and the contents of the abscess were infiltrated into the surrounding areola
tissue for the distance of an inch around. The abscess contained a few ounces of sero-
sanguineous pus, similar in character to the matter expectorated. In other respects,
the liver was normal, both in size and structure ; it projected about two inches below
the right false ribs. The left lung was healthy and free from adhesions. The intes-
tines were discoloured externally, but were not examined internally. The kidneys
were healthy. The heart was not examined.

110. Hepatitis, ending in abscess discharged through the lung. — An abscess in the
third lobe of the right lung, communicating freely through the diaphragm with the
abscess in the liver. — Mucous coat of the large intestine ulcerated. — Many of the ulcers
cicatrised, — John Shea, aged twenty-eight, was admitted into hospital on the 22nd
November, 1840, in a moribund state, and died eight hours after admission. He had
been sent from the sloop Clive, off Aden, and had been first taken ill with hepatitis
on the 6th August ; had improved, but the disease recujred severely on the 23rd of
the same month. There had been severe pain increased by decubitus on the left side,
and pressure upwards. On the 6th October, he was suddenly seized with expectora-
tion of pus, which continued with diarrhoea till the period of his death.

Inspection twelve hours after death. — Head. — Nothing worthy of note. Chest. —
Neither lung collapsed. The posterior part of the left one was very cedematous, the
anterior emphysematous with a few tu.bercles disseminated. The right lung adhered to
the costal pleura, and to the diaphragm by tender lymph ; there were a few tubercles in
the upper lobe. The rest of the lung was very edematous, but chiefly the third lobe,
which was also in parts hepatised. At the anterior part of the base of the third lobe,
there was a cavity the size of an orange, with a ragged and flocculent inner surface,
which communicated through the diaphragm with an abscess in the upper part of the
right lobe of the liver, about the size of a small orange, superficial, and Kned with a firm
membrane with irregular flocculent surface. The rest of the liver was healthy, and not
mottled. On the surface of the heart there were many white pearly spots ; but the
organ was sound. Abdomen. — There were a few ounces of serum in the cavity. The
stomach, much distended, occupied the whole space between the umbilicus and ribs ;
its mucous coat was pale and sound in texture. The colon, covered by the stomach,
was contracted, and had formed no unnatural adhesions. The mucous coat was red-
dened in parts, and there were a few small circular ulcers, with the cicatrices of many
others, chiefly distinguished by their dark grey colour, their depression below the rest
of the surface, and closer connection to the subjacent tunics. The edges of some of
the ulcers were puckered, but those of the greater number were rounded, and not
thickened. The kidneys and spleen were healthy.

111. Two Hepatic abscesses. — One opening into the lung, with expectoration of deep
hile-tingcd puriform sputa. — An Indo-Porttiguese, of twenty-six years of age, was ad-
mitted into the Jamsetjee Jejeebhoy Hospital, on the 8th January, 1848, ill with
symptoms of hepatitis for six weeks. He stated, that three days before admission,

PATIIOLOGr — ABSCESS OPENING INTO LUNG. 341

he began to expectorate sputa of bloody appearance and intensely bitter taste. After
admission, the sputa consisted of ordinary pus ; but on the 9th they became of deep
yellow colour, thick and glairy, easily expectorated, and in great quantity, and the
swelling of the right side, much less than on admission, extended downwards to a line
drawn transversely from the umbilicus. The abdomen was swollen, and pain was
felt to the right of the epigastrium under the cartilages of the false ribs. He said
that it had before extended over great part of the right side of the chest. Dejections
whitish. Died rather suddenly on the night of the 17th.

Inspection. — Abdomen. — Opaque pinkish or chocolate-coloured fluid, ndth flocculi
of lymph, was found in great abundance in the abdomen. The peritoneum of paries
and viscera was of red colour. A large abscess in the left lobe of the liver pressed on the
stomach, having at its upper part the substance of the liver extended over it, but this
gradually thinned away, and at the lower part, the wall was formed of the thickened
peritoneal covering. Another large abscess occupied the lower part of the right lobe
of the liver. Both these abscesses contained pus, very slightly tinted of a greenish
yellow, and that in the abscess of the left lobe was more abundant and thinner ; both
had ragged walls. There were adhesions to the stomach and duodenum. The capsule
of Glisson was thickened. The gall-bladder contained only a little viscid mucus of a
greenish coloxir. At the upper part of the right lobe there was adhesion to the dia-
phragm, and corresponding thereto the right lung was also adherent. On separating
the adhesion of the lung, a cavity was opened which extended into a small abscess in
the liver with thick firm Kning of adventitious membrane. The neighbouring portion
of the liver was much gorged with blood, and the cavity extended upwards into the
lower part of the lung ; its walls there being very ragged and uneven, and the sur-
rounding portion of the lung was hepatised and gorged with blood. The portion of this
common abscess which was in the liver contained only thick whitish pus ; while that
which was in the lung contained pus of deep yellow or greenish yellow, and its ragged
walls were deeply stained of the same colour, and on pressing the abscess before open-
ing it, deep yellow fluid was made to flow upwards through the divided bronchial
tubes.

Bemarks. — Dr. Leith was present with me at the inspection of this case. To him
I am indebted for the note of the appearances observed, and for the information that
he had not long before witnessed a somewhat similar case of bile-tinged sputa in the
hospital of the Bombay police corps.

112. Abscess in the liver opening through the diaphragm into the sac of the pleura
and causing purulent effusion there. — James Oakhum, aged thirty-two, a feeble man
of reduced and emaciated habit, was admitted into the European General Hospital on
the 27th September, 1843. He stated that he had been under treatment for eight
days, suflfering from pain of the right side, first under the clavicle, subsequently at the
margin of the right ribs, and that he had been leeched and blistered. On admission,
the skin was hot and dry, and the tongue florid at the tip. On the 28th he com-
plained of pain at the margin of the right ribs, impeding full inspiration ; and late-
rally and posteriorly there was perfect dulness and inaudible respiratory murmur.
Evening febrile exacerbation, and occasional diarrhoea, but seldom any complaint of
pain of the side were present till the 3rd October, when in addition he began to be
troubled with cough, accompanied on the 4th with expectoration of thin puriforni
fluid. The cough, the puriform sputa, the dulness of the right side, the febrile symp-
tonls, the occasional diarrhoea continued, accompanied with progressive emaciation
and collapse, and latterly short and oppressed breathing, till the morning of the 12th
October, when he died.

Inspection eleven hours after death. — The body was much emaciated. Chest. — On
the right side, from the fourth rib downwards, anteriorly, the lung adhered to the
costal pleura, and to the diaphragm ; but there was no adhesion of the posterior part

z 3

342 HEPATITIS.

of the lung. At tlie posterior part of the right side of the chest, and also the anterior
above the level of the foiirth rib, there were about two pints of faint reddish-coloured
puriform fluid. This effusion communicated through the diaphragm behind the lung,
with an abscess in the upper and posterior part of the riglit lobe of the liver, larger
than an orange. The lung was compressed, but healthy in texture. The left lung
was healthy. The abdominal viscera were not particularly examined, but the intes-
tines were healthy externally.

I have met with cases in which the symptoms of hepatic
abscess had been well marked, and the occurrence of puriform
expectoration suggested that communication had taken place be-
tween the abscess and the lung, and yet examination after death
failed to verify it. Three cases of this nature are before me.
In the two first an opening was carefully looked for, but not found ;
and the condition of the lung was not such as to account for the
character of the sputa. In the third the sufficiency of the examina-
tion is doubtful, and the base of the right lung was hepatised.
From such cases it may be surmised that when interstitial absorp-
tion is in progress in the wall of an abscess, between the liver and
the lung, and the tissues are becoming soft and succulent, the thinner
contents of the sac may perhaps pass through by imbibition before
the occurrence of actual rupture. At all events, this question may
be proposed for future inquiry to solve.

2. Hepatic Abscess opening into the Stomach or Intestine. —
Five cases, 3*57 per cent, of this termination have come under
my notice. Dr. Stovell's ratio to the admissions from hepatitis is
0*451. Of my five cases three recovered. In two the abscess was
supposed to have opened into the colon, in one into the stomach
and colon. In one of the fatal cases the situation and marked de-
crease of the swelling favoured the belief that an abscess had
opened into the stomach; but neither vomiting nor purulent
dejections occurred ; yet, after death, the diagnosis was proved to
be correct, for communication existed between the abscess and
the stomach. In this case the pus must have oozed slowly into
the stomach, and thence passed in small quantity at a time through
the intestinal canal, probably in an altered form. In the other an
opening into the colon was found after death, but the account of
the symptoms during life had been incomplete.

It is a common belief that the discharge of hepatic abscess into
the alimentary canal is not rare ; and that it is always clearly
indicated by the sensations of the patient and by free vomiting or
dejection of pus. My experience, however, does not confirm this
opinion. In two of my cases (113, 115) the pus must have drained
so slowly into the canal as not to affect the appearance of the dis-

PATHOLOGY — ABSCESS OPENING INTO STOMACH. 343

charges, though its presence had been carefully looked for. In
other two (116, 117) pus was present ; and in my remaining case
(114) there was no record of the symptoms. I am satisfied
that there has been much loose observation and inaccurate
record on this subject ; and that too much weight has been
generally accorded to the statement of the patient. At all
events, in two or three instances in which this supposed occur-
rence has been reported to me, the evidence has failed to
convince me.

The following are the five cases to which I have adverted : —

113. Abscess in the left lobe of the liver opening into the stomach. — No vomiting. —
No detection of pus in the intestinal discharges. — No intestinal ulceration. — Ibrahim
Mahomed, a Mussulman water-carrier, of thirty years of age, using spirits, and at one
time opium, habitually, was admitted into the clinical ward on the 30th June, 1853.
He was emaciated, countenance anxious, pulse small. In the epigastric region there
was a painful swelling, the size of a cocoa-nut, prominent, soft, indistinctly fluctuating,
not pointing, but somewhat tense. Decubitus on the back, or either side. Three
months before, a small swelling appeared in the situation of the present large one,
and gradually increased; it was not very painful, and not attended with fever.
He had suffered from fever before the swelling was noticed ; but then there was no
pain in the region of the liver. His bowels had been regular, and there had not been
any vomiting. On the 3rd July the size and prominence of the swelling were less,
the bowels had been four times opened, and the discharges were reported to be dark
coloured. From the 4th to the 15th there was no recurrence of diarrhoea, the evacu-
ations were feculent, and still the swelling lessened. Its prominence was gone on the
12th. On the 16th again diarrhoea, with discharges described as thin, feculent, and
of buff yellow. The swelling was now gone, and dulness did not extend more than
two inches below the ensiform cartilage. There had been no vomiting. From this
time there were occasional dysenteric symptoms, occasional slight febrile accessions,
and a failing pulse ; then, on the . 2nd August, copious intestinal discharges ; and
death on the 4th. Treated with anodynes and tonics. The urine gave no traces of
albumen.

Inspection twelve hours after death. — Chest. — The anterior surface of the lungs was
pale, spongy, and somewhat emphysematous at the edges. No adhesions. Heart. —
The walls of the left ventricle were thickened, and the cavity small. Abdomen. — The
external surface of the liver was of dark red colour. The liver extended to about
two inches below the ensiform cartilage, and about two and a half inches below the
margins of the right false ribs. There were not any adhesions between it and the
diaphragm, but the concave surface of the left lobe adhered firmly to the smaller cux-
vature of the stomach, and to the pancreas. On separating the adhesions to the pan-
creas, an opening about the size of a rupee, with dark grey edges, was apparent in the
liver. The opening conducted into an empty sac, about the size of a large orange,
situated in the inferior surface of the left lobe. This sac was lined by a firm mem-
branous layer, with irregular surface ; it also communicated, by an opening suffi-
ciently large to admit an ordinary blow-pipe, with the stomach close to its pyloric end.
The substance of the liver, for about half an inch beyond the upper wall of the sac,
was of dark grey colour, indurated and condensed. The inferior wall of the sac was
about a quarter of an inch thick, partly fibrous and partly condensed substance of the
liver. The substance of the right lobe of the liver was healthy. Stomach. — Much
distended, and containing about a pint and a half of light-coloured yellow turbid fluid
with white floating flakes, which, examined under the microscope, showed no pus glo-

z 4

344 HEPATITIS.

"biiles. Intestines. — In general pale, except at the end of the ileum and rectum ; in.
both these situations a blush of redness was seen, and the membrane was softer than
natm-al. Kidneys. — Eight one healthy. Left one somewhat lobulated, of pale buif
colour, externally and internally ; cortical substance encroached considerably on the
tubular portion, which in places was very indistinct.

114. An abscess of the liver communicating with the colon. — Others in process of
repair hy absorption. — An old man was admitted into the Jamsetjee Jejeebhoy
Hospital with fulness below the margin of the right ribs, indicating the existence of
hepatic abscess. Before death the fulness had lessened considerably, but how caused
was not understood.

Inspection after death. — Towards the thin edge of the right lobe of the liver there
was an abscess the size of an orange, having the concave surface adherent to the right
kidney for its lower wall. It communicated by an opening the size of a goose-quill
with the hepatic flexure of the colon. The mucous membrane around the opening was
free of disease. The walls of the abscess were almost cartilaginous in density. The
substance of the liver was very firm, and here and there were yellow dense circum-
scribed deposits the size of a horse-bean and upwards in size. They were tubercular-
looking in appearance ; and in one, the size of a walnut, the contents were so"'t and
putty-like. The contents of both were examined under the microscope. The dense
tubercular-like matter consisted of small granules. In the less consistent there were
also granules ; but some of them had, in many places, aggregated into distinct cor-
puscles : it seemed as if the breaking down of the pus corpuscles, and the escape of
their contained granules, had not proceeded to the same extent. These, then, had
been abscesses, and were in process of repair by absorption. There was Bright's dis-
ease of the kidney in this case.*

115. Hepatic abscess, recovered from, by probable opening into the colon. — Mahomed
JalFer, a Mussulman, forty-five years of age, a painter, using spirits occasionally, and
the subject, a year before the date of the present case, of hepatic symptoms, was ad-
mitted into the clinical ward on the 5th December, 1853. He was reduced, the coun-
tenance was anxious, skin hot, pulse frequent, small and sinking. The respiration
was somewhat hurried. Below the margin of the right ribs and the ensiform cartilage,
there was resistance, tenderness, and dulness, bounded below by a line drawn from
the eighth left rib, curving to about half an inch above the umbilicus, and extending
to the eighth rib on the right side. Decubitus easiest on the back and right side.
The tenderness on pressure was considerable ; fever and pain of abdomen had come
on simultaneously twenty days before admission. The fever was remittent, with mid-
day exacerbation and evening remission. On the 13th December there was epigastric
fulness with indistinct fluctuation. Now there was abatement of fever ; but he had
troublesome cough with frothy mucous sputa. On the 24th, while turning in bed,
he experienced a peculiar sensation in the swelling, as if something had given away,
and on examination it was found to be considerably diminished. No diarrhoea, no
trace of pus in the evacuations. There was now gradual slow decrease of the swelling,
with occasional febrile recurrences ; and he was discharged on the 15th February,
1854, with a small induration perceptible an inch and a half above the umbilicus, not
painful, but with dulness, continuous upwards with that of the liver. He was treated
chiefly with quinine and anodynes, then dilute nitric acid, and occasional laxatives,
and warm water application to the epigastrium.

* About the same time, somewhat similar appearances were brought to my notice
in a preparation sent to me from the European General Hospital. In this the mem-
branous sac was distinct, the contents being partly pulpy, partly tough, and presenting
an appearance of layers. It was in the cirrhosed liver of an emaciated sailor, who
died of ascites. In this case there was also granular degeneration of the kidney.

PATnOLOGT — ABSCESS OPENING INTO PERICARDIUM, ETC. 345

116. Hepatic abscess. — Opening into the colon (?) — Becomry. — CamajeeYellojee, aged
forty-eight, a Jew of intemperate habits, was admitted into hospital on the 6th March,
1837. There was tenderness below the margin of the right ribs, which he said had
existed for a month. On the 7th, purging during the night reported ; evacuations not
seen : but a pale-coloured stool passed on the 7th consisted chiefly of pus, as proved
by the microscope. After this there was no further appearance of pus.

117. Hepatic abscess. — Opening into the colon and stomach (?) — Recovery. — Pestonjee
Dadabhoy, aged twenty, an intemperate Parsee buggy driver, was admitted into
hospital on the 18th January, 1857, with symptoms of acute hepatitis. Fulness at
the epigastrium indicated the formation of abscess. On the 27th there was vomiting.
The ejected matters were not kept, but the epigastric fulness became very sensibly
diminished; and on the 28th, about two ounces of unmixed pus were passed by stool.
Afterwards there was no more vomiting, and no further traces of pus in the dejections.
He left the hospital on the 22nd March, improved in flesh, and with no signs of
hepatic enlargement.

3. Hepatic Abscess opening into the Pericardium — is very-
rare. Kokitansky and Grraves each report a case. There is one
recorded by Mr. Fowler.* Mr. Leahy, a very intelligent apothecary
of the Bombay establishment, gave me the notes of a case observed
by him at Peshawm- in the Bombay Fusileer Eegiment ; in it there
were two abscesses, one communicating with the right lung, the
other with the pericardium. I have never witnessed this termina-
tion of hepatic abscess.

4. Hepatic Abscess opening into the Biliary Duct. — It is stated
in systematic works that this is the most favourable course for
hepatic abscess to follow ; but surely this assertion rests on theo-
retic grounds. The only case, with which I am acquainted, proving
that hepatic abscess sometimes communicates with the ducts, and
may be discharged by this channel, is recorded by Dr. Leith in the
following words : — ^' The case of a foot-artilleryman, sent from
Bombay with abscess of the liver, who died in the hospital, is
worthy of notice, although he does not come properly within the
subject of this report. The tumefaction in the side gradually dis-
appeared ; and after his death the abscess was found nearly empty,
and two hepatic ducts communicating with it were foand carrying
pus to the duodenum." t

5. Hepatic Abscess opening into the Cavity of the Peritoneum.
— My cases do afford distinct evidence of rupture of hepatic abscess
into the sac of the peritoneum : in two it was probable, but was
not positively established.

Contents of Abscess removed by Absorption, — The different

* " Transactions of the Medical and Physical Society of Bombay," Second Series,
No. 2, p. 305.
t '* Transactions of the Medical and Physical Society of Bombay," No. 4, p. 57.

346 HEPATITIS.

directions in which hepatic abscess may discharge its contents have
been described, and we have found that, in a small proportion of the
cases, recovery results. But it is not only by this course that hepatic
abscess may be recovered from. Cases' sometimes occur in which
the existence of abscess has been undoubted, and the fluctuating
swelling has gradually lessened and finally disappeared without any
appreciable discharge.* The inference that in such cases the re-
moval of the pus has been effected by absorption, is confirmed
by appearances occasionally found after death. The process is
probably of this nature : first, normal capillary circulation in the
tissues around, then absorption of the liquor puris, with conse-
quent shriveling and breaking up of the corpuscles into their con-
stituent granules — an encysted putty-like or cretaceous residuum
being left. Three cases (118 — 120) which I shall presently narrate,
and case 114, will serve to illustrate this process of absorption,
which is fully recognised by Rokitansky. Case 121 was probably
recovered from by absorption.

118. Two hepatic abscesses in process of absorption. — Death from cholera. —
Painful decubitus on right side explained by situation of one of the abscesses. — Ul-
ceration of colon. — Annajee, a Hindoo labourer, of thirty-two years of age, accustomed
to the moderate use of spirits, and of six grains of opium daily, after eight days'
iUness was admitted into the clinical ward on the 10th of December, 1850, not reduced
by sickness. The respiration was somewhat hurried and oppressed, but occasional
bronchitic rales were the only signs of pulmonic disease. The abdomen was full and
somewhat resistant. On the riglit side, dulness on percussion reached from the sixth
rib to a line drawn obliquely from the left eighth costal cartilage to the point of the
last right rib. Between this line and the margin of the ribs, there was distinct in-
duration, and pain increased by pressm'e. Decubitus dorsal, and on the left side, but
causing pain and distress of breathing on the right. There was febrile disturbance, a
tremulous tongue, and regular bowels. The local symptoms had been present eight
days, and the febrile five. On the 23rd he complained of pain of the right shoulder.
Under the use of cautious leeching, small blisters and quinine, combined with
ipecacuanha and blue pill, the induration and dulness below the margin of the right
rib had almost disappeared by the 29th. But the pain of right shoulder continued,
and the cough was more troublesome, with increase of bronchitic rales. The urine
was frequently examined : it was generally free, somewhat turbid, and without albumen.
On the 7th January the indiiration was gone, and the dulness extended about an
inch below the ribs ; the pain of shoulder had ceased, and the cough was less trouble-
some. Had recurrence of febrile disturbance on the 13th. Symptoms of cholera came
on on the 15th, and he died on the morning of the 16th. There were slight dysenteric
symptoms on the 18th and 19th December.

Inspection six hours after death. — Abdomen. — On opening the cavity, the thin edge
of the right lobe of the liver was seen projecting to the extent of about an inch
beneath the ensiform cartilage and the cartilage of the eighth and ninth ribs of the

* I have not thought it necessary to consider the question of the elimination of
the contents of hepatic abscess by the kidney. I think with those who believe that
the transfer of entire pus corpuscles from the liver to the urine, through the blood
and secreting processes, is physiologically impossible.

PATIIOLOaY — ABSCESS REMOVED BY ABSORPTION. 347

right side. There were firm adhesions of the most prominent part of the convex
surface of the right lobe to the under siu'face of the diaphragm, and a good deal of
dithcnlty was experienced in removing the organ from the abdominal cavity. On
incising the right lobe of the liver at the site of the adhesions, corresponding in
situation to the bodies of the seventh and eight right ribs, there was a small abscess
the size of a pigeon's egg, with firm membranous walls, and containing healthy pus.
Between the cavity of the abscess and the diaphragm only a thin layer of the paren-
chyma intervened. A little above and to the left of this there was another abscess
the size of an olive, also bounded by a membranous cyst and containing yellow
putty-like substance, which was amoi*phic and granular, with here and there a
corpuscle. The rest of the liver was healthy. The small intestine was dis-
tended with gas, and the large one was contracted. At the end of the ileum
the mucous membrane presented enlarged glands, and small superficial ulcers
were observed in the sigmoid flexure and the upper part of the rectimi. Other-
wise the coats of both the small and large intestines were healthy. Spleen of
smaller size than natural. The kidneys were healthy. Chest, — There were firm
adhesions of both lungs to the costal pleurae, and of the base of the right lung to the
convex surface of the diaphragm. The pulmonary tissue was in part crepitating, and
in part woolly to the feel, and when incised presented a pale appearance, intermixed
vdth numerous black specks. The heai't was healthy.

119. Four hepatic abscesses. — General peritonitis, hut no evidence of abscess rupture.
— Two of the abscesses in process of cure by absorption. — Dajee Gungajee, a Hindoo
buggy driver, of thirty-three years of age, using spirits habitually, was admitted into
the clinical ward on the 4th of December, 1851. The coimtenance was anxious,
the respiration short, and thoracic ; the abdomen was tense, tender, and somewhat
tympanitic ; the decubitus was dorsal, and the thighs flexed ; the skin was coldish,
and the pulse thready. The tongue was coated white on the sides, but florid at the
tip and centre. His illness commenced seven days before with fever, followed by
uneasiness below the right false ribs, which gradually extended over the abdomen, and
three days ago attained its present severity. Under the application of a blister to
the abdomen, the use of quinine and opium, wine and ammonia, he lingered till the
9th December. He had received a blow on the right side of his chest two months
before the present attack.

Inspection nineteen hours after death. — Chest. — There were some old adhesions
between the base of the right lung and the diaphragm. The substance of both the
lungs was healthy. The heart of natural size and normal. Slight firm deposit on
the lining membrane of the ascending aorta. Abdomen. — There was about a pint of
red-tinged serum in the cavity of the abdomen. The intestines were distended, and
presented streaks of redness on the peritoneal surface, and flakes of lymph existed
between the convolutions as well as between the lateral parietes and the ascending
colon. The liver, much enlarged, extended three inches below the margin of the right
false costal cartilages, and across to those of the opposite side. Extensive lymph
effusion existed between the left lobe of the liver and the anterior parietes. The
concave surface of the liver was firmly adherent to the transverse colon, to the
stomach at its pyloric extremity and to the duodenum, by a thick layer of lymph.
There were also firm adhesions between the convex surface of the liver and the
diaphragm, and the posterior wall of the abdomen. On separating the adhesions
between the concave surface of the liver, stomach, and duodenum, the walls of an abscess
in the liver gave way about an inch to the left of the gall-bladder which was firmly
adherent to the colon. The abscess was about the size of a large orange, and yellow
flaky matter was attached to the inner surface of the membranous cyst which enclosed
it. In the centre of the right lobe of the liver was another abscess the size of a
cocoa-nut, not communicating with the one on the concave surface, but just above it ;

348 irEPATiTis.

it contained thick flocculent pus, enclosed by a thin membranous layer. At the po"
terior edge of the right lobe there was another abscess disthict from the two above
described. It was about the size of a hen's egg, and contained thick putty-like pus ;
the walls were of thickened membrane more organised. In the left lobe towards its
concave surface there was included, in a still thicker membranous sac, a fourth col-
lection of still more consistent and putty-like contents ; it was the size of a walnut.
The concave surface of the liver immediately over the cyst had a somewhat depressed
and puckered appearance. The substance of the right lobe of the liver presented
generally a dark red colour, and was not softened ; the left lobe was of pale colour,
and more lacerable. The putty-like contents of the third and fourth abscesses, sub-
mitted to the microscope, presented no trace of pus corpuscles, but consisted of small
granular matter, with an oil globule here and there. The spleen was much smaller
than natural. The right kidney congested and lobulated ; the left somewhat pale.
The mucous membrane of the stomach presented variegated patches of redness, best
marked at the lesser curvature.

120. Hepatic abscess in process of cure hy absorption. — Hybattee Sinday, aged
forty -nine, a water-carrier, was admitted into hospital under Dr. Ballingall's care,
on the 16th April, 1857. He was emaciated, affected with phthisis and diarrhoea.
He died on the 28th.

Inspection. — There were tubercles in both lungs, with cavities in the upper lobes.
About the middle of the Uver, posteriorly, there was a single abscess-sac about tlie size of
a small apple, filled with putty-like matter. The walls were thick and firmly organised.
The gall-bladder was full of dark-coloured concretions. The solitary glands of the
large intestine were distinct, and there were sloughy ulcers here and there.

121. Hepatic abscess. — Absorption. — Becovery. — Narayen Nuthoo, aged twenty-four,
admitted 25th November, 1857. A prominent fluctuating circumscribed swelling in
the epigastric region, reached to the umbilicus. It was suspected to be hydatid.
But after a fortnight it gradually lessened and finally consisted merely of slight in-
duration three inches below the ensiform cartilage — -without prominence or fluctuation.
The bowels were relaxed for three or four days, but the evacuations were not seen
and they were not coincident with the decrease of the swelling.

Secondary 'partial peritonitis. — Circumscribed Furiform Sacs.
— It has been already stated (pp. 327 and 329) that secondary
inflammation of the peritoneal covering of the liver, in the course
of hepatic abscess, with consequent adhesion, is the rule. In oc-
casional cases, there is absence of peritonitic inflammation. But
in other cases there is another kind of deviation : in this the
secondary peritonitis has not led to adhesion at all points, but a
portion of the lymph changing into pus has formed a circum-
scribed sac between the liver and the opposed surface. The most
common situation is between the liver and the diaphragm ; but it
may also occur in relation with the concave surface of the organ.
Sometimes the sac communicates with the hepatic abscess : more
frequently, however, it is merely superimposed.

A collection of pus, however, may form in close proximity to
the liver, independent of hepatic abscess, as is shown in the two
following cases (122, 123). The first was communicated to me by
Mr. Plumptre, the medical officer in charge of the Sanitarium at

TATHOLOaY — SECONDARY PARTIAL PERITONITIS. 349

Poorimdhur. On the 29th December, 1858, I saw the case on
the occasion of my visit to the station ^ — and never doubting that it
was abscess of the left lobe, recommended that it should be punc-
tured in a few days.

122, Purulent sae, between the liver and the diaphragm, communicating with the
left lung. — iVo hepatic abscess. — A private in the 3rd Dragoon Guards, aged thirty-
two, of 12 years' service, and ten months in India, after dysentery, reputed colic,
and dyspepsia, was sent from Kirkee to Poorundhur on 22nd September, 1858. He
had pain of epigastrium extending to the left hypochondrium. No enlargement.
The symptoms were considered to be dyspeptic, and he was discharged free of pain on
the 8th November. He was re-admitted on the 26th November, with return of
pain and suspected enlargement of the' left lobe of the liver. Discharged on 11th
December. Ee-admitted on the 20th. There was now distinct swelling at the left
side of the epigastrium with dulness for three inches around. On the 29th it was
prominent, obscurely fluctuating and tending to point. It was opened with a bistoury
on the 4th January. Ked-tinged pus discharged freely, and was always increased
after eating. There was hectic fever and increasing emaciation. On the 7th February
he expectorated with little effort a considerable quantity of greenish yellow pus.
Up to the 23rd February the puncture looked healthy, but now the edges became
gangrenous. On the 25th the abdomen was tense, distended, and tender, the features
anxious, the pulse 110, and somewhat sharp. He died on the 1st March.

Inspection fourteen hours after death. — Body emaciated. There were six pints of
sero-pus in the abdomen. The intestines were distended, and their surface smeared
with flakes of friable lymph. A large purulent sac existed between the liver and the
diaphragm. It communicated with the punctiired wound, also with the left Ixing, which
which was consolidated at its base and firmly adherent to the diaphragm. No direct
communication with the cavity of the peritoneum was discovered. The substance
of the left lobe was not implicated. The liver was enlarged and of nutmeg ap-
pearance. The diaphragm was adherent to the surface of the left lobe at the circum-
ference of the sac.

123. Amputation of the right hand, followed by general bad health, and chronic
hepatitis. — A purulent sac between the liver and the ribs filled with foetid pus. — Hepa-
tisation of the lower part of the right lung. — Grresham Stewart, aged thirty-one,
gunner's mate Honourable Company's steamer Cleopatra. On the 29th of July,
1842, the right arm was amputated above the wiist in consequence of a severe injury
received while incautiously extracting the charge of a gun. The operation was per-
formed immediately after the accident. On the 8th August he was admitted into the
European General Hospital. Union had not taken place and the stump presented a
sloughy appearance. He, by degrees, however, improved, and was discharged well on
the 5th October. He was re-admitted on the 5th November, sallow and reduced, with
feeble pulse, complaining of occasional shooting pain of the right hypochondriiim, and
at times suffering from diarrhoea. He continued labouring under these symptoms,
more or less till towards the end of January, when the pain of the right hypochon-
drium increased and became more constant, with coated tongue and sharpish pulse.
On the 10th February, it was reported that there was distinct hard swelling of several
inches in circumference over the lateral part of the right false ribs, commencing about
the sixth rib and extending to the tenth. There was no preceptible fluctuation.
During the night of the 11th, there was hsemoptysis to a considerable extent, succeeded
the following day by cough -with rusty-coloured sputa, at time's in considerable quantity.
Under these symptoms, much harassed by cough, he lingered, and died on the 27th
February, very much emaciated.

Inspection twelve hours after death. — The body much 'emaciated. Abdomen. — Be-

350 HEPATITIS.

tween the liver and the ribs there was a sac containing foetid dark-coloured pus ; the
walls of the sac being sloughy and ragged. [This purulent sac was opposed to the site
of the tumefaction during life, but there was no purulent effusion between the ribs
and the integuments, nor had the pus made a way through the intercostal muscles.]
The peritoneal surface of the liver was in one or two places abraded, but the substance
of the organ was not implicated. There was no communication between the abscess
and the sac of the pleura, or the lungs. Chest. — The right lung adhered to the costal
pleura and to the diaphragm, and was in the first stage of hepatisation, giving out
frothy blood-coloured serum when pressed. There was a considerable quantity of
serum in the pericardium. The other viscera, though attenuated, were healthy.

That purulent collections may occur consequent upon ordinary-
secondary peritonitis, and independent of hepatic abscess, is proved
by the cases just narrated. The occurrence may be held to indicate
a depraved diathesis. There is moreover a practical lesson in
these circumscribed sacs. They teach us to be cautious in attri-
buting a pointing fluctuating swelling in the right intercostal spaces
below the seventh, and in the epigastrium, to the presence of hepatic
abscess : it may be caused by a collection of pus between the liver
and the diaphragm.

Cases 124 to 127 are of secondary partial puriform peritonitis
in connection with hepatic abscess; also 160, 161, 168, 172.

124, Abscess in the liver. — Also one external and circumscribed communicating with
former. — Dark red colour of mucous surface of large intestine, which contained much

clotted blood. — Serjeant 0. M , of Her Majesty's 40th Eegiment, aged thirty-two,

was admitted into hospital at Belgaum, on the 21st June, 1830. This man was a hard
drinker, and was said to have been ill with dysentery fourteen days before admission.
There was much purging with severe tenesmus and griping. The dejections were
scanty, mucous and bloody, then became red, watery, and foetid, and for the last two
days before his death consisted entirely of grumous, dark-coloured blood. Tenderness
of abdomen moderate. He sunk gradually, and died July 2nd.

Inspection. — On opening the abdomen a superficial abscess presented itself; situated
on the superior surface of the thin edge of the right lobe of the liver, having for its
walls, posteriorly, the liver, anteriorly, the abdominal parietes, inferiorly, the colon ex-
tremely distended and adhering to the margin of the liver. The abscess dipped down
between the ascending colon and the concave surface of the liver, and then communi-
cated with another abscess, which occupied the whole interior of the right lobe of the
liver ; and below it terminated in a large collection of pus, situated behind the caput
coecum. The coecum and ascending colon were internally of dark red colour, and filled
with clotted blood ; and in parts of the colon the peritoneal was the only tunic left.
The liver was light coloured, and adhered to the right side and to the diaphragm.
Adhesions existed between the right lung and diaphragm, opposite to those of the
liver.

125. Hepatic abscess bounded by a firm sac. — A circumscribed sac in the peritoneal
cavity over the edge of the liver. — Substance of the liver mottled red and white. —
Thomas ConoUy, aged forty, of slight habit, a seaman, admitted on the 24tli March,
1841. He stated that he had suffered from acute pain of the right hypochondrium at
the margin of the ribs, for four days, attended with frequent purging. The pain was
acute, preventing full inspiration, and extending downwards in the direction of the
right iliac region. Pulse 100, sharpish, but easily compressed. Skin moist. Tongue

PATHOLOGY — SECONDARY PARTIAL PERITONITIS. 351

coated in the centre, and florid at the tip. He was bled to sixteen ounces and freely
leeched : he bore the depletion badly. The pain continued unabated, and frequent
vomiting was superadded. On the 28th, there was fulness and tenseness extending
from the right iliac fossa to the margin of the ribs and reaching as far as the umbili-
cus. The left side was supple. He died at midnight of the 30th. At the beginning,
two full doses of calomel with opium were given ; it was then omitted and camphor
mixture with spiritus ammonise aromaticus and wine substituted.

Inspection seven hours after death. — Head. — The brain was firm, and there was a
thin veil of serum beneath the arachnoid membrane at the interspaces of the convolu-
tions. Chest. — The lungs did not collapse, in consequence of their emphysematous
state. Abdomen. — The omentum adhered in places to the intestines and also to the
edge (partly overlapping it) of the right lobe of the liver. There was a portion of the
substance of the liver, the size of a large orange at the thin part of the right lobe, of
white colour, in parts tolerably firm, in others pulpy, in others breaking down into
pus, — bounded by a firm sac, from which the white part could be scraped ; and over
that portion of the liver there was a circumscribed abscess bounded by the abdominal
parietes, the omentum, and liver. The substance of the liver generally was mottled
red and white. The colon was contracted, with ulcers, here and there, on its mucous
coat.

126. Abscess in the liver communicating with purulent deposit in the right iliac
region. — Habitual constipation. — The sigmoid flexure of the colon much contracted. — A
gentleman, aged about forty-six, of full habit, and subject to occasional attacks of
gout and rheumatic swelling of the joints, after a residence of twenty-seven years in
India, at the end of 1832 (previous to which time, though subject to constipation, he
had never suffered from acute visceral disease), was attacked with inflammation of the
bowels attended with constipation, and requiring much general and local depletion for
its removal. After convalescence he went to the Cape of Good Hope, resided there
one year, and returned to Bombay at the commencement of 1835. About two months
before I saw him, consequent on exposure to cold, and irregularities of diet, diarrhoea
supervened, alternating with occasional constipation, and scybalous discharges. When
he came under my care on the 17th April, 1835, he was much reduced from his usual
fulness. The expression of countenance was languid and anxious. The tongue was
florid. The bowels were relaxed, the dejections being of dark-green colour, watery,
and offensive. There was tenderness on pressure of the right iliac region. On th.Q
27th April, occasional drowsiness was for the first time observed, and there was in-
creasing weakness. Death took place at noon of the 2nd May, having been preceded
by vomiting of inky coloured fluid.

Inspection four hours after death. — Abdomen. — The parietes of the cavity and the
omentum were loaded with fat. The stomach was flUed with dark inky coloured fluid,
but, Avith the exception of softening of some points of the mucous coat, was healthy.
There was a collection of pus in the right iliac region, eii-cumscribed by part of the
concave surface of the liver, the fundus of the gall-bladder, a matted portion of the
omentum, the ascending colon, and the right kidney. It communicated with an ex-
tensive, but very superficial abscess, on the inferior surface of the liver, to the right of
the lobulus Spigelii. The descending colon was contracted, and the sigmoid flexure
was of about the diameter of a swan's quill. The mucous lining of the coecum and
ascending colon was thickened, and presented black mottled patches with the traces of
cicatrices. AU the coats of the descending colon and of the sigmoid flexure were
thickened, but there was no puckered irregularity of the inner surface. The small
intestine was fllled with dark green viscous contents.

127. A circumscribed sac between the liver and the ribs. — An abscess in the substance
of the right lobe. — The mucous coat of the colon studded with circular ulcers. — George
Bignel, of moderate habit, aged twenty-eight years, and nme months resident in India

352 HEPATITIS.

for three days before admission into hospital on the 2nd January, 1840, had suffered
from pain of the right side, shooting to the shoulder, and impeding full inspiration.
He was twice freely bled and very freely leeched and blistered ; and on the 8th, 9th,
and 10th, he was mildly under the influence of mercury. He did not convalesce in a
satisfactory manner, and on the 29th there was recurrence of the pain of the side, and
the liver was distinctly felt two inches below the ribs. The fulness below the ribs
became subsequently more distinct, and there was hepatic sound almost to the nipple.
He suffered frequently from pain of the side, became emaciated, subject to hectic and
diarrhoea, with a tongue florid at the tip. He died on the 26th February.

Inspection. — Head. — There was an ounce of serum at the base of the skull and a
veil of serum between the arachnoid and pia mater on the convex surface of the brain.
Chest. — There were old adhesions of the right lung to the diaphragm and posterior
parietes, and firm adhesions of the liver to the concavity of the ribs. There was a
circumscribed purulent sac between the surface of the liver and the ribs. The liver
extended three inches below the margin of the ribs, and in the upper part of the right
lobe there was an abscess, the size of a hen's egg, with flocculent walls. The mucous
coat of the stomach was of red-brown colour, but sound in texture. The mucous coat
of the large intestine presented a surface of closely set circular ulcers, in places running
into each other, and giving a honey-combed appearance to the membrane ; in places
the margins of the ulcers were of bright red colour, and were generally softened in
texture.

Secondary Pleuritis, leading to General or Circumscribed
Empyema. — It has just been shown that secondary inflammation
of the hepatic peritoneum may lead to the formation of a purulent
sac instead of adhesions. A reference to the cases quoted in
different parts of this chapter will show that secondary diaphrag
matic peritonitis, is very frequently associated with secondary dia-
phragmatic pleuritis, leading to adhesion between the base of the
right lung and the diaphragm. But just as in the peritoneum, we
may have in the pleura a similar deviation from this rule. Instead
of adhesions taking place, or sometimes in association with them,
the lymph changes into pus, and general or circumscribed empyema
is the consequence. It is important to know that there may be
empyema co-existing with hepatic abscess, not caused by communi-
cation, but merely by extension of inflammatory action through
the diaphragm, — in individuals prone to the suppurative process.
It appears, then, that empyema, from communication, or indepen-
dent of it, is not an unfrequent complication, and it sometimes
renders the diagnosis of hepatic abscess obscure : the signs of the
empyema may be attributed to the encroachment of the liver on
the chest ; or, if rightly interpreted, they may throw a doubt over
the previous diagnosis of hepatic disease.

It is not, however, only in the pleura that we have evidence of
the extension of inflammation from one diaphragmatic surface to
the other. It may also occur, but much more rarely, in the
pei'icardium. Of this I have met with two instances (131, 132J.

PATHOLOGY — SECONDARY PLEUEITIS. 353

In one the relation of the pericarditis to hepatic abscess was well
shown. These two cases, and three (128 to 130) illustrative of
my remarks on empyema, are here submitted. The latter may be
considered in connection with cases 170, 171, which exemplify the
same morbid state.

128. Abscess in the liver. — Empyema of the right pleura. — Symptoms not Well
marked. — Dejection of a pint of clotted blood before death. — Mucous coat of the colon,
dark red with ulceration. — Kichard Dunstan, aged thirty-nine, two years in India,
was admitted on the 16th January, 1841. He was reduced in flesh, having been ill
for seA^eral days, and having taken no food. He complained chiefly of uneasiness at
the epigastrium not amounting to pain, nor increased by pressure, full inspiration or
decubitus on either side. Skin moist. Pulse 112, feeble, and easily compressed. He
continued languid, depressed, with collapsed and anxious countenance, feeble and quick
pulse, tong-ue sometimes dry in the centre, sometimes brownish, bowels generally
scantily moved, but on the 23rd there was passed by stool more than a pint of clotted
blood. He died early the following morning.

Inspection eight hours after death. — Chest. — The heart and left lung were healthy.
Adhesions connected the third lobe of the right lung to the diaphragm, and there were
about thirty ounces of sero-purulent fluid in the right sac of the pleura. Flakes of
lymph lined the costal pleura and parts of the pulmonary pleura. Abdomen. — The
liver filled both hypochondria, the right lobe adhered to the diaphragm, and in that
lobe there were two abscesses of considerable size. The left lobe was healthy in
texture. There were patches of vascularity here and there in the stomach. The
colon contained dark claret-red slimy contents ; the mucous coat had, throughout, a
reddish tint, and presented several patches of ulceration.

129. Abscess in the liver. — Effusion of four pints of serum., with lymph, in the right
pleura. — Ulcerated colon. — "No coma. — 8erum between the pia mater and arachnoid, and
two or three ounces at the base of the skull. — James Roberts, aged twenty-nine, a
gunner, of feeble habit, was under treatment for acute hepatitis, from the 30th April
to the 16th May, 1839, He was bled and leeched freely, took calomel and opium,
but not to ptyalism, and he was discharged well. Was re-admitted into hospital on
the 5th June, affected with diarrhoea, which, under much variety of treatment, con-
tinued more or less troublesome. On the 3rd July, distinct hardness and tumefaction
between the margin of the right ribs and the crest of the os ilium, was first noted.
Blisters were frequently applied without benefit. He continued to lose ground.
Became more emaciated and sallow, and on the 3rd August, it is noted for the first
and only time, that he had been much troubled with cough during the previous night.
The sinking increased, and he died at 3 p.m. of the 24th.

Inspection fifteen hours after death. — No evident tumefaction of either side of the
abdomen or chest. Head.— The membranes were exsanguine. The convex surface of the
brain was veiled with a thin layer of serum, and there were between two and three ounces
at the base of the skull. Chest. — The right sac of the pleura contained about three or
four pints of clear fiuid serum at the upper part, thickened with flocculi of lymph at the
posterior and lower parts. The costal and pulmonary pleurae were coated with adherent
flocculi of lymph. The lung was condensed against the mediastinum. There was about
half a pint of serum in the left pleura, and about three ounces in the cavity of the peri-
cardium. The left lung and the heart were healthy. Abdomen. — The right lobe of the
liver extended for three inches below the margin of the right ribs ; and the edge of the
lobe, to the right of the gall-bladder, was occupied by an abscess, the size of a large orange
with dense fibrous walls. The hepatic flexure of the colon and part of the omentum
were matted to the walls of this abscess. Close to the diaphragm there was another
abscess in the right lobe, and there were adhesions of the convex surface of that lobe

A A

354 HEPATITIS.

to the diaphragm. The rest of the surface of the liver was mottled white. The
mucous coat of the ccecum was studded with small follicular ulcerations, some of them
cicatrising. The rest of the mucous coat of the colon was nearly healthy. Stomach
healthy. The kidneys were both rather enlarged. The left of buff colour, with the
tubular and cortical parts not well defined. The right one was nearly natural in
texture, ^th buff streaks of the cortical part. There was about a pint of serum in
the cavity of the abdomen.

BemarJc. — The record shows a want of attention to the physical signs, as the exist-
ence of the pleuritic efiusion does not seem to have been detected.

130. A small purulent sac circumscribed in part by the base of the right lung and by
the diaphragm, and extending to the fissure between the second and third lobes of the
right lung, mistaken for hepatic abscess. — Serjeant James Deans, aged twenty-nine, of
feeble habit. From November 1842 to April 1843, was almost continuously under
treatment in the Artillery Hospital, suffering from dysentery, attended at times with
much abdominal tenderness. From the 5th to the 21st December, he was again under
treatment for a similar complaint. On the 29th January, 1844, he was re-admitted
with febrile symptoms attended with cough, pain of chest and frothy expectoration.
These symptoms continued with more or less alleviation, and the sputa at times as-
8um"ed a globular appearance with rusty tinge, till the 7th February, when he was
transferred from the Artillery to the European General Hospital. The cough continued
troublesome, there was occasional hectic fever ; the expectoration became more copious
and puriform in character with a reddish tinge, more or less deep. A mucous rale
was heard over the chest. He continued under these symptoms, gradually losing
strength, and latterly suffering from a complication of dysenteric symptoms, and died
on the 31st March.

Inspection six hours after death. — The body much emaciated. Chest. — The left lung
was healthy and collapsed completely. The right one adhered in parts to the costal
pleura and very generally to the diaphragm. The upper lobe was collapsed. Between
the base of the lung and the diaphragm, and also in the fissure between the second and
third lobe, there was a circumscribed sac containing about six ounces of thick pus, and
the portions of the lung adjacent to it were indurated and hepatised. There was no
communication through the diaphragm. Abdomen. — Old adhesions connected the omen-
tum in several places to the abdominal parietes. The liver was much enlarged, gi'ey,
and indurated, and extended to the crest of the os ilium, but was without any abscess.

131. Hepatitis. — Abscess m the liver. — Five pints of pus in the sac of the right pleura.
— A layer of lymph on the surface of the heart and inner surface of the pericardium. —
General peritonitis, with effusion of lymph and sero-piirulent fluid. — Stephen Cain, a
pensioner, aged fifty, of broken habit, after eight days' illness was admitted into
hospital on the 24th January, 1840. He complained of pain of the right side, shooting
from the margin of the ribs to the shoulder. On the 4th February there was tenseness,
fulness, and hardness, at the margin of the right ribs, and the pulse was feeble. The
feebleness of the pulse continued. On the 7th the breathing was somewhat oppressed,
and there was general painful distention of the abdomen. He died on the 14th February.

Inspection. — There was an ounce of serum at the base of the skull. Chest. — There
were five pints of pus in the sac of the right pleura. The inner surface of the pericar-
dium and outer of the heart, were red and roughened by a thin layer of firm granular
lymph. There was commencing disease of the aorta above the valves, but no hyper-
trophy of the heart. Abdomen.— The liver projected two or three inches beyond the
margin of the ribs, and there was an abscess about the size of an orange, and circum-
scribed, chiefly between the diaphragm and the upper surface of the liver. The
peritoneal surface of the intestines was dark red. The convolutions were united by
flakes of lymph, and sero-purulent fluid was effused among them. The mucous coat
of the stomach was of dark leaden grey colour.

PATHOLOaY— SECONDARY GENERAL PERITONITIS. 355

132. Pericarditis. — The inner surface of the pericardium and the outer side of the
heart covered with a thicJc layer of irregular lymph. — Also effusion of serum and displace-
ment of the liver, partly caused by the distended pericardium. — Abscess of the liver. —
John Devair, aged twenty-five, seaman, was admitted on the 12th November, 1840.
He stated that he had been ill for two months and a half ; that his complaint began
with pain of the abdomen, shooting from the hypogastrium and the left side, thence
through the chest. These symptoms were not attended with diarrhoea, constipation or
difficulty of micturition ; but his statement was confused. He passed a restless night,
and on the 13th, the epigastrium was tense, resisting, and painful on pressure; and
on percussion, the sound was dull almost to the umbilicus, also midway between the
crest of the os ilium of the right side and false ribs, and extended into the hypochon-
drium. The breathing was a good deal oppressed ; the skin above natural tempera-
ture; pulse 120, feeble and compressible; tongue pretty clean. Anteriorly, on the
.right side of the chest and below the nipple, the sound was clear on percussion. On
the left there was much dulness about the cardiac region, extending to the arch of the
left false ribs and to the sternum ; no bulging. On the 20th the uneasiness of the
chest and dyspnoea were increased, and he had suffered from rigors ; the pulse was
100, very irregular, unequal, with occasional intermission ; the abdomen fudl and tense.
Between the left nipple and the sternum the action of the heart was perceptibly
increased ; and there was a very distinct fremissement, more distinct at that situation
than at the apex of the heart. There was now almost constant orthopncea ; pulse
very feeble. On the 23rd the fremissement had ceased. He died on the night of the
24th.

Inspection ten hours after death. — Body not much emaciated. Chest. — The pericar-
dium completely occupied the anterior part of the chest and extended into the right
side for some distance ; its transverse diameter was fully ten inches, and it reached
from the top of the sternum to the diaphragm, to which muscle it adhered firmly, as
also to the inner aspect of both lungs. There were about twenty-two ounces of clear
serum in the cavity of the pericardium. The inner surface of the pericardium was
lined throughout with a layer of lymph, a line in thickness, with a rough reticulated
inner surface of dark red colour ; this layer could be peeled from the pericardium
with tolerable facility. The outer surface of the heart was coated with a similar layer
of lymph, more firmly adherent, however, and presenting a more irregular and reticu-
lated external surface ; where the greatest irregularity existed (chiefly at the posterior
part) thick bands of firm but friable lymph, about an inch or more in length, extended
between the pericardium and the heart. The heart itself and the vessels were healthy.
The lungs, with the exception of some old adhesions and some slight oedema, were
also healthy, and there was trifiing serous effusion in the right cavity of the pleura.
Abdomen. — The transverse colon, much distended with air, occupied the umbilical
region. The Hver, displaced by the distended pericardium, extended four inches dcIow
the sternum, and about three below the last right false rib. There was an abscess in
the left lobe of the liver, lined with a firm membrane with flocculent surface ; it was tho
size of an orange, and was adherent to the diaphragm where opposed to the adhesions
of the pericardium. The stomach was healthy. The cortical part of both kidneys
was streaked white and red, and these organs were considerably enlarged.

Secondary General Peritonitis. — Secondary general peritonitis
is not unfrequent in the advanced stages of hepatic abscess. It
occurred in 10 per cent, of the cases at present under review. Its
access is generally marked by s3n:nptoms sufficiently distinct ; and
flaky lymph or sero-purulent effusion is found after death. It has
been already stated that the opening of an abscess into the cavity
of the peritoneum is rare ; and there can be no doubt that in the

, 356 HEPATITIS.

majority of instances general peritonitis is not due to a direct cause
of this kind, but is merely additional evidence of the tendency of
secondary inflammations to arise in the course of hepatic abscess,
and, by the form which they assume, to indicate the degree of
cachexia present.

The four cases which follow are of this nature. On this point of
pathology reference may be further made to cases 140, 172, 185.

133. General peritonitis. — Abscess of the liver following head symptoms. — Serous
effusion in the head with thickening of the arachnoid membrane. — The kidneys had
undergone yellow degeneration. — Grarrott Dunn, aged thirty-eight, of spare habit, was
admitted into the European General Hospital, on the 6th August, 1838. He was deaf,
and could not give a distinct account of himself. He articulated indistinctly. Com-
plained of vertigo with a constant singing noise in his ears. He was bled from the
arm, and cupped on the back of the neck, his head was shaved, and his bowels were
freely acted upon by purgative medicine. He continued with more or less of these
symptoms till the 17th October. Throughout this period, the deafness was .constant,
the vertigo and noise occasional. He was cupped, leeched, and blistered several
times. Aperient medicine was from time to time exhibited. The action of mercury-
was induced mildly on the system. The decoction of sarsaparilla was also given, first
with the hydriodate of potass, and then with corrosive sublimate. The head symp-
toms at one time presented a periodic tendency, and quinine was exhibited. No
benefit resulted from these diiFerent courses of treatment, and on the 17th October, in
addition to the former symptoms, tenderness of the abdomen was complained of
attended with diarrhoea. Leeches were applied, and anodynes and absorbents given.
On the 25th there was distinct fulness to the right of the epigastrium, accompanied
with tenderness. Under these symptoms he gradually sunk, and died on the 8th
November.

Inspection twelve hours after death. — ^Body emaciated. Head. — There was increased
turgescence of the vessels of the pia mater on the upper surface of the brain and over
the posterior lobes. There was also opaque thickening of the arachnoid membrane in
many places, chiefly at the dipping down between the hemispheres of the brain.
There was about an ounce and a half of serum in the ventricles, and a considerable
quantity at the base of the skull. The substance of the brain was quite firm and
natural in all parts. Chest.- — The lungs were healthy. A thin layer of old lymph
for the extent of an inch in diameter was attached to the serous covering of the
heart. Abdomen. — There was a small quantity of sero-purulent fluid in the cavity
of the abdomen. The intestines were distended with gas, and adhered in places by
flakes of lymph to the abdominal parietes. The whole of the peritoneal covering of
the right lobe of the liver was covered with flakes of lymph, and there were flakes
between the stomach and liver, and a close matting of the edge of the left lobe to the
colon ; that intestine was also closely embraced by the omentum. In the left lobe of
the liver, at the point of adhesion to the colon (the site where there had been fulness
and pain before death), there was an abscess the size of an orange. The substance of
the right lobe was healthy. In places of the mucous lining of the colon, there was
dark grey discoloration. In others a thinning of the coats, chiefly to all appearances
induced by the removal of the free surface of the mucous tunic. In the descending
colon and sigmoid flexure, there were a few round ulcers, and some dark grey
cicatrices. The mucous lining of the stomach was covered with adhesive mucus, was
dark grey at the cardiac end, marbled dark red at the pyloric, but was neither softened
nor thickened. The cortical substance of both kidneys had undergone yeUow degenera-
tion to a considerable extent.

PATHOLOGY — SECONDAllY GENERAL PERITONITIS. 357

134. General peritonitis. — Matting of the omentum over the ccBcum. — Bound ulcers
in the colon, and an abscess in the liver. — Antone Lopes, aged forty-two, a Portuguese
seaman, who had arrived from Goa about two months before his admission into the
European Greneral Hospital, on the 22nd January, 1839. On admission into hospital,
his countenance was sallow and anxious. The abdomen was somewhat distended,
and tense, with tenderness over the ccecum. The tongue was expanded and little
furred. The pulse was feeble. He stated that he had been aflfected with dysenterie
symptoms for about twenty days, that the purging, at first considerable, had decreased,
and that the pain had increased, during the two or three days before admission. On
the 23rd there was a distinct defined hardness felt over the ccecum. He gradually and
slowly lost ground, and died on the 7th February. The tumour at the site of the
ccecum continued distinct, till the 2nd of February, when the fulness and tenderness
of the abdomen became more general. At first, leeches were applied to the abdomen,
and at three different times a blister was applied. For the first two or three days,
blue pill or calomel were given with ipecacuanha and opium, and afterwards sulphate
of quinine with a small quantity of hydrargyrum cum creta with opium and ipecacu-
anha. Then the ipecacuanha and mercury were left off, and the quinine was given
with opium and aromatic confection.

Inspection jive hours after death. — Body emaciated. Abdomen moderately distended.
Head. — -About an ounce and a half of serum in the cavity. Abdomen. — The omentum
crossed from the ninth or tenth left false rib, adhered to the anterior parietes, passed
obliquely to the hollow of the right os ilium, and thus divided the cavity into two parts.
The upper contained about a pint of pus in a circumscribed sac lined with false mem-
brane, and covering the projecting edge of the liver, the stomach, and part of the
omentum. The lower division contained about two pints of clear serum with fiakes of
lymph. There was vascularity of the peritoneal covering of the small intestine and much
matting of the convolutions in the pelvis, and to the bladder. The ccecum was matted
firmly to the omentum and to the hollow of the os ilium, and tore readily on attempting
to separate it. The descending colon was covered with flakes of lymph. There were
round isolated ulcerations, the size of a sixpence here and there, in the colon. The
liver was much enlarged and contained a large abscess in the right lobe lined with
fijm membrane ; the parenchyma was of dark red colour, and mottled white. The
mucous lining of the stomach was thickened. The left kidney had partly undergone
yellow granular degeneration ; the right one was not examined. Chest, — The
thoracic viscera were healthy.

135. General peritonitis, with sero-purulent effusion and abscess in the liver.-»-Ja.ixies
Harrison, aged thirty-three, of slight habit, a sub-conductor in the Ordnance Depart-
ment, was admitted into the European General Hospital on February 25th, 1839.
He had served thirteen years in India, had suffered from dysentery whilst at Deesa in
1829, and was under treatment in the General Hospital for fever about ten months
before the present date. On admission he stated that some days previously he had
experienced uneasiness at the epigastrium, for which he was leeched and took medi-
cines. Since the day before admission, there had been pain and much tenderness of
the right iliac region, with sense of induration and dulness, extending from two
inches above the crest of the os ilium, to the margin of the right false ribs, and to
within two inches of the umbilicus. Pulse 88, small, sharpish. The tongue was pretty
clean. Features sharp and anxious. He vomited the day before admission, but not
since. One hundred leeches were applied to the abdomen, a warm bath ordered, and
calomel with ipecacuanha and opium given. On the following day (26th), the pain
continued ; pulse 84, weak. A large blister was applied to the abdomen. At the
evening visit there was no febrile exacerbation, the bowels had been four times moved
by the castor oil, and the evacuations were yellow and watery. The pulse small and
feeble. Calomel three grains, quinine two, and opium one, in the form of pill, were

A A 3

358 HEPATITIS.

ordered at bed-time. From this time, the pain of the abdomen was more or less com-
plained of, and on the fourth, tlie distention had considerably increased. The pulse was
generally from 80 to 88, feeble and often thready ; the skin was cold and damp ; the
tongue was moist and without fur, and two or three watery yellow evacuations were in
general passed daily. The treatment consisted of quinine in combination with
hydrargyrum cum creta and half a grain of opium thrice daily. He died on the night
of the 5th March.

Inspection eight hours after death. — Body not much emaciated. Abdomen. — Was
moderately distended and tense. The omentum, vascular and thickened was matted
over the transverse colon, the edge of the liver, and the ccecum. It also adhered firmly
to the hollow of the os ilium. There was general redness over the peritoneal coat of
the bowels, with flakes of lymph. There were about three pints of sero-piirulent
fluid in the cavity of the peritoneum, chiefly between the right lobe of the liver and
the ribs, and in the iliac and pelvic regions. The liver was of natural size, mottled
and of pale fawn colour, except in the neighbourhood of two or three small abscesses
in the right lobe, where the mottling was dark red. The coats of the ccecum and
colon were not thickened ; their mucous coat was of dark grey colour, but not ulcerated.
The stomach was healthy. In the left kidney the distinction of cortical and tubular
portion was not well defined ; the right kidney was healthy. The thoracic viscera
were healthy. Head. — At the base of the skull there was an ounce of serum.

136. Frohably small superficial abscess of under surface oflobidus Spigelii, leading to
apuriformsac in g astro-hepatic omentum, and this by rupture to general peritonitis. —
Jaundice. — Ingan Khan, a Mussulman butler, using spirits in moderate quantity, of
forty years of age, and in reduced condition, was admitted into the clinical ward on
the 19th October, 1850. The respiration was somewhat hurried, partly abdominal
and partly thoracic. There was some degree of general fulness of the abdomen, and a
line drawn from the point of the right ninth rib to within two inches of the umbilicus,
and then obliquely upwards to the eighth left rib, formed the lower limit of a distinctly
full and almost circumscribed induration, of which the thoracic margin was the upper
boundary ; this space was dull on percussion, painful on pressure, deep inspiration, and
coughing. There was some yellowness of the conjunctivae, febrile disturbance, a
coated tongue, constipated bowels, and high-coloured urine. The illness was of twenty
days' duration, and commenced with febrile symptoms. These recurred every evening
with chiUs, and terminated with sweating. Suffering much as on admission, he con-
tinued under treatment till the 29th October, when, in consequence of alleviation of
the epi^stric uneasiness, he was urgent for his .discharge. He was re-admitted on
the 1st November with anxious countenance, hurried and short respiration, and small
frequent pxdse, and skin about the natural temperature. There was epigastric tender-
ness, and some degree of general abdominal fulness ; but the epigastric induration was
scarcely perceptible, and the dulness was limited below by a line curving from the
cartilage of the eighth right rib to that of the seventh left rib. On the 2nd the symptoms
of general peritonitis were fully marked. He died on the morning of the 3rd. The
urine was frequently examined, but gave no signs of albumen. He was treated chiefiy
with moderate leeching, small blisters, laxatives, quinine, diaphoretics, and anodynes.

Inspection eight hours after death. — Abdomen. — About two pints of straw-coloured
serum were contained in the cavity of the peritoneum. The intestines were generally
distended with flatus ; their peritoneal surface presented a dusky hue chiefly where
the convolutions were in contact, with flakes of lymph here and there. The lymphy
effusion was abundant on the convex surface of the liver, which seemed somewhat
compressed, and adhered to the diaphragm by friable bands. The thin edge of a part
of the concave surface of the left lobe of the liver was fij'mly adherent to the stomach,
the transverse colon, and the hepatic flexure. Easily separable adhesions also existed
between the right lobe of the liver, the fundus of the gall-bladder, and the lateral

PATHOLOGY — CONTENTS OF ABSCESS. 359

part of the diaphragm. The omentum was matted oyer the ascending colon, and
reached as far as the right abdominal ring. On separating the adhesions between the
concave surface of the liver and the stomach, a thick layer of friable lymph was seen
on the surface of the latter and on the duodenum, with a few ounces of sero-pus,
which seemed to proceed from a sac, chiefly formed in the gastro-hepatic omentum.
One part of its wall was in relation with the inferior surface of the lobulus SpigeHi.
This lobe was compressed, its tissue of a dark-red colour, mottled, and presenting
near the surface, and in relation with the wall of the sac, two or three purulent
deposits, each the size of a small bean. The transverse or portal fissure, with the
large blood-vessels and duet, were not involved. No other traces of abscess were
detected in any other part of the liver, which was of normal size, and extended from
the level of the fifth to the ninth rib. "When incised in various directions, its surface
presented an olive-green colour, and was somewhat indurated, seemingly from a state
of commencing cirrhosis. The upper surface of the right lobe was much puckered.
The mucous membrane of the stomach was covered with a large quantity of pultaceous
mucus, but its texture was in every respect healthy. The mucous membrane of the
duodenum presented a dark-red colour, but it also was normal in structure. Chest. — •
The lungs collapsed freely. Old adhesions connected in places the costal to the pul-
monary pleura on both sides.

These details show that circumscribed collections of pus in rela-
tion with the peritoneum and pleura, also puriform general peri-
tonitis, are not uncommon events in the course of hepatic abscess.
This result is probably dependent on the cachectic condition of the
individuals affected. But here the question may be proposed,
whether these complications are due to particular forms of cachexia ?
If so, and if we have diagnostic symptoms of these cachexiae, it is
evident that we shall be in possession of knowledge likely to bear on
prognosis and treatment. Is this tendency to suppurative inflam-
mation related to the cachexia of malaria, scorbutus, struma, mer-
cury, intemperate spirit drinking, syphilis, prolonged elevation of
temperature, habitual residence in a vitiated atmosphere, or to that
which co-exists, as cause or effect, with Bright's disease of the
kidney ? My own observations are insufficient to elucidate these
important practical questions ; but it is very probable that further in-
vestigation will establish a relation between these forms of secondary
inflammation and the cachexia of Bright's disease. On referring
to my cases, with a view of testing the likelihood of this suggestion,
I am disappointed by finding them so frequently defective. Many
of them were recorded at a time when attention had not as yet
been generally directed to this important part of pathology. Yet
imperfect as they are, granular degeneration of the kidney is noted
in six of the eighteen cases, and in the remaining twelve the state of
the kidney is not described.

Character of the contents of Hepatic Abscesses, — In the cases
detailed in these pages the appearance presented by the pus in
hepatic abscesses is so generally stated, that I should have thought

360 HEPATITIS.

it unnecessary to allude to the subject more particularly. But
there are statements made on this point by Kokitansky and Budd,
differing so materially from the results of my own experience, that
it would be an omission on my part not to advert to them.

Rokitansky says : " A large abscess of long standing, invariably
contains pus mixed with a considerable amount of bile, which arises
from the communication established between the cavity and larger
gall ducts."*

We are not told of the number of cases on which tEis general
statement is grounded ; nor whether the presence of bile was deter-
mined from the general colour of the pus, or by the microscope or
by chemical tests. Assuming from the expression, " considerable
amount of bile," that the inference has been drawn from the colour
as appearing to the naked eye, I find myself unable to assent to
the assertion of this eminent pathologist.

There are before me 98 cases in which the morbid appearances
of hepatic abscess are described, and ten others in which the
contents were artificially discharged. They were all observed and
noted by myself, but of only four (97, 111, 137, 141) is a bile-
tinged state of the pus recorded ; and I can hardly think that so
notable a character, if existing, would in 104 cases have failed to
attract my attention. I place the more confidence in my own
observations, because since becoming aware of the opinion of
Eokitansky, and feeling how opposed it was to my previous belief,
I have spoken with several of my professional friends, whose
experience in this form of disease has been considerable, and have
hitherto found that their conclusions coincide with my own. The
statement of the able Grerman pathologist cannot therefore be
considered applicable to hepatic abscess in India, as hitherto
observed.

In Dr. Budd's work on Diseases of the Liver are the following
remarks : —

% " Many of the old writers describe tlie pus of abscess of the liver as being generally
red or claret-colouxed, but this statement is incorrect. In all the abscesses of the liver
that I have examined, the pus was white or yellowish, just like that of a phlegmon.
The error of those who have described it as being reddish, resulted, perhaps, from
their having met witii a case in which the abscess opened into the lung, and in which
the pus, in its passage through the lung, became mixed with blood and broken-down
pulmonary tissue. They describe the matter expectorated, and not the matter con-
tained in the abscess. It is not very uncommon for an abscess of the liver to open
into the lung. Several instances of this kind have fallen under my own notice, and
in all of them the matter expectorated was a dirty red or brownish pus. The reddish

* "Pathological Anatomy," Sydenham Society, vol. ii. p. 132.

CAUSES — PREDISPOSING AND EXCITING. 361

colour of the pus was acquired on its passage through the lung. The matter in the
abscess was yellowish or white." *

Cases 108, 149, 161, 165, confirm the statement of the old
writers, that the pus in hepatic abscess is sometimes of a red
colour, and do not accord with the opinion above expressed by Dr.
Budd.

Haspell having observed a pink colour of the contents in two of
his three successful cases of puncture of hepatic abscess, has
inferred that this colour is a condition of the early stage of the
abscess, and that when present in punctured abscess it justifies a
favourable prognosis. These inferences, deduced from very limited
data, are not supported by my cases 161, 165.

Inflammation of the Portal or Hepatic Vein — is a pathological
state of interest and importance; but it is one with which I
have little practical acquaintance. Of portal phlebitis I have not
met with a case, and have only seen the morbid appearances in
one of hepatic phlebitis. In this case there was abscess, and the
branches of the hepatic vein in its neighbourhood were dilated,
contained pus, and their coats were somewhat thickened.

Section IV. — Etiology of Hepatitis. — Exciting Causes. — Ex~
ternal Cold, elevated Temperature, Intemperance, Mechanical
Causes. — Importance of Predisposing Causes stated. — The
Complication of Hepatic Abscess and Dysentery considered in
reference to the Pyoemic Theory of the Causation of Hepatic
Abscess.

In the etiology of dysentery, much importance was attached to
those conditions of the atmosphere which reduce the temperature
of the surface of the body, as an exciting cause. The same view
may be taken of the etiology of hepatitis. Dysentery was found to
prevail most in the cold months, November, December, January ;
next in June, July, and August ; and then in February and
March.

On comparing the proportional admissions from hepatitis per
cent, of the total hospital admissions with those from dysentery |,
the following differences may be noted : — 1 . The admissions from
dysentery are fully twice as numerous as those from hepatitis ; 2.
The months of February and March are those of greatest prevalence

* " On Diseases of the Liver," Second Edition, p. 98.
t Pages 274 and 362.

362

HEPATITIS.

of hepatitis, then follow November, December, January. The hot
months, April and May, as well as September and October, take
precedence of the monsoon months, June, July, August, which
latter, in the instance of dysentery, stood next to the cold
months.

Why the admissions from hepatitis in February and March have
in both hospitals exceeded those of the three preceding colder
months, I am unable to explain, but probably more extended data
will show that it is accidental. The fact, however, does not affect
the conclusion, that external cold is a common exciting cause of the
disease. It is not improbable, when we bear in mind the advanced
stages of disease at which admissions take place into general hos-
pitals, more especially at seaports, that a scrutiny of the admissions
of February and March would prove that a proportion of them had
commenced in the months which preceded.

The admissions of dysentery were fewest in the hot months
April and May * ; but we find that the admissions of hepatitis in
these months came next to the cold months, and took precedence
of the rainy months. Without attaching undue importance to
limited and partial statistics, it may be remarked that these results
tend to confirm the generally admitted impression, that elevated
temperature has more influence in the causation of hepatitis than
of dysentery. To this subject I shall presently more particularly
advert.

Proportional Admissions from Hepatitis in different Seasons.

European
General
Hospital.

Jamsetjee
Jejeebhoy
Hospital.

February, and March, — transition from cold months .
November, December, January, — cold months .

April and May, — hot months

September, October, — transition from rains

June, July, August, — rainy months ....

4-8
3-8
3-4
3-2
2-9

2-0
17
1-6
1-0
1-4

Annual proportion ....

3-7

1-0

When explaining the causes of dysentery I dwelt at considerable
length on the importance of a right appreciation of predisposing
conditions as favouring the action of the exciting cause. The
principles then inculcated are equally applicable to hepatitis.

* This remark is only strictly applicable to the European General Hospital ; for in
the Jamsetjee Jejeebhoy Hospital the admissions from dysentery in April and May
took precedence of those of February and March.

CAUSES — PEE DISPOSING AND EXCITING. 363

Whether, of the various kinds of cachexia alluded to as predis-
posing to dysentery, there are some rather than others which pre-
dispose to hepatitis, is a question for future inquiry to determine ;
but allusion may be made to one or two points relating to it.
There is nothing before me to show that there is any particular
connection between hepatic abscess and the tubercular diathesis.
Tubercles in the lungs were found only in one of the cases of hepatic
abscess. Tubercles in the liver were noticed in only three cases —
one (48) of melanosis of the colon, the other two of tubercular
phthisis.

The evidence that intemperance in drinking exercises a peculiar
influence in causing hepatitis is by no means conclusive. That a
considerable proportion of both European and native hospital
admissions from hepatitis are of intemperate individuals is
undoubted ; but this fact is equally true of other forms of dis-
ease. That the cachexia engendered by spirit drinking and the
exposure to cold and wet consequent on the direct effect of intoxi-
cation, are often operative in inducing disease, is also not to be
questioned ; but there is nothing in my notes or my impressions
to convince me that these are more frequent causes of hepatitis
than of dysentery. Spirit drinking as a special cause of cirrhosis
is not called in question, but this is a form of disease common to
the spirit drinker in all countries, and almost exclusively confined
to his class. That hepatitis, on the other hand, in its severest
forms, is not an unusual event in persons of temperate habits, — is
a statement which experience in India will generally confirm.

Is hepatitis, with a liability to suppuration, peculiarly related to
cachexia engendered by the prolonged influence of elevated tem-
perature ? I believe that it is so. It is very probable that future
research will show that the exhausted and enfeebled by continued
heat, and its associated debilitating conditions, are very prone to
hepatitis, and that in such individuals the inflammation is very
frequently excited by exposure to external cold — I mean to such
depression of temperature as suffices to influence bodies whose
power of generating heat is low.

But there is another question to propose in regard to heat. Is
it ever the exciting cause of hepatitis, as it assuredly sometimes is
of cerebral disease ? The occurrence in the hot months of the
year of hepatitis in plethoric Europeans, lately arrived in India,
with excreting functions deranged by free living, is probably
sometimes best explained on the supposition that tropical heat is
occasionally an exciting cause of hepatitis.

3G4 HEPATITIS.

Cases 166, 171, and two others not detailed, show that mechani-
cal causes are not to be overlooked in the etiology of hepatitis.

In my remarks on jaundice as a complication of remittent fever,
a case (38) is detailed, in which a lumbricus was found in the
hepatic duct. In the case which follows, a lumbricus * was found
in the centre of an hepatic abscess. These circumstances are suf-
ficient to justify the idea that hepatitis may be sometimes caused
by entozoa. The fact that dracunculi have also been detected in
the liver may countenance the probability that the lumbricus is
not the only entozoon which may act in this manner.

137. Large abscess in right lobe, flocculent walls, communicating with a branch of
the hepatic vein. — Lumbricus in the abscess. — Pus orange coloured. — No ulceration of
large intestine. — Jaundice. — Hurree Gromajee, a Hindoo cart-driver, of thirty-five
years of age, and using spirits to the extent of three ounces daily, was admitted
into the clinical ward on the 9th January, 1853. He was much reduced. The
conjunctivae were tinged yellow, and there was slight oedema of both feet. The
respiration was short and hurried, the pulse small and compressible, and the tongue
florid at the tip and edges. An indistinctly fluctuating swelling occupied the epigas-
trium, bounded inferiorly by a curved line from the tenth left rib to the eleventh
right rib, crossing the umbilicus. It was painfvd. He stated that fifteen days before
he was injured on the back by a log of wood ; that two days afterwards, pain of the
right hypochondrium, with febrile symptoms, set in ; and that the swelling appeared
six days before admission. The pulse became feebler, the dyspnoea increased, and he
died on the 12th with very slight diarrhoea. The urine gave no signs of albumen.

Inspection four hours after death. — All the white tissues were tinged yellow. —
Chest. — There were old adhesions between the costal and pulmonary pleura of the
right side. The lungs were crepitating and spongj'-. Opaque patches were found on
the external surface of the heart ; the cavity of the left ventricle was somewhat
smaller than natural. Valves healthy. Abdomen. — No traces of peritonitis were
observed except some adhesions which existed between the concave surface of the
liver and transverse colon, and also with the kidney of the right side. Adhesions
were also found between the convex surface of the liver and the diaphragm. The
liver extended as low as the tenth rib on the left side, and the last rib on the right
side, and occupied the whole of the abdomen above these points ; it was of dark mot ■;
tied red colour externally. On making an incision, an abscess was found occupying
almost the entire right lobe. It contained about two pints of orange-coloured sero-
pus, and a large quantity of pulpy flocculent matter was loosely adherent to the walls
of the abscess. A lumbricus was found in the abscess. The small portion of the
right lobe left around the abscess was of red colour. On incising the left lobe, thin
pus was seen to flow freely from a large branch of the hepatic vein, which could be
traced to the abscess, with which it communicated. The substance of the left lobe,
free of abscess, was mottled red and white. The stomach was contracted. The mu-
cous surface was rugous, and dotted red here and there. There was some degree of
increased vascularity of the mucous lining of the rectum, with commencing granular
deposit on the mucous surface. No trace of ulceration anywhere. The kidneys were
healthy.

* There is an excellent specimen of lumbrici in the biliary ducts in the Museum at
Fort Pitt, Chatham. I have also seen another in the Museum of Comparative
Anatomy at the Jardin des Plantes at Paris; and no doubt many others might
readily be found.

PYCEMIC THEORY OF ABSCESS. 365

The co-existence of hepatic abscess and ulceration of the mucous
wiemhrane of the large intestine, is treated by me, in connection
with the etiology of hepatitis in consequence of the explanation of
this event, lately proposed by Dr. Budd. His opinion is that a
very frequent, if not the exclusive, cause of inflammation of the
liver — not cirrhosis — is the transmission to the organ of pus or
vitiated secretions from an ulcerated intestinal surface. This
doctrine necessarily implies the termination in abscess of every
inflammation thus arising. In other words, it rejects the termi-
nation of hepatitis by resolution.

On these views I shall simply observe that, if we acknowledge
pyaemia as a pathological condition, we must allow that the
occasional occurrence of hepatic abscess, in the manner supposed,
is sufficiently probable. As a general proposition, however, it is at
variance with the results of clinical research in India, as the
following remarks will, I believe, sufficiently prove :—

1. Fatal dysentery with ulceration but without hepatic abscess
is a common occurrence in India. Fifty cases are now before me
and many of them have been cited in this work. Intestinal ulce-
ration without hepatic abscess is almost invariable in European
countries. Eecovery from dysentery, in which ulceration had pro-
bably been present, is not unfrequent in India. These facts, which
show a very large amount of intestinal ulceration without hepatic
abscess, are not consistent with the idea that abscess of the liver,
when existing, is always, or most commonly, the sequence of the
direct transmission to the organ, of the morbid matter of intestinal
ulcers. If this doctrine were true, ulceration of the intestines and
abscess of the liver would be much more frequently co-existent.

2. Primary uncomplicated hepatitis is not an unusual disease
in India. Restricting my inquiry to the five years of my service
in the European Greneral Hospital, I find that, of the total admis-
sions of hepatitis, 318, or 86 per cent, recovered; and this is a
result incompatible with the pyoemic origin of hepatitis. This state-
ment may be met by the objection that the numbers are probably
incorrect, from mistakes in diagnosis and the inclusion of cases of
cirrhosis. But making every allowance for this, it cannot be sup-
posed that the error was committed in all the successful cases, but
avoided in the 14 per cent, of fatal ones.

3. There are now before me, twenty-one fatal cases of hepatic
abscess without ulceration of the intestine. Setting aside all other
arguments, these positive facts are conclusive -against the theory that
pyoemia from intestinal ulcers is the exclusive cause of hepatic

3G6 HEPATITIS.

abscess. Six of these cases (138 to 143) will presently be narrated;
and seven others (107, 113, 135, 137, 162, 166, 168) are elsewhere
detailed.

4. There is good reason for believing that the records of patho-
logy misrepresent the natural proportion of intestinal ulceration
and hepatic abscess. I have long entertained the opinion that
mercurial and other purgatives, too frequently repeated in hepa-
titis, materially favour the access of muco-enteritis and subsequent
ulceration. This suspicion is confirmed by the fact, that of my
twenty-one cases of abscess without ulceration, sixteen occurred in
natives admitted into hospital in advanced stages and not pre-
viously treated with mercurial and other purgatives.

138. A large abscess in the liver. — No dysenteric symptoms. — No ulceration. — No
^projection of liver below the ribs. — John Williams, a seaman", aged twenty-eigh+, was
admitted into hospital on the 20th May, 1838, with acute pain at the scrobicnlus
cordis, increased by pressure, attended with febrile excitement, and on the 22nd,
extending to the right hypochondrium, and affected by deep inspiration and decubitus
on the left side. On the 30th he had rigors, followed by febrile excitement, and
subsequent hectic. There was no enlargement below the edge of the right false ribs,
but there was a perceptible though not great bulging of the ribs, and a want of
depression of the intercostal spaces, with dulness to the axilla. Latterly there was
much irritability of stomach, but nothing ejected except ingesta and the mucous
secretions. Throughout the whole period of illness there were no symptoms of
dysentery or diarrhoea. On the contrary, laxatives were often required ; and gene-
rally, and more especially latterly, the evacuations were formed, and perfectly natural.
He died September 5th.

Inspection fifteen hours after death. — Body much emaciated ; perceptible bulging of
the right hypochondrium and filling up of the intercostal spaces. Chest.— The lungs
were collapsed and crepitating. There was no effusion into the chest. Tender adhe-
sions existed between the upper surface of the diaphragm and base of the right lung.
The liver had pushed the diaphragm to the level of the second rib, at the most convex
part of its arc ; and its curve touched the ribs at the level of the upper part of the
fourth. The left side of the chest was natural. Abdomen. — The liver adhered to the
abdominal parietes at the margin of the false ribs, but did not project beyond it. The
entire right lobe adhered to the diaphragm, and was completely occupied by a large
abscess, containing serous fluid at its upper surface and pus below, in all about four
pounds. The sac was lined by a firm cartilaginous membrane, to which yellow floeculi
adhered. The thin layer of parenchyma interposed between the peritoneal covering
and the lining membrane of the sac was dense and fibroiis, and nowhere above half an
inch in thickness. The left lobe was mottled. The gall-bladder contained some bile.
The stomach and intestines were almost natural. There was a good deal of congestion
of the mucous coat of the depending parts of the small intestine, and also of the
ccecum ; but the texture was quite sound. The colon was partially occupied with
formed and perfectly natural feculence. The kidneys were healthy.

139. Hepatitis. — Abscess in the right lobe. — Mucous coat of the large intestine dark
red without ulceration. — Thomas Hall, aged thirty-two, private in Her Majesty's
15th Hussars, was admitted into hospital on the 9th January, 1840. He stated that
he had suffered more or less from pain of the right side for three weeks before admis-
sion. On the 13th there was dulness two inches below the margin of the right ribs,
but not extending into the epigastrium ; it subsequently reached as high as the nipple.
He died on the 15th March.

PY(EMIC THEORY OF ABSCESS. 367

Inspectmi. — Head. — There was a thin veil of serum on the convex surface of the
brain, and an ounce at the base of the skull. Chest. — The lungs were collapsed.
Abdomen. — The liver reached to the level of the third rib, and there were tender
adhesions between the right lung and the diaphragm. It also extended two inches
below the margin of the ribs, and there were adhesions to the diaphragm and con-
cavity of the ribs. An abscess containing three pints of thick pus occupied the right
lobe, and the upper wall consisted merely of the diaphragm and the peritoneal coating
of the liver. The rest of the liver was mottled. The cardiac end of the stomach was
mottled red. The mucous coat of the large intestine was dark red and dark grey in
parts, but not ulcerated.

140. Chronic pneumonia of upper part of left lung. — Secondary hepatitis and
abscess, with flocculent walls, and peritonitic inflammation. — No intestinal ulceration. —
Huree Mydhur, forty years of age, a Hindoo sailor, was admitted, after a month's
illness, into the clinical ward on the 27th June, 1848. He had cough, with muco-
puriform expectoration, and he pointed to the left subclavian and mammary regions
as the seat of pain, and there defective respiratory movement was evident. There
was also dulness on percussion, subcrepitus and bronchial sounds. He continued
under observation till the 17th July, when he died. There was more or less hectic
fever, and frequent cough with sputa, sometimes brick-red and pm'iform. On the 9th
there was delirium. On the 10th, fulness of the epigastric region, and dulness to
within an inch of the umbilicus, and uneasiness on pressure there. He gTaduaUy lost
strength, but there was no diarrhoea. From admission up to the 13th, a cautious
endeavour to affect the system with mercury was made, but without success. It was
during this mercurial course that the hepatic symptoms appeared.

Inspection. — The lung of the right side was crepitating and healthy. The left lung
adhered firmly to the lateral part of the parietes of the chest, and was separated with
diificulty. In the lateral part of the upper lobe, separated by a thin wall from the
pleura, there was an excavation of two or three inches in length, the evident result of
gangrene of that part of the lung. The inner surface of the excavation was irregular,
of dark grey and black colour ; and the boundary was dense and membranous. The
rest of the upper lobe was in a state of grey induration, and the upper part of the
second lobe was red and indurated, but in some parts still permeable to air. The
mucous membrane of the bronchial tubes was dark red. There were three or four
ounces of serum in the pericardium. The heart healthy. Abdomen. — General friable
adliesions of lymph over the entire peritoneal surface, with purulent effusion amongst
them. The liver mottled white in its texture. Two large abscesses existed in the
right lobe, with flocculent shreds adherent to their inner surfaces. The concave sur-
face of the liver adhered by thick layers of lymph to the stomach and colon, and,
on separating these, the lower wall of the largest abscess readily gave way ; it was
supported by these other viscera. The mucous coat of the large intestine was healthy.

141. Three abscesses in different stages of progress. — Pu^ bile-tinged. — General
peritonitis without rupture. — "No tdceration of the intestines. — Sagoo Beekia, a Hindoo
cultivator, thirty-five years of age, and of temperate habits, was admitted into the
clinical ward on the 15th January, 1854. He was in good condition. The respiration
was short and hurried, and chiefly thoracic. There was cough and mucous expec-
toration, and crepitus was audible in the right dorsal region. A swelling duU to
percussion occupied the space between the margin of the ribs, and a line drawn from
the tenth left rib across the umbilicus to the last right rib. The dulness reached
upwards to the right fifth rib. The tongue was fiorid at the tip and edges. The pulse
was small. Decubitus was easiest on the right side. The bowels were reported regular.
He stated that, a month before, he became affected with fever, ushered in with chills,
which left him about six days before admission, when the swelling and pain of the
epigastrium began to appear. On the 18th and 19th the bowels were relaxed, and

368 HEPATITIS.

febrile accessions were noted. Ho died on the 20tli of January. The occurrence of
general peritonitis was not distinctly marked.

Inspi'ction three hours after death. — There was about a pint and a half of senim in
the cavity of the abdomen. The serum was tinged yellow, and mixed with abundant
flakes of lymph. There were also yellow flakes effused on the surface of the peritoneum,
chiefly that covering the liver. The liver extended across the abdomen from the
eightii left rib to the crest of the right ilium. The convexity of the right lobe ex-
tended as high as the fourth rib. There were firm adhesions and exudation of lymph
between the convex surface of the liver and the diaphragm. On incising the liver,
an abscess about the size of a cocoa-nut was found at the upper part of the right
IoIdc. It was separated from the diaphragm by a thin layer of the sul)stance
of the liver. The abscess contained pus, in part thick and pulpy, and the walls were
lined by a thin membrane, which presented a flocculent appearance when floated in
water. In the lower part of the right lobe there was another abscess the size of
a mango, separated from the upper one by a layer of the substance of the liver,
about a quarter of an inch thick. The walls of this abscess were similar to those of
the other. The rest of the substance of the right lobe was of a dark red colour. At
the upper part of the left lobe there was a third abscess, about the size of a riango,
containing yellow-coloured pus (tinged with bile). The walls were lined by a thicker
and firmer membrane than those of the other abscesses, and less fiocculent when floated
in water. The remainder of the substance of the left lobe was not so dark-coloured
as that of the right. Emphysematous buUse the size of a pigeon's egg occupied the
thin edge of the left lung. There were adhesions between the left lung and peri-
cardium ; also between it and the walls of the chest. Slight adhesions existed
between the base of the right lung and the diaphragm. There was emphysema of
the middle and third lobes. There were white opaque patches on the surface of the
heart, but the structure and valves were healthy. The coecum was of dark red
colour. There was no thickening or ulceration of the mucous membrane of the
large intestine, nor of any part of the small intestine. Kidneys healthy. Spleen
healthy.

142. Hepatic abscess. — No ulceration of the intestine. — Shaik Ibrahim, aged twenty-
five, after two months' illness, was admitted on the 3rd May, 1857. He was emaci-
ated, and complained only of purging. There was no fulness of the right side noticed
during life. He died on the 9th.

Inspection. — An abscess the size of a cocoa-nut existed in the right lobe of the liver.
There were firm adhesions to the diaphragm. There was caries of the ninth and tenth
ribs, and a sloughy state of the tissues external to them. No trace of idceration in
any part of the intestinal canal.

143. Hepatic abscess. — No intestinal ulceration. — Deen Mahomed, aged forty, was
admitted into the clinical ward on the 22nd October, 1857, with well marked hepatic
abscess. Bowels confined. Secondary peritonitis came on, and he died on the 9th
November.

Inspection. — One large encysted abscess occupied the right lobe of the liver. There
was no trace of ulceration of the mucous membrane of large or small intestines, but
redness with slight granular exudation in places.

The co-existence of hepatic abscess and intestinal ulceration may
be classed in the following manner: —

1. Cases in which hepatitis has been primary, with secon-
dary ulceration, generally not coming on till suppuration has well
advanced.

2. Cases in which dysentery has been primary, with hepatic

PYOEMIC THEORY OF ABSCESS. . 369

secondary abscess, occurring generally in advanced stages of the
dysentery.

3. Cases in which dysentery and hepatitis have been coincident,
but, in general, not well marked, and with the symptoms of the
dysentery, not imfrequently for a time, giving place to those of the
hepatitis. This form, however, is rare compared with the other
two, and will be more particularly noticed in connection with the
symptomatology of hepatitis.

Primary hepatitis ending in abscess and attended by secondary
dysentery is not difficult to understand, when we bear in mind the
frequency, nay almost the universality, with which the hectic
stage of phthisis pulmonalis, and of other forms of extensive
suppurative disease, are associated with intestinal ulceration : this
event occurring in the hectic stage of suppuration of the liver is
merely an illustration of this general law, and nothing more.* In
my notes of fatal cases of hepatic abscess with ulcerated intestine,
there are seven in which this -sequence is evident.

Primary dysentery followed by secondary hepatic abscess, is the
only form of this complication which affords support to the
pyoemic theory. But that pyoemia is the ordinary cause even
of this is not for the following reasons a logical deduction from
the facts : — (a) Dysenteric ulceration, without hepatic abscess,
is common, (b) Intestinal ulceration is almost universal in the
advanced stage of phthisis pulmonalis, and is always unassociated
with hepatic abscess, (c) There is no reason for believing that
particular climates favour pyaemia, (d) There is much that is com-
mon in the predisposing and exciting causes of dysentery and
hepatitis, (e) It may be frequently observed that individuals, in
whom hepatitis occurs secondary on dysentery, have previously suf-
fered from hepatic disease. (/) It is a well-known pathological law
that, in the progress of primary inflammations, there is a predis-
position to secondary inflammations, and that these generally
prefer an organ weakened by previous disease, or by the in-
fluence of other predisposing causes, (g) The liver and large
intestine are associated in function. It might therefore be reason-
ably anticipated that they would also be occasionally associated
in their pathological conditions.

* This statement is not to be met by the argument that the ulceration of the intes-
tines in phthisis is tubercular, and consequently merely a further development of the
diathesis. That such is the character of the ulceration in a proportion of cases may
not be questioned, but the result of my obsers'-ation of phthisis in India leads me to
believe that in the majority of cases in that country the ulceration of the large intes-
tine does not differ in character from that frequently observed in dysentery.

B B

370 HErATITIS.

A consideration of these facts leads me to the conclusion that
hepatic abscess, occurring in the course of dysentery, is, for the
most part, simply an instance of a secondary inflammation arising
in an organ predisposed by previous disease or other influences,
and is not caused by pyoemia. The abscess was, apparently,
the result of secondary hepatitis, in nine of my cases.

In respect to those cases in which dysentery and hepatitis appear
to be coincident, I would merely observe that when we recollect
how much there is common in the causes of these two affections,
the wonder is that this original co-existence is not very frequent
instead of being rare.

Section Y. — Symptoms of Hepatitis. — Early Stages. — Pain,
Respiratory Movements. — Physical Signs. — Altered Secretion,
Jaundice. — Constitutional Disturbance. — Suppuration. —
Course of Hepatic Abscess.

The size, situation, and relations of the liver, the constitution of
the patient, and the duration of the attack, should always be borne
in mind in investigating the symptoms of hepatitis. It should also
be remembered that the inflammation may affect varying extents
of the organ, as well as one part, or several, of its surface or sub-
stance,— separate or combined.

In the early stages of acute hepatitis pain will vary in degree,
according as the inflammation affects the peritoneal covering or is
confined to the parenchyma. In the former case it will be distinct
and often acute. In the latter dull — a sense of weight and un-
easiness rather than pain — and apt to be obscure, when only
limited portions of the organ are engaged, and when the constitu-
tion is asthenic. The pain will be increased, occasionally indeed
only appreciable, by pressure, full inspiration, and turning to the
left side. Sometimes in obscure cases uneasiness, not otherwise
detected, may be elicited by meeting the liver, as it descends under
full inspiration, by gentle pressure, upwards, with the hand placed
on the anterior surface of the abdomen below the margin of the
right ribs.

Pain will vary in situation according to the part of the liver
affected. It may exist at the posterior, lateral, or anterior parts of
the arch of the right ribs below the sixth ; at the margin of the
right ribs from the seventh to the last, or at the epigastrium just
below the ensiform cartilage. But pain from the sixth to the
eighth or ninth rib, may be caused by pleuritis or pneumonia : in

SYMPTOMS — PAIN, RESPIRATION. 371

this diagnosis, auscultation will materially assist us. It is not often
that primary pi euritis or pneumonia is so limited in extent; but
should partial friction murmur, or crepitus, indicate that these
affections exist, then it may be inferred that the liver is not im-
plicated, because the co-existence of hepatitis and pleuritis or
pneumonia, common enough in the advanced stages of the first-
named disease, is rare at its commencement.

Care must be further taken not to confound costal pain, related
to muscular or fibrous tissue and rheumatic diathesis, with the pain
of internal inflammation. The history of the patient, and a
consideration of the other symptoms, should protect us from an
error of this kind.

Pain below the margin of the right ribs may proceed from the
colon, the duodenum, the biliary ducts or gall-bladder, and here
again a judicious review of the associated symptoms must guide
the diagnosis.

If the clinical student remembers what has been said (p. 327),
on the infrequency in India, of inflammation of the periphery,
compared with that of the substance of the liver, he must already
have arrived at the conclusion, that pain is often not a prominent
symptom of hepatitis.

What is the value of jpain of the right shoulder as a symptom
of hepatitis? It is present in a small proportion of cases, but
absent in the majority. "When present it gives additional emphasis
to the other symptoms, but its absence in no respect detracts from
their import.

We are often materially assisted in detecting inflammation of
the liver, by carefully attending to the movements of the lower
part of the right side of the chest and of the same side of the
abdomen, under inspiration. Defective movement of the lower
right chest, and of the abdominal wall below the right costal mar-
gin, in the absence of thoracic disease, suggests the existence of
hepatitis, as might be anticipated, when we recollect the great ex-
tent of the hepatic surface, in relation with the diaphragm, and the
movements impressed upon it by the contractions of this muscle.
But while importance is thus attached to these partial imperfect
inspiratory movements, it must not be forgotten that the inflam-
mation may be so limited and so deep as to be removed from the
influence of the pressure of the diaphragm. Therefore normal
respiration does not necessarily imply the absence of hepatitis.

Nor may we overlook the relations of the concave surface of the
liver to the stomach, and the explanation which this affords of the

B B 2

372: HErATiTis.

occasional occurrence of vomiting. But this symptom is more
frequently observed in the advanced than in the early stages of
hepatitis.

Do physical signs assist us in the diagnosis of the early stage
of hepatitis?

At the commencement of inflammatory action there is alwa3^s an
increased quantity of blood in the affected capillaries, and when
this derangement is of an organ well supplied with blood, aug-
mented bulk must be a necessary consequence.

If there be general inflammation of the substance of the liver,
the size of the organ will be increased, and a sense of weight and
tension in the hepatic region, usually aggravated by turning to
the left side, will be complained of.

Enlargement of the liver may be ascertained by careful nr.anual
examination, below the margin of the right ribs. There, the edge
of the organ may be felt, and this result will be favoured by
causing the patient to incline towards the left side, while we gently
raise the liver, with the left hand placed on the inferior dorsal
region, towards the right hand applied below the margin of the
ribs. But if hepatitis exists pain may materially interfere with ac-
curate palpation. This, however, is of little consequence, for the
lower as well as the upper limit of the organ may be more accu-
rately determined by gentle percussion. ClinicaF physicians doubt-
less differ in their estimate of these two methods of investigation.
My own preference is for percussion made gently and from below
upwards as respects the lower limit, and from above downwards
as respects the upper limit. It is hardly necessary to add, that
both in palpation and percussion regard must be had to the condi-
tion of the contents of the adjacent hollow viscera.

Enlargement is, however, not so common a sign of the early stage
of hepatitis as casual reflection might suggest. The capacity of the
capillaries of the hepatic artery — those concerned in inflammation
■■ — is small compared with that of the portal capillaries ; therefore
enlargement of the liver from capillary turgescence is a more pro-
bable sequence of fulness of the portal vein than of the hepatic
artery. Portal capillary turgescence is not hepatic inflammation,
but hepatic congestion ; therefore augmented size of the liver, quickly
appearing, is more likely to arise from the latter than from the
former ; moreover, general inflammation is rare, but the conditions
which favour general congestion are of common occurrence : they
are disease of the heart and of the lungs, also the deteriorated
blood, and deranged balance of circulation in malarious fevers.

SYMPTOMS — ENLARGEMENT, JAUNDICE. 373

A liver, tense and enlarged by congestion, is often also tender
on pressure ; therefore, on the detection of enlargement, we must
carefully inquire for the other symptoms of inflammation, and for
the conditions which favour congestion ; also whether the patient
has previously been the subject of hepatic enlargement from re-
curring fever, or from malarious or other cachexia. The result of
this inquiry will decide the diagnosis.

This question of diagnosis from enlargement rests on the hypo-
thesis of general hepatitis, but as the inflammation is commonly
limited in extent, it follows, that hepatitis, in its early stages, is
frequently unattended by enlargement.

Mr. Twining believed that deep-seated hepatic inflamma-
tion was generally indicated by a peculiar tense state of the upper
part of the right rectus muscle. Subsequent observers have not
confirmed this opinion. That the muscular fibres of the anterior
abdominal walls often spasmodically contract to keep off the pres-
sure of the hand from a tender organ beneath, is true ; and the
tension or resistance thereby occasioned, — whether occurring at
the margin of the right ribs, or elsewhere, — is often a valuable
sign of subjacent inflammation. But that this sign has any special
relation to deep-seated hepatic inflammation is not in accordance
with my experience.

Do altered states of the biliary secretion, as evidenced by the
condition of the alvine discharges, assist us in the diagnosis of
hepatitis ? Most certainly not. Clinical research is on this point
in keeping with physiology and pathology. If the bile be secreted
from the portal capillaries, if hepatitis be a derangement of the
capillaries of the hepatic artery, and generally only of a small
portion of them — then the reasonable inference is, that hepatitis
is not unlikely to be attended with a normal state of the biliary
secretion. Observation of the disease proves the accuracy of this
conclusion. In hepatitis the secretion may be normal ; or it may
be excessive or defective.

The bile is secreted by the portal capillaries. Pathology teaches
us that the circulation in these is often deranged, and suggests that
altered secretion is more likely to be related to deranged circulation
of the portal vein than of the hepatic artery ; and that when it
occurs in hepatitis it is not a symptom of it, but of co-existing
portal derangement. Both observation and theory justify the
statement that the state of the biliary secretion is of little value as
a symptom of hepatitis.

Jaundice is mentioned as a symptom of hepatitis in systematic

B B 3

374 HEPATITIS.

works on disease ; and considerable prominence has been given to
it, even in a recent able special treatise on the diseases of the liver.
But, as regards India, the statement is erroneous. In that
country jaundice is very seldom present in hepatitis ; and its
absence or presence is of no account in determining the diagnosis.
In evidence of the accuracy of this statement, I need only refer to
the numerous cases of hepatic abscess now before me. There are
only five in which jaundice has been noted, and in them the ex-
planation is sometimes supplied by such events as the presence of
a lumbricus in the abscess (137), or the pressure of pus in the
neighbourhood of the common and hepatic ducts* (136).

Pain, enlargement, deranged secretion of the liver, and modified
function of adjacent organs, in their relation to the symptomatology
of commencing hepatitis, have been considered ; but we have yet
to inquire whether general or constitutional symptoms are of
importance.

The local symptoms which have been described may be preceded
by a sense of chilliness, to be followed by heat of skin and fre-
quency of pulse; and some degree of this febrile disturbance
generally continues throughout the course of the disease.
The pulse is more or less full, the tongue more or less coated,
and the bowels are generally confined. The degree of these
symptoms has reference to the state of the constitution, being
more marked in the sthenic than in the asthenic.

It was stated that not unfrequently dysentery may exist without
much febrile disturbance. The same fact is true of hepatitis, more
especially when the central parts of the organ are the seat of the
inflammation ; and it is very probable when the morbid action is
of limited extent and the diathesis asthenic.

It has been already explained (p. 278), that when inflammation
attacks individuals, — European or native, — who have been ex-
posed, for some time, to the influence of malarious climates, the
symptomatic fever frequently assumes a remittent form. This
remark applies to hepatitis as well as to other inflammations ; but
the fact has been more frequently noted by me in natives than in
Europeans.

Such, then, are the symptoms on which we may rely for the

^ I do not, in connection with hepatitis, make prominent alKision to a dark, dingy-
appearance of the skin not unfrequently observed in Europeans suffering from acute
disease in India, and which may be held to indicate an inadequate elimination of bile ;
beeaxise, though occasionally present in hepatitis, it is not confined to that disease,
and can hardly be considered a symptom of it. "When observed, however, it neces-
sarily directs our attention to the condition of the liver and its functions.

SYMPTOMS. HEPATIC ABSCESS. 375

diagnosis of acute hepatitis in its early stages. They are some-
times, it appears, sufficiently distinct and expressive ; but at other
times, unfortunately, vague and unsatisfactory. This obscurity,
moreover, is most apt to attend inflammation of that part of the
organ, and in that kind of constitution, in which suppuration is
likely to occur.

Though, then, the diagnosis of hepatitis may be occasionally
doubtful, still I entertain the belief that too much prominence has
been given to this feature by practical writers. My conviction is,
that with a careful inquiry into symptoms, local and general, the
observation of the diathesis, and a just attention to the previous
history as respects former disease and exposure to predisposing and
exciting causes, hepatic abscess, unsuspected or undetected during
life, ought to be a much rarer event than, is generally supposed.
The contrary opinion has a manifest tendency to encourage
careless investigation.

When hepatitis occurs in individuals of good diathesis, is seen
early, and is met by judicious treatment, the symptoms, local and
general, will, for the most part, gradually disappear, and the
individual be restored to health.

In many cases, however, in consequence of bad diathesis, or
advanced stages, or other causes, recovery does not take place,
in some suppuration occurs, and hepatic abscess is formed. It is
of importance to be able eai'ly to detect this result and to note its
progress, because principles of treatment different from those suit-
able to the antecedent stages are indicated. There can be no doubt
that tardiness in detecting suppuration and in modifying the treat-
ment accordingly has led to undue mortality from hepatic abscess.

I proceed now to describe the symptoms which indicate that
hepatic inflammation has terminated in suppuration. When
the pain or other symptoms of hepatitis have continued with little
or no abatement, there may appear after some time — eight or
twelve days — increased fulness of the lower right false ribs, or
fulness or tenseness below their margin or in the epigastrium,
attended with increased dulness on percussion. Or the signs may
point to enlargement upwards. There may be short dry cough,
the respiration may be short and thoracic^ and dulness on percus-
sion may extend above the normal limit. Or in some cases the
signs of increase both upwards and downwards may be combined.
When such phenomena occur in succession to well-marked symp-
toms of acute hepatitis, there can be no doubt that abscess has
formed.

B B 4

376 HEPATITIS.

But this distinct transition of the inflammation into abscess is
not the usual course. Some degree of alleviation, consequent,
perhaps, on the treatment employed, is more common : the pain
may cease, or be very much lessened, and the febrile excitement may
pass away ; but emaciation increases, and a constant sense of lan-
guor is experienced. This state may continue for some days.
Then occasional chills * may be complained of, or some degree of
febrile excitement may be apparent towards evening, slight at first,
perhaps overlooked, but soon increasing in degree, and assuming
the character of hectic, with a tongue florid at the tip and edges,
or tending to be apthous. With all this constitutional disturbance,
there may, as yet, be no return of local symptoms — no signs of
enlarging liver ; but, notwithstanding this, slowly-developed hectic
fever, consecutive on previous symptoms of hepatitis, affords
almost conclusive evidence that suppuration is in progress, and will
shortly be proved by the positive signs of hepatic abscess. Some
degree of uneasiness and sense of weight will, however, be usually
experienced in the region of the liver ; or a feeling of oppression at
the lower part of the chest, attended with dry cough. Sometimes,
at this stage, acute pain of the right side comes on suddenly,
caused either by tension from the increasing contents of the ab-
scess, or by sudden recrudescence of the inflammation ; and now, if
the previous symptoms have not been carefully noted, and the right
diagnosis formed, a serious error may be committed. This sudden
access of acute pain may be interpreted as indicating the onset of
primary acute hepatitis ; and injudiciously active treatment may,
in consequence, be adopted.

The disease still advancing, the physical signs of consider-
able enlargement, gradually appear. If in the direction dowTi-
wards, it will be indicated by fulness and hardness and dulness at
the margin of the right ribs, and for some distance below them ; if
the left lobe is the seat, the fulness and dulness will be in the
epigastrium. If, on the other hand, the enlargement be towards
the chest, there will be cough, impaired movement of the lower
part of the right chest, and increasing dulness above the sixth rib.

With these physical signs of enlarging liver, and symptoms of
deranged function of a^acent organs, there will be increasing
emaciation, continuance of hectic fever, and at times acute pain of

* In respect to the occurrence of rigors, in tlie course of hepatitis, I would remark
that when distinct they afford strong suspicion, but not certain evidence, of suppu-
ration ; for I have known them present in cases in which abscess did not result. On
the whole, the symptom is not of much value, and the observer will be in continual
error if he allows their absence to influence his diagnosis.

SYMPTOMS — HEPATIC ABSCESS. 377

the side. Then, at this stage, dysenteric symptoms, chronic in
character, generally appear ; or, to express it otherwise, secondary
inflammation of the mucous membrane of the large intestine,
usually passing on to ulceration, is apt to arise.

The hepatic abscess has been traced to a stage in which its ex-
istence is no longer doubtful, and its still further progress has to
be described. But before doing so, I am desirous of also following
to the stage at which we have now arrived —1, abscess not preceded
by well-marked symptoms of hepatitis, — the obscure cases to which
reference has been made on several occasions ; 2, abscess secondary
on dysentery ; 3, those cases in which dysentery and hepatitis have
been coincident, but the symptoms of both have been badly deve-
loped, and the issue has been in hepatic abscess.

1. We have just learnt that hepatic abscess is sometimes deve-
loped in this manner, viz., the symptoms of hepatitis are more or
less, it may be entirel}^, removed, and are succeeded by certain
phenomena, which, viewed in connection with the fact of previous
symptoms of hepatitis, justify the conviction that suppuration has
taken place. But hepatic abscess may occur, unpreceded by dis-
tinct symptoms of hepatitis, and the question now is, by what
means, under these circumstances, may we detect or infer its pre-
sence. We fix our attention on the symptoms which are so expres-
sive in succession to those of marked hepatitis, viz., loss of flesh,
sense of languor and debility, florid tongue, occasional chills, even-
ing flushings of heat gradually passing into hectic fever. Should
these occur in an individual of sallow complexion, cachectic from
elevated temperature, mercurial courses, mental anxieties; or the
subject, at former times, of attacks of hepatitis, or of deranged
bowels with pale discharges, and not addicted to the intemperate
use of spirits, or certainly tainted with malaria, then we may
entertain a strong suspicion that we have to deal with an ob-
scure hepatitis passing into suppuration. In the instance of the
spirit drinker, we must keep in view the probability of cirrhosis.
In the instance of the tainted with malaria, we must consider the
probability of this influence, being a sufficient explanation of the
symptoms.

The chief difficulty, however, will be experienced in those
occasional cases in which the abscess forms slowly *, is small,

* An interesting case of long existing abscess is given by Dr. Budd, at p. 169 of
his work, second edition.

Dr. Maclean, of the Madras army, in a very valuable paper on the "Abuse of Mer-
cury in Hepatic Disease," in the third number of the " Indian Annals of Medicine,"
also quotes a case of obscure and old hepatic abscess. Careful perusal of the cases

378 HEPATITIS.

deep, becomes encysted, and quiescent, or has partially undergone
absorption. For such may endure for months, it may be years, and
give, only occasionally, and at long intervals, obscure indication of
its presence. Still, even in these rare instances, the feeble general
health and the character of the occasional derangements, viewed in
connection with the previous history, may generally serve to excite
our apprehension in respect to the condition of the liver.

I find in my notes the following case illustrative of the general
tenor of these remarks on the symptoms of obscurely forming
hepatic abscess. Several years ago I attended a delicate European
female, with acute hepatitis. She recovered under the cautious
use of leeching, and gentle mercurial influence. Subsequently she
became pregnant, and was delivered at the full period. She
nursed for several months, but was obliged to discontinue. Then,
as I learnt, she suffered from occasional febrile accessions, and re-
laxed bowels, and became emaciated, but made no complaint of
pain in the region of the liver. This state continued, with occa-
sional abatement, but no suspicion of serious organic disease was
entertained. The symptoms were thought to depend on debility
from lactation. I now incidentally saw her, as a friend rather than
professionally, between six and seven o'clock in the evening, and
was much struck with the great emaciation, the hot dry skin, the
feeble frequent pulse, and very florid tongue. I made no examina
tion of the side. Three or four days afterwards she died suddenly ;
hepatic abscess had burst into the sac of the peritoneum.

2. Let us next notice the cases of hepatic abscess which are
distinctly secondary on dysentery. The disease, we may suppose,
has been correctly viewed as dysentery, it has attained to such
degree of progress, that ulceration has probably resulted ; or, not
unfrequently, the symptoms indicate that improvement has com-
menced, but it is not steady, the emaciation and languor being
greater in degree than the amount of the dysenteric symptoms can
satisfactorily explain. If, under these circumstances of dysentery,
an evening febrile accession, with increasing floridity of tongue, is
detected, then there are good grounds for suspecting that abscess
has either formed, or is forming in the liver, to become evident, in
due course, by the usual physical signs. A large proportion of such
cases will be found to be of individuals predisposed to hepatitis by
former disease, or by those influences which have been already
several times mentioned, and the recognition of which, under the

narrated in this chapter will discover several in which the course of the abscess was
very slow.

SYMPTOMS — HEPATIC ABSCESS. 379

circumstances now adverted to, will tend to confirm the diagnosis of
hepatic abscess.

3. But it is not to the advanced stages of dysentery that a co-
existing hepatitis with tendency to terminate in abscess is con-
fined. It sometimes happens that the dysenteric symptoms have
been present for a few days only, have not been severe, perhaps
neglected; then the symptoms of hepatitis creep on slowly and
obscurely, and as they become confirmed, the dysenteric symptoms
may disappear, or continue in a subdued form. Here we have an
illustration either of the two diseases originating at the same time
under the influence of the same causes, or of a primary disease,
slight in degree, giving place to the greater development of a
secondary one. This relation of hepatic abscess to dysentery is
very rare compared with that in which the hepatitis is a feature of
the advanced stages of dysentery. But it is very important — its
gravity is apt to be overlooked. It is not confined to the cachectic
and old resident, but has been witnessed by me only in Europeans.
I have the impression that it will probably be found to be related
to the predisposing influence of depressed vital actions consequent
on malaria, mental anxiety, or other similar causes. This form of
disease is well illustrated by the following case : —

144. Slight dysenteric symptoms of some days' duration, followed by febrile symp-
toms.— Those of hepatic inflammation coming on obscurely, and ending in abscess. —

Mr. H , a gentleman, about thirty-five years of age, who had been resident some

years in Bombay, at the beginning of July 1847, suffered from occasional dysenteric
symptoms. He passed small quantities of blood-tinged mucus. This, however, had
abated much, without treatment. I saw him first on the 16th July. There was not
any febrile disturbance, no uneasiness on pressure of the abdomen, and the scanty
discharges did not take place more frequently than twice or thrice in the twenty-four
hours, but he passed sleepless nights. On the 17th slight uneasiness of the right side
of the abdomen was first complained of, and on the 18th there was a febrile accession,
which recurred with greater severity on the evening of the 19th, with uneasy epigas-
trium, occasional retching, a coated tongue, and a dingy yellowish tinge of the skin. The
dysenteric symptoms had ceased. There was now fever, with morning remission and
evening exacerbation ; and on the 22nd there was considerable pain below the right
ribs, on turning to the left side, and on full inspiration ; and on the 23rd there was
general fulness of the lower right ribs, but the liver was not detected below them.
On the 24th, after pain suddenly and severely felt below the right ribs and over the
abdomen generally, relieved by sinapisms and anodynes, a distinct defined hardness
midway between the ribs and iliac fossa became perceptible. There was now abate-
ment of the febrile disturbance, cessation of the dysenteric symptoms, and quiescence
of the hepatic ; and he was sent early in August to the Cape of Good Hope, in a com-
fortable ship. He died shortly after arrival there of hepatic abscess. He was ti'eated
with free leeching, calomel, ipecacuanha and opiates, with quinine during the febrile
remissions.

Having described the difierent circumstances under which sup-
puration in the liver may become developed, I return to the history

380 HEPATITIS.

at that stage when, however originating, the existence of abscess has
become certain ; and proceed to follow it to its several issues.

In a large proportion of cases, death takes place in consequence
of the exhausting effects of hectic fever, and co-existing diarrhoea,
without rupture of the abscess. This is the course when there are
many abscesses scattered about the substance of the liver, or when
one or two large abscesses exist deep in the parenchyma of the
right lobe. The fatal termination is, no doubt, in instances,
hastened by the too long-continued use of antiphlogistic remedies,
intestinal irritants, or injudicious operative proceedings. In these
circumstances of hepatic abscess, the prognosis is necessarily most
unfavourable, but it forms no part of the art of medicine to add to
the danger by unseasonable interference.

The abscess may advance to the external surface, fluctuate dis-
tinctly, and point at the margin of the right ribs, the epigastrium,
or an intercostal space. If life be prolonged, rupture will take
place, and the likelihood of a successful result will depend on the
state of the constitution, on the abscess being single or not, being,
seated in the thin parts of the organ or extending to its deeper
structures, and on its being associated, or not, with dysentery. But
the natural course in cases of this kind has been frequently modified
by surgical interference, and our data are therefore rendered im-
perfect. The question of the puncture of hepatic abscess will be
considered as part of the treatment.

Hepatic abscess may extend in the proximity of the diaphragm,
and pleuritis and pneumonia of the base of the right lung may be
excited. This may be indicated by, in addition to cough and de-
fective respiratory movement, friction murmur, or crepitus. This
event is most likely to occur when the abscess is large.

A "hepatic compression rhonchus" has been described by Dr.
Walshe, as present in enlargement of the liver, and is attributed by
him to expansion of the lower portion of the lung previously com-
pressed. It has been inferred, that this sign may serve to assist in
the diagnosis of abscess when pressing upwards, and causing
compression of the lung. I am unacquainted with this sign, and
though I may not question the accuracy of Dr. Walshe's observation,
or the justness of his explanation*, yet I may doubt its applicability
without great caution to hepatic abscess ; for here there is a great

* I may observe, that my knowledge of Dr. Walshe's opinion is derived from an
interesting inquiry into the " Statistics and Pathology of Abscess in the Liver," lately
published by Mr. E. J. Waring, Eesidency Surgeon at Travancore, and the able author
of a " Manual of Practical Therapeutics."

SYMPTOMS — HEPATIC ABSCESS. 381

probability that, by less practised ears, the rhonchus may be coa-
founded with friction murmur, and thus the existence of pleuritis be
overlooked. I am the more confident in this opinion, because my
late much valued friend, Dr. Malcolmson, committed this error, in the
year 1838. In a paper published in the 21st volume of the Trans-
actions of the Medico-Chirurgical Society, he describes a sound
between " a crepitous rattle and a bleating," and he attributed it
to compression of the thin edge of the lung ; but it is evident from
the description of the appearances after death, that the sound heard
had been a friction murmur. " At the spot where the sound was
heard, there was a slight adhesion of the thin margin of the lung
to the sixth and seventh ribs."

When the pleuritic inflammation has terminated, as occasionally
happens, in circumscribed or general effusion, then there may be
doubt whether the dulness, absence of vocal thrill, and other signs
of displacement and compression of the lung, are due to empyema,
or simply to enlargement of the liver. Perhaps this difficulty ought
only to be experienced in cases which come under notice at this
advanced stage, and in which there has not been the opportunity of
observing the early symptoms, and thus ascertaining the previous
existence of hepatitis. If the following case had occurred in a
hospital in Europe, there would have been little hesitation in at
once determining it to be one of right pleuritic effusion ; but
admitted into a hospital in India, in which hepatic abscess en-
croaching on the chest, sometimes associated with empyema, is not
an unfrequent event, there was room for the doubt which was
experienced, and which is expressed in the heading of the statement.

145. Diagnosis doubtful : whether right pleuritic effusion, or large hepatic abscess,
or both conjoined. — Shaik Chand, twenty-one years of age, a Mussulman butler, of
emaciated frame, and with anxious countenance, addicted to the moderate use of
spirits, was admitted into the clinical ward on the 13th November, 1852, The res-
piration was short, hurried, and chiefly thoracic, and the movement of the right side
of the chest was defective. The right dorsal, lateral, and mammary regions were
completely, the scapular and interscapular slightly, dull on percussion. In these dull
situations, bronchial respiration was audible, and vocal thrill altogether absent. In the
subclavian resonant region the respiration was puerile. The prsecordial dulness com-
mencing at the second left rib, was boimded internally by the left sternal border, and
below was continuous with the hepatic dulness. The heart's apex beat between the
fourth and fifth left ribs, half an inch below and external to the nipple. The right
side across the nipple exceeded the left by one inch. Below the margin of the right
ribs, there was sense of induration, with dulness, continuous with the thoracic dulness.
A curved line from the point of the right twelfth rib, to that of the tenth left rib, and
passing about an inch above the umbilicus, formed the lower limit of this indurated
and dull space. Decubitus easiest on the back, most difficult on the left side. Com-
plained of pain of the right side, and occasional cough. Stated that five months
before he had suffered from intermittent fever, and been cured. It recurred, how-

382 HEPATITIS.

ever, six weeks before admission, followed by cough. The induration below the ribs
had been first noticed fifteen days ago. He continued under observation, sufiering
from febrile accessions, dyspnoea, some increase in the size of the right side of chest,
till the 23rd, when he was removed by his friends. The urine had given no trace of
albumen.

I add another instructive case, in which the error in diagnosis
was committed, probably in consequence of adhesions preventing
the descent of the liver, and the great extension upwards of the
abscess preventing marked lateral bulging.

146. Hepatic abscess mistaken for pleuritic effusion. — Pascoal Kyttan, aged forty,
was admitted into hospital on the 28th February, 1857, after ten days' illness. There
was hurried respiration, febrile heat, feeble pulse, tenderness below the right ribs, with
dulness for an inch, defective movement of the right side of chest, dulness of lateral,
infra-scapular and lower scapular regions with defective breath sounds, occasional
crepitus and feeble vocal thrill ; also slight general fulness of the right infra-mamma cy
and infra- axillary regions. He continued suffering from evening febrile exacerbations,
more or less dyspnoea, sometimes pain of right side of chest. Crepitus was heard,
from time to time, and friction murmur was on one occasion suspected in the infra-
scapular regions. He died on the 2nd March.

Inspectio7i. — The right lobe of the liver was throughout its entire surface firmly
adherent to the diaphragm. It did not project above an inch below the ribs. It was
converted into a large abscess sac, the upper wall of which for a considerable extent
consisted chiefly of the diaphragm, which ascended to the third rib. The gall-bladder,
full of bile, was part of the lower wall. There was pretty firm adhesion of the
diaphragm to the base of the lung ; but no engorgement or solidification of the limg
there or elsewhere ; it crepitated throughout. The left lung was also healthy. The
left lobe of the liver was healthy, and was pushed over to the curve of the left ribs.
There was streaked vascularity of the mucous membrane of the colon, with two or
three superficial ulcers with granular exudation in the ccecum and rectum.

Hepatic abscess may point at the diaphragm, rupture, and
communicate with the lung, {a) If the abscess has been large and
has opened into a bronchial tube of some size, a considerable
quantity of pus may be quickly expectorated, and if the constitution
has been good, recovery may take place ; but communication with
the lung in this manner is of rare occurrence. (6) The abscess may
be small, and, on opening into the substance of the lung, may
excite, in some degree, inflammation in the tissues adjacent, then
muco-puriform sputa, generally tinged red, will be expectorated in
moderate quantity, for varying periods, and if the constitution
has been good and the abscess single, there will be a fair chance of
restoration to health. The majority of recovered cases of abscess
communicating with the lung are of this nature, (c) The abscess
may be large and open into the substance of the lung, excite
inflammation, softening, liquefaction of tissue, and lead to the
formation of a ragged cavity, of varying size, in the base of the
lung, and continuous with the sac in the liver. The sputa then

SYMPTOMS — HEPATIC ABSCESS. 383

will be muco-puriform or sero-puriform, often in considerable
quantity, generally of red or brown tint, very rarely bile-tinged,
and expectorated with harassing cough. A fatal result will take
place in periods longer or shorter, according to the diathesis. In
such cases careful auscultation should detect the presence of
cavernous sounds in the base- of the lung.

In " Notes on Hepatitis," as observed by me in the European
Greneral Hospital, presented to the Bombay Medical and Physical
Society in May 1845, and published in No. VI. of their "Trans-
actions," I find the following remark relative to the opening of
hepatic abscess into the lung : —

" This expectoration of brick-red puriform fluid I am disposed to consider as patho-
gnomonic of abscess in the liver opening into the lungs, because there is not any disease
of the lungs in which we can conceive, as a result, the co-existence of pus intimately
intermixed with blood ; the one, pus, being the result of an advanced stage of inflam-
matory action ; the other, blood, the result of an early stage of the same action. But
when we suppose that the pus comes from the liver, and the blood from the lung
irritated by the foreign body, the co-existence is sufficiently intelligible."

Dr. Budd, in his " Treatise on Diseases of the Liver," * published
in June 1845, writing of the opening of hepatic abscess into the
lung, thus expresses himself : —

" When this happens, it is marked by very characteristic symptoms, by a new train
of stethoscopic phenomena, which it is perhaps unnecessary to detail, and by the sud-
den expectoration of a dirty red or brownish puriform matter. The peculiar colour
of this matter, which has been already noticed, arises from the pus, in its passage
through the lung, becoming mixed with blood and broken down pulmonary tissue.
There is no matter like it expectorated in any disease of the lung itself ; and I believe
that its appearing is pathognomonic of abscess of the liver, or at least of abscess perfora-
ting the lung. I observed it in several instances in the Dreadnought, and more than once
was led by it to detect an abscess in the liver, of which I had previously no suspicion."

Here, then, are two observers, remote from each other, unac-
quainted with each other's researches, making at the same time,
and very nearly in the same words, the same observation relative
to a symptom of disease ; yet both were certainly in error in re-
gard to the exclusive light in which they viewed the symptom.

The kind of sputa, which I have described in my remarks on
pneumonia, under the designation of red-tinged muco-puriform
sputa, observed in states of asthenic pneumonia, is not to be distin-
guished from that which I formerly considered to be pathognomonic
of hepatic abscess having opened into the lung. Confiding in my
former investigations, I, in more instances than one, committed an
error in diagnosis, after my transference from the European to the
Jamsetjee Jejeebhoy Hospital brought me for the first time into
practical acquaintance with asthenic forms of pneumonia.

* First edition, page 88.

384 HEPATITIS.

•
The diagnosis between asthenic pneumonia and communicating
hepatic abscess, when undue importance is not attached to this
character of the sputum, may, no doubt, in the majority of cases,
be satisfactorily made out ; but yet not in all, as the following cases
will serve to illustrate : —

147. Asthenic pneumonia mistaJcen for communicating hepatic abscess. — Dhoondee
Pelajee, a Hindoo mason, fifty years of age, was after twenty days' illness, admitted
into hospital, on the 24tli January, 1846, affected with fever, anxiety, dyspnoea, and
pain across the lower and anterior part of the chest. There were bronchitic rales, with
crepitus and bronchial respiration in the posterior part of the right side of the chest.
The disease was considered to be pneumonia. But on the 26th the pain extended
from the right nipple to two inches beyond the margin of the right ribs ; and there
was dulness on percussion throughout this extent. The sputa were of brick-red
colour, and in detached masses. The opinion was then entertained that there was
abscess of the liver, which had opened into the lung, and that the pneumonia was
secondary. He died on the 30th January. The liver extended an inch beyon 1 the
margin of the ribs ; it had formed slight adhesions with the diaphragm, was congested
with blood, but without abscess or other disease of structure. The right lung adhered
to the diaphragm and the ribs by tender adhesions ; the lower lobe was in a state of
red induration.

148. Whether asthenic pneumonia or communicating hepatic abscess — doubtful. — •
Allawoodeen, a Mussulman weaver, thirty-seven years of age, was admitted into the
clinical ward on the 27th December, 1850. He had been ill four months. He was
emaciated ; his respiration was short and hurried ; there was dulness, with some slight
bulging of the lower part of right side of the chest. There was defectiveness there of
vocal thrill, and absence of sound under the stethoscope. There was tenderness
below the margin of the right ribs. He had constant troublesome short cough, expec-
torated red-tinged opaque mucus, and suffered from hectic. The illness had com-
menced with pain of the right side of chest and margin of the ribs four months
before admission ; the cough and expectoration had existed for six weeks. The sputa
became muco-puriform, and tinged red. About a month after admission there were
signs of a cavity at the lower angle of the right scapula, and dysenteric symptoms
came on. He was removed from the hospital in a moribund state. This case was
entered Pneumonia in the hospital returns, but I am very doubtful of the accuracy of
the diagnosis that was then formed. I believe now that hepatic abscess had opened
into the lung.

Abscess may open into the stomach or intestinal canal, the
peritoneum or pericardium, but I have not under this head any
remarks to make in addition to those already offered on the patho-
logy of these events (pp. 342, 345).

Section VI. — Treatment of Early Stages. — Blood-letting, general
and local, — Mercurial and other Purgatives. — Mercurial
Influence. — Blisters. — Treatment when Abscess is forming
and is perfected. — Question of Puncture considered. — Change
of Climate.

I shall first describe the treatment of the early stages of acute
hepatitis, and then that which is applicable after suppuration has

TREATMENT — BLOOD-LETTINa. 385

taken place. Several of the remedievS which have been noticed in
the chapters on fever and dysentery will again come under review ;
but I shall not deem it necessary to reiterate principles which
have been already fully explained.

Success in the treatment of hepatitis, as in all inflammatory
diseases, depends on the recency of the attack, and the diathesis
of the patient — ■ whether favourable to resolution or to disorga-
nisation.

General Blood-letting. — When the period of the attack renders
it probable that the inflammation has not passed the stage of
vascular turgescence or commencing exudation — when the general
aspect of the patient, the rate, fulness, and firmness of the pulse,
and increased temperature of the skin, indicate febrile disturbance
with sufficiency of blood and excessive action of a heart of adequate
power — then general blood-letting should be had recourse to.

Vascular turgescence will always be increased when the blood
not deficient in quantity is impelled by a heart of adequate power
and excited action ; and this evil may be best controlled by general
blood-letting.

But it is only in the early stage of hepatitis in Europeans not
long resident in India, and uninjured by the depressing influences
of malaria, elevated temperature and intemperance — or in the
sthenic natives of the more temperate regions of India — that
we may expect the conditions which are usually benefited by
general blood-letting. Moreover, we must be careful that even in
suitable cases this remedy is not used in an injurious degree.

It is the most prompt and therefore the best means of reducing
excessive action of the heart, co-existing with sufficiency of blood.
But when the action has been reduced, and the blood diminished
in quantity, the utility of general blood-letting ends ; and from
this time, if persisted in, it becomes injurious, by favouring
the change of exuded lymph into pus, and lessening the
chance of subsequent repair. The useful application of general
blood-letting is chiefly limited to the stage of vascular tur-
gescence. If it be used in the stage of exudation (exception
being made in favour of those occasional cases in which the
conditions indicating its expediency are still present), it will
generally prove ultimately injurious. It is impossible to be
more precise, or to lay down rules as to whether the quantity
of blood abstracted should be sixteen, twenty, or thirty ounces, or
whether it should be repeated or not; but there can be no
question, that the excessive blood-letting advocated by some

c c

386 HEPATITIS.

(especially Mr. Twining) is altogether at variance with the prin-
ciples which I have been endeavouring to inculcate.

When these remarks are regarded in connection with those
on the pathology, etiology, and symptoms of hepatitis, the con-
clusion must be evident, that general blood-letting is a remedy
not frequently required in the treatment of this disease as it pre-
sents itself to the practitioner in India.*

Local blood-letting, chiefly by leeches, is of more general appli-
cation. It is valuable in succession to general blood-letting, and
also in those cases for which general blood-letting is unsuitable.
The number used and the frequency of repetition must depend on
the size of the leech, the stage of the disease, the severity of the
symptoms, and the character of the diathesis. Though local blood-
letting is also most beneficial in the early stages of vascular tur-
gescence ; still it is of value after exudations have taken place —
even after their degeneration has commenced ^ — for it acts favourably
on the surrounding turgescent parts. It must always be remem-
bered that exuded lymph will not become absorbed — will not go
through the other processes that may be most favourable to resto-
ration — unless the capillary circulation immediately surrounding
it be in a tolerably normal state. In using leeches, however,
in these more advanced stages of inflammation, especial regard
must be had to the state of the constitution ; for if there be doubt
of its ability to bear further loss of blood without injury, we must
desist, and call to our aid other means of derivation.

As remedies subsidiary to blood-letting and useful in the same
stage as well as subsequently, fomentations frequently applied, or
the warm water compress with bandage and appliances to prevent
evaporation, may be mentioned.

Mercurial and other Purgatives, — The principle on which the
action of calomel and of other purgatives is useful, in certain con-
ditions of the early stages of dysentery, has been explained at
some length. They favour, by increasing secretion, the free
movement of the blood in the portal capillaries and the mucous
lining of the small intestine ; and thus tend to relieve stagnation
of blood in the capillaries of the large intestine. These remedies
form also an important part of treatment in the early stages of

* It can hardly be necessary to say, that this observation is to be understood as
applying to medical practice in India in the aggregate. The proportion of cases
calling for general blood-letting in the practice of different individuals, will vary ac-
cording to the field in which it is followed. I really fear that I may be charged with
tediousness in the reiteration of this principle ; but I have seen so much neglect of its
observance in the course of my service, that excess of caution may well be pardoned.

TREATMENT — MERCURIAL AND OTHER PURGATIVES. 387

certain conditions of hepatitis ; and their efficacy is explainable on
the same principle. The blood of the arterial capillaries of the
liver, equally with that of the mucous membrane of the large
intestine, is passed into the portal capillaries ; and, consequently,
free circulation in the latter must equally tend to lessen stagnation
in the capillaries of the hepatic artery. Therefore the frequently-
quoted remark of Abercrombie — " If the liver be supposed to be
in a state of torpor, mercury is given to excite it ; if in a state of
acute inflammation, mercury is given to moderate the inflamma-
tion and reduce the action," conveys to my mind no expression of
inconsistency.

Consecutive on general blood-letting, or the early application of
leeches, it is generally useful to give ten grains of calomel and
one of opium, with so much ipecacuanha as the stomach is tolerant
of, and in four or five hours afterwards, a moderate dose of castor
oil, or compound jalap powder. The necessity f repeating these
means will bear relation to the sthenic state of the system, the
recency of the attack, the presence of congestion of the portal
capillaries, and a deranged state of the biliary secretion. The
symptoms of portal congestion are : — (a) A yellow-coated tongue,
without irritation of the mucous lining of the mouth to account for
it. (h) Scanty alvine discharges, darker pale, (c) General fulness
of the upper part of the abdomen, with, it may be, the physical
signs of hepatic enlargement, {d) A dingy state of the skin and
scanty high-coloured urine.

Calomel and other purgatives are used, not to exercise any
direct effect on the inflamed capillaries, but to remove a co-existing
congestion of the portal capillaries, which must tend to prevent a
return to normal circulation in the capillaries of the hepatic artery.
This combined derangement is likely to be present, in such degree
as to require these remedies, only in the early stages of hepatitis
and in systems well supplied with blood. In advanced stages, in
previously healthy individuals, and in cachectic constitutions in all
stages, these means are contra-indicated, because a tendency to
dysentery is a characteristic feature of cachexia as well as of an
advanced stage of hepatitis ; and there is no more certain exciting
cause of it, in these states, than calomel and purgatives. When
under these latter circumstances there is suspicion of portal stag-
nation, or other indication for the use of eliminants, then small
doses of blue pill in combination with ipecacuanha, or the extract
of taraxacum with an alkali, and the external 'application of nitro-
muriatic acid should be resorted to.

c c 2

388 HEPATITIS.

Ipecacuanha is very beneficial in hepatitis, given to the degree
that may be practicable ; but there is not that tolerance which is a
characteristic feature of dysentery. So true is this that when a
dysenteric patient is intolerant of ipecacuanha, we should make it
a rule to investigate closely the condition of the liver.

In combining opium with calomel, the quantity must be regulated
by the tendency, or not, to gastric or enteric irritation.

Quiescence in the recumbent posture, and a very restricted diet,
are essential adjuvants in the management of the early stages of
acute hepatitis.

By steadily observing this system of treatment we may hope, in
persons of good diathesis, to cure the disease by resolution in a
considerable proportion of cases in which it has not advanced
beyond vascular turgescence or commencing exudation. But to
ensure this result an important caution is necessary. We must be
careful not to commit the error of thinking that the removal of
the inflammation and the cessation of the symptoms are always, or
even generally, coincident events. The deranged capillaries return
slowly to their normal state, and, probably, do not commonly
attain it till some time after the symptoms have disappeared. The
latter event is in all likelihood rather coincident with the period
when the onward progress of diseased action has been checked,
and return to a healthy state has fairly commenced. Eelapse is
apt to occur, and is often traceable to the error just adverted to.
When the disease has clearly existed recovery must still be regarded
as incomplete till several days have elapsed since the removal of pain
and febrile disturbance ; and during this period the patient should be
confined to bed, the diet should still be most carefully regulated,
and any derangement of the secretions be corrected by gentle means.

But the attack may be only moderated, not removed, by the
means of treatment recommended ; and the conclusion, that exuda-
tion and coagulation of lymph are taking place is forced upon us.
Or the case may have come under treatment at that stage which
renders it probable that this event had already occurred. What
are the resources of our art under these circumstances ? Let us
recollect what pathology has taught us, — (a) That plastic lymph
exuded and coagulated may become organised into fibrous tissue,
and thus cause more or less permanent organic injury. This
is an occasional but rare result of hepatitis. (6) Plastic lymph
exuded and coagulated, instead of becoming organised, may
speedily re-liquefy, and be absorbed, and thus complete recovery
may result. But this event necessarily implies a nearly normal

TREATMENT — MERCURY. 389

state of the capillary circulation, and of the quantity and quality of
the blood, in the surrounding tissues. To effect this termination is
the object of treatment in this stage of hepatitis, and we have good
reason for believing that it is not unfrequently attended with suc-
cess, (c) Plastic lymph may be exuded in such quantity, and so
remote from normal structure, that its organisation into tissue, or
its removal by absorption, is impracticable ; it necessarily, in part,
becomes converted into pus, and abscess is formed. Or, aplastic
lymph may be exuded. It is inorganisable, and has no tendency to
be absorbed, partly from its excessive quantity and bad quality,
partly because the capillaries around are unfit to absorb. It
changes into pus, and in this manner also abscess is formed.
Both these results are common in hepatitis.

It would seem, then, that it is only under the second contin-
gency ih) that there is still the opportunity of complete restoration.
The question may be thus put. Lymph not in excessive quantity
having exuded and coagulated, and efficient means for controlling
the surrounding deranged capillary circulation having been used —
do we possess remedies calculated to favour the fusion and absorp-
tion necessary to recovery ? The answer is, the mild constitutional
influence of mercury is believed, and probably with truth, to
possess this power.

But, does this admission not suggest that mercury may also be
beneficial when, from abnormal condition of surrounding parts,
excessive quantity or bad quality of lymph, pus is formed, but is not
absorbed ? Certainly not, for when exuded lymph tends to change
into pus, the action of mercury will favour this tendency, that is,
promote suppuration and the formation of abscess.

If these pathological and therapeutic doctrines approximate to
the truth, then we are provided with a principle of treatment of
hepatitis by induction of mercurial influence, viz. : — When the
disease, in a good diathesis, is at that stage in which the exu-
dation of lymph is likely to be going on, mercurial influence is
indicated. If, on the other hand, the diathesis is bad, or there is
reason to believe that suppuration has already taken place, mer-
cm'ial influence is contra-indicated.

It is evident then that mercury can only be used with advantage
in hepatitis when, by careful observation and inquiry, the stage of
the disease and the diathesis of the patient have been ascertained
with tolerable accuracy. The opinion at one time generally enter-
tained, that mercury exercises some special power in hepatic
inflammation, is unsupported by clinical experience. This erro-

c c 3

390 HEPATITIS.

neons doctrine is perhaps, in part, to be traced to inattention to the
distinction between the cholagogue and the constitutional action of
this agent : the nature and application of the former have already
been explained, and my present remarks are to be understood as
bavins: exclusive reference to the latter.

Instead of thinking that the constitutional influence of mercury
has a special value in hepatitis, I believe, for the following
reasons, that more caution and discrimination are required in
its application in this disease than in the other membranous or
parenchymatous inflammations, in the treatment of which it is
generally used.

1. There is no organ so prone in India as the liver to become
the seat of suppuration, and the constitutional states which favour
this result of inflammation and frequently cause it, are certainly
aggravated by mercury.

2. The opinion that gentle ptyalism may prevent hepatic abscess,
can only be true in those cases for which mercury is indicated in
accordance with the principles just explained. That suppuration,
after mercurial influence, has not been an unusual occurrence in
the treatment of hepatitis, has been amply proved by the clinical
experience of myself and others. The statement made long since,
and repeated by Annesley and others, that, hepatic abscess, when
present, prevents the constitutional action of mercury, probably
rests on very insufficient evidence, for it is difficult to believe that
the experiments necessary to determine the question have been
frequently made, I have myself no practical acquaintance with
the use of mercury in the treatment of hepatic abscess.

3. The cases before me, more particularly those of sick officers,
show a marked predisposition in those who have been the frequent
subjects of mercurial influence to suffer from uneasiness in the
region of the liv % and to be affected with pale alvine discharges,
languor, &c. Under these circumstances, the liver is undoubtedly
liable to become the seat of sub-acute inflammation from ordinary
exciting causes, as cold. This statement accords with the observa-
tion made by Graves *, that enlargement of the liver is sometimes
a feature of mercurial cachexia.

I now return to details of practice. If the symptoms of acute
hepatitis treated from the outset in a good constitution are not
speedily and decidedly removed by blood-letting, mercurial and
other purgatives, rest and appropriate diet, then mercurial influ-
ence with the continuance of other suitable measures, is indicated,
* " Clinical Lectures," vol. i. p. 448.

TREATMENT — COUNTER- IRRITATION. 391

and it may be best induced by from two to four grains of calomel,
with a quarter or half a grain of opium, and a grain of ipecacuanha,
when tolerated, every third, fourth, sixth, or eighth hour; so
regulating the dose as not to interfere with sleep, or to produce
more effect than distinct swelling of the gums with slight
ptyalism.

When, however, the case has first came under notice after two or
three days' illness, mercury may be expedient from the very com-
mencement of the treatment.

Should, on the other hand, the disease be first submitted to our
care at such stages, and with such symptoms, as render the exist-
ence of suppuration probable, then, whatever may be the character
of the diathesis, mercury is contra-indicated. And this is equally
the case, if, whatever the stage of the disease, the appearance of
the patient, or the history, denote a previous cachexia. When the
contra-indication depends on cachexia, then we may inquire whether
other alterative deobstruents, as liquor potassse or the iodide of
potassium, are likely to be advantageous. On this point I am un-
able to speak with confidence : liquor potasssB has seemed to me
of use in some cases.

To find an agent which improves the plasticity of the lymph and
the general nutritive processes, and to abstain from mercury —
which has an opposite action — are the points to which attention
should be chiefly directed in the treatment of hepatitis in cachectic
constitutions.

Blisters. — Sooner or later in all cases of persisting hepatitis there
comes a stage when we are no longer justified in attempting to
lessen vascular turgescence by the derivative action of leeches ; and
then we must avail ourselves of those other means which act
similarly without causing much evacuation from the blood, as dry
cupping, rubefacients, epispastics.

If a normal capillary circulation in the parts adjacent to exuded
lymph be a necessary condition of absorption — or of the organisation
of the limitary layer — when absorption is impracticable — the
reduction of vascular turgescence by derivation is an indication not
confined to the early stages of hepatitis, but extends also to the more
advanced periods, and is then to be effected by the class of remedies
now under notice. Of these, the cantharides blister is the most
generally used. But a very large one is inexpedient.* One from

* There is a caution relative to large blisters to which it may be useful to allude.
There is a risk that cutaneous and subcutaneous fulness, from serous infiltration con-
sequent on the irritation of a blister, when at and below the margin of the ribs, may

C c 4

392 HEPATITIS.

three to four inches square, placed over the affected part of the
liver, is preferable. The use of blisters may be commenced when
the stage for leeches has passed. Blisters cease to be beneficial
and begin to be injurious when abscess has fully formed, and is
advancing to the nearest surface. The reason is plain. At this
stage some degree of inflammation favours the interstitial absorp-
tion and the adhesions necessary to the safety of the remaining
chance of recovery. Nothing can be more irrational than the
application of a large blister over the right hypochondrium, tumid
from hepatic abscess, yet I have witnessed this.

My remarks have been confined to blisters, but dry cupping,
sinapisms, turpentine oil, iodine paint, and tartar emetic ointment,
all act on the same principle, though less efficaciously.

Let us now suppose that the treatment has been unsuccessful,
and that abscess has formed. Recovery may still take place by
one or other of the courses described in my notice of the pathology
and symptoms ; and we must now consider what are the means
which best conduce to this end, and what are those which tend
to prevent it.

Mercurial and all other depressing remedies must be at once
abandoned. There may be a transition stage when antiphlogistics
are contra-in,dicated, but in which, from the character of the febrile
disturbance, tonic remedies and regimen may be doubtful : in this,
opiates or other anodynes, with mild diaphoretics or other gentle
eliminants, may be temporarily employed. Then we may gradually
pass to the use of tonics — as quinine with dilute sulphuric acid, or
nitric acid, with a bitter infusion, — while the opiate is continued at
bed-time. The diet should also be improved, by addition of light
puddings, milk, animal broths, jellies, and eggs, adjusted to the
condition of the digestive organs and the assimilating powers.
Wine or beer, when they do not excite the pulse or irritate the
gastro-enteric linings, are also necessary.

I have already expressed my belief that the injudicious con-
tinuance of mercurial and other purgatives in the advanced stages
of hepatitis is, in part, the cause of the frequent co-existence of
intestinal ulceration. These remedies must be altogether omitted;
and should eliminants be indicated, we must trust to taraxacum,
alkalies*, nitric acid, and the external use of nitro-muriatic acid.

be mistaken for the sign of enlargement of the liver, and lead to an erroneous im-
pression of the progress of the disease.

* Of hydrochlorate of ammonia, used with this view by German physicians, I have
no experience, but the Indian practitioner will do well to try it.

TIIEATMENT — PUNCTURE OF ABSCESS. 303

When the abscess has opened into the lung, anodynes, tonics,
and support, regulated to meet the requirements of particular
cases, are the means of treatment. When the abscess has opened
into the alimentary canal, similar remedies must be given,
and intestinal irritants be carefully abstained from. When the
abscess has opened into the sac of the peritoneum, the pleura, or
pericardium, and inflammation of these serous tissues has been
excited, or when general peritonitis has arisen, in the more com-
mon manner, independent of rupture, then, though the issue is in
general too surely fatal, we may prolong life and palliate suffering
by giving opium, in doses of from one to two grains every third or
fourth hour, in the manner recommended by Dr. Stokes of Dublin.

When the abscess tends towards the external surface, then, in
addition to the means advised in the other courses, we may
endeavour to lessen discomfort by warm water applications, or
cataplasms. When fluctuation has become apparent, the question
of puncturing the abscess falls to be considered. I shall best
explain myself on this point of practice, by stating the amount,
results, and deductions of my own experience.

Puncture of Hepatic Abscess, — The notes of twenty-four cases
in which I have witnessed the puncture of hepatic abscess are before
me. Of these, eight may be classed as successful, and sixteen as
unsuccessful.

Of the eight favourable cases, there was complete recovery in
five ; the history was incomplete, but restoration probable, in two ;
there was recovery from the punctured abscess, but death a year
afterwards from a second abscess, in one. In all these cases the
abscess pointed at the epigastrium, or at the margin of the right
ribs, above the level of the ninth. They were all of moderate size,
and, from their position, it may be inferred that they had formed
in the thin part of the left lobe, or in the thin edge of the right
lobe. We may further, from the fact of recovery, conclude that in
each instance the abscess had been single.

These eight cases, 149 to 156, are here detailed.

149. Hepatic abscess pointing at the epigastrium and successfully punctured. — Trocar
used. — Cassim Mahomed, a MussiJman butcher, aged fifty, was admitted into the
Jamsetjee Jejeebhoy Hospital, on the 23rd August, 1848. There was a prominent
swelling in the epigastric region, chiefly in the mesial line and towards the right side ;
it was soft with obscure fluctuation without discoloration of the skin, or tension, and
the right side of the chest was resonant on percussion as low as the sixth rib. He
stated that about a year before admission he had received a blow on the epigastrium,
that the swelling made its appearance some time afterwards, and had gradually in-
creased to its present size. He continued under observation till the 1st of September,
not suffering from febrile accessions, when the swelling, which was much in the same

394 HEPATITIS*

state as on admission, was punctured by a trocar, and about four ounces of red-coloured
pus wore discharged. On the 2nd, one ounce, and on the 3rd, three ounces more
of reddish pus escaped from the puncture. He continued without fever, the discharge
gradually lessening, and left the hospital on the 13th September, when the discharge
had ceased, the wound had healed, and there was only a sense of thickening per-
ceptible in the situation of the swelling.

150. Hepatic abscess pointing at' the ejpigastrium, 'punctured successfully. — Gungajee
Saccaram, a Hindoo, aged twenty-five, after a month's illness was admitted into the
Jamsetjee Jejeebhoy Hospital on the 18th April, 1846. There was a prominent
tumour in the centre of the epigastrium, tense, and apparently superficial. There was
no tenseness at the margin of the right rib, and no didness on percussion ; there was
slight heat of skin. The abscess was punctured, and some dark grey-coloured pus
discharged. On the 19th the swelling had become considerably reduced, but there
was still a good deal of discharge of thick pus tinged with blood. On the 22nd there
was very little discharge, no tension, but considerable hardness around the puncture,
and the tongue continued coated, but there were no febrile accessions. On the 27th
the fulness and hardness had decreased much, but there was still slight discharge.
On the 12th May he left the hospital, the fulness and hardness and puriform dis-
charge having disappeared.

151. Hepatic abscess pointing between the eighth right rib and umbilicus, succcssfidly
punctured. — Through the kindness of Dr. Arbuckle I had the opportunity of seeing,
about the year 1850, an English medical gentleman affected with hepatic abscess. It
pointed about three inches below the margin of the right ribs, in about a line drawn
vertically from the cartilage of the eighth rib. The abscess was opened, and recovery
took place. This gentleman died about two years afterwards, but with what symptoms
there is no record in my notes.

152. Hepatic abscess punctured. — Recovery. — Krushnah Poonjajee, a Hindoo cart-
driver, of thirty years of age, a spirit drinker, was admitted into the clinical ward,
on the llth January, 1853. He was much reduced, and his countenance was anxious.
A prominent swelling reached from the margin of the right false ribs and the ensiform
cartilage to half an inch below the umbilicus. It was dull, and the dulness passed
upwards to the level of the fifth rib. The swelling was painful, distinctly fluctuating,
and at its lower part there was a small circular opening from which purulent discharge
issued. Two months and a half before he had suffered from febrile accessions, and
pain below the margin of the right false ribs. In fifteen days afterwards a small
swelling below the margin of the ribs was noticed. It had gradually increased, and
the opening with discharge of three ounces of pus took place the night before ad-
mission. He had suffered from frequent accessions of fever, commencing with chills,
but not from bowel affection. The opening was enlarged with a bistoury, and two
pints of brick-red pus discharged. The discharge continued profuse till the 20th, then
gradually lessened, and the wound fijially closed, and he was discharged well on the
4th March. Recovery was somewhat retarded by dysentery at the end of January
and early part of February.

Remark. — This case occurred in my absence, when Dr. Forbes Watson had charge
of the clinical ward.

163. Hepatic abscess, punctured at the point of the right ninth rib. — Recovery. —
Nursingah, a Hindoo labourer, of thirty-five years of age, suffered three months and a
half, before admission into the clinical ward, from daily accessions of fever, followed
in fifteen days by pain of right hypochondrium, which had continued till the time of
his admission, on the 15th September, 1851. He was in the habit of occasionally
using spirits. On admission he was reduced in flesh. The respiration was somewhat
hurried. There was some degree of fulness of the right hypochondrium, and dulness
from the fifth rib to two inches below the margin of the right false ribs, where an

TREATMENT — PUNCTURE OF ABSCESS. 395

induration was perceptible, somewhat conical, and obscurely fluctuating at the point
of the ninth rib. The pain was increased by decubitus on either side, and deep inspi-
ration. There was not any cough. There was slight heat of skin, and the bowels
were regular. The fluctuation having become more distinct, on the 20th September a
puncture was made at the point of the ninth rib, with a straight bistoiuy ; twenty
ounces of healthy-looking pus were discharged, and a similar quantity on the evening
of the same day; and again ten ounces on the 26th. From that time till the 19th
February, 1852, there was daily slight reddish-tinged discharge. Then it ceased, the
wound closed, and he was discharged well on the 15th March, when abnormal dulness
below the ribs no longer existed. Treated with tonics, wine and support.*

154. He'patic abscess pointing between the right ninth rib and umbilicus, punctured. —
Case not followed to the close, but in all probability successful. — Fakeer Mahomed, a Mus-
sulman Lascar, aged forty, addicted to the use of spirituous liquors, was admitted into
the Jamsetjee Jejeebhoy Hospital on the 17th April. Below the margin of the right
false ribs there was a distinctly circumscribed swelling, reaching from the cartilage of
the seventh rib to within two inches of the umbilicus, and in a transverse direction
from the ninth rib to the linea alba, painful on pressure and on full inspiration. He
stated that the swelling had first appeared about two months before admission, and
had gradually increased, during which time he had also been affected with irregular
febrile accessions. The swelling became slowly more prominent ; and on the 26th
May, when fluctuation was distinct^ an opening was made with a bistoury, and about
six ounces of pus evacuated, and slight discharge continued for several successive days.
On the 4th July another distinct fluctuating point, close to the former oriflce was
opened, and an ounce of pus discharged. Discharge from these orifices continued in
quantity daily from a drachm or two to an ounce. About the 25th July the swelling
again began to increase and to be painful ; and on the 29th, while coughing, the
orifice of the abscess, which had closed, again opened, and about seven ounces of pus
were discharged. The tumour again subsided, and a slight daily dischai^e took place.
During his residence in hospital he had frequently febrile accessions, and on two or
three occasions dysenteric symptoms were present for several successive days. He
had not lost in strength since his admission, and there was a fair prospect of recovery
when this note was taken. There is no further record of the case.

155. Hepatic abscess pointing at the epigastrium, punctured. — Result not hnown; pro-
bably successfid. — Shaik Mahomed, a Mussulman butler, about thirty years of age, of
intemperate habits, was admitted into the Native General Hospital on the 4th March,
1845. There was a prominent pointed swelling towards the left side of the epigas-
trium, with considerable surrounding indurated swelling, said to have appeared twenty
days before admission, but preceded for two months by fever. On the 24th the tumour
was opened, and about eight or ten ounces of pus were discharged. He continued in
hospital till the 6th May, with more or less discharge from the abscess, and frequent
recurrences of fever. When he left the hospital the discharge had ceased, and the
swelling was very much lessened, not painful, and the febrile accessions no longer
recurred. He was readmitted into the hospital on the 2nd June with return of swell-
ing of side and discharge from the opening. He remained in the hospital for five
days, and then left it ; and since then he has not been heard of. This case did not
come under my observation till about the middle of April, about twenty days after the
abscess had been opened.

* This patient was again in hospital in April 1857, with slight fever. He stated
that after he left the hospital, in 1852, he returned to his native place in the Deccan,
remained there well for three years, then came back to Bombay, and in good health
followed his occupation of labotu-er till eight days before his second admission, when
he became affected with slight fever and jaundice, but no hepatic pain or dulness.
The cicatrix from the puncture was distinct at the point of the ninth rib.

396 HEPATITIS.

156. Chronic hepatic abscesses : one was punctured and healed, hut there was no
adhesion to the abdominal wall at site of puncture found after death. — Ulceration of
colon, but dysentery clearly secondary. — Second abscess, and death. — Essoo Govinda, a
Hindoo labourer of sixty years of age, of emaciated frame, and using spirits freely,
was admitted into the clinical ward on the 9th December, 1848. An indurated painful
swelling occupied the epigastric and umbilical regions. It was indistinctly circum-
scribed, but its lower part was plainly felt about three inches below the margin of the
right false ribs. There was no fever. He was treated with bitter infusions, mineral
acids, taraxacum, iodine, and iron. The swelling was sponged with nitro-muriatic
acid lotion, a small blister was applied, and latterly iodine ointment. He was dis-
charged on the 24th January, 1849, with the swelling lessened, free of pain, but still
quite distinct. He returned to his village and to his usual occupations. A year
afterwards the swelling being, as he reported, in the same state as on his discharge
from hospital, was opened with a lancet by a native hakeen, and a pint of pus dis-
charged. It healed quickly. He was readmitted into the clinical ward on the 25th
December, 1850. There was general fulness of abdomen, and a curved line from the
ninth left to the tenth right rib marked the lower boundary of an indurated enlargement
duR on percussion. There was a smaU puckered cicatrix caused by the puncti^re,
about an inch below the point of the eighth right rib. He had been affected with
dysentery for about six weeks. Under these he sank, and died on the 28th December,
three days after admission.

Inspection seven hours after death. — Body emaciated. Abdomen somewhat full,
but not tympanitic. Abdomen. — There were about five ounces of serous fluid in the
sac of the peritoneum. Both the small and large intestines were contracted. The
liver projected about three inches below the ensiform cartilage, and for some distance
below the eighth and ninth costal cartilages of the left side, and the eighth, ninth
and tenth ones of the right. Below the point of the tenth costal cartilage of the right
side, on the convex surface of the liver near its free margin, corresponding in situation
to the fundus of the gaU-bladder, there was seen a small puckered cicatrix. There
was no adhesion of this or of any other part of the convex surface of the projecting
portion of the liver to the abdominal parietes, and the small puckered cicatrix ob-
served on the surface of the latter did not correspond to that on the liver, but was an
inch and a half above and internal to it. There were firm adhesions between the
posterior part of the convex surface of the right lobe of the liver and the under surface
of the diaphragm, also between the concave one and the upper extremity of the right
kidney and the hepatic flexure of the colon. On incising the liver in the situation of
the cicatrix, a white and fibrous appearance four lines in extent was seen. At the
place of adhesion of the right kidney, with the under surface of the right lobe, and in
the substance of the latter, there was an abscess of the size of a large orange, extending
half way up the lobe, and containing healthy pus. It was bounded by a membranous
sac, the inner surface of which was free from floating flocculi. The whole of the right
lobe, and especially that part of it surrounding the abscess, was red and mottled. The
left lobe was pale, and of natural size. No communication was found between the
hepatic flexure of the colon and the cavity of the abscess, or between the latter and
the right kidney. The mucous membrane of the ascending transverse, and a part of
the descending colon, was of a dark grey colour generally, with small circular ulcers
here and there. The walls of the small intestine were thin and pale, and the mucoiis
membrane extensively corrugated, but nowhere was any ulceration seen. The right
kidney, when incised, presented a healthy appearance, and there was no purulent
cavity or infiltration at its upper end. Chest. — There were firm adhesions of both
lungs to the costal pleurae, and of the base of the right one to the convex surface of
the diaphragm. The structure of both was spongy and crepitating, of white colour
and intermixed with numerous dark specks. About two ounces of serous fluid in the

TREATMENT — PUNCTUEE OF ABSCESS. 397

pericardium. Heart of natural size, but with a somewhat greater quantity of fat than
usual over its surface. Head not examined.*

Of the sixteen fatal cases, there was, in thirteen, gangrene of the
structures around the puncture, more extensive generally in the
tissues subjacent, than in the skin itself, thus showing that the
progi-ess of the gangrene had been from within outwards. Of these
thirteen cases fatal with gangrene, the opening had been made in
an intercostal space in five, and below the last rib in one. In these
six cases the abscess had been either in the thick part of the right
lobe, or there had been a sac between the liver and diaphragmf , or
both combined. In the remaining seven cases the opening had
been made at or near the epigastric region ; and on comparing
these with the successful ones punctured at the same situation, it
appears that in those fatal with gangrene the abscess was large, or
not single, or pointed rather at the concave than the convex surface
of the liver, so that some thickness of parenchyma had to be cut
through before the sac could be reached ; or the constitution was
very cachectic.

The thirteen following cases are those in which gangrene took
place : —

157. Abscess in the liver pointing between the right seventh and eighth ribs. — Opening
into the lung and also externally. — Gangrene of the integuments around the orifice, also
of the intercostal muscles, and caries of a rib. — William Harris, aged twenty-three, was
in hospital in September 1841, with hepatitis. Discharged on the 17th, re-admitted on
the 10th October, with return. The disease ran into abscess, and about the 28th there
was expectoration of brick-red sputa, which continued. There was tumefaction
between the right seventh and eighth ribs with fluctuation, and an opening was made
there on the 15th December. Brick-red puriform discharge and air passed from the
wound. He gradually lost ground and died on the 1st February.

Inspection six hours after death. — The orifice between the seventh and eighth ribs
not far from their junction with the cartilage was enlarged from sphacelus. The
parts underneath the integument were in a state of gangrene, and for aboiit the
extent of two inches between the seventh and eighth ribs the intercostal muscles
had been destroyed. The seventh rib, for about two inches in length, was carious,
and in consequence was fractured near its junction to the cartilage. The abscess in
the liver was very superficial, bounded by the convex part of the right lobe, the dia-
phragm and the ribs. The base of the third lobe of the right lung adhered to the
diaphragm; part of it was condensed and at its anterior point there was communica-
tion with the abscess in the liver, and an excavation in the substance of the lung the
size of a walnut. There were old adhesions of the surface of the liver ; also of the

* "We may not doubt the fact of abscess having been opened in this case and cured.
The question arises, "Was there absence of adhesion when the abscess was opened, or
may we suppose that, consequent on the cure of the abscess, adhesions previously
existing, but now no longer required, were gradually removed by atrophy ? The latter
is, I think, the probable view, and it is countenanced by the want of correspondence
found after death between the external and the internal cicatrices.

t Case 122 may be added to these.

398 iiErATiTis.

omeiitum to the abdominal parietes. Chest. — No effusion into the sac of the ploura
and the greater part of both kings were collapsed and crepitating.

168. Hepatic abscess punctured over the last right false rib. — Gangrene and sloughing

around the wound. — Death. — No inspection. — Mr. , apothecary on the Bombay

establishment, aged about thirty -four ; after an attack of fever, suffered from acute
hepatitis early in June 1843. He was freely depleted, and the constitutional effect
of mercury was induced. There was a recurrence of the attack, and he was again
similarly treated; but fulness of the right side, with pain, continued, and he had
become much reduced. In this state he was sent from Surat to Bombay, and came
under my care in the European General Hospital, on the 22nd August. He complained
of constant pain of the right side, and there was circumscribed, tumefaction over the last
false rib. On the 30th August there was an opening made in the swelling and a con-
siderable quantity of pus, at times tinged with blood, was discharged. On the 14th
September commencing sphacelation of the soft parts around the orifice of the abscess
was first remarked, and on the 16th the sphacelated portion was in diameter about an
inch and a half, the orifice being in the centre. He died on the 19th September.
There was not any examination of the body made after death.

159. Large hepatic abscess punctured. — Death from exhaustion, with sloughing of the
wound. — No examination after death. — Shaik Mahomed, a Mussulman, of twenty-one
years of age, not addicted to the use of spirits, a native of Bengal, and following for
a period of six years the occupation of stoker in a steam-boat, about a year before his
admission on the 13th March, 1850, into the clinical ward, had suffered from quartan
fever, when he relinquished his usual employment. Twenty-five days before admis-
sion he had been attacked with sudden sharp pain of the right side of the abdomen,
followed by fever. On admission the respiration was short, hurried, and chiefly
thoracic and the decubitus was dorsal. There was occasional troublesome dry cough,
and much pain of the right hypochondrium, aggravated by pressure, coughing, and
any movement of the body. There was general fulness and prominence of the right
hypochondrium, with tenseness and sense of induration below the margin of the right
false ribs. Dulness reached from the right nipple to midway between the last false
rib and the crest of the ilium, and extended obliquely across tlie abdomen to the
point of the left ninth rib. Fluctuation was perceptible opposite the point of the last
right rib. The impulse of the heart was increased and its apex beat in the intercostal
space between the fourth and fifth rib directly below the left nipple. There was heat of
skin, and a pulse frequent and compressible. The bowels were reported to be regular
and the urine scanty and high coloured. The fluctuation was more distinct on the
2nd October, and an opening was made with a straight bistoury between the eleventh
and twelfth rib. He died exhausted on the 24th. The edges of the wound showed
a sloughy appearance after the 16th. After the operation, the tenseness and pain
were lessened, the respiration became freer, and the cough less ; but there were even-
ing febrile accessions, with night sweats, more or less relaxation of the bowels,
increasing emaciation and failing pulse. The discharge of seventy- two ounces of pus,
sometimes tinged red, is recorded, but subsequent to the last quantity noted, there was
a constant draining from the wound. The treatment consisted of anodynes, mineral
acids, astringents, and support with milk, chicken-broth, eggs, and wine. Examination
of the body after death was not permitted.

160. Superficial abscess of right extremity of the liver leading to circumscribed sac be-
tween the organ and lateral abdominal walls. — Punctured between the tenth and eleventh
rib. — Sloughy state of wound, necrosis of rib, and death from hectic fever. — Mahangoo,
thirty years of age, a Hindoo washerman, using spirits, was, after two months' illness,
admitted in a reduced state into the clinical ward, on the 24th June, 1850. The
respiration was slightly hurried. In the right hypochondrium there was a hard circum-
scribed painful swelling, covered by the six lower ribs, which bulged outwards over it.

TREATMENT — PUNCTURE OF ABSCESS. 399

The abdomen was generally soft and retracted ; but an indurated edge was felt for
about an inch below the ninth, tenth, and eleventh right ribs. He was anaemic and
without febrile disturbance, or enteric irritation. Stated that the pain of side, first
felt two months before when engaged in his occupation, had gradually increased, and
that the swelling first attracted his attention seven days before admission. There had
been no fever. Febrile accessions, however, were noted while he was under observa-
tion. On the 29th the upper part of the swelling was distinctly fluctuating, and it
was opened with a bistoury on the 3rd July. Exhausted with hectic, and continued
red-tinged discharge, but without diarrhoea, he died on the 1 1th August. The wound
was puffy on the 23rd July, and sloughy on the 4th August. The urine gave no
signs of albumen. The treatment consisted of anodynes, quinine, and sulphuric acid,
and support.

Inspection ten hours after death. — Immediately below the end of the tenth rib
was an opening of about the size of a dollar. The surrounding parts were dark,
sloughy, and bounded by a dark blue line, about four inches in circumference ; and, on
looking into the opening, the eleventh rib was observed hanging bare at the bottom of
it. Chest. — The left lung was collapsed, and its structure soft and crepitating.
Numerous firm adhesions existed between the right lung and the costal parietes, partially
also to the diaphragm : its substance was healthy. There was about an ounce and a
half of clear watery fluid in the sac of the pericardium. On the posterior surface of
the right ventricle of the heart there was a white patch the size of half a rupee.
Abdomen. — There was an oval cavity of about the size of a large orange, apparently
bounded internally by the omentum, externally, by the diaphragm, corresponding to
the last four lower ribs, and the lateral abdominal parietes for about three -inches
below the margin of the right false ribs. Superiorly, the cavity was found to com-
municate freely and to be continuous with a large excavation about one inch and a
half in depth, and eight in circumference, situated at the right extremity of the liver.
This excavation was defined by a dark bluish line. The liver extended from
the eleventh rib on the right side to the middle of the seventh, left. On cutting
deeper into the substance of the liver, near to the abscess, two or three spots of
yellowish- white colour, apparently from eflusion of lymph, were observed. The other
portions of the liver were healthy. That part of the wall of the abscess in which the
substance of the liver was not involved, was much thickened, and on cutting into it, soft
pulpy matter was found to ooze out on pressure. There were adhesions between the
convex surface of the liver and the diaphragm, as well as between the concave surface
and the pylorus. The stomach was contracted, and its coats were somewhat thickened.
The transverse colon was much distended. The kidneys healthy.

161. Abscess in the liver punctured. — Carious ribs projecting into the abscess. — At
first superficial and leading to circumscribed sac between liver and diaphragm. — Also
empyema of right pleural sac without communication. — Cumblin Kowjee, aged twenty,
a Maratha labourer, emaciated ; after two months' illness, was admitted 5th May,
1852. Pulse small, breathing short and hurried. A distinct prominent, uncu'cum-
scribed, fluctuating swelling, neither tense, red, nor hot, existed on the right side of
the chest from the sixth rib downwards. In the epigastric region there was abnormal
dulness, and an indurated edge was felt to within an inch of the umbilicus, and ex-
tending from the tenth or eleventh right to the ninth left false rib. There was slight
cough, not communicating impulse to the swelling. The feet and legs became cedema-
tous. Dyspnoea increased. The swelling became more prominent and pointing. It was
punctured on the 13th May between the eighth and ninth rib, and four pints of brick-
coloured pus were discharged. On the 16th commencing gangrene around the opening
was observed. A slough larger than a rupee formed. He died on the 22nd.

Inspection twenty hours after death. — Chest. — There were fifty ounces of sero-
purulent fluid in the right pleural sac ; flakes of lymph coated the costal pleura, and

400 HEPATITIS.

the lung was condensed from compression. There was no communication between the
chest and abdomen. The left lung and heart were healthy. Abdomen. — The liver
descended lower than natural. Firm adhesions connected its upper surface for a con-
siderable extent, and there was a sloughy state of the tissues of the parietes corre-
sponding to these adhesions, and to the opening by which the contents of the abscess
had been discharged. The eighth and ninth ribs had separated by caries at their
cartilaginous junctions, and having started inwards projected into the cavity of
an abscess in the liver. The cartilages of these ribs were found in their normal
position. A similar process had commenced at the cartilaginous junction of the tenth
rib, but separation had not taken place. The surface of the liver in this situation
for the diameter of five inches, adherent by lymph at its margin, was somewhat
depressed below the level of the healthy portion, had flakes of lymph attached to it,
and felt rough and fibrous to the touch : in its centre was the opening of the abscess,
which was about the size of a large hen's egg. The opening corresponded to the space
between the eighth and ninth ribs, through which the abscess had pointed. A con-
siderable extent of the surrounding tissue of the liver was dense and fibrous. There
was commencing Bright's disease of both kidneys.

162. Two large hepatic abscesses. — One deep, the other a sac between the surj'ace of
the liver and abdominal walls originating probably in rupture of a small superficial
abscess, there being lymph nodules in the part of the liver adjoining. — This abscess
punctured. — Sloughing. — No ulceration of intestine. — Housayree, a Hindoo washer-
man, of forty-five years of age, using spirituous liquors, was in a much reduced state,
admitted into the clinical ward on the 13th February, 1851. The respiration was
somewhat short and hurried. There was dulness on percussion of the chest, below the
nipple on the right side ; and crepitus was detected in the right mammary region, and
in both dorsal and lateral regions. Occupying the right of the abdomen there was a
large, oblong, tense, painful, distinctly fluctuating swelling; it reached from the mai^n
of the right ribs to the crest of the os ilium. A vertical line, an inch to the right of the
umbilicus, formed its internal limit, and one three inches behind the posterior spinous
process of the os ilium, its external and posterior one. The skin covering the swelling
was red, tense, shining, and pitted on pressure. The rest of the abdomen was
slightly full and soft. The feet were (Edematous. He suffered from cough, and the
bowels were conflned. The pulse was frequent and small. His illness was of six
weeks' duration, and commenced with fever, remittent in type, and attended with cough.
Twelve days before admission a small swelling was noticed under the margin of the
right ribs, which gradually increased, but it had not been preceded by pain. On the
17th an opening was made into the abscess in front of the point of the right last rib.
The discharge was profuse, followed by relief and diminution of febrile disturbance.
On the 18th indication of gangrene at the puncture commenced, and slowly extended
to a diameter of two inches. He sunk without diarrhoea, and died on the 23rd.

Inspection twenty-nine hours after death. — Chest. — The right lung did not collapse
freely. The base was firmly adherent to the diaphragm. Its texture was somewhat
firmer, and it did not crepitate freely, but there was no hepatisation in any part. No
effusion into the sac of the right pleura. Left lung freely collapsed and crepitating.
A few old adhesions existed between the lung and the costal pleura at the anterior
and middle parts. No effusion into the sac of the pleura. Abdomen. — At the
situation of the opening made with the bistoury, the liver was adherent to the walls of
abdomen by very thick layers of lymph, softened by admixture with pus. Here the
collection of matter seemed chiefly to have been between the walls of the abdomen
and the surface of the liver. In this situation the substance of the organ seemed
compressed, but in places superficial lymph-nodules were observed. A considerable
part of the right lobe of the liver had contracted tender adhesions with the walls of
the abdomen and the diaphragm. In the upper part of the right lobe there was a
large abscess the size of an ostrich egg approaching to, but quite unconnected -with,

TREATMENT — PUNCTURE OF ABSCESS. 401

tlio abscess that was opened. The rest 'of the liver -was healthy. Flakes of lymph
wore effused on different parts of the small intestine, and in places formed a thin mem-
branous layer. The large intestine, as well as the lower part of the ileum, were laid
open. The mucous membrane not ulcerated, was healthy but pale. Kidneys healthy.

163, Hepatic abscess punctured at the epigastrium, — Gangrene and sphacelation around
the orifice. — Death. — No inspection. — Kustum Easid, a Persian Parsee, aged fifty,
after twenty days' iUness, was admitted into the Jamsetjee Jejeebhoy Hospital, on the
16th July, 1845. He complained chiefly of dyspeptic symptoms, and his disease was
looked upon as dyspepsia. On the 31st he was affected with febrile symptoms, and
there was a good deal of tenderness at the left side of the epigastric region, and a
slight degree of induration was perceived there, which at first was believed to depend
on enlargement of the spleen, but with its increase and extension in the direction of
the mesial line, it became evident that it was connected with the left lobe of the liver.
Febrile accessions recurred from time to time; leeches and counter-irritants were used,
and an attempt was made to induce the constitutional effect of mercury by the cautious
exhibition of calomel and opium, but without success. On the 31st August fluctuation
became perceptible in the tumour at the epigastrium. On the 2nd September it was
still more distinct, and an opening was made. Several ounces of thick pus were
evacuated ; and on the succeeding days there was daily a slight discharge. On the
4th there was considerable tenderness around the opening, and he complained much of
the pain of the swelling on the 7th. On the 9th, for an inch round the orifice, the
integument had become discoloured, and the epidermis was separating. On the 10th
the sphacelus was complete. On the 18th the line of demarcation was distinct, and
the sphacelated portion was about three inches in diameter. There was daily hectic
fever, and increasing exhaustion, and he died on the 25th, The sphacelated portion
had not separated. No examination of the body after death permitted.

164, Hepatic abscess pointing at the epigastrium, punctured. — Extensive sphacelus
around the opening. — Death. — Geenah Ambah, forty years of age, a Hindoo, was
admitted into the Bandora Dispensary, near Bombay, on the 4th May, 1852. There
was a prominent distinctly fluctuating and tense swelling between the margin of the
right ribs, the ensiform cartilage, and an inch and a half above the umbilicus. He
had been attacked with pain in that situation, and fever three months before. The
abscess was opened by Mr. Gomez, the officer in charge of the dispensary, and two
and a half pints of pus were discharged. He continued under treatment till the 14th
July, when he had improved in flesh, and the discharge was very slight. He was
now lost sight of, and again appeared at the Jamsetjee Jejeebhoy Hospital on the
18th August. There was some fulness below the ensiform cartilage, the skin was of
dusky-red colour, and there was an ulcerated opening. No fever. The ulceration ex-
tended, and became sloughy and excavated. He became emaciated, affected with
diarrhoea, and died on the 25th September,

Inspection (by Mr. Carvalho) eighteen hours after death. — Body emaciated. Occu-
pying the epigastric region, and extending over a space about twelve or thirteen inches
in circumference, there was a sloughy gangrenous surface ; at the central part of which
there was an opening the size of a rupee. The sloughing was superficial, and did not
affect the muscular tissue. On cutting through the abdominal walls, and reflecting
the flap of the skin, the cavity of an abscess was exposed immediately below the
ensiform cartilage. It lay just to the left of the suspensory ligament, and was about
the size of half an orange. Superiorly it corresponded to the central tendinous portion
of the diaphragm to which it was firmly adherent ; and anteriorly was in the greater
part covered by, and adlierent to, the lower part of the sternum which there con-
stituted a portion of its anterior wall. The surface exposed was of a dark blue
colour — gangrenous. The depth of the abscess was about a quarter of an inch, and
the surrounding walls were hard, almost cartilaginous. The lobe (left) in which the

D D

402 HEPATITIS.

abscess had been situated, was much reduced in size ; its structure was a good deal
indurated, and when incised it was found to be of a reddish-colour around the abscess.
The liver was smaller than natural, rather hard in t<>xturo, firmly adherent by its
right lobe to the diaphragm and abdominal wall ; and the adjacent portion of the colon
was firmly united to its concave or under surface. There was only one abscess. The
gall-bladder was contracted. The kidneys were healthy. The intestines were not
examined. Chest. — There were old adhesions, chiefly of the right lung to the costal
pleura and diaphragm. The posterior part of both lungs, and the second and third
lobes of the right, were redder than natural, somewhat indurated, and gave out
frothy serum when incised. The heart was healthy.

165. A single abscess at the thin edge of the left lobe of liver existing for five months,
punctured. — Gangrene of the orifice. — Dysenteric symptoms latterly. — Ulceration of
mucous membrane of the colon. — Antonio Francis, a native Christian, a sailor, of thirty-
four years of age, was under treatment in hospital for a swelling in the epigastric region
from the I7th May to the 15th June, 1849, when he was discharged relieved of pain,
but with persistence of the swelling. He was readmitted on the 5th October, in
reduced condition. The respiration was chiefly thoracic, but there were not any signs
of pulmonary disease. The abdomen for the most part was soft, but immediately above
the umbilicus, and ascending to midway between it and the ensiform cartilage, there
was a circumscribed prominent swelling tender to the touch without fluctuation, slightly
pulsating, but without murmur under the stethoscope on any part of its surface, and
with clear sound on percussion between it and the margin of the right ribs. The
bowels were regular. He suiFered from evening febrile accessions. The swelling
became more prominent, and fluctuation was distinct on the 16th, when the abscess
was opened, and seven ounces of pinkish-coloured pus were discharged. The febrile
accessions recurred, dysenteric symptoms set in on the 26th, and he died on the 18th
November.

Inspection three hours after death, — Abdomen. — The opening made into the abscess
was on a level with the ninth rib, and a probe passed readily through it into the sac.
On removing the skin over it, there was found a sloughy state of the parts around the
opening for about an inch and a half in diameter. The peritoneum was chiefly adhe-
rent to the abdominal wall over the abscess sac, which was about the size of a* small
orange, and occupied the very edge of the left lobe of the liver. It was empty. The
serous covering of the left lobe of the liver had in general an opaque appearance. The
liver was not enlarged. The small intestines were much distended with gaseous con-
tents, and a portion of them was displaced upwards. They presented externally, in
part a dark red, and in part a dark leaden grey colour ; but no patches of lymph were
observed. The transverse colon contained dark grey adhesive matter, and adhered
closely to the sac ; but there was no communication between them. Its mucous sur-
face was of dark red colour — presented a rugous appearance, with several variously
sized circular ulcers, some apparently cicatrised, and others in an active state of ulcer-
ation. No further examination was permitted.

166. Two hepatic abscesses : one punctured, with increase of febrile symptoms :
attributed to fist blows. — Habits temperate. — Diarrhoea, with redness of mucous mem-
brane of colon. — No ulceration. — Commencing gangrene at the openiny in the abscess. —
Dooluh Dewsell, a Hindoo carpenter, twenty-seven years of age, in good condition,
and reporting himself to be of temperate habits, was admitted, after twelve days'
illness, into the clinical ward of the Jamsetjee Jejeebhoy Hospital on the 13th July,
1849. The respiration was short, hurried, chiefly thoracic, and bronchitic rales were-
audible in different parts of the chest. The abdomen was full, somewhat tense, and
tender on pressure — chiefly so, however, at the upper part, where an indurated fulness
was perceptible, extending below the right false ribs, occupying the epigastrium and
part o*4he left hypochoudrium, and reaching almost to the umbilicus. It was some-

TREATMENT — PUNCTURE OF ABSCESS. 403

"What prominent in the epigastric region. The decubitus was chiefly dorsal. During
the first six days of his illness the symptoms had not attracted his attention much,
but then they increased in severity, and were attended with febrile disturbance. They
were attributed to fist blows, received in endeavouring to separate two individuals
who were fighting. He was under observation thirteen days. The hepatic symptoms
persisted ; the fever had marked evening exacerbations. There was occasional vomiting
and relaxed bowels. The prominence at the epigastrium increased, and fluctuation
was indistinct on the 18th. He died on the 25th. After leeching and a ten-grain
dose of calomel, with opium, four-grain doses of quinine were given, with blue pill, at
intervals during the remissions, and with the effect of lessening the exacerbation. On
the 23rd the abscess was opened with a bistoury. There was a good deal of bleeding
from the wound at the time, and free discharge on that day, and on the 25th ; but
there was increase of fever and diarrhoea, a failing pulse, and collapse of features.
The result was clearly hastened by the operation.

Inspection fourteen hours after death. — The costal cartilages and cellular tissue were
slightly tinged j^ellow. Chest. — Lungs collapsed and crepitating. The third lobe of
the right lung was compressed almost flat against the posterior wall of chest. Heart
natural. Abdomen. — Between the skin and subjacent structures around the opening
in the abscess, there was a boggy state of the tissue, caused by infiltration of dark red
serum. Stomach and intestines distended with gas. The liver extended considerably
beyond the margin of ribs, and for a space about four or five inches in diameter,
adhered firmly to the parietes. The omentum was also matted there. The thin edge
and a portion of the inferior surface of the left lobe of the liver had adhered firmly to
the anterior surface of the stomach. The abscess, the size of a cocoa-nut, occupied a
great portion of the left side of the right lobe, and to a considerable extent the sub-
stance of the left. It contained about half a pint of thick flocculent pus, and some
white firm bands were seen crossing it. Its walls presented a rough and irregular
appearance. The anterior part, the thinnest, was separated from the abdominal
parietes by a portion of liver about a quarter of an inch thick. A thin small portion
of its upper wall intervened between the abscess and the diaphragm, but was free from
adhesions to that muscle. On separating the liver from the stomach, the surface of
the latter was found adherent to the wall of another abscess, the size of a large orange.
Its walls were entire, with the internal surface irregular: it was filled with sero-
puriform matter. The two abscesses were separated from one another by a thin
portion of the substance of the liver. The large intestine was laid open, the mucous
surface was discoloured red, but no ulceration was detected anywhere. Kidneys
healthy.

167. Hepatic abscess pointing at the epigastrium, punctured. — Sloughing around
the wound. — Death. — Early in the year 1854, I saw, in company with Dr. Miller, of
Bombay, a case of hepatitis in a European artificer. The symptoms were well
marked ; abscess formed. The tumefaction was chiefly in the epigastrium. Fluctua-
tion became distinct, and after tendency to pointing had become apparent, the abscess
was opened with a bistoury, and considerable discharge of pus followed and continued
for the two or three succeeding days. Then a sloughy state of the edges of the punc-
ture took place and extended, and the patient died. These notes I write from recol-
lection, as I have no written memoranda of -the case, I do not know whether the
body was examined after death.

168. Cirrhosis of Liver. — Abscess in thin edge of liver, punctured. — Purulent sac
between liver and diaphragm. — Ulceration of large intestine. — Death. — Lingoo, a
Hindoo labourer, of thirty-six years of age, addicted to the habitual use of spirits, was
admitted on the 2nd July, 1852, into the clinical ward. He was a good deal emaci-
ated, and the respiration was somewhat thoracic. Close to the ensiform cartilage,
and extending about half an inch to the right of the mesial line, there was a swelling,

D D 2

404 HEPATITIS.

the size of a largo orange, somewhat conical, with its apex slightly reddened and"
fluctuating. It varied somewhat in position, according as decubitus was on the right
or left side, and became somewhat depending and more prominent in the sitting and
standing positions. It was free of pulsation. There was no dulness on percussion
around it, except at its upper and right side, where the dulness was continuous with
that of the liver. It was tender on pressure. No cough or vomiting. Decubitus
easiest on the right side. Bowels relaxed. He had first observed the swelling three
months before, when it was the size of an egg. Suffered from dysenteric symptoms
about six weeks before admission, and from irregular febrile accessions for fifteen days.
Pulse feeble, tongue coated in the centre, and florid at the tip and edges. The abscess
was opened on the 27th, and eight ounces of thick pus were discharged. With con-
tinuing discharge, relaxed bowels, nightly hectic fever, and sloughy ulcerated state of
the punctured wound, he gradually lost ground, and died on the 7th August. He was
treated with quinine, opium, nourishment, and wine.

Inspection twenty-one hours after death. — Body much emaciated. Chest. — The lungs
were collapsed, and in appearance perfectly healthy. The lower part of the base of
the right lung was found attached to the corresponding portion of the diaphragm by
firm adhesions. There was, however, no condensation of the lung. The heart was
healthy. Ahdoinen. — The intestines presented, externally, a healthy appearance. The
mucous membrane of the descending colon, sigmoid flexure, and a part of the rectum,
was somewhat thickened, and numerous small circular ulcers existed here and there.
The liver did not extend below the margins of the ribs. It was much smaller than
natural, dense and contracted. Its surface was corrugated, and studded with small
yellow projections, each about the size of a pin's head. It was firmly adherent to the
abdominal parietes, a little below and internal to the margin of the cartilage of the
left tenth rib, corresponding to the external opening in the skin. The exposed part
of the right lobe was likewise adherent to the adjoining parietes ; and at the lower
margin, a little above the gall-bladder, the surrounding adhesions formed a small sac,
containing a small quantity of serum. The diaphragm was firmly attached to the upper
surface ; and to the right, about opposite the middle of the seventh rib, it was sepa-
rated from the liver by a sac, the size of an orange, containing a quantity of glairy,
tenacious pus. At the parts corresponding to the puncture, two small abscesses, each
about the size of a small filbert, separated from each other by a thin septum, were
found ; their walls were dense and fibrous. A section of the liver presented a surface
studded with minute granules. The lower part of the liver, the pancreas, and duode-
num, were adherent together by dense fibrous tissue. The gaU-bladder was filled
with light-coloured greenish fluid. The kidneys were healthy. The spleen was a
little smaller than natural.

169. — Hepatic abscess in C2ngastric region, punctured ; very little discharge. — Dysen-
tery.— Death. — No eccamination. — Eaga Saiboo, a Hindoo bricklayer of twenty-fivo
3^ears of age, using spirits occasionally, was admitted in an emaciated state into the
clinical ward on the 1st October, 1852. At the epigastric region, in the middle line
between the ensiform cartilage and the umbilicus, there was a prominent fluctuating
swelling about the size of a large orange, painful on pressure, dull on percussion, and
immovable. Kespiration hurried and chiefly thoracic, pulse small, bowels relaxed.
Six weeks before, while at work, was seized with shivering, followed by fever and pain
at the site of the swelling, which when flrst noticed was small ; it gradually increased.
The actual cautery was applied ten days before admission, and had left an eschar
about the size of half a rupee. The d^^senteric symptoms were of fifteen days' duration.
The swelling was opened with a bistoury to the left of the eschar, but only blood was
discharged, and on the 4th about an ounce of unhealthy pus. The swelling did not
lessen much, the discharge was slight, the eschar separated, and was followed by
sloughy ulceration, which extended to the puncture. The diarrhoea continued. He

TREATMENT — rUNCTURE OF ABSCESS. 405

was removed on the 13th October in a moribund state by his friends. He was treated
with quinine, opium, and wine.

In the three cases, fatal without gangrene, the abscess had been
large and punctured at the margin of the right ribs. In two there
was complication of pleuritic effusion, and in one several abscesses,
with general peritonitis. These cases are now submitted. (170
to 172.)

170. Abscess 'partly of right and of left- lobe, punctured. — Death from secondary
dysentery. — Ulceration of large intestine. — Effusion in both pleural sacs. — Luximan
Luckman, agel thirty-five, a Hindoo labourer, using spirits habitually, but in moderate
quantity, was admitted into the clinical ward on the 19th December, 1853. He was
emaciated, and the respiration was somewhat short and hurried, and chiefly thoracic.
The pulse was small and frequent, the bowels regular. Between a curved line drawn
from the eighth left rib, — passing quarter of an inch above the umbilicus to the ninth
right rib, — and the margin of the right ribs, there was induration with constant pain,
increased by pressure and cough. The space noted was also dull on percussion, and
the dulness extended upwards to the fifth rib. Decubitus was easiest on the left side.
The tongue was moist, and somewhat coated in the centre. Fifteen days before ad-
mission he had felt pain of the right hypochondrium, followed by febrile symptoms,
ehtiracterised by evening accessions, commencing with chills, and terminating with
slight sweating. Slight swelling first appeared seven days after the commencement of
the attack. On the 28th the swelling became more prominent and indistinctly fluctu-
ating ; and on the 30th, the fluctuation being distinct, a puncture was made with a
bistoury, and seven ounces of red-tinged serous fluid with floating lymph-flakes were
evacuated. He was at this time also troubled with hiccup. From this date the discharge
continued, gradually, however, lessening with subsidence of the swelling, and no ap-
pearance of sloughing of the puncture. On the 12th January dysenteric symptoms
began, and continued more or less till his death on the 20th February. The urine
gave no traces of albumen. He was treated with tonics, opiates, gallic acid, suitable
nourishment, and wine.

Inspection eight hours after death. — External appearances: — Body very much
emaciated and free from rigor mortis. A little to the right side of the median line,
and about an inch below the ensiform cartilage, there was a small opening, through
which thin yellowish discharge oozed. Chest. — Neither lung was coDapsed. There
were about ten ounces of turbid serum in the right pleural sac, and about six ounces
in the left. There were flrm adhesions at the upper and back parts of the right lung ;
also some tender ones at the lower part anteriorly. There were no adhesions between
the base of this lung and the diaphragm ; nor any between the left lung and the
parietes of the chest. The external surface of the whole of the right lung, and the
anterior surface of the left lung were pale, dry-looking, and woolly to the feel. The
anterior parts of both lungs were emphysematous, but the posterior parts were healthy
and crepitating. On incising both lungs in diiferent parts, frothy serum oozed out
from some portions, but nothing further abnormal was detected. There were about
three ounces of clear serum in the sac of the pericardium. The heart was smaller than
natm^al, but healthy. Abdomen. — No traces of general peritonitis present. The liver
was somewhat larger than natural ; it reached an inch below the margin of the right
false ribs, and above as high as the flfth rib. The thin margin of the liver, with a
portion of the anterior surface, formed firm adhesions with the anterior parietes of the
abdomen to the extent of about three inches in diameter. These adhesions were
around the puncture. The convex surface of the right lobe^ of the liver was adherent
to the diaphragm in parts, and the concave surface was firmly adherent to the trans-
verse colon, part of the duodenum, and the pyloric end of the stomach. On enlarging

D D 3

406 HEPATITIS.

the artificial opening, the abscess was found to occupy part of the left, and part of the
right lobe of the liver, and was the size of a common orange. Its contents consisted
of thin, puriforin, orange-coloured matter. On removing the contents, the walls of the
abscess were found to be hard and somewhat cartilaginous. At the lower part of the
abscess the substance of the liver was of darkish red colour ; but the remaining por-
tions of the organ were healthy. The intestines were grey-coloured externally. The
transverse colon and the duodenum adhered to the concave surface of the liver ; but
there was no communication between the abscess and either of these hollow viscera.
There was some degree of vascularity of the mucous membrane of the rectum, and of
the transverse and descending colon, and there were about ten or fifteen circular ulcers
in the rectum, each the size of a large pin's head. The mucous membrane of the Ueura
and jejunum was also slightly vascular here and there; but no ulcer was anywhere
detected. The left kidney was somewhat larger than the right, and its cortical por-
tion encroached slightly on the tubular portion. The right kidney seemed to be
healthy. — The spleen was of natural size and healthy.

171. Pleuritic effusioyi. — Abscess in the liver 'punctured. — Attributed to a blow. —
Death the day after the abscess was opened. No examination. — ^Wittoo Bappoo, a
Hindoo cart- driver of thirty -two years of age, was under treatment from the 21st
December, 1851, to the 14th January, 1852, when he was transferred to the clinical ward.
The symptoms had indicated the presence of pneumonia and hepatitis, for which he
had been cupped, taken antimon}^, and been brought under the infiuence of mercury
with temporary advantage. From the 4th January, however,- there had been more
complaint of cough and pain of different parts of the right side of the chest, followed
by complete dulness on percussion of that side, and absence of vocal thrill ; and such
continued to be the state of the chest on admission into the clinical ward, when, also,
the circumference of the right side was found to be half an inch greater than that of
the left. There were fulness, sense of induration and dulness below the margin of the
right false ribs, bounded by a line curving from the point of the right tenth rib to that
of the left eighth. There was occasiojial cough, and decubitus was easiest on the
right side. There was some degree of febrile heat, and the gums were still tender
from the mercury. The swelling below the right ribs became gradually more prominent ;
and on the 27th January there was another oval swelling detected above the umbilicus.
On the 6th February there was fluctuation of both swellings. On the 7th the one
below the right ribs was opened at the point of the eighth rib, and twelve ounces of
pus discharged, with diminution of both swellings. He died on the 8th. The urine
had been frequently examined, but gave no traces of albumen. He attributed his
illness to a blow on the right hypochondrium from the cross-beam of a bullock-cart.
Examination of the body not permitted.

172. Large abscess of right lobe of liver opened with trocar. — Several abscesses
in left lobe in different stages. — Also nodules of lymph. — Emam Bukus, aged about
forty, was admitted into the Native General Hospital on the 13th January, 1845.
He suffered from febrile symptoms, and pain of the right hypochondrium of six days'
duration. By means of leeches, a blister, and mercurials, not, however, carried to the
extent of affecting the system, the pain of' the side was much relieved, but an evening
febrile accession persisted. On the 27th his breathing became short, the countenance
anxious, and there was slight fulness of the right hypochondrium apparent. On the
1st February the fulness of the side was distinct and somewhat prominent, and sense
of fluctuation was perceptible. The abscess was opened by a trocar below the edge of
the false ribs, and twelve ounces of thick pus were discharged ; and on the 3rd and
4th there was a further discharge of several ounces of pus following re-introduction of
the canula, which had been removed. After the operation there was increased anxiety
of countenance ; the breathing became shorter and more oppressed ; the febrile acces-
sions continued to recur, and he died on the evening of the 6th. There were not at
any time symptoms of dysentery or diarrhosa.

TREATMENT — PUNCTURE OF ABSCESS. 407

Inspection eight hours after death. — Abdomen. — In the cavity of the abdomen, amongst
the convolutions of the intestines, there wa^ about a pint of sero-puriform fluid. The
peritoneal surface of the small intestine and of the colon presented a deep blush of
redness ; and thin flakes of friable lymph were effused generally on the surface, and
caused adhesions of the convolutions. The liver adhered firmly to the abdominaf
parietes for some distance around the orifice made by the trocar, which had penetrated
a large abscess occupying the lower and anterior lateral part of the right lobe. The
inner surface of the sac was lined by tliick sloughy-looking shreds. Between the
diapliragra and the convex surface of the right lobe there was a circumscribed sac
containing about half a pint of sero-puriform fluid, similar in appearance to that con-
tained in the abdominal cavity. The abscess in the Kver seemed to communicate
with this sac ; but no communication could be traced between it and the cavity of the
abdomen. In the left lobe there were two or three small abscesses, ranging in size
from a walnut to a goose's egg. One or two yellow circumscribed portions were also
observed, caused by interstitial effusion of lymph — the condition which so generally
precedes the formation of abscess.

My opinions on this question of practice have been formed
chiefly on the facts now detailed, because observers who have
hitherto written with authority on this subject have done so on
still more limited experience. Annesley had witnessed only five
cases of puncture of hepatic abscess ; of these two recovered. Mal-
colm son five, all fatal. Stovell* fi.ve, with four deaths. Haspel
seven, with four deaths. Again, in many of the scattered records
of hepatic abscess, including cases in which puncture had been
practised, the situation of the swelling and of the opening is not
mentioned. Such cases are of no value in determining this prac-
tical question.

My cases show that when the abscess is not very large, is singlef,
situated in the thin part of the left lobe, or thin edge of the
right, and is allowed to point at the epigastrium, or margin of the
right ribs above the ninth, then puncture with a bistoury or lancet
will very generally be attended with success. This result will be
materially favoured by previous careful treatment and by the ab-
sence of dysentery or other complication.

The two successful cases quoted by Annesley were of this simple
nature ; and no doubt it was on them that this author grounded his
just opinion, that hepatic abscess ought not to be punctured till
distinct pointing and inflammatory blush on the skin have taken
place. A successful case alluded to by Twining, two narrated by

* Dr. Stovell, in his subsequent decennial report, gives seven cases with six
deaths.

t We may form a judgment as to the size of the abscess, and its being single
or not, by careful percussion . in all directions ; and it is of much importance that
this means of acquiring precise knowledge of the size of the liver be not neglected
in such cases. By inattention to this rule prognosis bedbmes needlessly vague and
uncertain.

D D 4

408 iiErATiTis.

Haspel, one by Stovell, and one by Arnott*, are also confirmatory
of the inference drawn from my own successful cases. But 1 would
go still further, and say there is nothing decisive on record to prove
that success has as yet attended the puncture of hepatic abscess
under any other circumstances than those which have just been
stated.

This degree of success, however, does not assert much in favour
of surgical interference ; for it is most probable that in such cases
a favourable termination would equally have resulted from non-
interference and spontaneous rupture. Dr. Budd has advocated the
latter course in such cases. The common surgical rule of punc-
turing when there is distinct pointing and inflammatory blush,
seems to me the preferable course ; but at best it is a difference of
little moment in practice.

Gangrene of the tissues around the wound took place in 13 of my
16 fatal cases.

This event was first noticed by Mr. Caesar Hawkins f, but he
considered his cases to be malignant disease not hepatic abscess.
Dr. Malcolmson, of the Madras Medical Service J, corrected Mr.
Hawkins's erroneous inference, and quoted two cases of hepatic
abscess opened and followed by gangrene. This result of puncture
of hepatic abscess, so familiar to myself and to others, and so im-
portant in reference to practice, is not even alluded to by any other
writer with whose works I am acquainted.

Malcolmson attributed the gangrene to the lowered vitality
of the thinned and diseased tissues, and recommended the early
opening of the abscess as the best means of preventing it; but
this explanation, and the practical inference from it, are only par-
tially correct.

I have elsewhere (p. 328) fully described the usual process by
which abscess is formed in the liver ; and I have called attention to
the fact, that when the abscess is large, some time must elapse before
the shreddy flocculent debris of the structiu-e of the organ, adherent
to the inner surface of the sac, can liquefy and disappear. If an
abscess in this state be opened and air admitted, then putrefac-
tion of these devitalised tissues must be the consequence, and the
weakened structures around becoming contaminated will readily
pass into gangrene. It is in this manner that, in many instances,
the liability to gangrene after puncture may be best explained. In

* " Transactions, Medical and Physical Society of Bombay," No. 1, New Series.

t " Transactions, Medico-Chirurgical Society," vol. xviii.

I Ibid., vol. xxi., and ''Edinburgh Medical and Surgical Journal," vol. li. .,^

TREATMENT — PUNCTURE OF ABSCESS. 409

such cases the error has not been delay. On the contrary, the
abscess has been prematurely opened in violation of a sound surgical
principle which directs that the operation should be postponed till
concoction is completed.

Yet, under some circumstances, there is truth in Malcolmson's
opinion that the gangrene may be due to lowered vitality from
thinning of the tissues, and defect of nutrition ; and that in these
the error of delaying the opening the abscess has generally been
committed.

The cases which have been detailed seem to me to point to a
practical rule in this apparent difficulty.

In the five cases in which the puncture was made in an inter-
costal space, the gangrene of the soft parts and the carious or
necrosed state of the ribs, was caused by the combined influence of
inflammatory action, and the increasing pressure of the pus over
an extensive surface. If surgical interference under these circum-
stances is to be of any avail, then it must be had recourse to, early
— so soon as bulging of the side and obscure fluctuation indicate
the presence of fluid. And we may act in this manner with less
apprehension of bad effects from putrefying tissues, because a
reference to the cases will show that the pus is collected chiefly
between the liver and the parietes, and that when it communicates,
the abscess is generally superficial and not likely to have much
flocculent debris adherent to its walls.

In seven of the cases fatal with gangrene, the opening had been
made at the epigastrium or near the margin of the right ribs.
From a consideration of these in connection with those fatal with-
out puncture, it may be inferred that when the liver occupies the
epigastrium, reaches to within an inch of the umbilicus, extends
two inches and more below the margin of the right ribs, becomes
gradually prominent in these situations, and in time gives a sense
of diffuse fluctuation, we have to do with large abscess in the
thick substance of the organ. This is the condition of hepatic
abscess in which there is much likelihood of parench3niiatous debris
requiring concoction, and in which there is danger of gangrene and
irritative fever consequent on putrefaction from premature punc-
ture. In these cases we should delay, and this course may be fol-
lowed with the less hesitation, for there is, in these circumstances,
little risk of gangrene from mere thinning of the tissues.

But, I have expressed my belief that success has, hitherto, only
attended the puncture of small, distinctly pointing abscesses,
situated in the thin parts of the liver; and the question natu-

410 IIErATITIS.

rally suggests itself, whether the operation ought to be confined
to these conditions, and altogether abandoned in the kind of cases
which are at present under review. My past experience would
prompt an affirmative reply; but we must not hastily conclude
that the resources of our art are thus limited.

From the cases narrated it is evident, that when a free opening
is made with a bistoury, or large trocar, the large abscess emptied,
and air admitted, death is not thereby prevented, but, on the con-
trary, is frequently hastened. Therefore if good is to be effected
by surgery in such cases, it must be by a different kind of opera-
tive proceeding. The modification in the operation of puncturing
the chest in pleuritic effusions, advocated by Br. H. M. Hughes
and Mr. Edward Cock*, might be extended to the opening of large
hepatic abscesses. The slow and gradual evacuation of the pus by
repeated puncture at suitable intervals with a small trocar, com-
bined with the careful exclusion of the atmospheric air, is worthy
of trial. The objection that the thick part of the contents of
the sac will not be evacuated by this method is not of much
weight, for we may believe that it may remain as a residuum,
and be subjected to those changes which take place in the cure by
absorption.

The following, then, are my conclusions on the question of punc-
turing hepatic abscess.

1. When the swelling is not larger than an orange, and points
conically at the epigastrium, or below the margin of the right ribs,
we should wait till an inflammatory blush appears on the skin, and
then open the abscess with a bistoury, sufficiently freely to admit
of the ready discharge of the contents without pressure. The case
should afterwards be treated in accordance with ordinary surgical
principles. If the abscess has been single, and the constitution
not very much impaired, success will frequently attend this pro-
ceeding.

2. When there is general bulging of the right ribs below the
seventh, with distinct fluctuation and pointing at an intercostal
space, it is immaterial whether a puncture be made or spon-
taneous rupture take place. In both circumstances there will be
gangrene, from thinning, of the soft tissues, and probably caries
or necrosis of one or more ribs.

3. When the liver occupies the epigastrium, reaches to within
an inch of the umbilicus, extends two inches and more below the

* " Guy's Hospital Reports," Second Scries, vol. ii. p. 48. Mr. Cock uses a trocar
of one-twelfth of an inch in diameter.

TREATMENT — PUNCTURE OF ABSCESS. 411

margin of the right ribs, becomes gradually prominent in these
situations, and after a time obscurely fluctuating, then prema-
ture puncture either freely with a bistoury or a large trocar, will
lead to irritative fever and gangrene of the soft tissues around
the opening from within outwards, due to the putrefaction, from
admission of air, of the devitalised tissues adherent to the inner
wall of the sac.

4. If there be general bulging of the right ribs below the
seventh, fulness of the intercostal spaces, and obscure fluctuation,
then puncture may be made with a small trocar, in the manner
advocated by Mr. Cock in respect to pleuritic efl'usion. As delay
in these circumstances is inexpedient, an exploring needle may be
used in doubtful cases.

5. When prominent extensive swelling at the epigastrium, or
below the right ribs, with diffuse sense of fluctuation, indicates the
existence of large abscess in the thick part of the liver, we should
allow sufficient time for maturation; and then, when fluctuation
has become distinct, we may puncture with a small trocar, observ-
ing the same princij^les in respect to gradual evacuation, repetition
of the operation, and careful exclusion of air. While, however, we
lay down the rule of waiting a suitable .time for the maturation of
the abscess, we must take care not to delay so long as to give time
for the formation of very dense unyielding walls, — an obstacle to
success which has been justly pointed out by Dr. Budd.

The three first conclusions are based on clinical observation,
but the fourth and fifth are suggestions grounded on sufficient
experience of the failure of other procedures.

Further, it must always be remembered, that the probability of
success, under all circumstances, will depend on the state of the
constitution, and the conservative care with which the medical
treatment has been conducted throughout, and the absence of
dysentery or other serious complication.

We must, moreover, be careful that the object of surgical inter-
ference be justly appreciated, for there is a tendency in many
minds, to over-estimate its value, and therefore to apply it un-
suitably. In the small distinctly pointing abscess, it is of little
consequence whether we puncture or trust to spontaneous rupture.
In the large and deep abscess, we know that restoration cannot
take place unless the contents of the abscess are discharged, and
that spontaneous rupture is unlikely, till such destruction of parts
and exhaustion by hectic fever have ensued as to render recovery
impossible; therefore, when the local conditions are appropriate.

412 HEPATITIS.

and the general strength still sufficient, the operation is proposed
as a reasonable measure. When, however, before local conditions
are suitable, great prostration of strength has come on, puncture is
an injudicious proceeding: it cannot possibly be of service, but
v^^ill probably increase the prostration, hasten the fatal issue, and
discredit the healing art.

There are still some points to notice in reference to this ques-
tion of practice. When the abscess is not single, then the chances
of recovery after puncture are very materially lessened, and the
frequent co-existence of several abscesses in the liver has been
urged as an argument against the operation. In 76 of my fatal
cases examined after death, the abscess was single in 27 ; and if to
these are added my 8 cases of successful puncture, it will give 35
single in a total of 84. In other words, 41*6 per cent. Mr.
Waring's* deductions from more extensive data are still more
favourable, viz. of single abscess 62*105 per cent.

From these facts, it may be concluded, that the other conditions
being favourable, we may act in the hope that the abscess may be
single, and not be swayed by doubts to the contrary.

Incertitude of the existence of adhesions, between the surface
of the liver at the seat of abscess and the abdominal walls, has
also been a difficulty with many in this operation. My own ob-
servation would lead me to say, that too much has been made of
this objection, for it certainly has not been confirmatory of the
remark made by Mr. Twining, viz. : — "It is surprising how often
suppuration of the liver occurs without any adhesion of its peri-
toneal coat to adjacent parts, although the abscess be near the
surface."

I find in my notes only three cases of this nature : of these
173 and 180 are the most striking. The absence of adhesion in
hepatic abscess has with me been very exceptional, and in none
of the cases could the question of puncture have practically
arisen; and I further incline to the opinion that the cases of
non-adhesion quoted by other writers may all be included in the
same category.

Moreover, if in practice we use the bistoury only when there is
distinct pointing and inflammatory blush, and the small trocar
under the other circumstances when puncture is determined on,
we incur no risk. In the first case we are sure that adhe-
sions exist. In the possible exceptional instances of the second,

* " An Inquiry into the Statistics and Pathology of Abscess in the Liver," p. 18.

TREATMENT — PUNCTURE OF A13SCESS. 413

the use of a trocar and the partial evacuation of the abscess remove
the danger of effusion into the peritoneal sac. I therefore attach
no value to the suggestion made by Grraves and others, of prelimi-
nary proceedings undertaken with the view of ensuring adhesion.

173. Large abscess in the right lobe. — The liver free of abnormal adhesions. — The
cicatrices of former ulcers in the colon.— Jaundice. — Enlarged glands in the course of
the ducts. — To the kindness of Dr. Bird, at a time prior to my appointment to the
European General Hospital, I was indebted for the opportunity of witnessing the
following case :—

A sailor from the Rattlesnake, who had been upwards of twenty years at sea and
much in hot latitudes, and lately affected with dysentery, succeeded by symptoms of
hepatic disease, was admitted into the European. General Hospital in January 1836.
He was jaundiced, and there was much pain and fulness of the right hypochondrium.
As the disease progressed the edge of the liyer was distinctly felt some distance
below the ribs. He died.

On examination a large abscess occupied almost entirely the right lobe of the liver,
and forced its thin edge much below its natural situation. The internal surface of
the abscess was lined with irregular, thick lymph, and the surrounding parenchyma
of the organ was dark red and friable. There were not any peritoneal adhesions to
the diaphragm or elsewhere, and none of the base of the right lung to the diaphragm.
The gall-bladder was much distended with bile and tense, and the site of the ducts
was occupied by numerous enlarged glands, some the size of an olive. The mucous
lining of the stomach at the pyloric end was of dark slate grey colour, but without
softening. There had been considerable vomiting during life. The colon was normal
externally, and without peritoneal adhesions. The coats were thin, and in many
places there were the distinct cicatrices of former ulcers, and the whole surface had a
metallic lustre, caused by tenacious light grey not abundant contents. There was not
any further disease detected.

The risk of wounding a distended gall-bladder has also been
urged as a difficulty in the practice of puncturing hepatic abscess.
The error would seem on more than one occasion to have been
committed, therefore extreme caution may very properly be en-
joined. Still I do not think that apprehension of this dan-
ger will often be experienced in practice in India. Considerable
distention of the gall-bladder is not of frequent occurrence,
at least, I have only met with five instances of it (42, 43, 173,
186, 187), and in only the two last was it evident during life.
The signs of hepatic abscess, when advanced to the stage justi-
fying puncture, are moreover so well marked as to afford little
room for error.

There is still another observation to make on this subject. Dr.
Budd remarks : " In India it seems now to be a common practice
to thrust a long exploring needle into the liver where the presence
of abscess is suspected ; and, now and then, perhaps the disease
may be cured in this way." Then follow some very just reflections
condemnatory of this practice. I desire to put the medical service
of India right with the profession on this point.

414 HEPATITIS

About twenty years ago, Dr. Murray, Inspector-Greneral of Her
Majesty's Hospitals, recommended the proceeding in question on
theoretic grounds, for his previous practical knowledge of hepatic
abscess had been very limited. The practice was for a time
followed by some of those who came within the sphere of his
official influence, and its vague and unsatisfactory records are to
be found in the Madras Medical Journal. It was never intro-
duced into the Bombay Presidency, and from personal inquiry, I
feel myself justified in saying, that it has now no existence in the
sister presidencies, and has almost ceased to be remembered.
Under these circumstances 'it is unnecessary to examine critically
Dr. Murray's peculiar doctrines. I will only add, in the words
with which Dr. Stovell concludes his very able comments on
hepatic abscess*: "For my own part, I must confess, I can'-iot
conceive the existence of any case which could require, or even
justify, the adoption of such a measure."

Cure by Absorption. — Eecovery from hepatic abscess by dis-
charge of the contents spontaneously, or by artificial opening, and
subsequent granulation and cicatrisation has been considered in
detail ; but we must not overlook the probability of cure, by
absorption of the liquid parts of the pus, and the formation of a
small cyst of putty-like or cretaceous residuum. Five cases in
which this process was distinct, have come under my observation
(p. 345); but I entertain the belief, that it is more common,
especially in small abscesses, than is at present supposed, and that
it would be a still more frequent result if, on the suspicion of sup-
puration, every attention were given to the conservation of the
constitution and of a normal capillary circulation in the unaffected
parts of the organ.

On Change of Climate, — The principles respecting change of
climate in dysentery are equally applicable to hepatitis, and need
not be repeated {p. 312).

In persons whose constitutions are deteriorated by long residence
in India, and who are subject to hepatic inflammation, there should
be no hesitation in recommending, at a suitable time as respects
the disease, and at the appropriate season, change to a more tem-
perate climate.

If the presence of hepatic abscess be suspected, and the strength
be still such as to encourage hopes of recovery by processes of
repair, this result will undoubtedly be favoured by change to a

* " Transactions, Medical and Physical Society of Bombay," No. 1, New Series,
p. 188.

IN FEMALES AND CHILDREN. 415

more temperate and tonic climate. But the measure must be so
conducted as to avoid the risk of recurrence of acute inflammation
from the excitement of travelling or sudden reductions of tempera-
ture ; while at the same time the advantages of appropriate regimen
and medical treatment are secured. If this principle be just, then,
a lengthened sea-voyage in a comfortable ship to more temperate
latitudes, is the only kind of change that affords the prospect of
benefit. A journey to an elevated hill-station, or the discomforts
and excitements of the overland route, destroy the remaining
chances of recovery and ought to be invariably discouraged.

When the existence of hepatic abscess is undoubted, and ' pros-
tration considerable, then change of any kind is injurious. The
fatigue of movement, the disappointed hope, and the absence of
that careful nursing which solaces the close of exhausting disease,
will increase the suffering, add to the prostration, and hasten
death. This, indeed, may seem a proposition so self-evident as
hardly to merit notice ; yet, I say it advisedly and from personal
knowledge, there is much popular delusion on this point, and not
unfrequently great professional weakness in ministering to it.

Section VII. — Hepatitis in Females and in Children.

Females. — The statistics* of the Bengal and Madras Presidencies
show that hepatitis is much rarer in European women than men.
The per-centage to strength in the former is 1*95, and in the
latter, 4*3. There is no record of the proportion in Bombay.

Though the symptoms in women correspond with the description
which has already been given, yet an error in diagnosis, against
which the practitioner should be on his guard, is not unfrequently
committed.

That acute pain, related to the hysteric diathesis and simulating
acute inflammatory disease, may be present in the female is a
familiar fact. When we bear in mind the inroads that are made
on female health in India by child-bearing, and lactation, in ad-
dition to climatic influences ; and that this lowered condition of
health favours the development of hysteric phenomena, we can
have no difiiculty in believing that acute pain in the hepatic region
in ansemic females in India has often been injudiciously treated as
hepatitis. But such mistakes ought not to occur ; for the history,
the diathesis, the presence of other hysteric phenomena, the
absence of febrile symptoms, the very acuteness of the pain, and

* Ewart's " Vital Statistics," p. 129.

416 HEPATITIS.

its relation to attention being fixed on it or removed from it, are
sufficient to prevent them.

Children. — The ratio of hepatitis in children is in Bengal 0*05,
and in Madras, 0-3 per cent, of strength ; and the returns of the
Byculla Schools prove the rarity of the disease in Bombay at the
same period of life : the admissions in 17 years were 9, and 1 death,
in a strength of from 250 to 300 children. I have no practical
knowledge of hepatitis in childhood. The case of hepatic abscess
in a Parsee child of ten years of age, reported * by Dr. Miller,
is the youngest with which I am acquainted.

Section VIII. — Occasional Difficulties and Errors of Diagnosis.

I conclude my observations on hepatitis by quoting two casf s, —
one reported by Mr. Impeyf, the other by Dr. R. H. Hunter.
They illustrate well the difficulties that may occasionally beset the
diagnosis of hepatitis.

* 174. Aneurism of the abdominal aorta. — Acute pain of right hypochondrium and
should.er. — The edge of the liver distinct. — Treated four times for disease of the liver. —
I abridge Mr. Impey's case : —

John Hudson was admitted into hospital on the 30th of October, complaining of
acute tenderness of the right hypochondrium. The pain affected the right shoulder, and
was most felt by decubitus on the right side. The edge of the liver was distinctly
felt. There was little febrile disturbance. The pain subsequently extended towards
the right groin. He continued to suffer without relief till the 23rd of November, when
he was found in a state of pulseless collapse, and died shortly afterwards. He had
been a temperate man, but latterly had used opium in considerable quantity. He was
treated with local blood-letting, counter-irritation, and purgatives.

Inspection four hours after death. — Abdomen. — The liver and intestines were in a
normal state. An aneurism of the abdominal aorta, of oblong shape, and the size of a
cricket ball, occupied with concentric layers of fibrine, was found resting on the border
and sides of the last dorsal and tliree superior lumbar vertebrae. The aneurism had
burst at its most prominent part below the riglit renal artery ; and blood was exten-
sively diffused under the peritoneum. The bodies of the second, thixd, and fourth
lumbar vertebrae were corroded to the depth of half an inch.

The case reported by Dr. E. H. Hunter J of Her Majesty's Second
Regiment is of interest. At one time the patient was supposed to
have hepatitis running on to abscess ; at another, hepatic abscess
conjoined with dysentery; at another, tumour over the aorta; and
at one time aneurism of the aorta.

^175. A tum.our, situated between the edge of the liver and the transverse colon. —
"Private Matthew Sellard was first admitted on the 11th of June with diarrhoea, ac-
companied with pain on pressure in the hypogastric region, for which he was leeched,
and took medicines, chiefly absorbents and opiates, with occasional laxatives ; and so

* " Transactions of the Medical and Physical Society of Bombay," No. 10. p. 303.
t Ibid. No. 7, p. 177. ' \ Ibid. No. 3, p. 134,

STATISTICS. 417

far recovered, as to be able to return to his duty on the 14th of the following month.
On the 19th, was again admitted with similar complaints. The pain on pressure was
now in the epigastric region, where a firm circumscribed tumour was very perceptible,
yielding a sharp, heaving impulse. Soon after, he became subject to occasional vomit-
ing, and at last his symptoms assumed a decided hepatic and dysenteric character ;
under which he rapidly sunk. Died on the 21st September, at 3 a.m. — Autopsy; 11
A.M. Liver enlarged and of a very pale yellow colour, very soft and lacerable, having
from its free edge hanging, and firmly attached to the transverse colon, an encysted
tumour the size of a large egg, fiUed with soft brain-like matter, and its cyst lined
with gritty osseous plates and spikes. The colon, particularly, in its transverse arch,
was extensively thickened and ulcerated."

Section IX. — Statistics of Hepatitis in the European General
Hospital and the Jamsetjee Jeejehhoy Hospital, at. Bombay,

We may conclude that cases of cirrhosis are also included in
these Tables. The great mortality under the head Chronic Hepatitis
in the Jamsetjee Jejeebhoy Hospital shows that a large proportion
of the admissions must have been of hepatic abscess.

The proportion of admissions to total admissions is 3*7 in the
European Greneral Hospital, and in 1*5 in the Jamsetjee Jejeebhoy
Hospital. The rate of mortality is 14*1 in the former, and 34 per
cent, in the latter. The comparative admissions in different sea-
sons have been already stated, p. 362.

In the European troops of the Bombay Presidency * the ratio
of attacks of hepatitis to the strength is about 7*4 per cent. ; the
proportion of deaths to treated, 5*7, and of deaths to aggregate
mortality, 9*5.

In the European troops of the Madras Presidency f the ratio of
hepatitis to strength is 7*178, and of deaths to treated, 4*009.

In the native troops of the Madras Presidency the ratio of ad-
missions to strength is 0*143 and of deaths to treated, 11*917.

Here, again, as in respect to dysentery, there is a higher rate of
mortality from hepatitis in the native than in the European troops
of the Madras army. The remark made on this feature of dysen-
tery, p. 237, is equally applicable to this disease.

* Mr. Webb's Medical Statistics.

t "Mortality and Chief Diseases of the Troops under the Madras G^ovemment," by
Lieut.-Col. W. H. Sykes, F.K.S. Journal of the Statistical Society of London, May
18-51, The statistics of hepatitis have been already stated (p. 321) from Dr. Ewart's
tables — but still I leave these figures, as in the first edition, drawn from other sources.
They very nearly correspond.

E E

418

HEPATITIS.

Table XXX. — Admissions and Deaths, with Per-centage, from Hepatitis^
Acute and Chronic, in the European General Hospital at Bombay, for
the Five Years from 1838 to 1843.

•

1838 to 1843.

Monthly Average.

Admissions.

Deaths.

Deaths on
Admissions.

Admissions

on total
Admissions.

Deaths on
total Deaths.

January-
February
March .
April .
May
June .
July .
August .
September
October
November
December

45
39
36
41
25
31
23
24
23
22
25
36

370

6
11
3
5
2
3

2
9
1
5
5

13-5

28-2
8-3

12-1
8-0
9-6

8-3
39-1

4-5
20-0
13-9

8-2
7-0
71
7-0
2-9
3-9
3-2
3-9
4-2
3 0
3-6
5-8

14-0

34-3

9-0

12-2

2-4

5-9

6-4

25-7

1-9

18-5
10-6

Total .

14-0

4-8

11-6

Table XXXI. — Admissions and Deaths, with Per-centage, from Hepatitis,
Acute and Chronic, in the European General Hospital at Bombay, for
the Five Years from 1844 to 1848.

1844 to 1848.

Average.

Admissions.

Deaths.

Deaths on
Admissions.

Admissions

on total
Admissions.

Deaths on
total Deaths.

January

13-3

2-4

4-3

February

20-0

2-9

8-6

March .

6-6

3-1

3-3

April .

10-0

1-9

3-2

May .

111

3-1

6-6

June

18-2

1-5

6-06

July .

14-3

1-03

2-8

August .

—

— •

3-1

—

September

25-0

3-5

18-2

October

30-8

2-1

10-6

November

15-4

2-3

6-4

December

5-2

3-6

2-5

Total

169

13-6

2-5

5-9

STATISTICS.

419

Table XXXII. — Admissions and Deaths^ with Per-centage^from Hepatitis
Acute and Chronic^ in the European General Hospital at Bombay^ for
the Five Years from 1849 to 1853.

1849 to 1853.

Monthly Average.

Admissions.

Deatlis.

Deaths on

Admissions.

Admissions

on total
Admissions.

Deaths on
total Deaths.

January-

23-5

3-8

10-2

February

13-3

4-1

11-1

March .

15-4

2-9

5-9

April

13-3

2-9

8-0

May

7-1

2-7

4-2

June

15-4

2-3

6-9

July

8-3

2-2

August

10-0

4-05

5-3

September

35-7

3-9

20-0

October

7-7

3-3

4-3

November

2-2

December

53-3

2-5

12-5

Tot

172

15-7

2-9

7-5

Table XXXIII. — Admissions and Deaths, with Per-centage, from Acute
Hepatic Affections, in the Jamsetjee Jejeehhoy Hospital at Bombay, for
the Six Years from 1848 to 1853.

1848 to 1853.

Monthly Average.

Admissions.

Deaths.

Deaths on
Admissions.

Admissions

on tot.il
Admissions.

Deaths on
total Deaths.

January

4-2

1-15

0-2

February

6-3

1-7

0-7

March .

5-0

0-9

0-3

April

—

0-9

—

May

—

0-6

—

June

9-1

0-5

0-3

July

—

0-6

—

August

34-8

1-2

2-4

September

28-6

0-28

0-6

October

—

0-2

—

November

21-0

0-9

1-2

December

15-4

1-01

Tot

208

11-06

0-8

0-6

£ E 2

420

IIErATITIS.

Table XXXIV. — Admissions and Deaths^ with Per-centage, from Chronic
Hepatic Affections, in the Jamsetjee Jejeehhoy Hospital at Bombay, of
the Six Years from 1848 to 1853.

1848 to 1853.

Monthly Average.

Admissions.

Deaths.

Deaths on
Admissions.

Admissions

on total
Admissions.

Deaths on
total Deaths.

January

Februar

March

April

May

June

July

August

Septeml

October

Noveml

Decemb

)er

er
er

27
16
13
18
22
18
7
21
19
11
15
11

16
9

5
6

63-0
100-0
69-2
38-9
54.-5
22-2
42-8
61-9
36-8
27-2
33-3
54-5

1-3

0-8'
0-6
■ 0-9'
1-01
0-9'
0-3
11
0-9
0-5
0-7
0-5

3-8
50
2-3
2-4

' 4-2
1-3

' 0-9
4-0
2-2
0-9
1-5
1-5

Tol

.al

198

102

51-5

0-8

2-5

421

CHAP. XVI.

ON CIERHOSIS, CONGESTION, LAHDACEOUS AND FATTY ENLARGEMENT,

CANCER AND HYDATID OF THE LITER. AFFECTIONS OF THE BILIARY

DUCTS AND GALL-BLADDER. — BILIARY CALCULI. — JAUNDICE.

INCREASED AND DEFECTIYE SECRETION OF BILE.

The subjects of this chapter will be treated very briefly, for they
are now well understood, and described in systematic works.

Section I. — Cirrhosis. — Pathology. — Symptoms. — Treatment,
— Complication with Hepatic Abscess.

This disease is common in India, as in other countries, in the classes
addicted to the habitual free use of spirits. It consists of chronic
inflammation of the areolar tissue of the portal canals, even to their
smallest ramifications, followed by exudation of lymph which be-
comes slowly organised into contractile fibrous tissue. This process
leads to a diminution of the calibre of the branches of the portal
vein, the hepatic artery and duct, with probably obliteration of
some of their smaller divisions. From this, atrophy of the lobular
structure of the liver results, and the diminished flow of blood
through the portal vein favours congestion of the capillaries of the
mucous membrane of the alimentary canal, hence haemorrhages,
also of the peritoneal capillaries, hence ascites.

The exudation in the early stages, before organisation, con-
traction, and lobular atrophy have taken place, may cause enlarge- .
ment of the liver and its extension below the margin of the ribs.
With progressing organisation the lymph contracts, the lobules
become atrophied, and the size of the organ is often very consider-
ably diminished. The liver now becomes hard and tough, and
when cut shows a surface variegated with white streaks, and some-
times presents the appearance of little globular nodules, the size
of a pea, imbedded in a capsule of fibrous . tissue. The external
surface becomes irregular and tuberculated in appearance — a state

£ E s

422 CIRRHOSIS.

caused, it is believed, by the contractile organisation of the lymp!
exuded in the proximity of the capsule. The colour of the liver in
cirrhosis varies according to the quantity and quality of the retained
bile. It may be of pale buff colour, or of bright yellow, or of
an olive-green tint. These statements will be found to be verified
by cases * detailed in this work.

It is further important to recollect that this condition of the liver
exists in a very depraved diathesis, the result of the habits which
induce the local disease, and of the imperfect purification of the
blood, arising from structural unfitness of an important excretory
organ.

The symptoms are more or less uneasiness or pain of the hepatic
region, with some degree of febrile disturbance, in the early stages.
In the more advanced periods, the diagnosis chiefly depends on the
deranged digestive functions, the sallow complexion, the increasing
emaciation, the intemperate habits, and finally the ascites, or the
gastric or intestinal haemorrhage.

Considering the circumstances in which cirrhosis occurs, the
treatment is necessarily unsatisfactory. When the early symptoms
are present, a modified antiphlogistic treatment by leeches, small
blisters, and moderate mercurial and other eliminants, will be of
benefit, but there can be no prospect of permanent improvement
unless the habit of spirit drinking be abandoned.

When the cachectic diathesis, always present in some degree in
this disease, is regarded, there can be little hesitation in determin-
ing that the constitutional action of mercury is contra-indicated
This conclusion may perhaps be occasionally questionable at the
commencement, but as the disease advances there can be no room
for doubt ; and on the whole we shall act wisely by making the
rule absolute. In the advanced stages there is little to be done
beyond adjusting the regimen to the ability of the impaired organs,
aiding the eliminating power of the liver by taraxacum, hydro -
chlorate of ammonia, nitric acid, and the external use of nitro-
. muriatic acid ; checking the haemorrhages by suitable astringents,
and favouring the removal of ascites by varying arrangements of
diuretics and the external application of iodine lotions.

The two following cases illustrate several of the features of this
disease : —

176. Cirrhosis, with enlargement. — Ascites and Jaundice. — Samuel John Adams, a
native Christian, of twenty-five years of age, using spirits habitually, was admitted in
an emaciated state into the clinical ward, on the 23rd July, 1849. The respiration

* Cases 61, 176 to 181.

PATHOLOGY. 423

was short and hurried. The abdomen was tense, swollen, bulging laterally, and dis-
tinctly fluctuating ; dulness on percussion reached to the right fifth rib, and fourth left
rib, anteriorly, and to the angle of the scapulae, posteriorly. The sounds of the heart
were normal, but least heard between the third and fourth ribs, midway between the
sternum and left nipple. There was oedema of the lower extremities. The pulse was
small. The tongue moist, but coated yellow in the centre, and florid at the tip and
edges. There was faint yellowness of the conjunctirse, and the bowels were relaxed.
He stated that the jaundice had been present for three months, that irregular febrile
symptoms had come on fifteen days before admission, were succeeded by the ascites,
and this by the anasarca. The diarrhoea increased after his admission, and he died
on the 27th. The urine gave no traces of albumen, and its quantity had increased
under the use of diuretics.

Inspection ten hours after death. — All the tissues were tinged yellow. The abdomen
was swollen, and the lower extremities were cedematous. Chest. — The lungs collapsed,
were soft and crepitating, and without adhesions. There was neither pleuritic nor
pericardial effusion. The base of the heart reached to the second costal cartilage, and
its apex was opposite to the fourth intercostal space from pressure upwards by the
abdominal fiuid. The structure of the heart was normal. Abdomen. — There were
about six * pints of yellow turbid serum in the peritoneal sac. The omentum was
somewhat thickened. The liver, chiefly its left lobe, was considerably enlarged, its
surface was very irregular and lobulated, and was of olive-green colour. It reached
transversely to the ribs of the left side, and upwards on both sides to the upper margin
of the fifth rib. The gall-bladder was empty, and its structure was indurated. The
kidneys were somewhat enlarged, but there was no trace of yellow degeneration. The
spleen was much enlarged, somewhat firm in structure. The whole tract of the intes-
tinal canal was laid open. The sub-mucous tissue was, in places, oedematous ; but
with the exception of patches of dark red discolouration of the mucous membrane of
the ccecum and some enlargement of the follicles there, there was no other disease.

177. Ascites. — Liver small and indurated. — Cirrhosis. — Considerable effusion of
serum in the head. — Patrick McDonald, aged forty-eight, a serjeant on the pension
list, a tall spare man, was admitted 23rd July, 1838, into the European General
Hospital. He had been twenty-eight years in India, and about four years ago suffered
from jaundice. On admission the abdomen was distended, fluctuation was distinct, and
the legs and feet were cedematous. His illness had commenced in the beginning of
June, with anasarca of the legs. The urine was scanty and not coagulable. The
treatment in the first instance consisted in the exhibition of diuretics of different kinds
and in different modes of combination — calomel with squills, colchicum wine, tincture
of squills, tincture of digitalis, nitrous ether, and the different neutral diuretic salts
combined latterly with some bitter infusion, or a solution of quinine ; an occasional
purgative was also exhibited. Under this treatment, at first the urine increased much
in quantity, and the swelling of the abdomen and the anasarca of the limbs decreased ;
the alvine evacuations were never pale or deficent in bile. The diuretics now lost
their effect, the fiuid re-accumulated; he was tapped about the 19th October; again
on the 2nd November, and thirty-five pints of of straw-coloured serum were drawn off;
again on the 12th November, and twenty-one pints ; on the 13th December, twenty-
six pints; on the 31st December, twenty- three pints; on the 7th January, twelve
pints ; and on the 4th February, twenty- three pints of slightly turbid serum were
drawn off. Throughout this period, the medical treatment was merely palliative and
tonic, with an occasional endeavour to re-excite the action of the kidneys. He
ultimately became occasionally delirious, and died on the 11th February,

Inspection four hours after death. — Body emaciated. Head. — There were about two

* The MS. is not distinctly legible in regard to the quantity of the serum, and that
stated above is therefore not positively given.

E E 4

424 CIIIRHOSIS.

ounces of scrum between the arachnoid membrane and pia mater, on the convex
surface of the brain, and at the base of the skull, and six drachms in the ventricles.
Chest. — The lungs collapsed and were healthy ; the heart was healthy ; and there was
no fluid in the cavity of the pleura. Abdomen. — Eight pints of whey-coloured serum
were contained in the cavity. The stomach was much dilated, and occupied the left
hypochondrium, the epigastrium, and part of the right hypochondrium. The trans-
verse colon was also much dilated. The peritoneal surface of the greater part of the
small intestine had a close-set pearly covering* in irregidar patches, about the thick-
ness of silver paper, easily peeled from the peritoneal lining, and extending in a con-
tinuous but thinner layer over the mesentery. The peritoneal coat was thinner, not
pearly, not easily separable from the tunics, and clearly distinguishable. The liver was
about half its natural size, and adhered by long areolar bands to the side ; its texture
was much indurated, pale buflF, like cow's udder, with many pale yellow granules scattered
throughout. There was a small quantity of bile in the gall-bladder. The spleen was
dense, its peritoneal coat was thickened and pearly. The mucous lining of the stomach
was of natural texture, but marbled red at the cardiac end and thinned at the pyloric.
The contents of the small intestine were tinged with bile. The mucous coat of the
sigmoid flexure of the colon was vascular. Where the transverse colon was dilated,
there were no rugse, but these were numerous and in all directions where the dilata-
tion ceased. The tubular and cortical parts of the kidneys were not so distinctly
defined as usual, but these organs were otherwise healthy.

It is generally stated that cirrhosis of the liver and hepatic
abscess do not occur together. This is doubtless correct of Euro-
pean countries, but it is not so of India, where the co-existence of
the affections is not very unusual. I quote four cases illustrative
of this remark : —

178. Abscess in the liver. — Cirrhosis. — Bloughy 'perforations of large intestine, but
no thickening of its coats noted. — Private M. E , aged twenty-seven, of Her Ma-
jesty's 40th Eegiment, was admitted into hospital, at Belgaum, on the 19th July,
1830. He had been six months in India, and never in hospital before; but had, for
some days before admission, suffered from pain of abdomen and deranged bowels. On
admission, there was tenderness of abdomen, hot skin, full pulse, dejections frequent
and morbid. On the 6th August he had slight pain of right side, but it was gone on
the following day. Died August 11th.

Inspection. — The liver was of natural size. Its whole surface was rough, granular,
and covered with healthy peritoneum. The internal structure was occupied by nume-
rous small abscesses, the size of a hen's egg, and containing thin green watery pus.
The parenchyma of the liver, when cut, presented a surface of light gamboge, yellow
colour ; and was found to consist of numerous small nodules, each about the size of a
pea, and confined to a distinct capsule, from which it could readily be picked out.

* I must call attention to the thin pearly layer that invested the peritoneum in this
case. I am doubtful whether it is to an appearance of this kind or not that Dr. Budd
alludes at p. 139 of his treatise, as induced by peritonitis. It seems to me that a
more likely explanation of the appearance described in this case may be suggested. In
the normal state of the peritoneum, a very slight epithelial investment suffices for
protective purposes ; but when serum has for a long time been in contact with the
peritoneal surface, then further protection is required, and epithelial hypertrophy
may ensue. I would look upon this thin layer as a thickened epithelium. This is a
point, however, in respect to which there should not be doubt, for the microscope will
readily resolve it.

PATHOLOGY. 425

It was in these capsules that suppuration seemed to have commenced. The liver ad-
hered to the concave surface, and the right lung to the convex surface of the diaphragm.
The gall-bladder was full of dark bile. The omentum covered the whole surface of the
small intestine, and, where not inflamed, was thinner than natural, as if stretched.
Fleshy and thickened at the points of adhesion, the omentum adhered to the ccecum
and descending colon ; and when pulled away from the latter situation, it was found
that the coats of one side of the descending colon had been completely removed, and
the loss supplied by the omentum and the abdominal parietes. The sigmoid flexure
formed two or three folds in the cavity of the pelvis, and at the angle of each fold the
coats of the intestine were destroyed on one side, for the extent of the size of a dollar,
the loss being supplied by the opposite side of the folds and by the omentum. The
iirinary bladder formed the wall of one perforation the size of a dollar.

179. Abscess in liver with cirrhosis, notwithstanding 'ptyalism. — Displacement of
colon. — Adhesion of it to the left side of diaphragm. — Sloughy ulceration of large

intestine, without thickening. — Private W. H , of Her Majesty's 40th Eegiment,

aged forty- three, after one day's illness, was admitted into hospital, at Belgaum, on
the 22nd July, 1830. There was much tenderness across the lower part of the epi-
gastric region, and the dejections were frequent. He was freely bled and leeched, and
the pain left him ; the dejections became bilious and no longer contained blood. On
the 25th, ptyalism, 28th, medicines omitted. The dejections were natural, and he
seemed to be convalescent. From the 1st of August to the 10th, the dejections con-
tinued feculent and formed, with occasionally, however, some drops of reddish mucus
passed with tenesmus. On the 10th the purging returned, the tenesmus increased, the
dejections became morbid, and the abdomen tender. From this time all the symptoms
became aggravated. Ptyalism could not be again induced, and he died, on the 26th
August.

Inspection. — The omentum was shrivelled up and laid upon the transverse colon.
This intestine, throughout its course, adhered to the abdominal parietes, and to the
great curvature of the stomach, following its cardiac extremity, and adhering to the
left side of the diapliragm. On the right side the transverse colon adhered to the
concave surface of the liver, and flmily to the gall-bladder. The coats of the bowel
were thinned, and in some places perforated : the gall-bladder, for example, formed
the wall of a perforation. The ascending and descending colon ulcerated internally,
were of rather contracted calibre, and adhered firmly to the parietes of the abdomen.
"When these adhesions were separated in some places, the contents of the bowel
escaped. The peritoneal surface of the small intestine was of a dark red colour with
here and there patches of effused lymph. The left lobe of the liver was small, hard,
and carneous. The right lobe not so hard, was mottled and contained many
small abscesses in its structure, none of them, however, larger than a horse-bean.
There was not any adhesion of the external surface of the liver, but in some places
there were depressed and puckered cicatrices. The coats of the different vessels in
the substance of the liver seemed thickened, and felt cartilaginous and hard under the
scalpel. The gall-bladder contained thin watery bile. The lung on the left side
adhered to the diapliragm, opposite to the'adhesions formed between that muscle and
the colon.

180. Abscess in liver, notwithstanding ptyalism. — Cirrhosis. — Coecum and ascending

colon thickened and ulcerated. — Private B. A , aged twenty-one, was admitted

into hospital at Belgaum, on the 1st August, 1830, affected with griping and passing
mucous dejections. On the 3rd, when the gums were tender, the dejections became
bilious and feculent, and continued so till August 17th, with however irregular action
of the bowels and occasional griping, but without tenderness of abdomen, or febrile
excitement. On the 17th, blood was observed in the alvine discharges. From this
date the symptoms became aggravated. The dejections, however, retained their bilious

426 HEPATIC CONGESTION.

colour, though there was no intermixture of blood and vitiated mucus. No ptyalism.
Died September 8th.

Inspection. — The liver, without adhesions, was of slate colour externally, somewhat
enlarged, and extended beyond the cartilages of the ribs. Near the thin edge of the
left lobe there was an abscess, yellow, elevated above the surface, about the size of
a hen's egg, and containing thick pus. The liver was hard in structure. The gall-
bladder was full of dark bile, and had formed firm adhesions with the colon and
the pyloric portion of the duodenum. There was less peritoneal inflammation than is
generally met with. The omentum was vascular, but had contracted few adhesions.
The caput coecum and ascending colon were distended, hard, and thickened. The
former was drawn upwards from its usual situation in the iliac fossa. The mucous
membrane of the larger intestine was ulcerated, but nowhere was there any trace of
perforation.

181. Dysentery complicated with delirium tremens. — Abscess and cirrhosis of the
liver. — Denis L. Donahen, aged twenty-eight, a man of stout frame but of dissipated
habits, aften ten or twelve days' illness with dysentery, was admitted into the
European Greneral Hospital on the 11th December, 1842. There was heat of skin,
full and frequent pulse, and considerable tenderness about the coecum. He was bled
to twelve ounces, had fifty leeches applied to the abdomen, and took calomel with a
full opiate. The following day he was tremulous, and the dysenteric symptoms
continued. On the 14th he was in a state of delirium tremens, and there was dis-
tinct induration at the site of the coecum. On the 15th the symptoms of delirium
tremens had passed away but the dysentery continued. He was treated chiefly with
free opiates without amendment ; and on the 29th, to the dysenteric symptoms was
added occasional uneasiness of the right hypochondrium shoeting to the shoulder.
This state persisted with occasional febrile symptoms, collapsing features and declining
strength, and he died on the 4th January.

Inspection ten hours after death. — Abdomen. — The omentum adhered firmly to the
coecum, and the transverse colon was rather contracted. The liver was in a state of
cirrhosis, and several small abscesses projected from its convex surface, and there was
a larger one, at the thin edge of the liver, of which the walls were in part formed by
the omentum.

Section II. — Congestion of the Liver, — (Edema,

The facts which it is important to remember in regard to this
pathological state are, the three degrees of congestion described
by Mr. Kiernan: the first confined to the hepatic vein, the second
implicating the portal capillaries in part, the third involving all
the portal capillaries. Thus the varieties of mottling frequently
observed on the incised surface of the liver are caused.

The two first of these degrees are liable to be produced by
cardiac or pulmonary disease obstructing the ready return of the
venous blood to the heart.

Consequent on the altered balance of the circulation and the
deteriorated blood in malarious fever, congestion of the portal
capillaries, leading to enlargement of the organ and derangement
of function, is apt to occur. This pathological state has been
already alluded to in connection with the subject of fever, and the

HEPATIC CONGESTION. 427

caution has been given not to mistake this condition co-existing
with fever, for hepatitis.*

It is a favourite theory with some, that blood vitiated by the
absorption of matters from the intestinal canal is a common cause,
and affords a ready explanation of certain biliary derangements.
That, consequent upon blood altered in quality being conveyed to
a secreting structure, the processes between that blood and the
cells — in other words, secretion — may be impaired and capillary
congestion result, is accordant with present physiological doctrine.
But t that the food of the middle and upper classes of society,
taken in excess, is liable to generate an immense variety of noxious
matter, capable of absorption by osmotic force, is surely a state-
ment unsupported by sufficient proof.

In ordinary digestion the assimilable portion of the food is
absorbed in the upper parts of the alimentary canal, while its foecal
residuum with the excreta from the surface of, or poured into, the
intestinal canal, are passed onwards for rejection. When delayed
in the large intestine, that portion of the contents which is absorb-
able by osmotic force is removed and the density of the residual
mass is increased, while the fluid part which has been absorbed is
carried to the portal blood; but no evil results, simply because
that which is noxious has been left behind, and that which has
been absorbed is innocuous.

Why should it be otherwise in the instance of excess ? Then
the undue quantity of foecal residuum is hurried through the canal
and speedily ejected. Instead of there being greater likelihood
under these circumstances of absorption into the portal blood of

* " Congestion of the liver " is at present a common phrase often however used,
very vaguely, and without any attempt to ascertain by percussion, whether the organ
is enlarged or not. Increased size of the liver is a condition of its congestion, and un-
less this exists, the assertion that there is congestion of the liver is hardly justifiable.

A persistent, enlarged and friable state, caused by congestion or other change of the
large parenchymatous viscera — the liver and spleen — of the abdomen is also important
in reference to questions of medical jurisprudence. For example, rupture of an
enlarged spleen and speedy death by haemorrhage, caused by slight and apparently
inadequate external injuries, is not a very unusual occurrence in India. Four such
cases are recorded by Mr. Heddle, in the 1st volume, " Medical and Physical Society's
Transactions," Bombay. The only instance which has come under my own observation
was that of police constable, who had strained himself in playing cricket. He was
admitted into the European General Hospital on the 1st February, 1840, with uneasy,
full abdomen and oppressed breathing, and died on the following day. After death the
cavity of the abdomen was found to contain four imperial pints of dark-coloured
blood, in part coagulated, which had proceeded from a laceration, an inch and a half in
length, on the inner surface of the spleen.

t Dr. Budd, " Diseases of the Liver," second edition, p. 61.

428 LAllDACEOUS AND FATTY LIVEll.

the so-called noxious matters, there must be less, for they are de-
layed a much shorter time in relation with the structures which
are supposed to absorb. That excess in eating and drinking de-
ranges the digestive functions, those of the liver included, is very
true ; but that this effect is usually caused by the direct transmis-
sion of noxious matters of food, by the portal blood, from the
intestine to the liver, is for the reasons just assigned, an impro-
bable theory.

(Edema of the Liver — is a pathological state with which I was
unacquainted till I met wiCh the following case. This condition
is not noticed by Eokitansky, and the only mention of it to which
I am at present able to refer, is in the Library of Medicine.*
There it is said that oedema of the liver, uncombined with inflam-
mation, has often been observed ; but by whom is not stated.

182. Eemittent fever, oedema of the liver. — Cassim Ibrahim, aged thirty-si^x, admitted
after ten days' illness, on the 6th February, 1857. The skin was hot and dry, the
breathing hurried, general tremors, sordes on the lips, the tongue dry and florid, the
pulse frequent and small, no abnormal cardiac sounds. The exhaustion increased, and
he died in twenty- four hours.

Inspection fifteen hours after death, — The white tissues? were tinged yellow. No
abnormal vascularity or effusion in the head. The lungs healthy, with exception of
considerable oedema, and dark redness of the bronchial mucous membrane. The heart
was healthy. The liver, of dark olive colour, reached two inches below the right ribs,
and touched the point of the eighth left rib. It weighed four pounds four ounces,
and when cut, and gently pressed, serous fluid oozed freely from the surfaces, six
ounces were collected. The parenchyma broke down readily under the finger. The
incised surfaces presented a dark olive colour, with brown intermixture, but not the
mottled redness of congestion. There was commencing Bright's disease of both
kidneys. The mucous membrane of the stomach and intestines was, with exception of
mottled redness of the former, healthy.

Section III. — Lardaceous and Fatty Liver, — Cancer, and
Hydatid Formations,

Lardaceous Liver, — This state, termed by Dr. Budd scrofu-
lous enlargement of the liver, found in scrofulous, syphilitic, and
mercurial cachexia, is, I believe, very similar to that caused by
malaria. I have already, when treating of hepatic enlargement
consecutive on intermittent fever, stated my own limited infor-
mation on this subject, and what seem to me the chief desiderata
in its further investigation.

Fatty Degeneration of the Liver, — The etiology and pathology
of this morbid state in India are subjects for future inquiry; for

* Vol, iv. p. 180.

CANCER OF THE LIVER. 429

it is probably more common than recorded facts have yet proved
it to be. This, and all allied processes which imply perversion of
nutrition, of great interest in all countries, are particularly so in
India, where, for reasons elsewhere adverted to (p. 154), the ten-
dency to degenerative action, is, in all likelihood largely developed.
The reader will find a full exposition of the present state of patho-
logical knowledge on scrofulous enlargement and fatty degenera-
tion of the liver in Dr. Budd's work.*

Cancer of the Liver. — Judging from the considerable space
allotted to descriptions of this morbid state in works on the patho-
logy of the liver, it would seem that it is not of unfrequent occur-
rence in European countries.

It is certainly rare in India, and therefore, clinically speaking,
it is undesirable that it should fill a prominent place in the mind
of the practitioner in that country.

The following is the only case which has come under my ob-
servation : —

183. Treated for stipposed dyspeptic symptoms. — Numerous cancerotcs tubera dis-
seminated throughout the liver. — One had opened into the stomach. — Chayia Eaggia, a
Hindoo fisherman, of fifty years of age, a resident of Caranja near Bombay, and using
spirituous liquours habitually, was, not much reduced in flesh, admitted into the
clinical ward, on the 11th July, 1849, under the head "Dyspepsia." The abdomen
was flaccid, and without induration. The tongue was clean and moist. He com-
plained of pain at the epigastrium extending up the sternum coming on in parox-
ysms three or four times in the day, generally, he thought, when the stomach was
empty. The paroxysms were attended with flatulence and a sense of burning and
acidity of stomach which were relieved by firm pressure, and also, he said, by the
use of spirits. He had suffered more or less from these symptoms for four years.
During his stay in hospital the urine was frequently examined, but gave no indications
of albumen. He continued under treatment till the 29th July, when he was dis-
charged relieved. He returned to the hospital several times, and was treated for his
dyspeptic symptoms as they were termed. The last admission was on the 24th
November, 1850. There was pain at the epigastrium, with distinct induration extend-
ing in a direction below the margin of the right ribs. The alvine discharges were
clay coloured. On the 10th December there was vomiting of dark-coloured fluid, under
which he sank and died.

Inspection twelve hours after death. — The liver enlarged, chiefly the right lobe.
From different parts of both the convex and concave surfaces there projected in relief
circumscribed white elevations of various size, from a pea to an olive. These, when cut
into, were found to be white, indurated, circumscribed tubera. There were also
numerous similar nodules in different parts of the substance of the liver in size from a
pea to a small orange. Some of the large ones were softened at their centres into a
pulpy matter, almost of the consistence and colour of pus, which under the microscope
exhibited the granular cellular appearance of the encephaloid cells. The intercurrent
portions of the liver were natural in appearance and consistence. The concave surfiice
of the left lobe adhered to the surface of the stomach near to the pylorus, and the

* For further remarks on fatty degeneration of the liver and fatty liver, see
note, page 9.

430 HYDATIDS IN THE LIVER.

inner surface of the stomacli at the site of adhesion presented a cup-like depression
invoh'ing the substance of the liver, the evident consequence of the opening of a tuber
into the stomach. Both kidneys, on removing the capsule, presented a buflf mottled,
somewhat granular appearance, and on incision the cortical portion was pale buflf, and
encroached on the tubular. There was some degree of hypertrophy of the left ven-
tricle of the heart, and some thickening of the mitral valve.

Hydatid formations in the liver are also rare in India. I have
met with only three cases. Two occurred in natives, and in both,
echinococci were present in great abundance. The subject of one
of these two cases was a negro sailor, a native of Muscat, admitted
into the clinical ward with fulness of the right false ribs, and a
dull prominent swelling reaching to the eighth left rib, and to near
the umbilicus. There was also fever and dysentery. The history
was imperfect, but from the hepatic enlargement, the fever and
dysentery — the diagnosis was hepatic abscess. He died ten days
after admission, and after death a large hydatid sac was found in
the right lobe of the liver, containing five pints of clear colourless
fluid with floating acephalocysts and echinococci ; and numerous
nodules of lymph deposit, some softening into pus, were scattered
throughout the left lobe. There was sloughy ulceration of the
large intestine. The diagnosis was therefore correct, though in
complete, and the inference from the enlargement erroneous.

The third case is detailed below — it occurred before the atten-
tion of the profession had been called to the general presence of
echinococci in the hydatid sac. The subject of it was a soldier
of the 15th Hussars, lately arrived from Europe — so that the
hydatid in this case as well as that in the Muscat sailor were not
of Indian origin.

184. Fhthisis jpulmonalis. — Lungs tuherculated, hydatid sac in the abdomen, also in
the liver. — Feritoneum studded with miliary trans'parent tubercles . — Edward Colling-
ridge. Her Majesty's 15th Hussars, aged twenty- two, had been troubled with a pectoral
aflfection during the voyage, and was admitted into the European General Hospital, on
the 10th November, 1839. He was pale, sallow, and had frequent dry cough. Tuber-
cular deposition in the lungs was suspected. On the 3rd December the abdomen was
tense and full, with sense of fluctuation. There was constant hectic fever with
increasing emaciation, and he died on the 2nd January.

Inspection twelve hours after death. — Body much emaciated. Head. — There was a
thin veil of serum between the archnoid and pia mater on the convex surface of the
brain. The substance of the brain was soft. Chest. — There was a pint of serum in
the sac of each pleura. The anterior part of the lungs was emphysematous, and
miliary tubercles were disseminated throughout. The posterior part of the upper lobe,
and almost the whole of the lower lobe of the right lung, were impermeable from
tubercular infiltration ; in places there were tubercular masses, the size of a pigeon's
egg, but generally it was intermixed with the red parenchyma, and presented the
variegated appearance (when incised) of shell marbles, in which red and white are the
predominating colours. The posterior part of the left lung was cedematous, but there
was little tubercular infiltration. The heart was healthy. Abdomen. — The intestines

AFFECTIONS OF THE GALL-BLADDER. 431

were displaced, and the central part of the abdominal cavity was occupied by a
hydatid sac which completely filled the pehas, rose over the promontory of the sacrum,
and reached to the margin of the left lobe of the liver. This sac was filled with many
pints of hydatids, transparent and clear, ranging from a marble in size to a large
orange ; there was also a great quantity of yellow membranous shreds, the evident
teguments of dead hydatids. In the left lobe of the liver were two sacs, each the size
of a small orange, also fiUed with hydatids. The intestines were of a dark leaden
colour, and generally contracted. The mesentery, and much of the peritoneal surface
of the intestines, and also the omentum, were studded closely with miliary tubercles,
about the size of a mustard seed ; and to these the small red ramifications of vessels
very frequently extended. The stomach was small. The kidneys healthy. The
examination was not further pursued.

Section IV. — Inflammation of the Gall-Bladder and Biliary
Ducts. — Distention of the Gall-Bladder, — Biliary Calculi,

My observations supply very little information on these affections.
The cases of jaundice complicating remittent fever, detailed at
page 98, do not countenance the idea of inflammation of the
mucous lining of the biliary ducts being a common cause of jaun-
dice ; and if I may judge from my own experience, inflammation of
these structures, as well as of the gall-bladder, is not of frequent
occurrence.

A case (185) of inflammation * of the gall-bladder, associated
with abscess in the liver, is subjoined; also two cases of distention
of the gall-bladder, previously referred to.f In association with
the two last cases, 42 and 43 may also be considered.

185. Hepatitis. — Abscess. — Inflammation of the external and internal surface of the
gall-bladder. — 8udden collapse, continuing with varying symptoms for several days. —
John Mclnnes, aged thirty-three, had been employed as an engineer. After ten days'
illness with hepatitis, he was admitted into the European General Hospital on the
12th April, 1841, with the disease unsubdued. On the 20th there was unexpected
collapse with vomiting. He continued, till his death on the 30th, with occasional
vomiting, hiccup, pulse frequent, and failing in strength. Latterly abdomen full, with
pain shifting from place to place.

Inspection. — There were two abscesses in the right lobe of the liver. There was a
small quantity of sero-purulent eiFusion in the abdomen, with tender adhesions of the
convolutions of the intestine to each other, and firm adhesion of the liver to the con-
cavity of the ribs. The gall-bladder was moderately distended, its peritoneal surface
was of bright red colour, and adhered to the colon ; the lining membrane was also of
bright red colour, and the contents consisted of tenacious mucus in places almost

* I find, in my notes of fatal cases of officers, one of a stout corpulent man of thirty-
four years of age, who suffered frequently from pain of the hepatic region, and clay-
coloured evacuations. After six weeks' illness with these symptoms, treated freely
with general and local blood-letting and calomel, he died exhausted. The liver was
found much enlarged, mottled, and readily lacerable. The gall-bladder was small,
and filled with calculi, from a pigeon's egg to a pea in size, but without bile ; the
mucous membrane was red and livid, with sphacelated patches.

t Page 413.

432 AFFECTIONS OF THE GALL-BLADDER.

membranous in character ; a probe passed through the duct met with resistance. The
mucous coat of the stomach was lined with adhesive mucus, and presented a rosy tint,
but was imchanged in structure.

186. Fever, with jaundice. — Gall-bladder distended, seemingly from inflammation of
the common duct. — Little improvement from treatment. — Jamsetjee Sapoorjee, a Parsee
carpenter, of fifty-five years of age, following his occupation in the Government dock-
yard, and habitually using spirits, was admitted into hospital, on the 24th June,
1852, iU with intermittent fever, complicated with jaundice. On the 2nd July, a
pyriform indistinctly fluctuating swelling was observed below the margin of the 10th
right rib. It was about an inch and a half in length and an inch in breadth, and was
dull on percussion, but not painful. There was pain increased by pressure at the margins
of the seventh and eighth ribs, also felt in a direction inwards from them. There was
no swelling or abdormal dulness elsewhere. The alvine discharges were pale, and the
urine tinged with bile. Leeches and small blisters were applied over the tender part.
Quinine combined with taraxacum and rhubarb or aloes was given, also alkalies and
diuretics ; but he benefited i^'ttle by the treatment, and left the hospital on the 8th Sep-
tember, with the swelling unchanged.

187. The gall-hladder, distended, reached to the umbilicus. — Gastritis. — Colon
contracted. — A negro cook, of fifty years of age, a native of the island of Cayenne,
resident for some years in France, and latterly in Jamaica, had suffered at different
times from illnesses, the nature of which he could not clearly explain ; they seemed,
however, to have affected chiefly the abdominal viscera. This individual arrived in
Bombay about the middle of December 1835, and complained occasionally of irregular
action of the bowels, and the tongue was generally thickly coated. These complaints,
though relieved by the exhibition of mercurial purgatives, recurred towards the end
of December, and were attended with pain of the margin of the right false ribs,
relieved by leeches. From the 1st January to the 20th he suffered more or less from
irritability of stomach, irregular and torpid action of the bowels, frequently colicky
pain, but -without distention or tenderness of the abdomen. The tongue was thickly
coated, the pulse was natural, the skin was scaly and dry, but of natural appearance.
Various purgatives with anti-spasmodics, anodynes, enemata, &c., were freely used.
On the 20th the matter vomited was dark-coloured and offensive ; there was tender-
ness round the umbilicus, and pressure there induced vomiting. From this time the
irritability of stomach became distressing ; vomiting was excited by speaking, and by
all ingesta ; the matters ejected were watery, foetid, and sometimes tinged with blood.
There was trifling pain of the epigastrium ; the pulse became rapid, and feeble, and
the skin morbidly hot ; there was subsultus tendinum and low delirium ; the abdomen
was collapsed, and the action of the bowels irregular ; and during the last days of life
there was occasional tenesmus. He died on the 28th of January.

Inspection five hours after death. — Abdomen. — The lower part of the thorax was
contracted, so that the liver and stomach were pushed more towards the iimbilicus
than is natural. The gall-bladder was distended, and extended two inches beyond
the edge of the liver ; it passed over the hepatic flexure of the colon, and was opposed
to the right edge of the umbilicus ; the gall-ducts were natural. The stomach was
moderately distended, the mucous lining of the cardiac end was dotted red and
softened ; that of the body and pyloric end thickened, and presenting a mammillated
surface. The small intestine was empty, pale, and contracted. The large intestine
was throughout of small calibre, with frequent and considerable contractions, chiefly
in the transverse and descending portions ; but there was no thickening of the coats ;
the prevailing tint of the inner surface was dark grey, occasionally merging into
streaks of grey black, with here and there dark red patches. There was in places
softening of the mucous coat, and cicatrices of former ulcers were apparent, but the
traces of the most recent inflammatory action were in the sigmoid flexure of the colon,
and the commencement of the rectum.

JAUNDICE. 433

Biliary calculi have seldom come under my notice in post
mortem examinations in India, and I cannot bring to my recollec-
tion above three or four cases of individuals suffering from the
symptoms characteristic of obstruction of the ducts from this
cause.

These results accord with Dr. Budd's experience in the Dread-
nought Hospital among men returned from India. But he justly
adds, and the remark applies in part to my own field of inquiry,
" It is, however, not fair to judge from these men, who were sailors
and had probably great immunity from gall-stones, on account
merely of their seafaring life." To this may be added that they
were also, for the most part, men at a period of life of acknow-
ledged little liability to this affection.

Dr. Budd states that gall-stones are common in the cancerous
diathesis. Judging from my own experience, as well as inquiry
from others, both cancerous degeneration and biliary calculi are
rare in India compared with other countries.

It may be, that the circumstance of my pathological investiga-
tions having been chiefly carried on among males, is another
reason why biliary calculi have not frequently come under my
notice.

If the proclivity of the female sex to the formation of gall-stones
be due to the sedentary life which they lead, the affection ought
to be common among those females in India who lead secluded
lives. My opportunities of witnessing disease in these classes in
Bombay have not been unfrequent, yet I cannot call to my recol-
lection a single case of jaundice or of other symptoms that could
be attributed to the passage of gall-stones.

The inference to be drawn from these remarks is, that there is
still room for further research on the formation of biliary calculi in
India.

Section V. — Jciundice, — Pathology.— Causes, — Treatment

Though this symptom of hepatic disease has been, from its
prominent character, long familiar to medical men, we are still
imperfectly acquainted with its proximate causes. These, as at
present believed, may be stated to. be —

1. Obstruction of the hepatic or common duct by viscid mucus
or gall-stones, and by external pressure of enlarged lymphatic
glands, the head of the pancreas, gravid utertls, loaded colon, or
other mechanical influences of a similar nature. When obstruction

F F

434 JAUNDICE.

has continued for some time, the hepatic cells become destroyed,
their place being taken by granular amorphous matter; and
the liver, losing its firmness, becomes soft, flaccid, and pulpy.
When the obstruction has become permanent, death takes place
by a slow process of exhaustion and emaciation. Jaundice under
these circumstances is caused by re-absorption of bile.

2. Destruction of the hepatic cells, independent of obstruction
in the ducts. This is the yellow atrophy of Kokitansky. It is
characterised by reduced size and a flaccid, pulpy state of the
liver, with absence of the nucleated cells. It is attributed to causes
affecting the blood-mass as the poison of fever, of serpents, &c.
The course is sometimes rapid, attended with adynamic febrile
phenomena, delirium, and coma.* This state of the liver has been
treated of at some length by Dr. Budd, and he countenances
the idea that it may at times affect the organ partially, follow
a slower course, and terminate in recovery. The jaundice thus
arising is generally believed to be the consequence of suppressed
secretion.

3. Congestion is another proximate cause of jaundice, perhaps
partly by absorption, partly by suppression.

The notes of forty-five cases in which jaundice had been present
are before me : of these, twenty-seven have been already adverted
to as complicating remittent fever (p. 98) ; thirteen were entered
as simple jaundice, but from the attendant pyrexial symptoms
eight of them might have been more correctly classed with the

* This form of jaundice has also been fully considered by Frerichs in his " Klinik
der Leber Krankheiten." The greater prevalence of this severe and generally fatal
form, in females, is shown by facts referred to both by Budd and Frerichs. The
former alludes to eleven cases of which eight were females ; the latter to thirty-one
cases of which twenty-two were females. Frerichs further mentions that one half of
the twenty-two females were pregnant.

In twenty-eight of Frerichs' cases, death took place in the first week in 13 ; in the
second week in 6 ; in the third in 5, and in the fourth in 4. In twenty-three carefully
observed, the spleen was enlarged from congestion in 19, nonnal in 3, and small in
one. The ages of the thirty-one cases were —

6 . . . from 10 to 20

20 . . . „ 20 „ 30

3 . . . „ 30 „ 40

2 . . . „ 40 „ 60
Of eleven cases referred to by Budd, the ages were —

3 . . . „ 10 to 20

3 -. . . ,,20 „ 30
1 . . . „ 30 „ 40

4 . . . „ 40 „ 60

Of the four, between 40 and 60 — two were males, and the third male was between
20 and 30.

PATHOLOGY. 435

twenty-seven febrile cases. The five remaining cases were of
hepatic abscess. Ten of the febrile cases * and the five of hepatic
abscess proved fatal.

My investigations do not support the opinion that obstruction
of the ducts by inflammation of their lining membrane is a common
cause of jaundice, for the traces of inflammation have not been
found in any of the fatal cases ; and it is fair to infer that this state
vfas not generally present in the successful ones, even though pain
at the right costal margin had been complained of. In only three
cases was there satisfactory evidence of mechanical obstruction of
the hepatic or common duct : the cause in two f was a lumbricus ;
in the third J, not fatal, it was possibly biliary calculus, and this
is my only case which can be fairly related to this obstructing
cause. In seven § there was enlargement of the lymphatic glands in
the course of the common duct, but it is very doubtful whether, in
these cases, it was sufficient to cause obstruction by pressure : at
all events, distention of the ducts behind was noticed in only one. ||

In six If of the fatal cases, inflammation of the mucous membrane
of the duodenum was observed, and it is reasonable to infer that it
may also have been present in a proportion of the recovered cases
characterised by tenderness at the margin of the right ribs.

I am unable to explain the relation which duodenitis bears to
jaundice. It may be that they are only coincident sequences of
one antecedent. As already stated, the usual theory of extension
of inflammation from the duodenum to the common duct is not
supported by my cases. May it be that from a protective sym-
pathy (if I may be allowed the expression), the bile is pre-
vented from coming in contact with the inflamed surface of the
duodenum ?

In none of my fatal cases was yellow atrophy of the liver
noticed. It is true that the microscope was used in only three
instances, but in the others the appearances of the organ, as
described, do not accord with those characteristic of this lesion.
It is moreover fair to infer that yellow atrophy was also absent
in all the recovered cases, though in some of them drowsiness and
tendency to coma had been well marked

The opinion entertained by Dr. Budd, that some cases of jaun-
dice may be accounted for on the supposition of the existence of a
partial yellow atrophy, and that of recovered cases some may be
of this nature, does not seem to me very probable ; because, 1. The

* Cases 36—45. f 38, 137. t 186. § 36-39, 42, 44, 173. || 36.

t 36, 37, 40, 42, 43, 45.

F r 2

436 JAUNDICE.

suspended function of only portions of the liver is generally
insufficient to occasion jaundice, as is proved by the rarity of its
occurrence in hepatitis. 2. A general blood-cause is not likely to
operate partially. 3. As regards the recovered cases the inference,
from a review of the whole subject, is against the supposition.

Such, then, are my reasons for concluding that there is still
room for further careful investigation of the proximate causes of
jaundice, and that much which has been written on the subject is
merely hypothetical.*

The exciting and predisposing causes of jaundice are also a
subject of much interest. Three of my cases occurred in the
guards of an opium convoy, proceeding from Marwar to Bombay,
exposed to fatigue and to elevated temperature. They are a class
of people frequently addicted to the habitual use of opium.

* The precise constituents of the bile, — whether only the pigment, or the acids
also, — present in the blood and urine in jaundice, are not yet determined. lam
indebted to Dr. Parkes for the following statement on the present state of this question
as regards the urine.

" The changes in opinion respecting the presence or absence of the bile acids in
icteric urine have been considerable, and even now the subject is very obscure.

" Before the experiments of Strecker had elucidated the composition of the bile,
Thenard and Orfila believed they had found the so-called ' resinous bodies ' in the
urine. Subsequently, however, it seemed to be acknowledged that though the bile
acids could be sometimes found, this was uncommon, and that they w^re generally
absent in the urine of icterus (Lehmann ; G-orup-Besanez ; Scherer). It has been
therefore surmised either that these acids are destroyed in the system or that in icterus
the liver ceases to form them, although it continues to produce pigment. Frerichs
and Staedeler (a) however advanced a most remarkable hypothesis, viz. that in jaun-
dice the btle acids are converted into bile pigment. Into their reasons for advocating
such a conversion it is not necessary now to enter, as they do not seem to have won
many adherents. The fact on which their hypothesis was based (viz. the deficiency
of bile acids, and the presence of bile pigment in the icteric urine), has been disputed
by Kiihne {b), who by the employment of another method believes he has succeeded
in proving that bile acids, or rather their derivatives (choloidinic acidi or dyslisin ?)
can really be found in the urine. If Kiihne' s experiments can be relied upon,
they would imply that the formation of glycin (and perhaps of taurin) in the liver
is impeded in jaundice, but that cholic acid is stiU formed, and that there is no
conversion of bile acid into pigment. Kiihne believes he has shown that benzoic acid
does not form hippuric acid in cases of jaundice, owing, he presumes, to the absence
of glycin.

" Still more lately, Folwarczny (<?) has repeated Kiihne' s experiments, and does not
confirm them. In four cases of jaundice he examined the urine in the same manner
as Kiihne, and found no bile acid. He also gave benzoic acid and found hippuric
acid in the urine, as in health. The question is then yet doubtful and a stricter
investigation Ib still required."

(a.) Miiller's Archiv. 1856, p. 55.

(b.) Virchow's Archiv. fiir Path. Anat. x. p. 310.

Ic.) Wien Zeitschrift: 1859. Neue Folge ii. p. 15.

PATHOLOGY. 437

Fatigue, heat, opium-eating, — are these common predisposing
or exciting causes of jaundice?

The Bombay Fusileer Regiment, after many months' active ser-
vice in the field, which terminated with the dispersion of Shore
Sing's army, were encamped, at the end of March 1849, in front
of the Khybur Hills, near Jumrood. They remained under canvas
till the 7th of May. The ground was badly selected, being partly
on the banks and partly in the bed of a mountain torrent which
divided the hospital from the rest of the lines, and which, on more
than one occasion, nearly swamped the whole of the sick and com-
pletely cut off all access to them. The tents were crowded one
upon another, and the place soon became filthy in the extreme,
and very offensive. The slime deposited by each subsiding flood,
and the dead, putrid, and unburied camels, deposited all around,
produced the most offensive odours and a plague of flies, which
effectually prevented rest of any kind or anywhere from sunrise to
sunset, or the enjoyment of a single meal. Fortunately during
this time the weather had not been very hot. Dr. Arnott, from
whose interesting report * of the Fusileer Regiment this description
is taken, thus continues : —

" The eflfects on the men of change from the active, regular and excited life of
a campaign, to the sedentary, inactive life and looser habits of a standing camp,
soon became apparent in their diminished relish for their meals, their predisposition
to indigestion, jaundice, and in the prevalence of nausea and vomiting after meals,
which, during the time we lay at Jumrood, affected nearly every man and officer of
our regiment, and, indeed, I believe almost every man of the force. The complaint,
for complaint it was, and a very annoying one too, though not dangerous, I admit, I
coidd not account for in a manner satisfactory to myself. The natives, as they always
do, attributed it to swallowing flies, and some became converts to this opinion ; they
no doubt did soil and corrupt every article of diet or whatever else was left for the
shortest period exposed ; and if anything could give one an idea of the third plague
inflicted on the land of Egypt in days of old, it was here realised in perfection. Many
attributed the complaint to the presence of antimony in the water, as it is found in the
hills from which the streams issue, but none could be detected in it ; and I considered
that the real cause lay in the new life and habits we had entered upon. The disease
was characterised by no peculiar symptoms besides those mentioned. There was
nausea most frequently in the middle of, or immediately after, a meal, suddenly fol-
lowed by vomiting, till the whole contents of the stomach were ejected; and the
feeling of nausea continued for some time afterwards, ^ut gradually subsided, very
probably to return again, however, at the following meal.

"In the matter ejected there was seldom anything either bilious or acid, and the
bowels were in a natural state, or perhaps rather confined. This state of things might
occur once, or might recur frequently, a,nd then the men would apply at the hospital for
an emetic or a dose of physic, but seldom to be admitted. From not being able to retain
anything on the stomach, and consequently from Want of due sustenance, the men felt
languid and low-spirited, but no other permanently bad effpcts resulted from it ; and

* " Transactions, Bombay Medical and Physical Society," 1st Series, No. 10, p. 28.

r F 3

438 JAU^'DICE.

after we moved back towards Pesliawur, on the 7 th May, there was scarcely a case
of it.

'■'■ Icterus. — Subsequently to this disease, and, as it appeared to me, proceeding from
the same causes, cases of jaundice became very frequent, amounting in the nine months
we lay at Peshawur to no fewer than thirty-four admissions against two in the corre-
sponding period of the previous year. They were characterised by the usual appearances
of yellowness of the skin and eyes, high-coloured urine, obstipation, and clay-coloured
stools, want of appetite, languor, &c. An emetic was almost uniformly given on
admission ; cathartics daily, and most frequently mercury was given to ptyalism.
Under this treatment they all did well, though occasionally a considerable degree of
debility remained for some time afterwards, which was treated with aperient bitters,
alkaline medicines, tonics, and mild nutrient diet."

The European troops employed in the expedition to the Persian
Gulf, in 1857, suffered, at Mohamarah and Bushire, in the month
of April, from nausea and vomiting, just as the Fusileers did at
Jumrood. The 14th Dragoons returned from Persia to K^rkee
towards the end of May, and in the month of June ten cases of
jaundice were admitted into hospital. Of the men selected
as healthy in the first week of June to accompany a force to
Aurungabad, four became affected with jaundice. The disease
yielded readily to treatment.

TreatTKient — The uncertain state of the pathology of jaundice
necessarily affects the treatment.

A preliminary question before commencing the treatment of
jaundice, is, whether we have to do with a liver previously
healthy, or affected with congestion, cirrhosis, or other organic
change.

Whenever tenderness at the margin of the ribs is present, we
may infer the existence of congestion of the liver, or inflammation
of the duodenum or adjacent structures, and conclude that these
conditions are related, in some way or other, to the jaundice ; and
that their removal by leeches and counter-irritation ought to be a
leading indication of cure.

To increase excretion from the intestinal surface is also an object
to be held in view, and it may be effected by such means as aloes,
rhubarb, and saline cathartics ; used, however, with caution, in
order that inflammation of the duodenum, or adjacent structures,
when present, may not be increased, and that in cachectic
individuals dysenteric symptoms may not be excited.

The expediency of the cholagogue action of mercury is an
important question in the treatment, and from the obscurity which
involves the proximate cause of jaundice, it is often difficult to
determine. If the existence of a mechanical obstructing cause be
suspected, then to stimulate the secreting action of the liver must

TllEATMENT. 439

be injurious. If there be a general destruction of the hepatic
cells, is mercury likely to reconstruct them ? If we accept the
theory of a partial cell destruction, then will mercury, if given,
not rather affect the healthy cells and leave the destroyed ones
uninfluenced ?

These are perplexing questions, and all that we can do in prac-
tice is to follow those principles which under the circumstances
seem to be most reasonable. So long as symptoms of gastro-enteric
inflammation are present we must use mercurials very cautiously,
and trust chiefly to local depletion and counter-irritation, the
combination of taraxacum with alkalies and ipecacuanha, and
mild saline purgatives, as the potassio-tartrate of soda.

When the inflammatory symptoms have been removed, and the
jaundice persists unchanged, or when evidences of inflammation
have not been present, and the constitution is not much impaired,
then two or three grains of calomel, or of blue-pill, or chalk and
mercury, may be occasionally combined with aloes or rhubarb.

To give large doses of calomel forms no part of the treat-
ment of jaundice, unless we except the early stages of occa-
sional cases in plethoric Europeans, in whom there is good reason
for suspecting a congested and stagnant condition of the portal
circulation.

The error, to which I have already on several occasions alluded,
of confounding the cholagogue action with the constitutional
effect of mercury, has been frequently committed in the treat-
ment of jaundice. The induction of mercurial influence in this
disease is unsupported by any rational argument with which I am
acquainted.

When that state of constitution in which, on general principles,
we abstain from the use of mercurial remedies, co-exists with
jaundice, we may use some of the other milder means which are
believed to exercise a similar action on the liver, as taraxacum,
alkalies, hydrochlorate of ammonia, nitric acid internally, and
nitro-muriatic acid externally.

It should be further remembered, as previously stated in refer-
ence to jaundice complicating remittent fever, that saline diuretics
are often given with great advantage ; and, as a rule of practice in
this disease, it should also be recollected that time is required for
the removal of the bile from the blood, and that we may err by too
great haste or too active interference.

if t 4

440 BILIOUS DIAHRHCEA AND CHOLEKA.

SECTION VI. — On Increased and Defective Secretion of Bile,

Increased Secretion. — That bilious diarrhoea and cholera may
attack Europeans not long resident in India, after injudicious
exposure and excesses in eating and drinking, is true, but that they
are common affections under any other circumstances is not
confirmed by experience.*

Excess of biliary secretion is a rare disorder in the European
who lives with ordinary prudence in India, and in the native it is
hardly ever observed. The chief importance of bilious cholera is
the risk of confounding it with epidemic cholera. The diagnosis
of the two affections has been stated in general terms at p. 213.
The mistake is not likely to occur to a careful inquirer. The
pathology of bilious cholera is very simple. From excess of the
constituents of bile in the blood, and active determination of blood
in the portal capillaries, an undue quantity of bile is secreted, and
as a necessary consequence is speedily ejected.

The leading indication of treatment is to palliate the discomfort
by diluents, to allay the vomiting by effervescing draughts, with a
few minims of tincture of opium, and the external use of sinapisms,
and to watch for symptoms of prostration, and then give opium
more freely, as well as stimulants. After the primary symptoms
have ceased, gastro-enteritis may follow, and require to be treated
on ordinary principles, by leeches, alkalies, ipecacuanha, opium, and
perhaps mild mercurials.

The question whether, at the commencement, the discharge of
bile ought to be increased or not by the cholagogue action of
mercury, will arise. If the subject be a robust European, if the
tongue be much coated, and there is tendency to jaundice, or un-
easiness of the hepatic region, with signs of enlargement of the
liver, then it will be of advantage to give ten grains of calomel
with a grain of opium, to be repeated or not, according to cir-
cumstances ; and the effervescing draught may be made slightly
aperient by the addition of small doses of the potassio-tartrate of
soda, or other saline cathartic.

* Subsequently to the expression of this opinion, the following statement of Dr.
Marshall came under my notice : —

" It may be observed, that the cholera morbus of the systematic writers, a complaint
w-hich is supposed to arise from an inordinate secretion of bile, very rarely occurs in
Ceylon, either among European residents or the indigenous inhabitants." — Notes on the
Medical Tcpography and prevailing Diseases of Ceylon, p. 145, by Henry Marshall,
Staff-Surgeon to the Forces.

DEFECT OF EILE. 441

Defect of biliary secretion^ characterised by clay-coloured alvine
discharges, — a state to which the name torpor of the liver has been
given, — is sufficiently common in India.

Torpor of the liver is an unsuitable term, for it expresses a
pathological theory which is probably erroneous, and suggests a
system of treatment which is often injurious.

The symptoms are white-coloured alvine discharges, often formed
and not passed with more than usual frequency, a sense of languor,
depression and anorexia, and a pale but little coated, tongue,
without jaundice. This derangement occurs for the most part in
adults, cachectic and anaemic from malarious influence, prolonged
exposure to elevated temperature, abuse of mercurial or other
depressant remedies. Mental anxiety is in these states of con-
stitution sometimes the exciting cause. Anaemic children are
also liable to this affection, and in Bombay it is observed in them
more towards the close of the hot season than at any other period
of the year.

That this condition proceeds from torpor of the liver is an im-
probable theory. There is absence of bile in the intestinal canal,
but also absence of it in the blood (jaundice). The just inference
from these facts, is, not that the liver, specially, is inactive, but that
the metamorphosis of waste tissue into the excreta of bile is not
duly carried on in the blood. All the attendant phenomena point
to languid general assimilation and excretion, and the leading
indication of cure is, not to stimulate the liver by cholagogue re-
medies, but to lessen the cachectic state by appropriate regimen and
tonics.

While holding these opinions on the pathology of this affection*,
I would caution against neglect in inquiring into the state of the
liver ; for a pre-existing defect of the organ, congestive or organic,
will necessarily favour a more early development of the symptoms,
and when existing ought to receive due consideration in the treat-
ment.

We shall best treat this derangement by a suitable adjustment
of diet, of which animal food should form a part. In two cases
the use of strong coffee two or three times in the day, seemed to be
beneficial, and in one it restored the secretions to a healthy st-ate,

* Anaemic European children, sent at the close of the hot season of Bombay to
Poona at the commencement of the rains, or to Mahubuleshwur at the end of October,
are very apt, unless there be great attention to the temperature and action of the skin,
to be affected with clay-coloured alvine discharges. Under these circumstances the
presence of some degree of congestion of the liver is a ^obable event, and shoidd
always be looked for.

442 DEFECT OF BILE.

after various preparations of taraxacum had been freely used and
failed. It is worthy of further trial, but the coffee must be
genuine and fresh. Should observation confirm this impression, the
result will probably be explained on Liebig's theory of the identity
of caffeine and the principle of bile. Along with appropriate
regimen, such remedies as quinine, bitter infusions, iron in small
doses, or dilute nitric acid should be used. Change to a more
temperate climate will be of benefit, but considerable and sudden
reductions of temperature should be avoided. Under all cir-
cumstances external cold or damp must be guarded against by
suitable clothing.

If deficiency of bile be truly related to anaemic or cachectic
states, then it may be predicted that under a rational sanitary sys-
tem and better therapeutic principles, it will cease to be familiar,
as now, to the practitioner in India.

Though the use of cholagogue remedies has not been distinctly
admitted, yet reflection will suggest that the milder members of
the class may occasionally be beneficial. It is reasonable to sup-
pose that even with an improving condition of the blood, the
hepatic cells, in consequence of suspension of function, may evince
a want of readiness in assuming it again, and that special remedies
may be useful under these circumstances. Whether this theory be
just or not, still I believe that the inference drawn from it is prac-
tically correct, viz., that though any but the most guarded use
of mercurials is sure to be injurious, we may always look for
benefit from such means as taraxacum, coffee, and the external
application of diluted nitro -muriatic acid by sponging or stupes.

Children with deficiency of biliary secretion are very predisposed
to dysentery ; but in this fact there is probably nothing more than
an illustration of the general predisposing influence of anaemic and
cachectic states.

443

CHAP. XVII.

ON PERITONITIS, ILEUS AND COLIC.

Section I. — Peritonitis. — Pathology. — Plastic and sero-puri-
form Exudations related to Diathesis. — Chronic Tubercular. —
Chronic not Tubercular, and not Consecutive on Acute, —
Treatment,

In the chapters on Dysentery and Hepatitis it has been shown that
acute general peritonitis, secondary on the advanced stage of
dysentery, or the formation of hepatic abscess — but independent
of perforation or rupture, — is not an uncommon event in the
course of those diseases in India, and is, in all probability, favoured
by constitutional states. A secondary partial protective peritonitis
is likewise not unfrequent.

But acute idiopathic general peritonitis in a sthenic diathesis,
independent of traumatic causes, is a rare form of disease in India,
as in other countries. In the notes of my own practice there is
not a single illustrative case. On examining my memoranda of
fatal cases of sick officers, I find seven of peritonitis, which is in
the ratio of 2*25 per cent, of the deaths from all causes. But of
these seven there are only three which can be regarded as idio-
pathic and sthenic. Two of them occurred in officers consequent
on exposure to cold after fatigue in the heat of the day. The
third was caused by excesses in eating.

It is of interest to note carefully all fatal cases of traumatic
general peritonitis, for they may demonstrate the morbid changes
which result from this inflammation in persons of good diathesis,
and affi^rd more precise knowledge than we can otherwise obtain,
of the length of time requisite for their development. Much in-
terest also attaches to those slighter wounds, which though pene-
trating the abdomen — as proved by slight visceral protrusion —
and followed by distinct peritonitis, are amenable to judicious

444 PERITONITIS.

treatment. They are so, because the tendency of inflammation
under circumstances of moderate injury and good diathesis is not
to extend, but to be restricted to the neighbourhood of the wound,
and to yield to the repeated use of leeches, opium, warm water
stupes, and complete repose: I have seen several cases which
illustrate the truth of this observation. Three fatal cases of
traumatic peritonitis* are subjoined : —

188. General peritonitis from a penetrating wound of the liver. — Considerable
effusion of serum in the head without symptoms. — James Harrison, aged twenty-eight,
born in India, tall, and of moderate strength, was admitted into the European General
Hospital on the night of the 22nd October, 1838. He stated that, whilst in a state of
intoxication, he had stabbed himself.* On the left side of the epigastrium there was a
wound about an inch long, filled with charcoal and oil, but apparently not deeper than
the muscles. It was attended with considerable tenderness of the abdomen. Twenty
ounces of blood were taken from the arm, and a purgative enema was exhibited. On the
morning of the 24th he still complained of general tenderness of the abdomen, attended
with considerable fulness. The pulse was 120 and compressible; the tongue was
covered with a thin yellow fur ; there was present a short cough, from which he had
suffered for some days previously ; there was, however, neither vomiting nor difficulty
in micturition. One hundred leeches were applied to the abdomen, and in the evening,
the symptoms, having somewhat increased, twelve ounces of blood were taken from
the arm, and seventy-two leeches were repeated to the abdomen ; the warm bath was
directed to be used, and piUs of calomel and opium to be given at bed-time. On the
25th he was considerably relieved ; but on the evening of the 26th the symptoms of
peritonitic inflammation were again on the increase ; a large blister was applied to the
abdomen, and a turpentine enema exhibited. On the 27th the pulse was 120 and
feeble, the countenance anxious, and there was occasional vomiting. An attempt was
made to induce the action of mercury on the system by inunction, and the internal
exhibition of calomel and opium. The pain was never very acute, but the symptoms
progressed, and he died at 10 p.m. of the 28th.

Inspection nine hours after death. — Body stout ; abdomen distended. — Abdomen.
On tracing the wound, it was found to penetrate transversely the lower edge of the
sixth rib on the left side also, the entire of the cartilage of the seventh rib, about a
quarter of an inch from its junction with the other cartilages. The wound passed
through the diaphragm and through the left lobe of the liver, and was about half an
inch in its long diameter. The intestines adhered to the abdominal parietes, and the
convolutions to each other ; and among the adhesions there was much extravasation
of dark bloody serum. In the pelvis, between the rectum and bladder, and in the
right iliac region, there was much dark coagulated blood. AU the intestines were dis-
tended with air; but, with the exception of the lymph effused on the peritoneal
surface they were healthy. The liver was pale coloured. The mucous coat of the
stomach was thickened, but otherwise healthy. Chest. — The lungs were emphyse-
matous. In the lower lateral part of the left side of the chest there were flakes of
lymph effused on the costal plexira, and blood extravasated in smaU quantity under-
neath the pleura of the diaphragm. Head. — There was considerable effusion of
serum between the pia mater and arachnoid membrane, and at the base of the skull ;
also considerable venous congestion of the posterior lobes of the brain.

189. Fracture of both thigh bones. — Abdomen bruised. — Death in fifty-four
hours from peritonitis. — General redness and effusion of lymph on the peritoneal sur-

* The knife was shown to me on the following morning ; it was a blunt, somewhat
rusty, worn, table carving knife.

TRAUMATIC. 445

faces. — A 'pint of turbid serum in the cavity. — John Birch, aged twenty- two, of the
ship Cornea was brought to the General Hospital at 4^ p.m. of the 5th March,
1842. It was stated that he had just fallen from the yard-arm of the ship on deck ;
both thigh bones were fractured about the middle of the shaft ; the abdomen was
bruised and tender to the touch ; and the breathing was oppressed and attended with
sense of sinking. He passed an indifferent night, and on the morning of the 7th the
tenderness and tension of abdomen had increased, and the pulse was feeble. Fomen-
tations and enemata were used. Towards evening the tension of the abdomen had in-
creased, and there was pain of left side complained of, with oppressed breathing.
Pulse small, 120. He died at 10 p.m.

Inspection twelve hours after death. — Purple sugiUations on the posterior part of
the trunk. The abdomen distended. Chest. — The right lung adhered firmly to the
costal pleura. In the left sac of the pleura about six ounces of red-coloured serum
were effused. The lungs and the heart were healthy. Abdomen. — The intestines
were distended with air. The external surface of all the intestines was of a brown red
colour. The omentum was matted over the intestines, and adhered to them by bands
of friable lymph, and similar adhesions existed between their convolutions. In the
cavity of the abdomen there was about a pint of brown turbid serum effused. The
liver and spleen were healthy. The mucous coat of the stomach was healthy.

190. Wound of the abdomen with protrusion of intestine. — Vascularity of and
lymph-exudation on the peritoneum and the protruded intestine. — A man was brought
to the Native General Hospital at 9 a.m. of the 24th February, 1845, with a consider-
able portion of the small intestine, and a part of the attached mesentery, protruding
from a wound between the umbilicus and margin of the right ribs, to the right of the
mesial line. It had been inflicted by himself about three hours before. The intestine
was of a bright red colour. The wound was small, and it was enlarged with the view
of reducing the intestine. But, in consequence of the opposition and struggles of the
individual, reduction could not be effected. The following morning, at 7 a.m., the
protruded intestine, now consisting of several convolutions, was covered with a toler-
ably thick layer of friable red-coloured lymph, which united the protruded convolutions
to each other.

Remark. — Thus, assuming the intestine to have been healthy before, we find active
vascularity in the course of three hours after protrusion, followed by effusion of a layer
of lymph in twenty-four hours — a process, however, which must have commenced
many hours earlier. I do not find the date of death in my notes, which were made
merely to record the periods of vascularity and exudation.

When attention is turned from peritonitis in individuals of good
constitution, characterised by exudation of plastic lymph, to that
form in which puriform or sero-puriform effusion predominates,
we shall always find this difference of result attributable to con-
ditions of diathesis.

In the first of the three cases * about to be narrated, the special
character of the cachexia does not appear, — the patient is merely
stated to have been long ill. The second is related to parturition ;
and the third is a case of circumscribed purulent effusion, probably
due to cachexia from intemperance. These, however, form but a
small portion of the cases of this nature which, at different times,
have come under my observation. There is reason for believing
that among the cachectic natives received into general hospitals

* Cases 191 to 193.

446 PEllITOiNITIS.

in India, death is not unfrequently hastened by the access of aplas-
tic peritonitis, overlooked during life in consequence of the latency
of the symptoms. I have more than once seen patients, under
these circumstances, sink v^ith cooling skin, collapsing features,
thready pulse, and no suspicion of peritonitis; yet examination
after death has proved its existence. When, in cachetic states,
unexpected prostration, unexplained by discharges, comes on, we
shall do well to direct our attention to the peritoneum.

191. Peritonitis. — Purulent effusion into the cavity of the abdomen. — Lymph general
071 the peritoneal surfaces. — Eobert Piper, aged sixteen, seaman, ship Oriental, after
having been unwell for a long tinie, chiefly with recurring constipation of the bowels,
was admitted into the General Hospital on the 9th August, 1842. The abdomen was
uneasy on pressure, but quite supple. Till the 16th he continued complaining of oc-
casional pain of abdomen, and had generally an evening accession of fever. Leeches
were applied two or three times ; the bowels were kept open with laxatives, ai.d an
attempt was made to control the febrile accessions by the exhibition of quinine. On
the 17th, the tenderness of abdomen was increased, and the pulse rose to 120, and
was irritable. On the 19th, to the pain was added fulness and tenderness of abdomen,
which had considerably increased by the 21st with occasional vomiting; and pyrexial
symptoms were generally present. Leeches were again had recourse to, followed by
blisters, and an attempt was made to induce the constitutional effect of mercury. On
the 28th, wandering delirium commenced. The other symptoms persisted with in-
creasing failure of strength, and he died on the 2nd September.

Inspection fifteen hours after death. — Body emaciated. Abdomen distended. In
the abdomen there was about a pint of pus ; and the interior surface of the parietes,
the omentum, and the external surface of the small intestine were more or less coated
with a thin layer of lymph. The body was not further examined.

192. Peritonitis after parturition, hut probably caused by blows. — ^Mary Anne, a
native Christian, of twenty-three years of age, was admitted into hospital, on the 26th
November, 1848. She stated that she had been affected with diarrhoea for about a
month. That three days before admission she had given birth to a child which had
died : that two and a half hours before admission she had been kicked on the chest
and abdomen. There was tenderness of the abdomen about the umbilicus, the ex-
tremities were cold, the pulse 120 and thready, the countenance coUapsed. She was
treated with ammoniated stimulants and opium, sinapisms and fomentations. She
continued in the sunken state as on admission, with frequent vomiting and little
vaginal discharge, and died on the 28th.

Inspection seventeen hours after death. — The abdomen was considerably distended ;
there were no marks of bruises on the external surface. There was general redness,
with lymph effusion on the peritoneal surface of the small intestine, the omentum was
matted to the fundus of the uterus, and there was about a pint of purulent effiision in
the pelvis. The uterus, upwards of six inches long and four wide, rose like a flaccid
bag above the pubes, inclined to and occupied the right iliac fossa. There was lymph
on its peritoneal surface, but no redness or purulent infiltration of its structure. The
inner surface as well as upper part of the vagina was lined with grey and black
pultaceous adhesive matter with gangrenous foetor, and the lining membrane when
exposed by removal of the adherent exudation presented a red colour. The mucous
membrane of the colon showed numerous circular ulcers.

193. Partial peritonitis leading to formation of a large circumscribed purtdent sac. — .
Dewjee Grunnoo, a Hindoo horse-keeper, of twenty-five years of age, using spirits oc-

TUBERCULAR. 447

casionally, was, after two months' illness, admitted into the clinical ward, on the 18th
August, 1851. He was a good deal reduced. The countenance was anxious, and the
respiration thoracic. A large, prominent, distinctly circumscribed, somewhat elastic,
and obscurely fluctuating swelling occupied the abdomen. It extended from the ensi-
form cartilage almost to the pubes. It engaged more of the right than of the left side
of the abdomen. The right boundary was a vertical line dropped from the ninth rib,
but the left a line passing obliquely from the seventh rib to the left of the umbilicus,
and reaching the right iliac fossa. The swelling was dull throughout on percussion, it
was tender on pressure, and pain was increased by decubitus on the left side. No
abnormal chest signs. The pulse was small, the bowels were regular. He stated that,
two months before, he had noticed a small swelling below the margin of the right ribs
unattended by pain, that twenty-five days before admission this swelling, subsequent
to the action of a purgative, had disappeared, but it reappeared after eight or nine
days, and was situated more in the direction of the umbilicus, and since had gradu-
ally increased to its present size. He further added that he attributed his complaint
to pressure made by some friends, a month before admission, for the purpose of re-
lieving pain that existed there. He was under treatment till the 3rd September, when
he died. During his stay in hospital there were irregular febrile exacerbations, with
night sweats, and the swelling increased in size, and became more tense, and promi-
nent, and painful. His friends would not permit a post mortem examination, but
they did not object to the introduction of a trocar and canula, which were inserted a
little above, and an inch and a half to the right of the umbilicus. On removing the
trocar about half an ounce of reddish-coloured fluid escaped through the canula, and
on making a good deal of pressure on the tumour, about eight ounces of flaky pus,
mixed with coagula of dark-looking blood, were slowly drawn off. It was necessary,
frequently, to clear out the canula, as it became stopped up with the flakes of pus. The
tumour, after the removal of the pus, had not diminished much in size, but had be-
come much softer.

Remark. — Many years ago I saw a case similar to this, both in situation and size,
in an old Hindoo tailor, in company with Dr. Bird. At the urgent entreaty of the
patient the fluid, of dark-red colour, was drawn off by a small trocar. The operation
perhaps rather hurried the fatal issue.

CliTonic Tubercular Peritonitis is an interesting and well-under-
stood form of disease. I find among my cases four * of tubercular
peritonitis. Two in Europeans, with tubercular deposit in the
lungs, and two in natives without this complication. In one of the
Europeans t the intestines were firmly adherent to each other,
and tubercular deposit was intermixed with the organised tissue.
In the second European | the tubercles were miliary and semi-
transparent, without adhesions, and with very little serous effusion.
The appearance presented in this case by the tubercles on the
diaphragmatic peritoneum of the right side was of interest ; they
were compressed by the liver into flattened patches, instead of
standing in granular relief as elsewhere. I do not find this effect
of pressure mentioned by any author, and yet some. Dr. West for
example, particularly allude to the diaphragm and the surface of
the liver as common seats of granular tubercular formation.

* Cases 194 to 197. t 194. { 195.

448 PERITONITIS.

In both natives there was abundant serous effusion, and the
disease had been considered to be ascites. In one * the effusion
disappeared consequent on an attack of cholera. In my re-
marks annexed to this case, attention has been called to the evi-
dence which it affords that the peritoneum, studded with tubercles,
is still fitted for absorption ; and to the fact, that the supply of
fluid derived from a peritonitic and pleuritic effusion delayed the
fatal result.

In the other native f case there is a feature of diagnostic import-
ance. The diagnosis of peritonitic effusion from ovarian dropsy,
by percussion, is now well understood: that in the former, we
generally have clearness of the uppermost surface of the swelling ;
in the latter, dulness all over.

Dr. Watson directs attention to two exceptional conditions which
in peritoneal effusion may occasion dulness throughout as in ova-
rian dropsy. 1. When the distention is so great as not to ad-
mit of the floating intestines reaching the surface of the fluid.
2. When the intestines are fixed down by adhesions. Case 196
points to a third cause, viz., a contracted state of the intestinal
canal in an asthenic person who, for some time previously, had
used very little food. This explanation, suggested to my mind
before death, was confirmed by dissection. The uniform character
of the swelling and the history forbad the belief in ovarian dropsy.

194, General peritonitis. — The lungs studded with crude tubercles. — The mesenteric
glands tuberculated. — The end of the ileum, the coecum, and colon ulcerated. — Consider-
able effusion in the head. — ^Daniel Eumbell, aged twenty-two, of slight habit, a marine
on board Her Majesty's sloop Cruizer, was admitted into the European General Hos-
pital on the 19th December, 1838. Dxiring the six previous months he had suffered
from frequent attacks of catarrh excited by slight exposure to cold, and latterly at-
tended with oedematous swelling of the feet. His general health had also become much
impaired. He was debilitated and emaciated, and complained of pain at the epigas-
trium, and across the lower part of the chest, also of dyspnoea and dry cough. The
pulse was generally frequent, and there were profuse nocturnal sweats. On admission
into hospital pain across the epigastrium, increased by pressure and full inspiration,
was complained of ; the tongue was florid but not furred ; there was thirst, but no
vomiting. He complained of occasional dry cough, and the pulse was 96, of good strength.
During the thirteen first days of his residence in hospital, attention was chiefly directed to
the abdomen, which was moderately distended and tense, with, on one or two occa-
sions, an obscure sense of fluctuation. There was also generally tenderness on pressure,
but at no time acute. The tongue was usually florid, and every evening there was a
distinct febrile exacerbation. The abdomen was leeched and blistered, and on one
occasion ten ounces of blood were taken from the arm. Small doses of calomel and
opium were given, but the mouth did not become affected. On the 2nd of January,
dyspnoea and uneasiness across the chest were complained of, and sibilous and sub-
crepitous rales were audible on the anterior part. The feet became oedematous, and

* Case 197. t 196.

TUBERCULAR. 449

the pulse increased in frequency and lost in strength. A blister was applied to the
chest with relief; two grains of pulv. scillse, in combination with a grain of calomel,
half a grain of ipecacuanha, and a similar quantity of opium, were given thrice daily.
The urine was examined, but found not coagulable. On the 4th of January there was
diarrhoea for the first time during his stay in hospital, it recurred from time to time ;
the evening febrile exacerbations persisted; the pulse became feebler; emaciation
increased, and he died on the 15th. The pectoral symptoms were not, with exception
of on the 2nd of January, much complained of.

Inspection four hours after death, — Body emaciated. Head, — > There were about
three oimces of serum in the cavity of the head. Chest. — The liver had encroached
on the cavity of the chest to the level of the third rib on both sides, and the heart was
in consequence placed more transversely than is natural. The pericardium contained
several ounces of serum. Both lungs adhered firmly to the costal pleurae ; and in both,
there was abundant deposition of crude grey tubercles, with emphysema. Abdomen. —
There was no distention. The peritoneal lining of the parietes, and all the viscera,
with the omentum, were firmly united by adventitious adhesions. Between the layers
of these adhesions there was seram in some places, and in others nodules and masses of
firm, almost schirrous lymph, frequently of tubercular form. The liver was much en-
larged and firm, and the cut surface presented a white mottled appearance. The
spleen was also enlarged, its texture was firm, and part of the edge was matted to the
left lobe of the liver by means of a thick mass of lymph. The mesentery was much
thickened, and when cut showed the glands enlarged, and in many places under-
going tubercular degeneration. The mucous lining of the stomach was of a pale
rosy tint, and softened. The mucous coat at the end of the ileum for the extent of
several feet presented large transverse ulcerated bands. Some of which, on the
separation of the peritoneal adhesions, opened into the cavity of the abdomen. The
coecum was in a similar state of ulceration, but the transverse part of the colon was
undiseased. The right kidney was healthy. The left was of chocolate-red colour, 'k

195. Extensive ulcer on the groin. — Miliary tubercles in the lungs and underneath
the peritoneum throughout its whole extent. — Follicular ulceration of the large intestine.
— Three ounces of serum in the cavity of the cranium. — No head symptoms. — Charles
Sutherland, aged twenty-foiir, a seaman, of fair complexion and strumous habit, was
first admitted into the hospital on the 16th October, 1838, affected with extensive
ulceration of the left groin, and of the under and upper part of the thigh of the same
side. This affection was of several months' duration, and was attributed to a venereal
sore, with which he had been affected some time previously. He remained in hospital
without improvement till the 17th January, when being impatient from the tedious
nature of his illness, and at the want of success attending the treatment, he was dis-
charged at his own desire. He was re-admitted on the 17th February, having been
during his absence from hospital under the care of a Hakeem in the bazaar, who had
used various applications, and given internal remedies, in consequence of which the
mouth had become affected. At this second admission the ulcer on the groin had a
more unhealthy appearance, its edges being ragged and irregular ; that on the thigh
had become double its former size, and had also irregular ragged edges. Sarsaparilla
and hydriodate of petass were prescribed and continued for some time, and the ap-
plications to the ulcers were frequently varied. The ulcers did not improve in
appearance, the general health declined, and on the 9th April he first complained of
cough with scanty expectoration. The cough continxied more or less troublesome,
chiefly so during the three weeks immediately succeeding its fijst appearance. The
ulcers were generally stationary, sometimes, however, for a few days assuming a more
healthy appearance, and then again relapsing. The strength declined ;. night sweats
became troublesome, the cough ceased; and on the 19th June diarrhoea commenced,
and was more or less urgent, and attended witH florid tongfte, till the period of death
on the 15th July.

G G

450 PERITONITIS.

Inspection six hours after death. — Body emaciated ; abdomen collapsed. Head. —
There was no turgescence of the vessels, and there were about three ounces of serum
at the base of the skull. Chest. — There were adhesions of the upper lobe of the right
lung to the anterior parietes, and opposed to these adhesions there was a crude tuber-
culous nodiile the size of a walnut. The lowest lobe of the right lung was moderately
congested with frothy serum. The upper lobe of the left lung was healthy; the
lowest part of the lower lobe was in a state of red hepatisation, and at the upper part,
and immediately below the pleura, there were miliary tubercles deposited. The hearl
was healthy. Abdomen. — There were about five ounces of clear serum in the cavity
of the pelvis. Over the peritoneal lining of the lateral part of the abdomen, of the
pelvis, and of much of the intestines, there was a blush of ramified redness, and the
tunic was studded in these places with isolated miliary tubercles, transparent, none
larger than a pin's head, and many smaller; in many instances they seemed to con-
stitute the termination of a vascular ramification. Underneath the peritoneal lining of
the diaphragm where opposed to the liver there was a similar tubercular deposition,
but here, instead of standing in relief, it was compressed into flattened patches — a
modification evidently caused by the resistance of the liver, because, on the left side
of the diaphgram, where there was no resisting object, the tubercles stood out in relief as
elsewhere. These appearances where much more developed on the right than on the left
side of the abdomen. The mucous coat of the stomach was dotted dark red at the cardiac
end, but it was healthy in texture; towards the pylorus it was mammillated and
thickened. The liver was pale and mottled. The mucous coat at the end of the
ileum was vascular and studded with mucous glands. The mucous coat of the colon
and rectum was studded with ulcerated follicles, and in some cicatrisation had
commenced. Here and there there were patches of reddish lymph, with occa-
sionally a yellow central point like a tubercle. The mesenteric glands ranged in
size from a pea to a horse bean, but they were not tuberculated. The kidneys were
healthy.

196. Chronic peritonitis. — Tubercular. — Much effusion, and complete dulncss on
percussion. — Eamni Penack, aged fifty, a Hindoo female, much emaciated, was ad-
mitted on the 28th July, 1852. The abdomen was swollen, tense, fluctuating, dull all
over on percussion. The dulness rising to the fourth rib on both sides. The feet and
legs were (edematous; the rest of the chest was resonant, and vesicular respiration
was distinct. The soimds of the heart were natural. There was no increased heat
of skin. Pulse small, and very easily compressed. Tongue coated brown in the
centre ; urine scanty ; bowels confined for five or six days. She stated that twenty
days before admission there had been pain below the ribs, and that eight days after-
wards the abdomen began to swell, and was attended by difficulty of breathing. She
died at 3 p.m. of the 30th.

Inspection seventeen hours after death. — Abdomen. — About fourteen pints of turbid
yellowish serum were found in the sac of the peritoneum. The intestines were in
general much contracted, and occupied the left lumbar region, but were not fixed by
adhesions. On the surface of the intestines here and there slight redness was seen.
Studding the mesentery and the inner surface of the abdominal walls, chiefly at the
hypogastric region, and also the pelvic viscera (bladder, rectum and ileum), were
numerous miliary tubercles, ranging from the size of a mustard-seed to a small pea,
and situated in the subserous tissue. Firm adhesions connected the under surface of
the right lobe of the liver to the upper ends of the right kidney. The liver was
smaller than natural, but did not feel indurated when incised. The gall-bladder was
full of bile. The kidneys were somewhat smaller than natural, and externally mottled
red and white, finely granular, and presenting numerous serous cysts. One of the
cysts in the right kidney, when laid open, was found to contain puriform matter,
wliich showed under the microscope broken-down pus corpuscles. The cortical portion

TUBEBCULAB. 451

of both kindeys defective. Lungs healthy ; heart healthy. There was atheromatoua
deposit on the aortic valves,

197. Effusion in chest and abdomen. — Access of cholera. — Disappearance of the
effusions. —'Brighfs disease of the kidney and tuhercidar peritonitis. — Mooburick
Nuseeb, an African, of fifty-eight years of age, was admitted into the clinical ward on
the 10th of September, 1849. He was somewhat emaciated ; the abdomen was swollen,
tense, and fluctuating, and somewhat tender on pressure. On the left side of the chest
there was dulness below the level of the third rib, varying with change of posture,
accompanied with absence of vocal thrill, and the heart's impulse was most distinctly
felt to the right of the sternum. There was no febrile disturbance observed, but he
complained of nausea and abdominal distention and discomfort after eating. The
pulse was small, of natural frequency. The tongue ncft coated, but somewhat florid at
the tip, and the bowels occasionally relaxed. He stated that he had been ill fifteen
days, and that the uneasiness and fulness of abdomen had come on gradually during
that period. On the 15th and 19th the urine was examined ; its specific gravity was
about 1020, and it gave no traces of albumen with heat and nitric acid. On the 20th,
the occasional diarrhoea from which he had suiFered since admission, passed into dis-
tinct cholera, and he died on the 26th. The rice-water-like dischai^es continued
more or less abundant till the 23rd. The pulse became feebler, but remained distinct
till shortly before death. The surface of the body was sometimes cold, at others re-
gained its natural temperature. The urine was passed scantily on the 23rd and 25th.
Drowsiness first showed itself on the evening of the 21st, and he became quite comatose
before death. On the 21st the falness and tenseness of the abdomen were much
lessened ; the thoracic dulness extended no higher than the fifth rib, and the heart's
impulse was less to the right of the sternum. On the 25th the abdominal fulness and
the thoracic didness had almost entirely disappeared, and the heart's impulse was
most distinct between the third and fourth ribs of the left side, an inch from the
margin of the sternum.

Inspection twelve hours after death. — Qhest. — There was not any serous eiFusion
found in the sac of the left pleura, and the left lung was soft and crepitating. Two
or three bands of firm adhesion connected the inner surface of the lung to the pericar-
dium. The right lung was also soft and crepitating, and united by old adhesions to
the costal pleura. There were no traces in the costal or pulmonary pleura of recent
inflammatory action. A lai^er than normal portion of the heart was to the right of
the mesial line. There were opaque patches here and there on the surface of the
heart. A slight degree of dilatation of the left ventricle, and of thickening of the
mitral valve, was observed ; the right ventricle, and the aortic valves, were healthy.
Abdomen. — The whole of the peritoneal covering of the anterior parietes was closely
beset with granular deposits, each granule was about the size of a small pin's head.
Similar deposit was also present on the peritoneal surface of the intestines, and the
convolutions were closely and firmly adherent to one another, and, in places, here and
there, to the anterior parietes chiefly below the umbilicus. The concave surface of the
liver adhered to the stomach, and to the hepatic flexure of the colon, and also by old
and firm adhesions to the diaphragm. There was no serous fluid in the cavity of
the abdomen. The liver was harder than natural, resisting to the knife, and granular.
The left "kidney was considerably enlarged and flabby; and when incised the sur-
face showed, chiefly in the body of the organ, considerable encroachment on the
tubular portion by a pale buff finely granular structure. The external surface, on
removal of the capsule, presented a finely mottled appearance (red and yellow). A
similar state of the right kidney existed, in greater degree. The Head was not ex-
amined.

licmarhs. — This case occurred at a time when cholera was prevalent. It presents
several points of considerable interest. The abdominal effusion, co-existing with a

G G 2

452 rERITONITIS.

pleuritic eflfusion, was due in all probability to the kidney disease, not to the pre-exist-
ing, and probably not recent, tubercular peritonitis. The incomplete coUapse, and the
long coiirse of the cholera attack, are to be attributed to the replacement, from the
pleiiritic and abdominal eflfusions, of the water of the blood lost in the intestinal
discharges. It shows that endosmosis and exosmosis may go on freely from a serous
surface studded with grey granular deposit. It is an instance of this deposit present
in the peritoneum, but absent in the lungs.

Chronic peritonitis consecutive on an acute attack, and tuber-
cular peritonitis, chronic in its character from the commencement,
are well known to pathologists. But I apprehend that idiopathic
peritonitis, not tubercular, yet chronic from its outset, is not a form
of disease very generally recognised.

Mr. Scott, now Inspector-Greneral of Hospitals of the Bombay
Army, at the time Surgeon of the 10th Kegiment Bombay Native
Infantry, called attention*, in 1842, to a very interesting form of
disease which he correctly designated " Chronic Peritonitis."

The regiment was stationed at Aden at a time when, from
defective arrangements, a scorbutic taint was prevalent among the
native classes there, and rheumatic affections were also common.

The disease in question was most prevalent at the commence-
ment of the cold season, and the symptoms, as observed in twenty-
nine cases, were of the following nature : — There was uneasiness
on pressure, or a sense of pricking or heat about the umbilicus
with anorexia, distention after eating, and subsequently vomiting.
The urine was scanty and high coloured, but there was no febrile
heat. So little importance did the sepoys attach to these symp-
toms, that, in some cases, they had been present for a week or two
before application was made for admission into hospital. Then
signs of effusion into the abdomen succeeded at varying periods.
Sometimes the men did not report themselves ill till effusion had
commenced ; and in others, the effusion began to appear three or
four days after admission. In some there was jaundice and en-
largement of the liver. A few cases, treated at the commencement,
after the true nature of the disease had been determined, are be-
lieved to have recovered; but all in whom effusion had taken
place, died within a month from its appearance. A post mortem
examination was made in three cases. In all, the liver was hard
and granular, the peritoneum was opaque ; and in two there
were extensive deposits of coagulable lymph among the intestines.
The kidneys were healthy.

There can be no doubt that the disease was chronic peritonitis.
Mr. Scott attributed it to a rheumatic diathesis which prevailed to

* •* Transactions, Bombay Medical and Physical Society," No. 6, p. 153.

ILEUS AND COLIC. 453

a considerable extent. His words are : " Perhaps what excites
rheumatic pains in the muscles and joints of one man, fixes on the
peritoneum in another, and creates this complaint."

When we bear in mind that Mr. Scott's report was written at a
time when diathetic disease did not occupy the place in pathology
which has since been accorded to it, and when little notice was
taken in medical writings of rheumatic pneumonia, pleuritis, or
bronchitis, it must be allowed that the words just quoted are con-
ceived in a spirit of happy suggestion.

I would only further add that Eokitansky, and probably other
pathologists also, recognise a rheumatic form of peritonitis.

On the treatiment of peritonitis, generally, I shall be very
brief.

Of the utility of general and local blood-letting, the use of opium,
and gentle mercurial influence in the early stages of idiopathic
peritonitis in a good constitution, there can be no question ; but it
must be recollected that the proportion of this form of the disease
is very small. There can be no doubt that the too ready asso-
ciation of antiphlogistic remedies with the name peritonitis has
been attended with injurious consequences in practice.

Greneral peritonitis, secondary on other serious forms of abdomi-
nal disease, or idiopathic in cachectic constitutions, ought not to be
treated by much blood-letting, or mercury. It is true that in
these forms the chances of recovery are very limited ; but they
should not be still lessened by injudicious treatment. There ought
not, in these conditions of peritonitis, associated as they generally
are with marked collapse, to be any hesitation in setting antiphlo-
gistic means altogether aside, and in trusting to opium, — after the
manner recommended by Dr. Stokes, — with rubefacients, and
stimulants to sustain the failing pulse.

In the chronic forms of the disease we shall have further to keep
in view the character of the diathesis, and the means, gently
eliminatory or other, which science may suggest for its removal or
improvement. The injury often caused by active purgatives, in
the treatment of peritonitis, is well enforced by Dr. Watson in his
excellent lectures, and is I apprehend, now universally assented to.

Section II. — Ecus and Colic,

Setting aside cases of strangulated hernia, the instances of ileus,
which have come before me, are few in number.

The first of the two following cases came under my observation

G a 3

454 ILEUS.

at Kirkee, in the hospital of the 4th Dragoons, aiid is of the form
depending upon paralysis of muscular fibre, consequent on com-
mencing inflammation (enteritis), which Dr. Abercombie has so
well illustrated in his writings. In the second, a portion of the
small intestine was strangulated by old adhesions resulting from
former peritonitis. To Mr. Carter I am indebted for the notes and
the opportunity of inspecting the morbid appearances of a case
which had come under his care. In this the obstruction was from
colloid-cancerous degeneration of the sigmoid flexure. It is the
only instance of malignant disease of the alimentary canal which
has come under my notice.

198, Reus, with granular effusion on the inner surface' of the ileum. — Biliary calculi.
— Mrs. Horton, aged thirty-seyen, admitted into fhe hospital of the 4th Light
Dragoons, September 6th, 1832. A few months in India. Had been for some
years subject to occasional pain in the abdomen, with constipated bowels; good
health in the intervals. Had an attack some months ago in Bombay, also another
about ten days since, from which she recovered under the use of purgatives and
leeching. In the course of the day of admission, had been aiFected with violent pain
of abdomen; belly tender. Little vomiting. Actively treated, leeched, blistered.
Some dark-coloured stools procured after the use of active purgatives and enemata.
Pain undiminished, insensibility ; moaning and sinking on the 7th. Died early on
the 8th.

Inspection six hours after death. — Abdomen distended and tense, the integuments
loaded with fat ; a small quantity of serum in the cavity of the peritoneum. On the
incisions being made, the intestines protruded, distended with gas and fluid. The
ileum externally, principally at its most dependent parts, was dark red, and vascular,
with very slight and partial exudation of flakes of lymph. There were old firm ad-
hesions at the upper part of the ascending colon, which connected it flrmly to the
whole surface of the gall-bladder, and to the thin edge of the right lobe of the liver.
The gall-bladder shriveled, contained no bile, but was filled with small angular earthy
concretions. In portions of the descending colon and sigmoid flexure there were con-
tractions for some extent, but no unnatural condition of the tissues. The lower end
of the ileum to a considerable extent, also the ccecum, were laid open. Where the
peritoneum was discoloured, there the inner surface of the ileum presented a similar
discoloration, and there more especially, and elsewhere also, for the extent of about two
feet, there was effusion on the inner coat of the ileum of fine granules, forming an
aspect as if a moist surface had been sprinkled with fine sand : this effusion, with the
thin mucous tunic, peeled easily off with the nail. The large intestine also, in part
distended, contained, as well as the small, thin light-coloured feculence ; no scybalous
matter, no obliteration of the cells of the colon. The upper part of the descending
colon was marked with red clotted softened patches of the mucous membrane ; in the
contracted portion no disease of the tissue. Liver somewhat dark in colour, otherwise
pretty healthy. Uterus of natural size, with some vascidarity of its peritoneum ; but
no exudation.

199. Ecus. — Strangulation of part of the intestine by old peritonitic adhesions. — A
lady, aged twenty, of very delicate habit, the subject, it was said, of abdominal in-
flammatory attacks at different times in early life, had for some time been suffering
from diarrhoea. On the morning of the 26th July the bowels had been relaxed, and
to check this an opiate was given. About 3 p.m. was seized with excruciating pain of
abdomen, with much prostration, cold skin, anxiety, and frequent vomiting. This

COLIC. 455

coutinixed during the night, and the pain was relieved by friction and pressure. Seen
by me, with Dr. Bum, on the 27th at 2 p.m. From the period of the attack no action
of the bowels had taken place, though enemata had been freely used for this pm^ose.
When seen, the abdomen tender and tense, the pain was increased by pressure and
the shghtest motion ; pulse 120, easily compressed. Thirty-six leeches were applied,
and Dover's powder, with hydrarg. cum creta, given. At 5 p.m. «he had borne the
leeching well ; the pulse was rather more developed ; tenderness and pain of abdomen
continued, and just above the pubes, and inclining towards the right iliac region, there
was an irregular knotty induration perceptible. The pain was constant, but it increased
in paroxysms from time to time with eructations, but no return of vomiting. Five
dozen leeches were applied. Seen at 9 p.m. The pain and tenderness of abdomen
were very little alleviated, pulse upwards of 120, and very feeble. No discharge from
the bowels, and she was anxious and exhausted. Opium one grain, calomel two grains,
every third hour. 28th, 6 a.m. Had dozed much during the night. Pulse very
feeble. The tenderness of abdomen and tenseness continued ; no evacuation. The
opium was directed to be continued without the calomel, and an enema to be exhibited
in the course of the day. 5 p.m. The vomiting recurred, and was frequent. The
exhaustion had been great, and the paroxysms of increased pain frequent. Some dark
feculent matter was brought away with the enema. Now skin cold ; pulse thready ;
features collapsed ; breathing hurried. Stimulants were given. She died about 7 p. m.
Intelligence entire to the end.

Examination fourteen hours after death. — Abdomen tense. Not much distended.
The omentum vascular, adhered to the convolutions of the small intestine, dipped into
the pelvis, and was adherent there. A dark reddish tint of the surface of the small
intestine generally, and the stomach also at its great arch, was observed. On separa-
ting the tender adhesions of the convolutions of the intestines, and raising them from
the pelvis, very dark-red effusion was found to the extent of about ten ounces, and a
portion of the smaU intestine to the extent of about two feet was observed to be in
a perfectly black state. Over this the omentum was in part matted, but the greater
part of the dark-coloured portion of the intestine had sunk into the cavity of the pelvis.
On examination it was found that this portion of the intestine had been strangulated.
A ligamentous band passed from the free end of the appendix vermiformis to a part
of the mesentery. The side of one convolution (about six inches from the ileo-coecal
valve) was united to another by a firm ligamentous band not more than quarter of an
inch in length. The ring thus formed was about two inches in diameter. The strangu-
lated portion of intestine had passed through this ring, and the size of the ring had
been lessened, by part of its circumference and its diameter, having been compressed
by the band connected with the appendix vermiformis. But of the exact manner of
the strangulation I was not quite certain. The part strangulated was a portion of the
ileum commencing a few inches above the ring which has been described.*

Ordinary colic from some casual error of diet is not uncommon
both in Europeans and natives, and is in general readily cured by
a purgative combined with an anodyne.

M. Boudin remarks f that " colique vegetale " is not alluded to in
the first edition of this work, and adds, that when he questioned
me on the subject I seemed astonished at the name. Doubtless

* Case 86 may be referred to in connection with that now detailed.

t "Traits de Geographic et de Statistique M^dieales," par J. Ch. M. Boudin.
Vol. ii. p. 377. His words are, — " Nous ajouterons meme, qu'ayant tout r^cemment
interrog^ M. le professeur Morehead sur la colique vegetale, le seul nom de la maladie
parut I'etonner beaucoup.

G G 4

456 COLIQtJE V^GJ^TALE.

this impression is correct, as the name was then new to me, and
I find on a careful perusal of the interesting description in M,
Boudin's work, that the disease is also unknown to me.

It is said to occur in greatest degree in French ships, particularly
steam vessels, in the proximity of tropical coasts. It is observed
much less frequently, and in a milder form, on shore. It attacks
several individuals at a time, and consists of recurring paroxysms
of severe colic, succeeded by emaciation, tremors, paralysis, delirium,
and convulsion. The mortality is considerable, and the occun-ence
of cerebral symptoms always indicates a fatal result. The water,
the wine, the provisions, and the circumstances of crews thus
affected, have been carefully examined, without the slightest
evidence of the presence of lead. The disease has therefore been
attributed to a miasmatic poison.

It is difficult to explain why this form of colic is unknown in
India in English troops, or, as I believe, in the crews of English
ships in tropical seas. The statement in M. Boudin's work, that
English surgeons in Bombay receive a large number of patients
affected with this form of colic from Scinde and the Persian Grulf,
is certainly erroneous.* The European Greneral Hospital is the only
hospital in Bombay for the reception of sick sailors, and with the
occurrences in this hospital I have been familiar for the last
twenty years.

I quote, in connection with this subject, the only case of lead-
colic which has come under my observation, and this chiefly on
account of the morbid appearances found after death.

200. CoUca-Pictonum. — The colon was much distended and displaced. — Death, with
head symptoms. — Only slight serous effusion at the base of the skull. — W. Keilly, of
twenty-eight years of age, a seaman in moderate condition, a painter by trade, who
had at different times, after working with paint, been affected with severe colic. The
last attack was about two years before he came under observation, and it continued
for eight months. On the 5th of May, 1839, he came to the Greneral Hospital in a
gtate of intoxication. He was affected with vomiting, and complained much of pain
at the epigastrium ; his hands were tremulous and the bowels constipated. He had
lately been engaged in painting the ship to which he belonged. The pulse was feeble,
the skin damp. The pain and constipation were relieved by the warm bath and tur-
pentine enemata, but they recurred from time to time, with vomiting, during his stay

* The words are, "Les chirurgiens Anglais de Bombay, dit M. Lemaxie (th^se
Montpellier, 1851), re9oivent un grand nombre des malades atteints de colique s^che
des postes et des bdtiments du Sihd et du Golfe Persique; ceux de Calcutta de la
navigation du Grange et du Grolfe de Bengale." I am not entitled to speak with the
same confidence respecting Calcutta, but I have very little doubt that here also there
is some misapprehension. The experience of the medical officers of the steam vessels
of the Oriental and Peninsular Company would be of value on this question.

COLICA PICTONUM.

457

in hospital, and were attended with retraction of the wrists, and convulsive movement
of the fingers. On the 8th, 9th, and 10th, he had several convulsive fits, followed by
moaning, restlessness, and incoherence ; accompanied with a cold, damp skin, a quick
and feeble pulse. On the 11th and 12th he was delirious, and death on the latter day-
was preceded by drowsiness. He was treated with opiates, stimulants, blisters, and
purgatives.

Inspection fifteen hours after death. — Head. — An ounce and a half of serum was
effused in the cavity, the greater portion at the base of the skull ; the substance of the
brain and the membranes were in their natixral state. Chest. — The lungs were healthy
and collapsed. The heart was soft in its texture. Abdomen. — The whole of the large
intestine was dilated and varied in calibre from about two to three inches. The trans-
verse colon coursed along the margin of the right false ribs, concealed the liver, reached
to the ensiform cartilage, thence coursed downwards at the margin of the left false
ribs, thence passed directly upwards to the diaphragm, opposite to the apex of the
heart, thence turned downwards and formed the descending colon; the distended
sigmoid flexure occupied the hypogastric region and reached to the umbilicus ; the
coats were natural, perhaps thinned, and there was much thin feculence in the gut ;
the mucous follicles were here and there enlarged. The stomach was contracted and
concealed by the colon ; at its cardiac end, there were dark, extravasated patches,
elsewhere the coat was mammillated, but there was no softening. The small intestine
was contracted. The liver was paler than natural. The kidneys were healthy.

45S AFFECTIONS OF THE STOMACH.

CHAP XVIII.

AFFECTIONS OF THE STOMACH.

Section I. — Gastritis, Acute and Chronic.

Acute Gastritis. — In my remarks on remittent fever *, it is stated
that bright redness of the mucous membrane of the stomach is
occasionally found after death, in the fevers of plethoric Europeans
in whom irritability of the stomach had been present during life ;
but this condition is probably rather congestive than inflammatory.

In my notes of fatal cases of small-pox there is one in which
symptoms of acute gastritis were present during life, and the
characteristic morbid appearances were found after death ; but
with this exception, all the other cases of acute gastritis which
have come under my observation have been instances of irritant
poisoning.

Poisoning by arsenic, with suicidal or criminal intent, is unfor-
tunately common in India, as is well known to medical ofiicers
connected with native general hospitals.

I have the notes of several before me, but I shall be satisfied
with the narration of two, selected not only as illustrative of the
symptoms and morbid appearances of acute gastritis, but also of a
a remark previously made relative to the diagnosis of cholera.t In
the absence of a faithful history, the following case, in a season of
epidemic cholera, might very readily have been taken for one of
that disease : —

201. Poisoning hy arsenic^ admitted in the stage of colla'pse, after the active sym'p-
toms of gastritis were passed. — Furdonjee Jewajee, a Parsee liquor seller, of thirty-
years of age, was brought by his friends to the hospital at 7 a.m. on the 28th February,
1851. He was said to have taken arsenic at 2 a.m., and at the same time half a bottle
of brandy. He vomited frequently, and the ejected matters contained blood. He
had also been frequently purged. On admission he was drowsy and restless, and the
conjunctivae were vascular, the skin cold, the pulse imperceptible, and the tongue some-

* Page 93. t Page 214.

ACUTE GASTRITIS. 459

wliat florid. He complained of pain of the loing, but not of the abdomen. He died at
eleven o'clock.

Inspection four and a half hours after death.— 'Rigov mortis present. The heart
contained liquid blood, and there was concentric hypertrophy of the left ventricle.
The stomach contained about seven ounces of dark liquid blood. The mucous mem-
brane was throughout of bright red colour, abundantly studded with dark red points
of extravasated blood. There were patches of viscid mucus here and there, with
white particles intermixed. Liquid blood flowed from the vessels of the dura mater,
as it was divided. The pia mater was congested. The substance of the brain wad
redder than natural, and showed many bloody points.

Analysis. — Some of the white gritty particles from the mucous membrane of the
stomach, heated with black flux in a test tube, gave a grey metallic ring. This por-
tion of the tube, heated in a large tube, gave on its sides deposit of a white sublimate,
which was dissolved in boiling distilled water ; tested with the ammonio-nitrate of
silver, it gave a canary-yeUow precipitate, with the ammonio-sidphate of copper,
a bright green precipitate, and with a stream of sulphuretted hydrogen, a yellow solu-
tion.

202. Poisoning from arsenic in which symptoms of narcotism were prominent at the
commencement. — A Hindoo goldsmith, of about thirty years of age, was brought to the
Jamsetjee Jejeebhoy Hospital on the morning of the 21st May, 1847, at 6 a.m. He
had been picked up by the police on the public street. He was comatose ; his pupils
were dilated, the breathing was natural, the pulse frequent. There was no appearance
of injury, and no emaciation or sign of long- continued sickness. As he was being
lifted from the cart in which he had been conveyed to the hospital, he vomited a little
bilious matter. Nothing was known of his history. Cold aflPusion was used to the
head, and an emetic of ipecacuanha and carbonate of ammonia was given. The emetic
acted readily, and he became sensible. He vomited several times during the day, and
was purged two or three times, the evacuations consisting of gelatinous-looking mucus.
Towards evening the pulse had become very feeble, the breathing hurried, the thirst
and anxiety considerable, with occasional retching. He died about five o'clock a.m.
on the 22nd instant. The only statement he made was, that he had eaten some sweet-
meats the night before he was brought to the hospital. The result of the coroner's
inquest was, that he had taken poison himself.

Inspection six hours after death. — The body was in good condition. Abdomen. —
There was a general blush of redness over the peritoneal covering of the stomach and
small intestine, but no effusion into the sac of the peritoneum. The stomach was
opened and found to contain about six ounces of a dark watery fluid with mucous sedi-
ment, partly tinged with blood, and containing some white gritty particles. There was
general redness of the mucous lining of the stomach, characterised towards the cardiac
end by a dark patch-like arrangement ; and towards the pyloric end there was a dark
and more diffused redness leading to an almost black patch about three inches long,
and two in short diameter, raised somewhat above the general level, and abraded in
part of its surface. There was dark redness in patches of the mucous lining of the
duodenum, and a general blush with increased secretion of mucus on that of the
jejunum, and of the ileum and ccecum. The thoracic viscera were healthy, there was
slight congestion of the vessels of the pia mater of the brain. For the following note
of the analysis of the contents of the stomach I am indebted to Dr. Giraud : —

*' About four ounces of a mucous flocculent fluid taken from the stomach, containing a
few minute white brittle particles. These particles, weighing about the tenth of a grain,
were sublimed in a tube into a white crystalline ring ; — this, with the part of the tube
on which it was deposited, being placed in a reduction tube with charcoal powder, gave
a steel grey metallic ring, which, on being heated in a wide tube, was reconverted
into a white crystalline sublimate. By Reinsch's process metallic deposition on copper

460 CHRONIC GASTRITIS.

was obtained from the above-mentioned fluid ; this yielded a white crystalline subli-
mate, which on solution in water gave the characteristic effects of arsenious acid
with ammoniaco-nitrate of silver, ammoniaco-sulphato of copper, and sulphuretted
hydrogen. By the foregoing processes arsenious acid and metallic arsenic were ob-
tained from the white particles found in the fluid of the stomach ; and from the fluid
itself metallic arsenic was procured, and made to pass through its various compounds
of arsenious acid, arsenite of silver, arsenite of copper, and orpiment."

Remark. — The interest in this case consists in the strongly marked narcotic symp-
toms shown on admission into hospital. It was viewed then as a case of narcotic
poisoning, and treated as such. Subsequently its nature was sufficiently evident. A
circumstance, not noted in the case, attracted my attention when the narcotic symp-
toms were present. There was a fixed frown on the countenance, an expression of
suiFering not usual in simple narcotism, and to which probably more importance as a
diagnostic sign should have been attached.

Chronic Gastritis. — A review of the fatal cases of disease now
before me, and partly detailed in this work, show that some degree
of chronic inflammation of the mucous membrane of the stomach
is frequently observed in persons addicted to excesses in drinking,
— indicated by streaked or dotted redness, generally at the cardiac
end of the stomach, associated with softening, or a hypertrophied
and mammillated state of the tissue.*

Ulceration of the gastric mucous membrane has not been
frequently met with by me f ; and the same remark applies to
fibrous growths in the sub-mucous tissue. A small fibrous tumour
is mentioned in case 50. I have also notes of the history of a
soldier of the 4th Light Dragoons whom I saw in the hospital at
Kirkee in 1837 in a state of great emaciation. He died shortly
afterwards. The pyloric orifice of the stomach was so contracted
by cartilaginous thickening as barely to permit the passage of a
quill. Vomiting had only been occasionally present, and in conse-
quence of the pale colour of the evacuations the disease had been
considered hepatic, not gastric.

I have not met with a single case of malignant disease of the
stomach, though the occurrence of two or three in the higher
classes of Europeans, in the practice of others, has come to my
knowledge. My own observation in India would lead me to infer,
that malignant growths generally are of infrequent occurrence.

* Though a remark pertaining rather to the symptoms of cerebral irritation, it may
be well even here to aUude to the risk of mistaking the irritability of stomach sympa-
thetic with cerebral aiFection, for that symptomatic of gastric inflammation. In respect
to children, caution on this point is well understood, but it is also necessary in regard
to adults. I have known cases of cerebral determination from undue exposure to the
sun, in which the vomiting was so prominent as to tend to overshadow the uneasiness
of head, the flushing of countenance, the restlessness, and tendency to mental confu-
sion, and to divert attention from the true seat of the disease.

t Cases 89, 90.

GLOSSITIS. 461

Whether the circumstance of their having come rarely under my
notice is to be attributed to absolute in frequency, or to my field
of inquiry not having extended to the classes and the periods of
life most susceptible of malignant disease, I am unable to deter-

Section II. — Glossitis.

This serious disease is of very rare occurrence. I have met with
only two cases. The first in a sthenic soldier of the 1 5th Hussars.
The half of the tongue was affected ; but the organ was so swollen
as to fill the mouth, protrude between the lips, and cause appre-
hension for the result. Eecovery took place under the use of
general blood-letting.

The second case occurred in February 1846, in a very asthenic
native child, who was brought to the dispensary of the Jamsetjee
Jejeebhoy Hospital for relief. Both sides were affected, and the
swollen tongue protruded from the mouth and completely prevented
deglutition. Leeches and superficial scarifications were used with-
out relief. The child was so reduced that the bleeding consequent
on free incisions was dreaded, and yet the symptoms had become
very urgent. I pencilled the tongue freely with nitrate of silver.
On the following day the swelling was much reduced. The
caustic was again used, and nothing further was necessary to
perfect the cure.

I have alluded to the subject of glossitis that I might record the
efficacy of the nitrate of silver in this case. It is a practical fact
well worthy of being borne in recollection.

* As connected with the pathology of the stomach, I would allude to a peculiar case
of injury which came under my observation in the European Greneral Hospital in 1839.
A sailor was violently squeezed between the bulwark of a steam vessel and a tense
cable which passed across the epigastrium. "When received into the hospital, an hour
after the accident, there was an ecchymosed mark distinct on the epigastrium and op-
posed part of the spine. There was much collapse. He vomited some dark-coloured
blood. After reaction there was much tenderness of abdomen, hurried respiration,
but no return of vomiting. He died twenty-four hours after admission. After death, a
pint of dark fluid blood was found in the left pleura : a large rent, through which three
fingers could be passed, existed at the posterior part of the left side of the diaphragm,
near to the spine. No fracture of the ribs. In the pelvis and neighbourhood of the
kidney there was a pint of dark fluid blood. Transversely across the centre of the
great arch of the stomach there was a strip of the mucous membrane above an inch in
breadth, torn from the subjacent coat, hanging loose with lacerated edges.

462 DYSPEPSIA.

Section III. — Dyspepsia. — General reflections on Pathology
and Principles of Treatment

Though ^* dyspepsia " occupies a prominent place in hospital
returns, it is my intention to treat very briefly the train of symp-
toms to which this term has been applied. By dyspepsia, or
indigestion, is meant more or less of such symptoms as anorexia,
nausea, vomiting, epigastric distention and pain, gaseous and
watery eructations. Much has been written on this affection, but
the question may be suggested, whether the tendency of elaborate
disquisitions on dyspepsia has not been to obstruct the progress
of enlarged views in pathology and rational doctrines in thera-
peutics.

Indeed, I venture to predict, that the time is not very distant,
when consequent on advancing generalisations in pathology, the
term dyspepsia will be removed from our nosologies, just as
dyspnoea has already been.

That, consequent on inflammation of the mucous membrane, or
organic lesion of the stomach, the taking of food will be followed
by more or less of the symptoms called dyspeptic, may be readily
allowed. Gastric inflammation and organic lesion should be treated
in accordance with the general principles applicable to their class,
adapted to the diathesis of the individual affected.

My present remarks, however, are not intended to apply to
dyspeptic symptoms thus arising, but as they occur independent
of inflammation or organic disease, — ■ the form of dyspepsia called
functional.

In the first chapter of this work, and in other places also, much
importance has been attached to diathesis in its bearing on etiology
and therapeutics, and to no affection is this principle more justly
applicable than to the so-called disease — functional dyspepsia.

In the most robust constitution, great excess in eating will be
followed by imperfect digestion with its attendant phenomena, but
here the pathology is clear and the indication of cure self-evident.
These, however, are not the circumstances under which functional
dyspepsia usually occurs. It is among the asthenic and cachectic
that it is generally met with. In these states of defective assimi-
lation of food to blood and blood to tissue, or of blood vitiated by
mal-assimilation, retained excretion, or reception of external in-
jurious agencies, the stomach partakes in the infirmity of the
whole system, its functional power is enfeebled, and that quality

DYSPEPSIA. 46a

and quantity of food which in vigorous health would be digested
with ease, is followed by indigestion.

Then there are associated with these dyspeptic symptoms,
phenomena which indicate derangement of other organs, as irre-
gular action of the heart, headache, restless nights, muscular and
mental languor, depressed spirits, irritable temper, morbid alvine
discharges, constipated bowels, u.rine vitiated with urates, phos-
phates, or oxalates, &c. In this assemblage of deranged actions
the dyspeptic symptoms are prominent, because the functions of
the stomach are frequently called into exercise, the phenomena of
derangement are well marked, the act of placing food into the
organ is voluntary and often injudiciously performed. This pro-
minence of the indigestion naturally tends to favour the belief
that the other co-existing disorders are sequences of it. It may
be admitted that as the function of the stomach is essential to re-
covery from asthenic and cachectic states, its frequent derangement
must tend to increase these states with all their attendant evils ;
and thus in a limited sense the continuance of the other derange-
ments may be said to be consequent on the persistence of the
dyspepsia.

But this is not the large and practical view of the relation of all
these events to each other.

The deranged digestion, circulation, assimilation, secretion,
nervous and muscular functions, are conditions of the diathetic
state, which, when developed, tend mutually to aggravate each
other ; but still they are all equally traceable to the causes which
induced the asthenia or cachexia, and are only to be permanently
cured by the removal of these causes and by the substitution of
the causes of health.

The truly essential practical consideration in the treatment of
functional dyspepsia, is to determine the causes of the asthenia or
of the cachexia, to remove the individual from the sphere of
their influence, and to place him in circumstances favourable to
health.

The conditions of health may be summarily stated to be : relief
from mental care and anxiety, a pm:e atmosphere, nutritious food
in quantity adapted to the power of the stomach, exercise in the
open air always short of fatigue, attention to the functions of the
skin by ablution and suitable clothing, cheerful occupation, due
amount of sleep, and avoidance of excessive evacuations. Under
these influences the dyspeptic symptoms and their associated
derangements will gradually disappear; but if these influences

464 DYSPEPSIA.

be overlooked and neglected, there cannot be restoration to
health.

But this statement does not comprise all the resources of the
medical art. The progress to recovery may be smoothed and
hastened by various remedies, as sedatives, alkalies, tonics, alter-
atives, eliminants. It is not my object to enter here into the
details of these means ; they are well set forth in systematic works
on disease and on Materia Medica, and their powers and applica-
tions should be carefully investigated by the clinical student ; for,
when the circumstances of the patient do not admit of change of
scene and relaxation from occupation, or when the cachexia has
become irremediable, these remedies, with the adjustment of diet,
ai*e unfortunately the only means by which relief may be obtained.

My present purpose has been to enforce the doctrine that these
gastric and associated derangements are very generally induced by
neglect of the conditions necessary to health, and are only to be
permanently recovered from by a suitable adjustment of the vital
stimuli, on which health depends, and without due attention to
which it cannot be maintained or restored.

Articles of the Materia Medica, when the conditions of health
are attended to, conduce to the cure, but in many instances are
not essential to it. When the conditions of health are neglected,
articles of the Materia Medica, judiciously used, may alleviate
discomfort and suffering, but they are insufficient of themselves
to effect recovery, and are liable, in unskilful hands, to prove
injurious.*

It is from reflections such as these, that I have ventured
to hint that elaborate treatises on dyspepsia tend to interfere
with enlarged views in pathology and rational doctrines in thera-
peutics; and to predict that the term, at no remote period, will
be used merely to express a symptom, not a disease.

I am very sensible that in these remarks I have laid myself open

to the charge of inculcating trite and very simple principles, yet

they can hardly be deemed uncalled for. It is, in fact, to the

neglect of these obvious truths which lie upon the very surface of

our science, that are due the exaggerated pretensions of partial

systems of treatment, and the attempts to throw discredit on

rational medicine.

* It would be easy to enlarge upon the evils whicli have resulted, and the discredit
which has attached, to the profession of medicine, in consequence of the excessive and
habitual use of purgative and mercurial medicines in India, as in other countries, in the
treatment of the symptoms called dyspeptic. I would fain hope that the subject is
now well understood.

465

CHAP. XIX.

ON beight's disease of the kidney and albuminous urine.

Section I. — Prevalence of BrigkCs Disease in the hospital-
frequenting classes of the natives of India,

In the year 1849 I first called the attention of the Medical and
Physical Society of Bombay to Bright's disease of the kidney, as
occurring in the hospital-frequenting classes of the native popula-
tion of Bombay; and subsequent experience has confirmed my
belief, that the morbid states to which the name of this eminent
physician has been given, are as common in these classes of the
community in India as in European countries.

I have before me the notes of fifty-eight cases which have been
under my care in the clinical ward in the com*se of six years:
thirty proved fatal, and twenty-eight were discharged, of whom
nineteen were improved, and nine had received no benefit from
treatment. These, however, form but a part of the admissions
for this disease into the Jamsetjee Jejeebhoy Hospital during
this period. Many cases have come under the observation of
other medical officers in other wards of the hospital ; and there is,
in the following circumstance, evidence that many more must
have passed through the hospital unrecorded. During these six
years 782 patients have been admitted under the head *' Cachexia ;"
and of these 493 have died. This is 12 per cent, of the total
hospital deaths. The term cachexia is used in the hospital
register when the imperfect history of previous illness, or the short
time which has elapsed between admission and death, has pre-
vented the discovery of the character of the cachexia, or of the
existence of important organic disease. It is not to be doubted
that a proportion of this class has been affected with Bright's
disease. Indeed, if the relation which these structural changes of
the kidney have to processes of degeneration be recollected, and,

H H

466 bright's disease op the kidney.

at the same time, the fact of the greater prevalence of asthenic and
cachectic types of disease in warm climates be borne in mind, then,
not only an equal, but a greater frequency of this affection in
India, may be assumed as the fair inference from a review of all
the attendant circumstances.

In respect to the occurrence of Bright's disease in Europeans in
India, my dissection reports show that it was not unfrequently
noticed by me in the European General Hospital. At that time,
however, my attention was more given to other subjects of
pathology ; and I therefore believe that my observations at that
period do not indicate the full proportion of this disease in the
classes who resort to that hospital. Of its frequency in European
regimental hospitals in India I am unable to speak ; but I need
hardly observe that in this, as in all other questions of pathology
relating to European soldiers in India, the comparison is between
them and soldiers elsewhere, and not between them and the civil
population of European countries. I am also without satisfactory
facts respecting this disease in officers, civil servants, and others of
the higher classes of Europeans in India. Of the 311 fatal cases
of officers, of which I have notes, Bright's disease is mentioned in
only three, and these were subsequent to the year 1849. These
data, however, as bearing on this question of pathology, may be
set aside as inconclusive ; for it is very evident that the attention
of medical men in India has been, till very lately, imperfectly
directed to its investigation.

The remarks which I am about to make have been chiefly sug-
gested by the fifty-eight clinical cases now before me, viewed
in connection with the statements and opinions advanced by
European writers. They may be arranged under the heads —
1. Pathology. 2. Causes. 3. Symptoms and Treatment.

Section II. — The Relation of BrigMs Disease to Albuminous
Urine stated. — The Morbid Anatomy and Pathology of the
Fluids. — Pathology of the Secondary Affections. — The
Urcemic Theory. — The Proximate Cause of Albumen in the

Urine.

Albuminous urine may occur independent of structural change
of the kidney, caused by cold applied to the surface of the body,
when the eliminating and sensory functions of the skin are in an
abnormal condition. Under these circumstances, the urine is
scanty, more or less tinged with the hsematosin of the blood, and

PATHOLOGY. 467

abounds in albumen, depending on an excessive afflux of blood to
the capillaries of the kidney, with, it may be, an increase of the
epithelial cells of the uriniferous tubes. But this state is tran-
sient, and may readily be removed by appropriate treatment : it
has been most generally observed secondary on scarlatina.

Albuminous urine occasionally exists in connection with forms of
fever, independent of renal disease. The albumen is then present
in small quantity, only for a few days, and disappears with the
febrile disturbance.* The history, the condition of the patient, the
fact, ascertained by frequent and careful examination, of the disap-
pearance of the albumen, will always suffice to distinguish these
cases.

The various morbid states to which the term Bright's disease has
been applied are characterised by urine, more or less albuminous,
at some period or other of their progress. This condition of the
urine is generally persistent throughout the entire course of the
disease ; but occasionally the albumen is absent from the urine for
varying periods, and such cases may usually be distinguished from
transient albuminuria, related to a febrile state, by the history, the
condition of the patient, and the fact that the urine from which the
albumen has disappeared is generally in abnormal quantity, and of
density too low to be explained by the increase of watery consti-
tuent alone.

The prevailing opinions on the morbid anatomy of Bright's dis-
ease may be summarily expressed in the following terms : —

1. The kidney, when enlarged, is so: (a) from accumulation of
epithelial cells, or of more or less degenerate lymph, in the inte-
rior of the tubuli of the cortical portion ; (b) from exudation, ex-
ternal to the tubuli of the cortical portion, in the areolar matrix of
the organ. The greater or less redness, and the various degrees of
mottling, depend upon the proportion and situation of the blood
present in the capillaries of the kidney at the period of observation.

2. When the kidney is small, granular, and indurated, it is
so : {a) from collapse and cohesion of the sides of the tubuli of the
cortical portion consequent upon the removal of pre-existing accu-
mulations ; (h) from atrophy of the cortical structure consequent
on pressure from the contractile organisation of pre-existing caco-
plastic deposit in the areolar matrix.

There has been much discussion in regard to the relative im-
portance of deposit, external or internal to the tubes, and to the

* The presence of albumen in tlie lu'ine, from the existence of blood or pus in the
secretion, is apart from my present subject, and does not call for remark in this place.

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468 BlliailT's DISEASE OF THE KIDNEY.

nature of tlie deposit. Into these questions I shall not enter, but
merely observe that there is one fact common to all — viz., that
they tend to destruction of more or less of the secreting structure
of the organ.

The following fifteen cases will illustrate the general features of
the disease in the natives of India. They show the kidneys en-
larged in five, of natural size in two, small in four, lobulated in
six, and mottled in five. The encroachment of the cortical on the
tubular portion is noted in ten, and small cysts were present in
the kidney in two.

203. A diver bi/ occupation. — Anasarca, ascites. — Urine of low density and albuminotcs.
■ — Dilatation of the right ventricle of the heart. — Hypertrophy/ and dilatation of the left. — •
Kidneys enlarged, lobulated, in a state of yellow granular degeneration. — Suliman Seedee,
a Mussulman, twenty-five years of age, an inhabitant of Zangibar, and resident in Bombay
about a month. He had followed the occupations of a diver and a blacksmith, used ^.pirits
and ganja habitually, and opium occasionally. About five years before he came under ob-
servation, he was the subject of dropsical symptoms for about ten days, which made their
appearance after he had been engaged in his occupation of diver. There was no recur-
rence of them till about five months before his admission into the clinical ward, on
the 7th March, 1849. Then they had been preceded by febrile symptoms, coming on
frequently with chills, not terminating by sweating, and attended with scanty urine.
On admission there was general anasarca and ascites, the respiration was somewhat
hurried, and dry bronchitic rales were heard in different parts of the chest ; the im-
pulse of the heart was rather increased, but the sounds were natural ; uneasiness of
the loins ; urine copious, and passed frequently ; the pulse of good strength ; no
febrile heat; the bowels regular, and the tongue moist and clean. He continued
tinder treatment till the 24th April, when he died. During the first month the urine
ranged in quantity from forty to eighty ounces and upwards in the twenty-four hours,
was clear and pale, sometimes alkaline, at others neutral, and always gave a consider-
able flocculent deposit by heat and nitric acid. The dropsical symptoms were sta-
tionary ; a sense of uneasiness across the chest was frequently complained of, attended
with some degree of dyspnoea, cough, and crepitous rale in both dorsal regions. On
the 17th April prsecordial uneasiness was complained of, and there was increased dul-
ness over the region of the heart, with accelerated action and confused sounds. The
pulse was very small ; and now the urine was reduced to nine ounces ; the dropsical
symptoms, the dyspnoea, and asthenia increased ; and diarrhoea was superadded. He
became somewhat drowsy, and died the 24th April. The treatment consisted of
diaphoretics, diuretics, and purgatives ; rubefacients, antimonials, and on two occa-
sions leeches were used for the chest affection, and latterly stimulants were exhibited.

Inspection seven hours after death. — Chest. — The pericardium contained eight
ounces of serous fluid ; the cavities of the right side of the heart were dilated and
filled with blood; the left ventricle was also dilated, and its walls hypertrophied ;
the valves were all healthy; the inner surface of the aorta near to the arch w^as
roughened from yellow deposit. The lower lobes of both lungs adhered to the costal
pleurse firmly, posteriorly ; and a considerable part (more of the right lung) of these
lobes was in a state of red hepatisation. Abdomen.— Serous effusion, but to no great
amount, was present in the cavity of the abdomen. The liver was enlarged, indm'ated,
and its incised surface mottled. Both kidneys were slightly enlarged, and somewhat
lobulated; their surface, when denuded of the capsule, was mottled dark red and
yellow, and was granular. The kidneys, when vertically incised, showed much granular
degeneration, — the surface being mottled red and yellow, granular, with confusion of

PATflOLOGY. 469

the tubular and cortical structures. This state was most marked in the central part
of the right kidney ; it was more diffiised in the left one. In both, in one or two
places, there was tubular structure, not encroached upon ; but the cortical portion
external, showed commencement of yellow granular deposit.

204. Dropsical symptoms. — Urine of low density and albuminous. — Bronchitis,
diarrhoea, periostitis, erysipelas, as secondary affections. — Kidneys large, and in a
state of yellow granular and fatty degeneration. — An opium eater. — Hurrichund, a
Hindoo writer, of thirty years of age, a native of Cutch, and resident in Bombay for
about seven months, was the subject of primary and secondary syphilis about five
years before he came under observation, but no traces of the disease were present. He
admitted that he had been in the habit of eating opium to the extent of twenty-five
grains daily for about four years, and that he occasionally drank spirits. About four
months before his admission into hospital he had been affected with dropsical swel-
lings, which had disappeared without any medical treatment. About a month before
admission he had experienced pain in the lumbar region, and the dropsical symptoms
had returned. He was admitted into the clinical ward on the 22nd April, 1849.
There was oedema of the lower extremities ; the abdomen was full, but without
distinct fluctuation. The respiration was calm ; there was no dulness on percussion
of the chest. The sounds of the heart were natural, but an occasional crepitus mixed
with the vesicular respiration in the dorsal regions, chiefly the left. The pulse was
soft, the skin cool, the tongue moist, the bowels were reported to be regular, the urine
copious, and the pain of the lumbar region, formerly complained of, had ceased. On
the 24th the urine was amber-coloiu'ed, of specific gravity 1-007, and gave an abundant
flocculent deposit under heat and nitric acid. During the seven months that he was
imder treatment the quantity of urine passed was noted daily, and there are upwards
of sixty observations on the character of the secretion to be found in the diary of tho
case. The urine fluctuated a good deal in quantity ; it was seldom less than twenty
ounces in the twenty-four hours, and during the months of June and July very gene-
rally amounted to about five pints. Whether this great flow of urine was due to the
diuretic remedies which he was at the time using, or to the influence on the cu^dneous
surface of the cold damp air of the monsoon season, is doubtful. For the most part,
the specific gravity of the urine ranged from 1-003 to 1*012 ; and it was always very
albuminous. To the low density of the urine there were several exceptions, chiefly in
the month of May, when the urine was about twenty ounces in quantity : on these
occasions the specific gravity ranged from 1-018 to 1-030, and then the urine was
generally of a deep brown colour, and very albuminous, and sometimes febrile symp-
toms were present. Throughout the course of treatment the dropsical symptoms were
more or less present. Bronchitic symptoms were also at times complained of, at
others diarrhcea, sometimes dysenteric in character. There were also periostitis of
the sternum, and erysipelas of the left thigh, in the month of October, with febrile
symptoms, which tended much to increase the asthenic state. Febrile symptoms
recurred about the 10th November, attended with occasional delirium; the dropsical
effusions increased, and he died, with much hurry of the respiration, but without
distinct coma, on the 12th November. The dropsical state was treated with diapho-
retics and diuretics, and the other indications, as they arose, were attended to.

Inspection eight and a half hours after death. — The body swollen from anasarca.
Chest. — There were about seven pints of clear serous fluid effused into the sac of the
right pleura, and about one pint into that of the left. The right limg was compressed
against the spinal column, did not crepitate on pressure, but was soft and tough ; the
left lung was crepitating. There was no redness, or other trace of inflammatory action,
observed in any part of the pleura. There were about three oimces of clear serous
fluid in the sac of the pericardium, but no redness of the membrane, or other trace of
inflammation. The heart was of smaller size than natural, and the mitral valves were

H n 3

470

somewhat thickened. Abdomen. — There was about a pint of serum in the cavity of
the ahdomen. The liA'cr, not enlarged, was in the first stage of hepatic congestion.
The spleen was enlarged. Both kidneys were increased in size, the left one most so —
it weighed eleven ounces, and the right one eight; both were somewhat lobulated,
externally mottled red and yellow, but not granular. On incising the kidneys, the
cortical portion of both was in increased proportion, was mottled red and yellow, and
was somewhat granular and fatty in appearance ; the tubular portion was encroached
upon, but was quite distinct. Head. — The vessels of the pia mater were somewhat
injected, and there was slight serous effusion into the sub-arachnoid space.

205. Grastro-enteritis, anasarca, and ascites. — Urine of low density and albuminous.
— Paracentesis. — Death f7'om peritonitis. — Kidneys small, in a state of yellow granular
degeneration. — Imam Khan, a Mussulman Hakeem, of thirty years of age, a native of
Dowlutabad, and resident in Bombay for two years and a half. He was in very indi-
gent circumstances, and often very badly supplied with food ; was in the habit of
smoking ganja and tobacco, but did not use spirits. For about eleven days before his
admission intx) hospital he suiFered from fever and dysentery. He was admitted into
the clinical ward on the 2oth June, 1849. He was reduced in flesh; the respLation
was calm ; there was no dulness of the chest ; and vesicular respiration was general
and unmixed. The abdomen was collapsed, tender, slightly resistant, and an indu-
rated enlargement was perceptible for two inches below the margin of the left ribs.
The skin was of natural temperature, the tongue rather florid at the tip and edges,
the pulse small and easily compressed ; he complained of frequent calls to stool, and
the evacuations, passed with griping and straining, were said to contain blood and
mxicus ; he also suffered from occasional vomiting after eating. At first attention was
directed to the removal of the dysenteric symptoms. As these improved, bronchitic
symptoms appeared ; and on the 1 1th July there was puflflness of the face and oedema
of the feet. The urine was now examined, and was found to be of pale amber colour,
of specific gravity 1'004, and albuminous. It was frequently examined during his
illness, and varied a good deal in quantity, frequently above forty ounces in the
twenty-four hours, and latterly often below twenty, the specific gravity ranging from
1-004 to 1-018, and the presence of albumen always clearly indicated. Diarrhoea suc-
ceeded an alleviation of the bronchitic symptoms, continued present for several weeks
in succession, and often in an aggravated degree ; the dropsical symptoms increased ;
there was troublesome dyspnoea ; the abdomen swelled, and became tense and fluctu-
ating. Paracentesis was had recourse to on the 9th December, and foTirteen pints of
clear serous fluid, of specific gravity 1-006, and giving a copious deposit under nitric
acid, were drawn off. On the 11th there was general tenderness of abdomen, with a
very feeble pulse. This increased, and he died on the 12th.

Inspection eleven hours after death. — Head. — There was considerable serous effusion
in the cavity of the arachnoid and in the sub-arachnoid space. The vessels of the pia
mater were congested ; and there was about an ounce of serum in the ventricles of the
brain. Chest. — There was about a pint of reddish serum in the sacs of the plcTira.
Both lungs collapsed and crepitated ; the right lung was in part adherent to the costal
pleura, but the left was free. The heart was contracted and smaller than natural ; the
valves were healthy, and there was no hypertrophy of the walls. About two ounces
of serum were found in the sac of the pericardium. Abdomen. — About ten pints of
serum in the cavity of the abdomen. The peritoneal covering of the small intestine
presented in some places a dotted red appearance, and shreds of recent coagulable
lymph were found upon its surface and between the convolutions of the intestine,
causing tender adhesions of the convolutions to each other, and to the parietes of the
abdomen. The peritoneal aspect of the trocar wound was cicatrised, and there was
no greater trace of inflammatory action around it than elsewhere on the peritoneum of
the anterior wall. The convex surface of the liver adhered to the diaphragm by a

PATHOLOGY. 471

thin layer of lympTi ; tlie organ was smaller and harder than natural, and yet presented
appearances of congestion. The kidneys were smaller than natural, and each weighed
three ounces. On removing the capsule the siu-face appeared of a pale buff-coloiir,
mottled red and granular. On incising the right kidney the cortical part was also of
pale buff colour, with a mottling of red ; it was slightly granular, and in parts en-
croached considerably on the tubular portion. The left kidney presented much the
same appearance as the right, with this exception, that the cortical portion was pale,
and the tubular less red.

206. Anasarca and ascites. — Urine of low density and albuminous. — Was eight times
tapped. — Kidneys in a state of yellow granular degeneration. — Ahmed Senna, a Mussul-
man beggar, thirty years of age, a native of Scinde, and originally a cowherd. About
three years before he came under observation he suffered from fever while in Scinde,
and was subsequently on several occasions affected with oedematous swelling of the feet
and ankles. He denied being addicted to the use of spirits, and stated that he had
never taken them tUl two months before admission, when he was advised to do so,
moderately, for the relief of the dropsical symptoms. He was in the habit of smoking
tobacco, but not of eating opium. Four years before admission he had been the sub-
ject of sj^hilis, for which he had been salivated. He was admitted into hospital on
the 28th September, 1849. There was general anasarca, and the abdomen was much
swollen, tense, and fluctuating. He was under treatment in hospital till the 19th
January, 1851. Throughout this period the urine was generally less than twenty
ounces in the twenty-four hours, was pale, of specific gravity (varying with the
quantity) from 1*007 to 1*015, and giving a flocculent deposit, more or less copi-
ous, under heat and nitric 'acid. From the 10th October, 1849, to the 10th No-
vember, 1850, he was eight times tapped, and about one hundred pints of fluid, in
all, evacuated. After the first tapping it was discovered that the spleen was much
enlarged, reaching beyond the umbilicus in the median line, and as low as the crest of
the ilium ; but after the latter tappings it was found to have considerably decreased in
size. In the months of July and August, 1850, he suffered from diarrhcea, sometimes
dysenteric in character ; and during this time the fiuid re-accumulated slowly in the
abdomen. He died from exhaustion, and without coma. The treatment was very
varied, consisting of purgatives, diuretics, with tonics and stimulants, but without any
advantage. The operation of tapping was in each instance performed at the patient's
urgent request, to relieve the discomfort attendant on the distention of the abdomen.

Inspection. — Abdomen. — There were about twenty-six pints of serous fluid in the
sac of the peritoneum. The diaphragm was pushed up by the effusion, as high as the
interspace between the third and fourth ribs. The liver was much reduced in size,
and was suspended by its ligaments, separated by a considerable interspace from the
concave surface of the diaphragm. Bands of old adhesions united the lower part of
the right lobe of the liver to the diaphragm. After detaching the liver from its con-
nections, it weighed twenty-eight ounces ; the external sm'face was pale, and its peri-
toneal covering opaque ; the surface was also granular, chiefly that of the left lobe ; the
tissue, when incised, appeared dense and compressed, and pale, — but had none of the
lobulated appearance of cirrhosis. The body of the gall-bladder adhered to the
duodenum. The spleen was of about the natural size, weighed eleven ounces, and its
capsule was opaque and thickened; its texture was very indurated, and its incised
surface appeared red, and abundantly studded with white spots and streaks of fibrous
tissue. At the upper end the fibrous constituent was so abundant as to form
a pale indurated nodule, of about the size of a pigeon's egg. The left kidney was
larger than the right, and weighed about four ounces. On removing its capsule, the
surface appeared somewhat lobulated, mottled red and yellow, and granular; when
incised, it presented a surface also mottled red and yellow, but not granular; the
tubular portion was encroached upon by the cortical, chiefly at the central parts ; at

H H 4

472 bright's disease of the kidney.

the upper end tliere was a cyst, of about the size of a pea. The right kidney weighed
three and a half ounces ; the external and internal appearances were very similar to
those of the left, but more marked in character. The colon was contracted, and the
small intestine was gathered together in the centre of the abdominal cavity. Chest.
— The right lung was firmly adherent to the costal pleura, but its texture was spongy
and crepitating ; the left lung was also healthy. The heart was of about the natural
size, and weighed eight ounces ; there were some opaque patches on the surface of the
right ventricle ; the aortic and mitral valves were healthy.

207. Anasarca and ascites. — Urine of low density and very albuminous. — Sunk
binder diarrhoea. — The kidneys in a state of yellow granular degeneration. — The
mucous coat of the colon and ileum with dotted red patches and granular deposit. — A
spirit drinker. — Cirrhosis. — Shaik Abdoola, a Mussulman sailor, of thirty years of age,
addicted at one time to the excessive use of spirits, but not to opium or other narcotic
drug, had for two months before his admission into hospital, on the 28tli May, 1850,
suffered from frequent vomiting, and latterly from cedema of the feet and legs. He
was received into the clinical ward on the 15th June, when the abdomen was some-
what full, soft, and with an indistinct sense of fluctuation, but without any indur ation
below the margin of either ribs. The feet and legs were also cedematous, the respira-
tion was calm, the sounds and impulse of the heart were natural, and there was no
dulness on percussion of the chest ; the pulse was small and soft, the tongue moist
and clean. He was the subject of a large reducible scrotal hernia of the left side,
which had commenced three years pi'eviously. He continued under treatment till the
27th June, when he died. The urine in the twenty-four hours was generally above
fifty ounces, was clear amber-coloured, of specific gravity from 1*007 to 1-012, and
very albuminous. He became affected with diarrhcea, which increased, and caused
death by asthenia. The treatment was chiefly directed against the diarrhcea.

Inspection. — The body was emaciated. Head. — There was some serous fluid effused
in the sub- arachnoid space. Chest. — The lungs were collapsed and crepitating ; the
heart small in proportion to the body. Abdomen. — The large intestine generally was
contracted, — its coats were thickened. The omentum was contracted, and matted
over the colon. The inner surface of the large intestine was rugous and irregidar,
dark grey coloured, variegated of different shades, with bright red patches, and spots
here and there, chiefly in the ccecum ; the mucous coat had a granular appearance,
and was flrmly adherent to the subjacent coat. For a foot and a half the inner surface
of the lower end of the ileum presented the same appearance as the large intestine ;
above, for about three feet, the inner sm*face of the ileum was rugous, of a dark red
colour, with grey granidar patches here and there. The portions of the ileum just
described occupied the large scrotal tumour. The stomach was contracted, and the
mucous coat was rugous, of dark grey colour, with some dark red patches, and covered
with adhesive mucus. The liver was granular externally, and hard under the scalpel ;
the left lobe was very small. The left kidney was larger than the right, — its external
surface was mottled red and yellow, the cortical portion buff-coloiu'ed and granular.
The red colour of the tubular portion was quite distinct. The right kidney presented
the same appearances as the left. The spleen was small, and denser than natural.

208. Anasarca with ascites. — Urine of low density and generally albuminous. — Died
comatose. — Kidneys small, with cysts and excess of cortical portion. — Cirrhosis. — Thrice
admitted. — Antonio de Souza, fifty-five years of age, a Portuguese inhabitant of Goa, but
resident in Bombay for about eight years, and occupied as a servant in a baker's shop.
For many years he had been in the habit of drinking about three ounces of spirits
daily ; was the subject of incomplete paralysis of the right arm from his boyhood ;
but, with this exception, had enjoyed good health till about three weeks before his
admission into the hospital, on the 19th February, 1849, when he had become, con-

PATHOLOGY. 473

sequent on exposure to cold, he believed, the subject of intermittent fever, which after
fifteen days was followed by dropsical symptoms.

State on Admission. — He was somewhat emaciated, but with general anasarca, and
the abdomen full and fluctuating. The respiration was somewhat hurried, and there
were dry and moist bronchitic rales general on both sides of the chest, obscuring
the sovmds of the heart. The pulse was feeble and somewhat frequent, the tongue
slightly coated, but moist, and the skin of natural temperature. Diiring his stay in
hospital, the urine ranged in quantity from twelve to thirty ounces, was generally
clear, sometimes of acid, at others of alkaline reaction, of specific gravity from 1*007
to 1*017, and very generally gave a scanty flocculent deposit with heat and nitric
acid : this deposit, however, was sometimes absent. He continued in hospital till the
loth March, when he was discharged, at his own desire, with the dropsical symptoms
somewhat less, and the bronchitic rales considerably decreased. He was treated with
stimulant diuretics, of which squiUs was generally a constituent, and also at one time
the ferri-potassio tartras ; rubefacient applications were also used to the chest. He
applied for readmission on the 27th March. The emaciation and the dropsical symp-
toms had much increased ; the respiration was more hurried and oppressed, and the
cough more urgent ; the pulse was very feeble, and the urine very scanty. Under
the use of eight grains of sesquicarbonate of ammonia, a drachm of spiritus setheris
nitrici, with camphor mixture every third hour, and four oimces of arrack daily, and
an adequate diet, he speedily began to improve. The pulse gained somewhat in
strength, the breathing became less oppressed, the urine increased to sixty ounces and
upwards in the twenty-four hours, and the dropsical symptoms gradually lessened.
On the 5th April the acetate of potass was substituted for the sesquicarbonate of
ammonia. The urine still increased, and the dropsical symptoms had altogether
disappeared by the 10th April; on the 13th, quinine and the muriated tincture of
iron were substituted for the diuretic; and he was discharged on the loth, at his
earnest request. The urine was in general clear, sometimes alkaline, of specific gravity
from 1*006 to 1*017, and was, except on one or two occasions, unaffected by heat or
nitric acid. He was admitted again into hospital on the 23rd October, 1849. The
face was puffed, the feet and legs cedematous, the abdomen swollen. He complained
of cough and muco-puriform expectoration. Sounds of the heart natural, impulse
feeble. He stated that since his discharge from hospital he had used spirituous
liquors moderately, had been to Goa, and been exposed to the inclemencies of the
weather, to which he attributed the return of the dropsical symptoms, as well as irre-
gular febrile accessions, to which he was also subject. The pulse was very feeble ;
the asthenic and bronchitic symptoms increased. He became comatose on the 29th,
and died on the 30th. The urine, during the time he was under treatment on this
last occasion, ranged in density from 1*011 to 1*013, and was albuminous.

Inspection twenty hours after death. — Head. — The vessels of the pia mater were
congested, and there was more than the normal quantity of serum in the sub-arachnoid
space, but none in the ventricles. On incising the brain, numerous bloody points
appeared, but no softening was observed. Chest. — The lungs adhered firmly to the
costal pleura, and to the diaphragm, and when incised gave out much sero-puriform
fluid on pressure. The substance was crepitating, and the mucous membrane of the
bronchial tubes was of dark red colour. The heart was well covered with fat, chiefly
over the left ventricle ; the right ventricle was somewhat dilated ; the left slightly
hypertrophied ; no disease of the valves, but the ascending aorta was somewhat
dilated with opaque deposit, in parts ossific, on its inner surface. Abdomen. — There
was about a pint and a half of clear serum found in the cavity. The liver was some-
what smaller than natural, with some degree of irregularity on its external surface,
mottled dark red, and indurated in texture under the knife. The kidneys were
smaller than natural. In the cortical portion of the left kidney there were two cysts,
each of about the size of a small bean, but no distinct granular degeneration was

474 I3RiaiIT'S DISEASE OF THE KIDNEY.

found ill any part. The cortical part of the right kidney was mottled red and buff on
its s\irfaco, and it somewhat encroached on the tubular portion, but it was not granu-
lar, and there was an appearance of commencing cysts in some places.

209. Febrile symptoms^ followed by anasarca, ascites, and dysenteric symptoms. — Urine
of low density and albuminous. — Death by coma. — The kidneys in a state of yellow
granular degeneration. — The mucous membrane of the large intestine ulcerated, and with
granular exudation. — Elepa, a Hindoo shopkeeper, of fifty years of age, an inhabitant of
Hydrabad, in the Deccan, but for twenty-five years resident in Bombay ; not addicted
to the use of spirituous liquors. He stated that about two months before he came under
observation he left Bombay, in good health, on a pilgrimage to Nassick ; that about
fifteen days after his arrival there, he, consequent on exposure to wet, became affected
with febrile symptoms and diarrhoea, followed by cedema of the feet and legs. He was
admitted into hospital on the 29tli July, 1850, feeble, and reduced in flesh; the feet
and legs were cedematous ; the abdomen full, and with distinct sense of fluctuation ;
there was no dyspnoea or sign of disease of the lungs or heart ; the pulse was small
and thready. The day after his admission the urine amounted to fourteen ounces,
was pale, neutral, of specific gravity I'OIO, and gave a copious fiaky deposit under
nitric acid, but less under heat ; and such continued to be its character whilst
he was under treatment. On the 8th August, dysenteric symptoms set in, and he died
on the 17th August, having been very drowsy for twenty -four hours before death.

Inspection twelve hours after death. — Head, — There was slight turgescence of the
vessels of the brain, but the substance of the organ was of natural consistence. Chest.
— There were old adhesions on both sides, but chiefly on the right, and the base of
this lung was also adherent to the diaphragm. There were about two ounces of fluid
found in the cavity of the pericardium. The heart was small, but healthy in structure.
Abdomen. — There were about two pints of clear serous fluid in the sac of the peri'
toneum. The liver was of natural size and consistence, but its incised surface showed
the presence of congestion in the second degree ; upon its external surface there were
two or three opaque puckered patches of cartilaginous consistence. The spleen was
smaller than natural, and its substance healthy. The left kidney was somewhat
larger than the right, and on removing the capsule the external surface presented a
granular appearance, and was somewhat mottled. When incised, the cortical portion
was found to encroach upon the tubidar, which was here and there of a dark red
colour, and arranged in distinct bundles. The right kidney was smaller in size, and
presented very much the same appearance as the left, with the addition of two or three
small cysts, of about the size of a split pea. The apices of some of the papillse were
also somewhat indurated, and fibrous in appearance. The rectum was contracted, and
its mucous membrane was thickened, and presented irregular ulcerations, the surfaces
of which were covered with a deposition of granular lymph. The mucous membrane
of the descending colon and sigmoid flexure was also ulcerated, but the ulcers were
more follicular in character. The mucous membrane of the remaining portion of the
large intestine was attenuated, and there were transverse strise of vascularity seen,
apparently an early stage of the inflammatory action, which in the rectum had passed
on to ulceration and granular exudation.

210. Vesicular emphysema of both lungs. — Displacement of the heart. — Dilatation
and hypertrophy of the ventricles. — Atheromatous deposit, with ulceration, in the
aorta. — Granular degeneration of the kidneys. — TJo'ine once noted, albuminous. —
Dropsy. — Kawogee Canojee, a Mahratta gardener, of fifty years of age, resident for
twelve years at Parell, was admitted into hospital on the 15th October, 1850, affected
with dyspnoea and cedema of the lower extremities. He had been ill for two years, but
no account is given of the nature of his illness. The chest, including the prsecordial
region, was preternaturally resonant ; there was faint respiration, and sonorous and
sibilous rales; the impulse of the heart was most distinct at the scrobiculus cordis,

PATHOLOGY. 475

and there the sounds were distinct, and no murmurs were audible. The dropsical
symptoms increased, and also the dyspnoea, and he died on the 4th November. The
urine passed during the night after admission was sixteen ounces, of specific gravity
I'OOo, and unaffected by heat and nitric acid. After the 24th it became more scanty
— about ten ounces in twenty-four hours ; it was of specific gravity 1-020, and gave a
turbid deposit under heat and nitric acid.

Inspection sixty hours after death. — Chest. — Both lungs were emphysematous, and
rose beyond the margins of the chest; they were soft and spongy. The heart was
displaced downwards and towards the right side. Firm adhesions connected parts of
the surface of the heart to the pericardium, and there were opaque patches on other
parts of the heart's surface. The heart was enlarged from dilatation with hypertrophy
of the right ventricle, and hypertrophy with dilatation of the left. There were coagula
of blood in the left auricle and right ventricle. There was slight opaque deposit
towards the attached margin of the mitral valve. The aortic valves were healthy; the
inner coat of the aorta, from its commencement, and throughout its thoracic portion,
was closely studded with variously-sized patches of atheromatous deposit. At the origin
of the left carotid and subclavian arteries the deposit was ossifie in character, and the
inner coat was ulcerated^to the extent of a quarter of a rupee piece. Abdomen. — The
left kidney was small, the surface pale yellow, granular, in places lobulated, and the
tubular portion was distinctly encroached upon by the cortical, chiefly at its central
parts. The right kidney was of the natural size, but presented the same abnormal
appearances as the left.

211. Admitted in an advanced state of disease. — Hepatisation of both lungs. — Circum-
scribed pleuritic effusion of the right side. — Kidneys enlarged, and in a state of yellow
gramdar degeneration. — Urine not tested. — Balloo Ragoo, aged forty, a Maratha, a
native of Poena, but resident in Bombay for ten years, was admitted into the Jamsetjee
Jejeebhoy Hospital on the 1st October, 1849, affected with diarrhoea and oppressed
breathing. He had been ill a month, but was unable to give any connected account
of his illness. On the 5th October, Atmaram Pandurang, at the time an intelligent
student of Grant College, now a graduate, made the following note of the physical
signs : — " Eespiration short and hurried ; the whole of the posterior and lateral part
of the right side of the chest is duller than natural, and here bronchial sounds, mixed
with mucous rale, are heard under the stethoscope ; elsewhere on this side of the chest,
and in the whole of the left side, the resonance was natural, and puerile respiration
mixed with mucous rale is audible. There is equal movement of the two sides of the
chest, and the dulness noticed does not vary by change of position. The vocal thrill
is distinct on both sides." He died on the 7th.

Inspection fifteen Jwurs after death. — Chest. — The inner edge of the right lung
adhered firmly to the pericardium, and its anterior surface from the first to the sixth
rib, adhered to the costal pleura by old firm adhesions. Below the fourth rib the ad-
hesions did not extend externally beyond the nipple, but above that rib they were
general to the lateral and posterior costal parietes, as well as to the anterior. There
were about thirty ounces of sero-puriform fluid in the sac of the right pleura, chiefly
between the base of the lung and diaphragm, and between the costal pleura and the
lung, below the level of the fourth rib. The costal and pulmonary pleurae were there
covered with flaky lymph, forming, in parts, friable bands which extended across the
effused fluid. The liver was displaced by the effusion, and projected below the
margins of the right ribs. The right lung was, in great part, in a state of red
induration, in parts passing into grey infiltration. The left lung adhered firmly to
the costal pleura ; the lower lobe was in a state of red induration ; the upper cre-
pitating, but oedematous. The kidneys were both enlarged and flabby, appearing
mottled externally on the removal of the capsule, and on incision considerable encroach-
ment of the tubular portion by pale yellow, slightly granular substance was evident.

476 brigiit's disease of the kidney.

212. The subject of intermittent fever, followed by bronchitis, and slight anasarca. —
Urine of low density, and very albuminous. — Moria Pheena, a Hindoo labourer, of
fifty years of age, an inhabitant of Benares, but for four or five years employed as a
labourer at Aden, which place he left about eight months before admission into
hospital ; he had been addicted to the use of opium — ten grains daily for about eight
years; he smoked ganja occasionally, but did not take spirituous liquors. He was
admitted into the clinical ward on the 20th June, 1851 : he stated that he had been
the subject of intermittent fever about four months before, succeeded by cough, with
copious expectoration, some oedema of the arms and feet, and subsequently with swel-
ling of the abdomen. On admission he was a good deal reduced ; the abdomen was
somewhat full, and obscurely fluctuating, and there was slight oedema of the legs,
scrotum, and fore-arms, with puffiness of the face; the lungs and heart showed
no signs of disease on percussion and auscultation ; there was no induration detected
in the abdomen ; the pulse was small and feeble ; tongue moist ; the bowels rather
confined ; no pain of loins. He continued under treatment up to August 7th, with
no change in his state. The urine ranged in quantity from thirty to seventy ounces in
the twenty-four hours, in specific gravity from 1-005 to 1*015, was generally clear,
of pale lemon colour, neutral, and giving a copious flocculent deposit with heat and
nitric acid. The urine being free, and the dropsical symptoms slight, it was thought
advisable to tiy whether any impression could be made on the degeneration of the
kidney by cod-liver oil : he took it to the extent of an ounce, and latterly an ounce
and a half daily, and at the same time quinine was used twice daily in tliree-gTain
doses ; but there being no improvement in the urine, or in his general state, these
remedies were omitted, and the syrup of the iodide of iron was substituted. This
was not followed by any amendment, and Dover's powder and the occasional use of
the warm bath were had recourse to, with lessening of the oedema of the feet. He
continued under treatment tiU the 22nd October, when he left the hospital, having
derived little or no benefit from treatment. He was again seen on the 21st December,
much in the same state as on discharge. From this time he was lost sight of till the 4th
April, 1853, when he was re-admitted into hospital with feeble pulse, coldish skin, puffed
face, oedematous feet, full abdomen. The urine, scanty and very albuminous, became
almost entirely suppressed, and he passed into a drowsy state, and died on the 17th.

Inspection sixteen hours after death. — Head. — There was much opaque granular
thickening of the arachnoid membrane, at the situation of the glandulse Pacchioni.
There was increased serous effusion in the sub-arachnoid space, and there was about a
drachm of fiuid in each lateral ventricle. The substance of the brain was healthy. There
were about three pints of reddish-coloured serum in the sac of the left pleura. The
left lung was compressed against the spine, and both costal and pulmonary pleurae were
thickened by granular lymph deposit. The right lung was oedematous, but healthy
in other respects. The heart did not present any abnormal appearance. The left
kidney was small, lobulated, granular, and pale externally. Internally the cortical
part encroached much on the tubular, particularly at the centre. The right kidney
not so pale, was more granular on the surface than the left, but in other respects was
in the same state. The liver was congested in the second degree.

213. Febrile symptoms and dropsy after exposure to cold and wet. — Traces of albu-
men in the urine, slight throughout, finally disappeared. — Addicted to the occasional
use of spirits and opium. — Finally sunk under increasing asthenia. — Granular
degeneration of the kidneys. — Shaik Isood, a Mussidman horsekeeper, of eighteen years
of age, a native of Kattyawar, apparently somewhat weak in mind, and using opium
and spirits occasionally, was on the voyage to Bombay, two months before he came
under observation, for two days exposed to cold and wet. After this he began to suffer
from irregular febrile symptoms, generally commencing with chills, and the feet and

PATHOLOGY. 477

legs became swollen. On admission into the clinical ward on the 24th August, 1851,
tlie face was puffed, and there was some degree of oedema of the body and the extremi-
ties, but no swelling or fluctuation of abdomen. No signs or symptoms of pulmonic or
cardiac disease, or of enlargement of any abdominal viscus. The pulse was small, the
bowels confined, and the urine free. On the 26th the urine had been thirty ounces in
the preceding twenty-four hours, was of pale amber colour, neutral, and specific
gravity 1-015, and became slightly turbid, by heat and nitric acid. He was treated
with Dover's powder five grains, quinine two grains, ipecacuanha half a grain, every
fourth hour for four times. This was continued, with the occasional use of warm
baths, and one dose of castor-oil, till the 2nd September. There was generally
sweating after the bath, the febrile symptoms ceased to recur, the dropsy lessened.
The urine from thirty to fifty ounces, specific gravity I'Oll to 1*015, now showed a less
degree of turbidity under heat and nitric acid. The same treatment, with substitution
of six grains of nitre for the quinine, was continued tiU the 8th, when the dropsical
symptoms were gone, and the urine, unchanged in other respects, ceased to give traces
of albumen. The warm bath was stiU occasionally used, and fifteen mimims of the
tincture of the sesquichloride of iron was now substituted for the powders. He con-
tinued in the clinical ward till the 12th October, gaining strength slowly, but without
return of fever or of dropsical symptoms, and with the urine free of albumen. There
was occasionally turbidity by heat, but it disappeared with effervescence, on addition
of nitric acid. Latterly, ten minims of the compound tincture of iodine had been
added to the tincture of iron. From this date he continued in another ward of the
hospital, tin the 5th April, without any regular record of the symptoms. Then
imbecility of mind is noted, with occurrence of febrile disturbance, painful swelling of
the left lower extremity, and pain of loins. He was with difficulty persuaded to keep
his urine, which on the 11th was reported to be clear and high coloured, of specific
gra\^ty 1-020 and almost unaffected by heat, but showing a dark brown colour on ex-
cess of nitric acid. On the 15th, uneasiness of the cardiac region was complained of,
and the pidse was weak and irritable : no signs of cardiac disease were detected. He
now became affected with diarrhoea ; sank rapidly, and died on the 17th.

The inspection after death was made by Dr. Forbes Watson, the Curator of the
Museum, and the following note is abridged from his description.

Inspection. — Head. — On removing the scalp, a small ulcerous opening was detected
over the right parietal protuberance. Opposite to it the bone was absent for the space
of a circle an inch in diameter. The foramen was found to be filled with dense fibrous
tissue, about quarter of an inch in thickness, and adherent pretty firinly to the dura
mater. At this situation the brain felt less elastic, but did not present any abnormal
appearance. Chest. — Slight adhesions existed between the left pleural surfaces at
their lower part, biit otherwise no disease of the lungs. The heart was healthy.
Abdomen. — The liver rather increased in size ; the external surface rough, and the
surface of an incision mottled. The mucous membrane of the large intestine, and of
the ileum, about Peyer's glands, was more vascular than natural. The size of the kid-
neys is not noted. On removing their capsules, the surface was granular, and of brick-
red colour, and the texture was friable. These appearances were more remarkable in
the left kidney. A section showed encroachment of the cortical on the tubular portion,
and some fat was found in the pelvis, about the mammary processes. A portion of the
healthy tubular part adjoining the cortical was examined imder the microscope. The
tubuli were distinctly made out in several parts, but only an occasional fat molecule
detected. The cortical part showed multitudes of granular cells, and an occasional fat
granule.

214. — Dropsical symptoms with diarrhoea, following exposure to cold and wet.

Urine very albuminous. — Drowsiness co-existing with sinking pulse, removed by stimu-
lants, did not recur. — Death by exhaustion. — Kidneys large and granular. — Spirit
drinking not admitted, — AbdooUa, a Mussulman Lascar, of thirty-five years of age.

478 bright's disease op the kidney.

and in indigent circumstances, abstaining, according to his own statement, from the
use of opium and spirits. Three months before he came under treatment had suffered
from oedema of the feet, removed by the remedies used, and one month before his
admission on the 16th September, 1851, into the clinical ward, he, consequent on ex-
posure to wet and cold, became affected with diarrhoea, uneasiness of the right iliac
region and loins, oedema of the feet and scanty urine. On admission, he was con-
siderably reduced. The feet and legs were oedematous. The abdomen somewhat full,
but without fluctuation, No signs or symptoms of pulmonic disease. The impulse of
the heart was feeble, but the sounds normal. Hepatic dulness reached half an inch
below the the margin of the ribs. The pulse was small. The tongue clean but glazed.
The bowels relaxed. The urine scanty, high-coloured and very albuminous. He con-
tinued under treatment till the 23rd October, when he died. Throughout the diarrhoea,
with more or less abdominal uneasiness, persisted. From the 26th September, febrile
symptoms began to appear, and frequently recurred. On the 22nd September the
pulse became very small, and there was drowsiness, which, removed by stimulants,
did not again return. The urine, examined daily, was sometimes of brownish tint, at
others amber coloured. At first the quantity was below twenty ounces. After the
1st October it ranged from twenty to thirty ounces. The specific gravity was aiways
below 1-018. The albumen was throughout very copious, often filling half the tube,
and latterly there was some degree of bronchitis. He died exhausted, without coma.
He was treated with quinine and opium and stimulants.

Inspection seven hours after death. — Chest. — About one pint of senim was found in
the left, and half a pint in the right cavity of the pleura. The middle lobe of the
right lung was somewhat emphysematous, and firmly adherent to the costal pleura by
old adhesions. The rest of the lungs was healthy and crepitating, excepting the
upper part of the upper lobe of the left lung, which was compressed. Abdomen. —
About two pints of serous fluid were found in the cavity. Firm adhesions connected
the convex surface of the liver to the diaphragm. The peritoneal surface presented
generally an opaque appearance, and the surface of the viscus was of a yellowish (not
mottled) colour. The right lobe was larger than natural. When incised the surface
had also a general yellow colour, was not mottled, and had a smooth appearance. Its
texture was rather soft. The mucous membrane of the ileum was healthy. No
enlargement of Peyer's glands or ulceration anywhere. In the mucous membrane of
the large intestine, viz., part of the transverse, and the whole of the descending, colon,
the sigmoid flexure, and rectum, numerous small, circular, follicular ulcers were seen
scattered here and there ; some completely cicatrised and others in process of ciatrisa-
tion. No ulceration could be detected in the ascending colon or in the coecum. The
right kidney was very large ; it weighed six and a half ounces. When divested of its
capsule it presented a somewhat lobulated, granular surface, of a generally buff
colour, with small red patches here and there. When vertically incised, the cortical
portion presented also a buff mottled granular surface, encroaching upon the tubular
portion, chiefly at the central parts. The tubular portion, where not destroyed, was
distinct and of a reddish colour. The left kidney was similar in colour and appear-
ance to the right, both externally and when incised, but there was more of encroach-
ment upon the tubular portion by the buff granular cortical part. It weighed seven
ounces. Under the microscope a small portion scraped from the yellow granular sub-
stance showed an amorphous granular appearance. No oil globules.

215. Syphilis, primary and secondary. — Mercurial influence. — Slight dropsy. —
Albuminous urine, pain of loins, dysentery. — Fatal. — Bright' s disease. — Ulceration
and granular exudation on intestinal mucous membrane. — Cirrhosis. — A cretified gxunca-
worm encysted between the right lung and the pericardium. — Shaik-Hussain-Adam,
a Mussulman drummer, a native of Madras, of thirty-flve years of age, and using
spirits habitually to the extent of two ounces daily, suffered from primary syphilis, for

PATHOLOGY. 479

which he was salivated five years before he came under observation. From this time,
however, till six months ago, his health had been good ; then he experienced irregular
febrile accessions, with mnch pain of the limbs, particularly of the tibiae. For these
symptoms he was received into the hospital ; and while under treatment, orchitis
came on, the 21st June, 1853, relieved by leeches, succeeded on the 25th by pain of
loins and scanty urine, which on examination was found to be albuminous. He was
transferred to the clinical ward on the 28th. Eeduced in flesh, with oedema of the face
and feet, pulse of moderate volume and jerking ; no signs of cardiac disease, but bron-
chitic rales were audible in different parts of the chest. The liver was felt below the
ribs, and the spleen was enlarged. The pain of loins, testes, and joints continued. There
was slight heat of skin, with venous murmurs above the middle of the clavicles. The
appetite was impaired, and he vomited occasionally. On the 1st July the urine was
fourteen ounces, of light amber colour, and gave a deposit with heat and nitric acid.
Under the occasional use of the warm bath, infusion of chiretta and diluted nitric
acid, or the tincture of the sesquichloride of iron, there was lessening of the dropsical
symptoms and some degree of general improvement up to the 15th, when dysenteric
symptoms began to show themselves, and an abscess to form in the left natis,
associated with frequent febrile accessions. Under these complications he sank without
drowsiness, and died on the 27th July. The vomiting had been troublesome
throughout. The urine had ranged from sixteen to thirty-eight ounces, specific gravity,
1-007 to 1-012, and was always albuminous.

Inspection nineteen hours after death. — There was not any effusion into the sac
of the peritoneum. The kidneys weighed about four ounces each. The external
surface was mottled red and white. The cortical portion encroached upon the tubular,
and the latter was in some places indistinct, and in others spread out and ex-
panded- The liver weighed 2 lb. 6 oz. There was much atrophy of the left lobe, and
the external sm-face had an irregular puckered aspect. The mucous membrane of the
end of the ileum ascending, transverse, descending colon and rectum presented a
mottled brown and red granular appearance. There was extensive sloughy ulceration
of the mucous membrane of the ccecum, and the tissue around was dark red, almost
black in colour. Peyer's glands were not enlarged. The pleural and pericardial sacs
were free of effusion. The lungs were crepitating but did not collapse. Between the
inner surface of the middle lobe of the right lung and the pericardium, and connected
to both by areolar tissue, there was an indurated tubular-looking body about three
inches long, and much convoluted at one end. It resembled a guinea-worm. The
large bronchial tubes contained frothy mucus, and their lining membrane was vascu-
lar. There was congestion of the left lung. The heart was abnormally small —
concentric h^^Dertrophy of the left ventricle — no disease of the valves.

BemarJc. — The cretified guinea- worm, situated between the lung and pericardium,
is of interest. It is not unusual to find them in this state in subcutaneous areolar
tissue in the dissecting-room of Grant Medical College.

216. Dysentery, dropsy. — Albuminous urine, with fai globules, in an old spirit
drinker and opium eater. — Fatal. — Ulcerated intestines. — Kidneys enlarged. — Fatty
degeneration. — ^Baldeen Pectum, aged sixty, a Hindoo barber, a native of Lucknow,
and residing for the last twenty years in Bombay, drinking spirits freely in his early
youth, and using opium occasionally in more advanced age, became affected with
diarrhoea six months, followed by scanty urine and dropsical symptoms one month,
before admission into hospital, on the 27th September, 1853. He was emaciated. The
countenance was anxious and puffed. The upper and lower extremities were oedema-
tous. The abdomen resistant, and uneasy on pressure in the course of the colon. The
diarrhoea persisted. Had cough, but no signs of cardiac, disease. The pidse was
hardly perceptible and the skin coldish. On the 2nd eight ounces of urine of light
amber colour, and specific gravity 1-010, gave a copious white precipitate by heat and

480 bright's disease of the kidney.

nitric acid. He continued to sink under the diari'hcea, and died on the 8th October
•without coma. The urine continued albuminous and scanty, and showed epithelial
cells and abundant fat globules under the microscope.

Post mortem examination three hours after death. — Body emaciated. Chest. —
There were firm old adhesions of the lungs on both sides all around. The right lung
was very oedematous, in parts hepatised, and broke down under the fingers. The left
lung was spongy and crepitating. There was about an ounce of fluid in the cavity of
the pericardium. Heart diminished in size. The cavities were contracted and the
valves healthy. On the anterior surface of the right ventricle there was an opaque,
white, membranous patch the size of quarter of a rupee. Abdomen. — There
were about eight ounces of turbid serum in the cavity of the abdomen. The in-
testines collapsed. The peritoneal surface of the intestines had an opalescent ap-
pearance ; but no trace of inflammation was observed on the peritoneal surface of the
anterior wall of the abdomen. There were large ulcerated patches here and there on
the mucous membrane of the large intestine, evidently consequent on the separation of
sloughs. About a foot of the mucous membrane of the ascending portion, and the
commencement of the transverse colon, was in a dark grey and sloughy state. Similar
disease was observed in the ccecum and also at the end of the rectum. There was
redness of the mucous membrane of the ileum, as well as other parts of the small in-
testine; but no softening or ulceration observed. The stomach was distended,
reached across the abdomen into the right hypochondriac region, and occupied half the
space between the margins of the right false ribs and the right crest of the ileum. The
mucous membrane of the stomach was healthy. The liver was not enlarged. It was
of a dark brown colour both externally and internally. The right kidney weighed
eleven ounces ; externally it was of a pale yellow colour and lobidated ; when incised,
the surface presented, for the most part, a pale yellow granular appearance ; the tubular
portion had disappeared, except at the ends of the kidney, where there remained two
or three bundles of bright red colour. The left kidney weighed nine ounces, and the
morbid appearance was the same as that of the right kidney, with the exception of the
tubular portion, which was more abundant and still present in the body of the organ.
The scrapings of the surface, placed under the microscope, showed epithelial cells
abounding with fat globides, similar to those observed two days before death in the
urine. The spleen was somewhat increased in size, and the structure was found to be
firm and hard on incising it.

217. Dropsy. — Albuminous urine. — Death from dysenteric symptoms. — Kidneys en-
larged^ with fatty degeneration. — Redness in patches of the intestinal mucou^s lining. —
Habits not ^woww.— Chimajee, a Hindoo horsekeeper, of thirty years of age, and of
whose habits there is no note, after two months' illness, was admitted into hospital on
the 4th June, 1852. The face was puffed, the feet and legs oedematous, and the abdo-
men tumid and fluctuating. He also suffered from febrile symptoms. The urine was
scanty, of specific gravity 1*017, and gave a copious flocculent deposit with heat and
nitric acid. It was tested several times and always found to be albuminous. He be-
came affected with diarrhoea, lost strength rapidly, and died on the 17th June, without
head symptoms.

Inspection thirteen hours after death by Mr. Carvalho. — Chest. — Both lungs were
collapsed. The whole of the middle lobe of the right lung and the posterior part of
the first and third lobes were in a state of red hepatisation and easily lacerable.
There was congestion of the posterior parts of the left lung, but no hepatisation. The
heart was normal in size and structure. Abdomen. — The liver was about the natural
size and of normal structure. The mucous membrane of the lower end of the ileum,
and of the whole of the colon, was of dark grey colour, with streaked patches of redness
here and there, chiefly at the end of the ileum and rectum. No ulceration, thickening,
gr enlargement of the follicles. Both kidneys were considerably enlarged. The

PATHOLOGY. 481

right weighed eleven and a half ounces, the left eleven, when denuded of their
capsules. Both, when incised, presented a similar appearance. The cortical substance
was found considenihly augmented, pale yellow, fatty-looking, and encroaching
much on the tubular structure which was of reddish colour. Under a cursory
examination with the microscope numerous fat globules were apparent. The spleen
was somewhat enlarged in size.

Under the continuance of Bright's disease, the quality of the
blood is changed. The albumen and the red corpuscles decrease,
the water increases, and an excess of urea is present. The urine
may be defective, normal, or increased in quantity; and may
contain varying proportions of albumen, be deficient in urea, and
of diminished density.

Dropsy is of frequent occurrence. Some degree of anasarca and
ascites was present in forty-six of my cases. The effusion may
take place under two sets of circumstances. 1. In the early
stages of the disease, while yet there is no deficiency of blood in
the system, from the decided application of cold to the sur-
face of the body. 2. In advanced stages, when cachexia is
apparent, the blood watery, and all the actions of the system
manifestly enfeebled. The occurrence of dropsy in these latter
conditions is also very generally favoured by abstraction of heat
from the surface of the body. My cases chiefly, though not
exclusively, illustrate this second form.

In estimating the relation of dropsy to Bright's disease, we must
not lose sight of the fact, that the structural changes throughout a
considerable part of their progress are unattended by this symptom.
Cases observed by me in the European Greneral Hospital and re-
ported in the chapters on Fever, Dysentery, and Hepatitis, con-
firm this truth.

The relation of Bright's disease to head symptoms — drowsiness,
coma, convulsion — has been much dwelt upon by all observers in
European countries, and is supposed to substantiate a pathological
theory.

Head symptoms — drowsiness, or coma — were present in eight
of my cases. In four * there was general exhaustion sufficient to
explain these symptoms. In one (214) the drowsiness was not at
the close of the disease, but some days previously, associated with
failing pulse, and removed by stimulants. In two there were febrile
symptoms of that kind, which not unfrequently lead to drowsiness
and coma, irrespective of kidney disease. In one (203) there was
complication of heart disease to which the head symptoms were as
fairly chargeable as to the affection of the kidn^.

* Of these, three, 208, 209, 212, are detailed.
I I

482

Nor do my cases confirm the opinion, that when head symptoms
take place, they may be explained by the existence of intercranial
serous effusion. I have already shown* that increased serous
effusion in the cranium, without head symptoms, is a common
occurrence in India ; and of my twenty post-mortem examinations
of Bright's disease, there are three (204, 205, 207) in which
increased intercranial effusion existed without head symptoms.

The relation of Bright's disease to structural change of the
heart J has also been much insisted • on. Not only has valvular
disease been observed, but hypertrophy of the left ventricle f,
without affection of the valves or of the aorta, has also been
noticed, and regarded in the theoretic pathology of this disease.
Complication of cardiac disease existed in six of my cases, and
in one the aorta alone was affected. In two J of the six cases
there was aortic disease, but the subject of one had followed the
occupation of a diver, and the heart affection, more particularly
the dilatation of the right ventricle, was probably as much due to
this as to the aortic lesion. In one (210) of the six cases, there
were old pericardial adhesions, and considerable emphysema of the
lungs. In three there was disease of the mitral valve, and the
subjects of two had formerly suffered from rheumatism. I have
not met with a single instance of simple hypertrophy of the left
ventricle. My observations, then, do not show a very frequent or
evident relation between cardiac and renal disease ; and a similar
inference may be drawn from the facts stated by me in a subse-
quent chapter on pericarditis and organic affections of the heart.
As bearing on this question, I would refer to two of my cases, in
which an anaemic cardiac murmur was present. That this S3rmp-
tom should occasionally occur in a disease characterised by deterio-
rated blood is very probable, and the fact suggests a caution lest
ansemic be mistaken for organic murmur ; an error the more likely
to arise when the mind of the observer is fully preoccupied with
the idea, that disease of the heart is a very frequent sequence of
Bright's disease of the kidney.

Various other secondary affections have been observed in the
course of this disease — as pleuritis §, pericarditis, bronchitis,

* Chapter on Eemittent Fever, p. 90.

t Dr. Bright, in the First Volume of Guy's Hospital Eeports, records this state of
22 cases in 100.

X Cases 203, 208,

§ The relation of puriform pleuritis and peritonitis, secondary on hepatic abscess,
to the cachexia of Bright's disease, has been already suggested in the chapter on He-
patitis, p. 359.

PATHOLOGY. 483

pneumonia, peritonitis, cirrhosis, diarrhoea, and dyspeptic symp-
toms. Of all these, occasional instances have come under my
notice.

The morbid actions in the kidney which lead to disorganisation
by deposits internal or external to the tubuli, and their ulterior
changes, may be fairly attributed to a degenerate state of the pro-
cesses by which constituents of the blood, in the renal capillaries,
are assimilated to tissue, or appropriated to secretion. This
abnormal action may be dependent on a pre-existing altered con-
dition of the blood, the precise nature of which is unknown, but
which forms part of those states of the system to which the
terms ^' asthenic " and " cachectic " are applied. The morbid
changes in the kidney will doubtless be favoured by the capillary
circulation becoming the seat of inflammation. It is very pro-
bable that, when the structural lesion has taken place apart
from well-marked cachexia, inflammatory action has been an
operative condition.

The opinion that the organic change of the kidney is the result
of a blood-poison seeking for local elimination, is altogether
hypothetical, and hardly accordant with the fact of relation to
various and different cachectic conditions which even a toxoemic
theory of disease must attribute to separate poisons.

That the dropsical, cerebral, cardiac, and other secondary affec-
tions are dependent upon uramiia, is another favourite pathological
theory. It is sufficiently plausible, and may ultimately prove
correct ; but I cannot avoid the conclusion, that it has been in-
ferred from very insufficient premises, and too hastily and generally
adopted. It may be admitted that when a part of the secreting
structure of the kidney has become unfit, excess of urea in the
blood, and defect in the urine, are probable sequences ; but at the
same time it should be borne in mind, that when an important
organ becomes gradually unfit for function, then all the other
actions of the system gradually harmonise with this defect. The
lungs slowly unfitted by tubercular deposit, or the liver by cirr-
hosis, does not lead to excess of carbonic acid, or oi bile in the blood,
but to an anaemic state of the general system. The blood is by
degrees reduced to the quantity which these imperfect organs are
capable of depurating. For a similar reason, when the kidney
becomes gradually disabled, it follows that there will be defect of
urea in the urine, but by no means, necessarily, excess of this
excretion in the blood. On the contrary, the inference from
analogy is, not that there will be excess of urea in the blood,

I I 2

484 biiight's disease of the kidney.

but that the blood will be brought down to that quantity which
the kidney is competent to purify.

But chemistry has detected urea in excess in the blood in
Bright's disease. On this point the questions may be put : (a) what
proportion do the cases, in which the blood has been analysed by
competent inquirers, bear to the total number of cases of Bright's
disease which have been clinically studied? (6) Has care been
taken, in selecting cases for analysis, to discriminate the recent
from the advanced, the rapidly from the slowly-occurring struc-
tural lesions? (c) There are cachectic states from malaria, scurvy,
mercury, syphilis, insufficient food, &c., in which the secondary
affections, noted in Bright's disease, also occur. What amount of
information do we possess in respect to the proportion of urea in the
blood and in the urine, in these varied and frequently-occarring
conditions? (cl) Moreover, the cerebral and dropsical symptoms
do not usually take place in chronic cases till the advanced
stages of the renal affection have arrived. When dropsy occurs
earlier, it, as well as many of the other secondary phenomena, may
be removed by treatment and remain absent for months or years.
Yet all this time the urine is albuminous, and in theory there is
uraemia, but why is the poison quiescent ?

Frerichs, appreciating this latter difficulty in regard to the
secondary nervous affections, has propounded the theory that urea
does not, while in that state, exercise a poisonous influence, but
only after decomposition and formation into carbonate of am-
monia. This theory, to be good for anything, will require to be
extended in its application to all the other secondary affections
which pathologists have, equally with the head symptoms, attri-
buted to uraemia.

It is consequent on reflections such as these that I have ven-
tured to suggest that the ursemic theory of the secondary affec-
tions of Bright's disease has been too hastily adopted, and on data
altogether insufficient for the logical affirmation of an important
pathological doctrine.

The facts as they now stand relative to the kidney-degeneration
itself, and the secondary affections which attend on it, seem to
me merely to afford another illustration of that general law on
which I have already so frequently insisted, viz., that structures
in cachectic states are apt to be injured and unfitted for function
by degenerate processes of assimilation ; and that, when this occurs
in an important organ, the effect must be to aggravate the cachexia
by reducing the blood and the actions dependent on it to a degree

PATHOLOGY. 485

proportionate to the impairment of the organ. Further, that in
cachectic states, various secondary affections are apt to arise, under
the influence of slight, sometimes even without appreciable, ex-
citing causes.*

That special structural changes may, at some future time, be
proved to be related to special cachexiae is very probable ; but this
advance in science can only be achieved by time and a far more ex-
tended range of investigation than has as yet been applied to these
subjects. The hasty generalisations, too characteristic of patho-
logical inquiry of late years, serve to retard sure and steady pro-
gress, and to detract from the philosophy of medical research.

Having in view, in the remarks which have just been concluded,
the ursemic doctrines which have been applied to the pathology
of the secondary affections of Bright's disease, I have confined my
observations to the supposed alteration of the blood in respect to
the proportion of urea; but the blood is also said to be defec-
tive in its proportion of albumen, in the ratio of the excess
of the albumen in the urine, (a) It may perhaps be inquired
whether, in thus relating the loss of albumen in the blood to
the gain of albumen in the urine, sufficient attention has been
given, in the cases submitted to analysis, to the fact of presence or
absence of dropsical effusion ; for surely when dropsy is present,
deficiency of albumen in the blood may more fairly be attributed
to its presence in the effusion than to its transudation into the
urine. (6) Again, is it not likely that deficiency of albumen in the
blood will be found equally characteristic of other dropsies as of
renal dropsy ? (c) Further, is it not probable that much of the
deficiency of albumen in the blood may be attributable to the co-
existing anaemic state ? (<i) In a word, pathologists in explaining a
defect of albumen in the blood in Bright's disease, seem to lay

* That when an important organ is structurally unfit, the eo- existing cachexia may
favour one secondary affection rather than another, is very true and very intel-
ligible. In malarious and scorbutic cachexise, secondary dysentery or dropsy are
sufficiently common, but when certain structural changes of the liver co-exist, there is
still greater liability to secondary dysentery and ascites, in consequence of the obstruc-
tion to the portal circulation. When heart disease co-exists with cachexia, general
dropsical effiisions more certainly take place. When we recollect the function of the
kidney in regulating the proportion of water in the blood, there need be no difficulty
in understanding why a cachexia, attended with certain structural changes of this
organ, should have more of secondary dropsical affections than cachexise unassociated
with this structural change ; but I am unable to appreciate the necessity of calling in
the aid of a special toxoemia, in explanation of the dropsy of Bright's disease, more
than in that of the many other pathological states with whieh this symptom is also
often associated. I shall have to return to the subject of dropsy in a subsequent chap-
ter, which may be considered in reference to my observations now made.

I I 3

486 bright's disease of the kidney.

chief weight upon one event — albumen in the urine — to the
exclusion of other co-efficient events — dropsical effusion, and
general anaemia.

The supposed accordance of the latest theory of urinary secre-
tion, and albumen in the urine in Bright's disease, is certainly not
exempt from difficulty and doubt. In regard to normal secretion
it is assumed that the peculiar arrangement of the capillaries of
the Malpighian bodies leads to an abrupt retardation in the velo-
city of the current of the blood passing through them ; by which,
and by the aid of cilia, facility is given to the escape, by transuda-
tion, of the water of the blood from the Malpighian capillaries. It
escapes without albumen. In regard to the presence of albumen
in Bright's disease, it is argued that defect of the processes be-
tween the blood external to, and the epithelial cells internal to,
the cortical tubuli, leads to retardation of the blood in the Mal-
pighian bodies behind ; hence transudation of the serum of the
blood takes place, just as obtains in a dropsical effusion from
venous obstruction. We are further told that after a time under
this deranged action the walls of the Malpighian capillaries be-
come thickened.* In the early stages of the disease when the
urine is scanty, and the Malpighian capillaries, we may assume, as
yet unthickened, this explanation of the proximate cause of albu-
men in the urine is perhaps satisfactory. But when we refer to
the advanced stages, when the urine is more than normal in quan-
tity, and the walls of the Malpighian capillaries are said to be
thickened, the explanation fails to convince, for it is not in accord-
ance with the theory of normal secretion. In Bright's disease
with excess of urine there must be a continuous current through
the capillaries as in the healthy state; but in the latter we have a
condition of the capillary walls more favourable to transudation,
yet the albumen is retained, and only transudes when the condi-
tion of the capillary Avails is, from hypertrophy, less favourable for
the process. It seems to me, however, that this difficulty rather
invalidates Mr. Bowman's theory of the function of the Malpighian
bodies than the explanation of the albuminous urine ; for in order
to complete the theory of urinary secretion, advanced by this dis-
tinguished physiologist, is it not necessary to show some reason
why, under circumstances described as so favourable to transuda-
tion, the albumen is retained during the process which is supposed
to take place normally in the Malpighian capillaries? Is there

* "On the Diseases of the Kidney :" London, 1852. By George Johnson, M.D.,
p. 240.

CAUSES — PREDISPOSINa AND EXCITINa.

4{8:7\

any other instance of free transudation, tlirough thin capillary-
walls, in which the water of the blood is not accompanied by a
portion of the albumen ?

Section III. — Etiology. — Scarlatina not influential in India, —
Relation to Caste, Age, Occupation, Habits, Season. — Cold
an exciting cause sometimes of the Kidney Disease, gener-
ally of the Secondary Affections.

The frequent occurrence of dropsy, with albuminous urine, during
convalescence from scarlatina, and the history of occasional cases of
Bright's disease in European countries, have suggested the idea
that scarlatina may be related, as a cause, to Bright's disease.
This may be true of these countries, but it cannot be of India ; for
I have elsewhere * stated that there, scarlatina, if not altogether
unknown, is undoubtedly very rare.

The native population of Bombay is very varied and fluctuating,
and includes all castes, and the inhabitants of different and widely
separated countries. This is well shown in the following classi-
fication of my fifty-eight cases of Bright's disease.

Hindoos, 19 — natives of the following districts : —

Bombay

Mooltan

. 1

Concan

Benares . . . . 1

Deccan

Lucknow . . . . 1

Cutch

Country not stated . . 7

Jeypoor

Mmsulmatis, 22 — from

Bombay

Scinde .... 2

Concan

Mooltan

Deccan

Khorassan

Cutch

Lucknow

Kattywar .

Cabool

Guzerat

Arabia

Bengal

Africa

Madras

Not stated

Parsecs, 8 — from Bombay

and Siirat.

Christians, 9— chiefly Portuguese,

from (

jroa.

From this statement it is evident, that the frequency of Bright's
disease in Bombay is not attributable to the influence on the
native resident population, of the example of the lower classes of
Europeans who frequent the port. It rather justifies the belief
that further inquiry will show that this disease prevails in certain
classes of the varied tribes and natives of Asia and Africa, as
well as of Europe.

* Chapter on Eruptive Fevers, p. 199.
I I 4

488

BRIGHTS DISEASE OF THE KIDNEY.

The ratio per cent, of these fifty-eight cases in the different
castes stands thus : —

Mussulmans 36-9 per cent.

Hindoos 327 „

Christians 15-5 „

Parsees .^ 13*2 ,,

But in order to determine whether these data suggest the pro-
bability of a greater prevalence in one caste than another, it is
necessary to show the ratio of the hospital admissions of these
castes. It is as follows : —

Hindoos 33-9 per cent.

Mussulmans 28*9 „

Christians 16-2 „

Parsees . . . . . . .6-8 „

On comparing these two ratios we find that they show the great-
est proclivity to Bright's disease in Parsees and Mussulmans. In
the ratio of castes to the hospital admissions, females are not
included ; but the women of all castes are 14 per cent. ; and of
the fifty-eight pases of Bright's disease, two were females, which
is 3*4 per cent. But these data do not justify any inference
relative to sex, because my clinical researches were pursued chiefly
in the male wards of the hospital.

In classifying my casies with reference to age, occupations, habits,
and season, the following results appear : —

From 15 to 20
„ 21 „ 30
., 31 „ 40
„ 41 „ 50
„ 51 „ 60

Not stated

3
27
16
8
2
2

OCCUPATIONS.

Baker . • .

Barbers

Beggars

Cooks .

Coachmen

Diver

Hakeems

House painter

Labourers

. 7

Liquor sellers

Pilgrims 3

Sailors . . . . . .6

Sen^ants 2

Sepoys 2

Shopkeepers 2

Weavers
"Writers
Women
Not stated

2
2
2

CAUSES — PREDISrOSINa AND EXCITING.

489

Spirit drinkers

Opium eaters

Ganja smokers.

Spirit drinkers and opium eaters

Spirit drinkers and ganja smokers

20
4

4
7
2

Spirits, opium, and ganja

Not stated

Denied use of spirits or narcotics

11
9

January-
February
March .
April .
May .
June .
July .

MONTHS OF ADMISSION.

2
2
2

2
4

August .

September

October

. 16
11

November

• . 4

December

The bearing of these facts on the etiology of Bright's disease
may be thus stated : —

1. The great number, forty-three, between the ages of twenty-one
and forty, is consistent with the opinion, that intemperate habits
are influential. 2. Seventeen occupations are named, but twenty-
nine of the cases are comprised under four, viz. : cooks, coachmen,
labourers, and sailors, all of which, more or less, involve exposure
to alternations of heat, cold, and wet, and imply habits usually more
or less intemperate. 3. The habits of only thirty-eight are stated,
but in these, the use of spirits, opium, or ganja, singly or com-
bined, is acknowledged. 4. Twenty-seven were admitted in
September and October, months in which neither cold nor wet
are influential as excitinoj causes of disease. But considerinof that
a very large proportion were not residents of Bombay, and that all
were admitted in advanced stages of the disease, the period of
admission into hospital has no bearing on the etiology. September
and October, the months immediately succeeding the rainy season,
are those in which the influx of strangers is great, and to this cir-
cumstance the large number of admissions in these months is
doubtless attributable.

The inference from my cases is, that there exists a relation
between structural degeneration of the kidney, and the cachectic
states induced by the habitual use of spirits and narcotics.

They however afford no evidence of the influence of syphilis in
causing Bright's disease, because though a syphilitic taint is re-
corded of eleven cases, they all, with two exceptions, are also
included in the list of spirit drinkers, opium eaters, or smokers of
ganja.

Malaria is a fertile source of cachexia in India, and conduces.

490 biugiit's disease of the kidney.

as we have already found, to degeneration of structure in the liver
and spleen. It is interesting to inquire whether this influence is
also exercised on the kidney. It is difficult to separate the effects
of malaria from the other causes already named, for they are often
combined together. It is, therefore, sufficient to note, that, in
nineteen of the fifty-eight cases, the influence of malaria on
the system is clearly recorded.

That inflammation, though by no means essential, is often oper-
ative in producing the structural lesions of this disease, is probably
true. If so, we may expect occasional evidence of the ordinary
exciting causes of inflammation acting as the exciting causes of
Bright's disease. Therefore, we can be at no loss in understanding
how this disease may, in some instances, be clearly traceable to the
influence of external cold. Indeed, the functional relation of the
skin and the kidney might lead us to anticipate that interruption
of the actions of the former (more particularly if previously dis-
ordered), by reduction of its temperature, may be followed by
inflammation or other derangement of the latter.

So much, then, in regard to the causes of the renal disease.
We have next to inquire into those of the secondary affections. I
shall not again advert to the question of uraemia; for I have
already expressed my opinion that it ought to be regarded as still
sub judice ; the more so, as the phenomena of the disease are, for
practical purposes, sufficiently explainable on certain general well-
understood pathological principles. That a more intimate know-
ledge of deranged actions ought to be earnestly sought for, is not
denied ; but a practical art, such as medicine, is as likely to be
damaged, as advanced, by uncertain science ; and it is therefore
well not to set aside useful and safe, though incomplete principles,
for others which, though full of promise, are still hypothetical, and
may lead us into errors of practice.

In the cachectic state, associated with Bright's disease, there is
ample explanation of the predisposition which exists in the system
to become affected with inflammatory and other forms of disease.
In this cachectic state, as in others, of which I have previously
treated, the deranged actions a-re very generally excited by the
application of external cold to the surface of the body. In regard-
ing cold as an exciting cause of the secondary affections of Bright's
disease, we must remember the lessened capacity for the generation
of animal heat in cachectic states ; and wlien our inquiry has
reference to tropical countries, we have also to recollect the relation
of heat- generating power to climatic temperature. Further, in

SYMPTOMS. 491

respect to the class of individuals from which my experience in
Bright's disease has been chiefly derived, there is, in inadequate
clothing and insufficient habitations, another circumstance favour-
able to the abstraction of heat from the surface of the body. On
referring to my cases for confirmation of the influence of cold as an
exciting cause, I find that the dropsy has been attributed to cold or
wet by the patients themselves in seven instances, and that it
occurred in sixteen others at times when the heat-abstracting
conditions of the cold or rainy season were operative.

Section IV. — Symptoms. — Referable to the Kidney. — Condi-
tion of the Urine. — Treatment — Of the Kidney Disease. —
Of the Secondary Affections, chiefly the Dropsical Effusions.

Symfiptoms. — In cases in which the scanty, high-coloured, and
very albuminous character of the urine rendered probable the
existence of preternatural, inflammatory, or other afllux of blood
to the kidneys, this inference has been further confirmed by the
presence of more or less uneasiness in the lumbar region, with
sometimes nausea and vomiting. But in the large proportion of
my own observations this has not been the character of the urine,
and pain of loins has not been a common symptom.

The disease has generally been indicated in my cases by the
occurrence of dropsy in cachectic individuals, suggesting inquiry
into the state of the urine. In order to the detection of this
disease, the safe practical rule is, that in all asthenic or cachectic
states — whether simple or complicated — we ought to search for
Bright's disease of the kidney by examining the urine, just as in all
cases of rheumatism and of idiopathic fever we search for peri-
carditis and pneumonia by percussion and auscultation. Indeed,
I have previously remarked that in asthenic and cachectic states
the clinical rule should be invariably observed of determining,
by the application of all the diagnostic means at our command,
the presence or absence of local disease ; for, without this pre-
liminary step, the prognosis will be needlessly uncertain, and the
treatment vacillating and unsafe. My present remark, in re-
ference to Bright's disease, is merely an application of this
general rule.

In all the cases in which the urine was carefully examined, its
albuminous character and low density have been well marked. It
has been, for the most part, of pale amber or lemon colour, clear

492 brigiit's disease of the kidney.

and neutral, varying in specific gravity from 1*003 to 1-018.* In
quantity it has generally ranged from twenty to forty ounces in
the twenty-four hours ; and in cases beyond these limits it has
more frequently exceeded forty ounces than fallen short of twenty.
My earlier cases occurred before much attention had been given to
the microscopic character of the urine ; but in the later ones the
characteristic tube casts, epithelial debris, and oil globules, were
frequently observed.

Treatment — The treatment resolves itself into that which is
appropriate for the disease of the kidney, and that which conduces
best to the removal of the several secondary affections.

When uneasiness of the loins, scanty, very albuminous, and
high-coloured urine, indicate excess of blood in the kidney, then
local depletion from the loins by cupping or leeches, the use of the
warm water, vapour, or hot air bath, the removal of constipation,
and confinement to bed, are appropriate and efficacious means of
cure. When the state of constitution is such as to contra-indicate
loss of blood, much diaphoresis, or other evacuation, then dry
cupping, a moderated use of baths, and a greater attention to warm
clothing, is the modification of treatment required. By these
means the lumbar uneasiness will disappear, and the urine will
gradually become more copious and of lighter colour. The per-
sistence or not of albumen will depend upon whether the excess of
blood has been in a kidney previously healthy, or affected with
structural degeneration.

In cases in which freedom from lumbar pain, and a flow of pale
urine, of normal or increased quantity, point to the absence of ex-
cess of blood in the kidneys ; but in which the presence of albumen
and a low specific gravity of the urine, generally with a co- existing
cachectic state, prove the existence of structural degeneration, the
indication of cure as respects the kidney, is to promote, moderately,
the function of the skin by great attention to clothing, and to en-
deavour to lessen the general cachexia by well-adjusted tonic
regimen and remedies. The cases observed by me have been
chiefly of this nature, and the remedies which have seemed to me
most efficacious, have been preparations of iron, combined with
quinine, in instances in which the influence of malaria was sus-
pected.

* The specific gravities are noted as observed witli a urinometer, graduated for a
temperature of 60°. These observations have been made at a mean temperature of
about 80° ; and may be sufficiently corrected by an addition of 2° to each specific
gravity.

TREATMENT. 493

Though by this course of treatment we can hardly hope to remove
the structural degeneration when fairly established, yet we may
expect to check its progress, and lessen the predisposition to attacks
of the secondary affections. Moreover, though we may not be
sanguine enough to anticipate the restoration of structures already
degenerate and changed ; still there is surely no more likely method
of effecting an object so desirable, than by that regimen and those
remedies which tend best to re-induce normal assimilation to blood
and to tissue.

In noticing the treatment of the secondary affections, I shall
consider first the dropsical effusions, as being the most frequent,
and perhaps the most important, of them. When dropsy comes on
early in the disease, it is generally accompanied with the symptoms
which indicate excess of blood in the kidney, and will be best
removed by the means already recommended as most appropriate
for this state, viz., local blood-letting, the warm or vapour bath,
attention to the bowels, and confinement to bed. When dropsy,
as is most frequently the case, occurs in the more advanced stages
of the disease associated with a cachectic state, and not characterised
by scanty iirine and lumbar uneasiness, then the following rules of
practice may be observed : —

1. Attention to the functions of the skin by warm clothing, and
the occasional use of the warm bath, is a ruling indication in the
management of all the forms of dropsy.

2. When the effusions, from situation or degree, are not of a
nature to interfere much with the functions of important organs —
as the lungs, the heart, or the kidneys themselves — the treatment
of the dropsy simply resolves itself into that adjustment of regimen
and tonic remedies, which is most likely to ameliorate the nutritive
condition of the blood. With improvement in the general system,
the dropsical effusion will disappear.

3. When the dropsy, from situation or extent, interferes with the
functions of important organs, the reduction of the effused fluid
by evacuation from the blood becomes an important indication
in the treatment. The channel of elimination must be selected
according to the circumstances of individual cases.

4. When there is no evidence of gastro-intestinal irritation, eva-
cuation by purgatives holds out the greatest prospect of speedy
relief — bitartrate of potass combined with jalap or gamboge, and
elaterium, are the most useful remedies of this class. In asthenic
states, complicated with dropsy, purgatives may probably be given
to a degree which would be unsafe in similar states of constitution

494 imiGIIT's DISEASE OF THE KIDNEY.

unattended by dropsy, because the efifusion is a ready source 6
supply to the blood of that fluid which has been eliminated from
the intestinal surface.* But risk from the use of purgatives in
the dropsy of Bright's disease rests on the fact of the proclivity
which obtains in this, as in all other cachectic states, to muco-
enteritis, from the application of irritants to the mucous sur-
face. This difficulty is very likely to arise in tropical countries,
and in my own practice it has proved very generally obstructive to
the use of this class of remedies.

5. When purgatives are contra-indicated, then we may select
between evacuation by diaphoresis or diuresis. If there be no con-
gestion of the kidney to remove, I doubt whether much will be
gained by evacuation by the skin. Indeed, in those cases of dropsy
with renal congestion, in which determination to the skin in general
acts so beneficially, the good effected is not by diaphoresis, but by
the restoration of improved circulation and secretion in the kidney
itself. The frequent use of the warm bath must tend to increase
the cachexia ; therefore, in the kind of cases of which I now treat,
diaphoresis, beyond that which is involved in my first rule, is
inexpedient.

6. When there are no symptoms of excess of blood in the kidneys,
when purgatives are contra-indicated, when the dropsical symptoms
are such as to call for speedy removal, — then we must use com-
binations of diuretics, as the acetate of potass, with tincture of
squilJs and of digitalis, and spiritus setheris nitrici. The addition
of the potassio-tartrate, or other salt of iron, or of quinine, is often
very useful. When the state of the constitution suggests the use
of stimulants, the sesquicarbonate of ammonia may with advantage
be substituted for the acetate of potass.

7. I have already said that, when the dropsy is not present to
that extent which interferes with important functions, evacua-
tion from the blood is not required ; for the effusions will disap-
pear under attention to the state of the skin, and improvement in
the condition of the general system. And it may now be added,
that when, under these circumstances, the intestinal discharges
and the quantity of urine are adequate, we are likely to do harm
by the use of evacuant remedies, for they tend to increase the
asthenia.

* In the chapter on Peritonitis I hare narrated a case (197) in which cholera came
on in the course of Bright's disease, with dropsj^, and in which I attributed the slow
course of the cholera to the fact that the loss to the hlood by intestinal discharges was
supplied from the fluid of the dropsical effusions.

TREATMENT. 495

8. While appropriate evacuants are being used in those cases in
which the degree of the dropsy calls for reduction by evacuation,
great attention must, at the same time, be given to the regimen,
and to the tonic or stimulant remedies, which may be indicated for
the correction of the diathesis. Success in the treatment of such
cases will be commensurate with the skill and steadiness with
which these two indications are simultaneously carried out.

It is unnecessary to explain the details of treatment of the
secondary infiammations in Bright's disease. They must be con-
ducted with reference to the state of the constitution, the improve-
ment of which must also be kept in view as a leading indication in
the management of the case. Hence the great importance of
ascertaining, in respect to all asthenic inflammations, whether they
are co-existent or not with structural degeneration of the kidney.
The only secondary inflammation which I shall notice, in conse-
quence of the frequency of its occurrence in India, is dysentery.
The treatment must be conducted in accordance with those princi-
ples Tfhich I have already elsewhere so fully explained, combined
with much attention to warmth of the surface of the body.

To conclude. In Bright's disease, as in other structural degenera-
tions, for the restoration of which the powers of the animal system
are inadequate, we have impressed upon us the importance of care-
ful inquiry into the causes, with the view of preventing their action.
It is thus, in respect to these forms of disease, that we shall best
apply the resources of medical science in prolonging life.

It may seem that by making no reference in my remarks on
treatment to the ursemic theory, and the therapeutic principles
which it naturally suggests, the value of medical art has not been
fully appreciated. I would, therefore, on this question of practice,
express my belief that, in the present state of the science, the only
conditions which justify the use of eliminant remedies are excess of
vascular action, adequate amount of blood and diminished excre-
tion ; and that the eliminant should be selected with reference to
the excretion which is most markedly defective.

Some degree of asthenia or cachexia is always present in the
chronic forms of disease supposed to be dependent on an abnormal
materies in the blood ; and attention to the amount and variety of
elimination which is involved in a well-adjusted tonic regimen,
holds out, it seems to me, a better and a safer prospect of benefit
from the therapeutic principle in question, than the empiric use of
special eliminant medicines. A well-adjusted tonic regimen im-
plies a just attention to pulmonary, cutaneous, alvine, and urinary

496 BRIG Ill's DISEASE OF THE KIDNEY.

excretion. It aims, also, at bringing about increased activity of
those actions by wliicli food is assimilated to blood and blood to
tissue ; and every step of success towards this end must improve
the structural fitness and other functional conditions of excreting
organs, and lead to augmented excretion. Increased excretion is
a necessary sequence of increased assimilation. That these are
sound principles of practice, in the present uncertain state of the
pathology of blood diseases, cannot, I think, be questioned ; but I
venture to go further than this, and to predict, that even with that
greater knowledge of blood poisons and of excretions which chemi-
cal science has yet to confer on pathology, these principles will still
prove applicable and essential.

497

CHAP. XX.

ON ABNORMAL STATES OF THE URINE.

Section I. — Preliryiinary Pathological Remark, — A want of
Information in respect to the Normal Condition of the Urine
in India,

Albuminuria has, in the last chapter, been related to transient
congestion, or to structural degeneration, of the kidney : the
proximate cause is therefore supposed to exist in the secreting
organ itself. But there are other abnormal conditions of the urine
occurring without structural change of the kidney, whose proximate
cause is believed to reside in derangements of primary or secondary
assimilation : the precise nature, however, of these derangements
is unknown. But before noticing these abnormal states of the
urine, a preliminary question suggests itself for consideration, — In
what respect does the normal condition of the urine in warm
climates differ from that in cold ?

In the months of July, August, October, and November 1852,
and in February and March 1853, Mr. Sebastian Carvalho, an in-
telligent graduate of Grant College, while officiating as one of the
medical officers of the Jamsetjee Jejeebhoy Hospital, conducted a
series of observations on the urine of five healthy Hindoo Ward
boys, with the view of determining the normal quantity and specific
gravity of the secretion. The average quantity amounted to about
forty-two ounces in the twenty-four hours, and the specific gravity
was found to range from 1-007 to 1*016.* But on other questions

* In my remarks on the urine in Bright' s disease of the kidney, I stated the specific
gravity observed in my cases to range from 1-003 to 1-018; or, when coiTected for
temperature, from 1-005 to 1*020. The normal specific gravity, as deduced from Mr.
Carvalho's observations, does not accord with this. The inference I believe to be
simply this — that further and more extended investigation k necessary, in order to
establish a trustworthy standard of the normal state of the urine both in Europeans
and natives in India.

498 ABNORMAL STATES OF THE URINE.

relative to the quality of the urine, no light has been thrown by
these observations. They were submitted by Mr. Carvalho to the
Grrant College Medical Society, and a summary statement of them
has been published.* I have already f expressed my belief that all
the solid excreta are considerably less in India than in colder cli-
mates; and the investigations just referred to, so far as they go,
tend to strengthen this opinion in regard to the urine.

Section II. — Chylo-serous Urine. — Short Notice of its Pathology

and Treatment,

This term has been applied to urine of a milky, opaque
appearance, coagulating on the application of heat or addi-
tion of nitric acid, and sometimes spontaneously. The opacity
depends upon fatty matter, the coagulability by heat on albumen,
and that which occurs spontaneously on the presence of fibrine.
This abnormal state of the urine has been generally noticed in
association with more or less asthenia or cachexia, and has been
attributed to faulty assimilation, and not to disease of the kidney ;
because, in the few instances of which post mortem appearances
are recorded, this organ has been found healthy; and, on the
other hand, restoration to health, with coincident normal urine, has
not been infrequent. Proutf had met with thirteen cases of this
disease ; and as seven of them occurred in residents of hot climates,
it was inferred that the affection was probably more common in
tropical than in temperate countries. Still it cannot be viewed as
of frequent occurrence in India. There is the case of a female
reported § by Dr. H. H. Goodeve ; also one || of a female observed by
Dr. Pearse, with a careful chemical analysis by Professor Mayer.
These are the only recorded Indian cases with which I am ac-
quainted. My personal knowledge of the disease is limited to
eight cases. The first, made known to me at Belgaum in 1830,
occurred in an European officer's wife. The urine coagulated spon-
taneously into a white gelatinous mass : with the termination of
this case I am not acquainted. The second was observed by me
about 1839, in the European Greneral Hospital at Bombay. The

* " Transactions, Medical and Physical Society of Bombay," new series, No. 2.

t Page 4.

\ " Nature and Treatment of Stomach and Eenal Diseases," 4th edition.

§ " Transactions, Medical and Physical Society of Calcutta," vol. viii.

II " Transactions, Royal Medical and Chirurgical Society," vol. xxxiv.

(

CHYLO-SEROUS URINE. 499

subject was a young female born in India, of European parents,
and the wife of a warrant officer of the garrison. She was pale and
feeble, the urine was white and spontaneously coagulated into a
jelly-like mass. Much variety of treatment was adopted without
benefit. This patient left the hospital, and was lost sight of for
about two years, when I accidentally met her in the ward visiting
a friend. She had lost her pallid appearance, and was in good con-
dition. I inquired into her state of health ; but so completely had
the former abnormal condition of the urine passed from her mind,
that the object of my questions was not at first readily understood.
It appeared that after leaving the hospital she had gone to Scinde
to join her husband, who was on duty there. Her general health
improved, and the urine became normal without the use of medi-
cines of any kind.

The remaining six cases are annexed in detail to these remarks ;
three of them occurred in Parsees, one in the clinical ward, and
two communicated to me by Mr. Dossabhoy Bazunjee, a zealous
graduate of Grant College. The fourth was observed in a Hindoo
by Mr. Carvalho. The fifth is extracted from Mr. Balchrishna
Chintoba's report of the Poona Charitable Dispensary for 1858.
The sixth occurred in a Portuguese servant, under my own
observation.

I shall not speculate on the nature of the faulty assimilation
by which fatty and proteine principles, instead of being normally
appropriated, are excreted with the urine. Albuminous and chylo-
serous urine would seem to differ simply in this, that in the former,
albumen is the only proximate principle present, whereas in the
latter, albumen, in greater- quantity, is associated with fat and fre-
quently with fibrine. There is in the chylo-serous urine a more
complete transudation of organic constituents of the blood on the
free, surface of the uriniferous tubes. Though it maj^ probably be
added that urea is deficient in albuminous, but not in chylo-serous
urine ; yet it may be doubted whether investigation has been suffi-
ciently extensive in both affections to justify an assertion so positive.

There is good reason for relating both derangements to cachectic
states, that is, to mal-assimilation. In Bright's disease, degenerate
proteine and fatty principles are deposited in the structures of the
kidney, and albumen transudes with the urine. In chylo-serous
urine the proteine and fatty principles are separated from the
blood at the kidney, with the urine, and no part is left behind to
clog and destroy the structure of the organ. In both affections
proximate principles unsuited, from some cause or other, for their

K K 2

500 A13N0KMAL STATES OF THE UllINE.

normal purposes, are carried to the kidney. In the one they are
partly deposited in the organ to the injury of its structure, and are
partly removed with the urine. In the other all are removed with
the urine, none are deposited in the kidney. Such, I think, is
the view which, in the present state of pathology, we are justified
in taking of the points of resemblance and difference between
these two diseases. Why, in the one, the same principles are all
excreted, and in the other partly deposited in the kidney, is
one of the many questions which pathology has yet to determine.
I would further remark, that the doubts which I ventured to ex-
press, relative to the generally received explanation of the proxi-
mate cause of albuminous urine in Bright's disease, are increased
by the fact of the greater albuminous transudation which takes
place in chylo-serous urine.

On treatment a very few remarks will suffice. The indica-
tion is to remove the cachectic state, in other words, to correct the
error of assimilation ; and six of my cases distinctly show, that all
means having this object in view failed till suitable change of air
was enforced. The balsams, lytta, diosma, gallic acid, prepara-
tions of iron and other remedies supposed to have special influence
on the urinary organs, have signally failed — a further proof that
the proximate cause of the disease is not to be sought for there.

218. Urine thick, white, opaque, coagulating with heat and nitric acid. — No improve-
ment under the use of varied remedies. — Bccovery by attention to the general health,
chiefly to change of air. — ^A Parsee, of twenty-one years of age, following the occupa-
tion of English clerk, of temperate habits, never the subject of syphilis, but of weak
constitution, consulted Mr. Dossabhoy Bazunjee on the 13th October, 1851. There
was no indication of pulmonary or cardiac disease, but the pulse was feeble, the appe-
tite impaired, and he attributed his feeble health to close application to study. He
was also the subject of reducible femoral hernia of the left side. He stated that for six or
seven days he had been voiding thick, white opaque urine, without, however, frequent
calls to micturate. This state of the urine had been attended with pain of the loins
and limbs, but no distinct fever. He had never suffered thus before. The urine, on
being examined, was found to be white, thick, and opaque, of specific gravity 1-040,
and gave a copious white flocculent deposit under heat, and on the addition of nitric
acid. He was treated wdth creosote and tincture of the sesquichloride of iron, and
plain nourishing food ; a rubefacient liniment of turpentine oil, liquor ammonia?, and
olive oil was applied to the loins. This treatment was followed till the 29th October,
by which time he had gained in flesh, the pulse had improved in strength, the un-
easiness of loins was less ; the urine, for the most part unchanged in character, was,
however, occasionally clear, of amber colour, slightly acid, and unaffected by heat and
nitric acid. The same treatment was continued, with exception of the liniment to the
loins ; and on the 1st November he went to the seaside at Breach Candy, and resided
four days with a friend. There he improved in general health, the urine also became
clear, and remained so for four days after his return home to the Fort of Bombay.
On the fifth day the urine was clear in the morning, but in the middle of the day had
become white and opaque as before. Mr. D. Bazunjee recommended a longer resi-

CHYLO-SEROUS URINE. 501

dence at Breach Candy, but another practitioner undertook to cure him by other
means. The infusion of diosma, balsam of copaiva and aperients, with restricted diet,
were freely tried. He became emaciated and feeble, and the urine remained unchanged.
About the 15th December he again became a patient of Mr. D. Bazunjee, and I
was asked to see him in consultation. The tincture of the sesqui chloride of iron,
with tincture of lytta, was prescribed. He improved in flesh and strength, but the
urine continued white, thick, and opaque. And on the Uth March he again went to
Breach Candy, and remained there for two and a half months. In ten days the urine
became clear. He returned home on the 1st June in good health, and afterwards con-
tinued so. Wliile at Breach Candy he took no medicine, and lived on good food
without any particular restriction.

219. Urine thick, white, opaque, coagulating with heat and nitric acid. — No improve-
ment from medical treatment. — Becovery from change of air. — On the 1st May, 1852,
a Parsee, of forty-five years of age, of stout frame and temperate habits, never the
subject of syphilis, nor under the influence of mercury, but generally in the enjoyment
of good health, consulted Mr. Dossabhoy Bazunjee. No visceral disease could be
detected ; but he complained that his urine was white, thick, and opaque, and that
the calls to micturate were generally six times in the night and four in the course of
the day. He had suffered thus for five months, and had been treated with balsam of
copaiva and various other remedies, with some relief. The urine, when examined,
was found to be of high density, and to give a copious flocculent deposit under heat
and nitric acid. Mr. D. Bazunjee prescribed creosote, without benefit ; then tincture
of the sesquichloride of iron, with tincture of iodine, tincture of lytta, gallic acid, and
sulphuric ether were in succession tried, with as little success. On the 15th July
medicine was omitted, and change of air recommended. This advice he could not
follow for twenty days, during which time the urine continued unchanged. About
the middle of August he went to reside at Negaon. He remained there for a month,
became quite well in fifteen days, and has continued in good health since his return home.

220. Urine opaque and white, occasionally coagulating spontaneously. — Recovery
from change of air. — A Hindoo clerk, of twenty- three years of age, attended the
Jamsetjee Jejeebhoy Hospital, as an out-patient, from the 21st May to the 1st Jidy,
1851. He was under the care of Mr. Sebastian Carvalho, to whom I am indebted for
the following information. Five years before he had been affected with white opaque
urine, which continued for two months, — then ceased, he thought, not from the reme-
dies used, but gradually and spontaneously. He remained well till eight months and
a half before he came under observation at the hospital, when the urine suddenly
became opaque and milky, but without pain of loins or fever. On admission the
urine was milk-like, of specific gravity 1-012, and gave a copious coagulum by heat
and nitric acid ; and the rest of the urine was left clear. Blood and mucus were also
present, and subsided to the bottom of the vessel. Latterly the urine spontaneously
separated into a coagulum and a pretty clear fluid ; it was frequently passed with
pain, and obstructed by coagula in the urethra. His only other complaint was of
weakness. He was treated with tonics without benefit. He ceased attendance that
he might avail himself of change of air, from which he is reported to have soon reco-
vered, and after his return to have continued in good health.

221. Urine milky, coagulating by heat and nitric acid, becoming clear by addition of
sxdphuric ether.— No improvement from treatment. — Change of air recommended. —
Result not known. — Coverjee Maneckjee, a Parsee schoolboy, of sixteen years of age,
and temperate habits, but in feeble health, was admitted into the clinical ward on the
12tli December, 1852. With exception of slight bronchitis, he was free from thoracic
or abdominal visceral disease. He stated that, six months before admission, his urine
had begun to be scanty, and that two months ago it had assumed a milky appearance.
There was also pain of loins. The urine was passed without pain, except occasionally

K K .3

502 ABNORMAL STATES OF THE URINE.

from urethral obstruction by coagula. He continued under observation till the 2nd
January. The xu'inc was of milky appearance, coagulated with heat and nitric acid,
lost its turbidity by addition of sulphuric ether, ranged in quantity from twenty-five
to forty ounces, and was of specific gravity from r022 to 1*030. He was treated with
gallic acid, phosphate of soda, and creosote, without the least benefit, and was dis-
charged with a recommendation to proceed to Surat for change of air. The residt is
unknown.

222. Chylo-scrous urine removed by change of air. — Junardhun Kesho, a Hindoo
clerk, of twenty-one years of age, applied at the Poona Dispensary. He was in
reduced health, and on the 17th September, 1858, passed a pint of curdy urine, of
specific gravity 1-012, giving a cloudy deposit with heat and nitric acid. There was
no fever nor syphilitic taint. He was treated with gallic acid, then with the tincture
of the sesquichloride of iron ; but the urine continued opaque, with a brick-red tint.
He went for change of air on the 22nd, and on the following January was reported
well, and the urine natural.

223. Chylo-serous urine removed twice by change of air. — Antone , a Portuguese

butler, about forty-five years of age, left Bombay for Groa in May 1854, after having
been for some months the subject of chylo-serous urine, with occasional fever and
generally impaired health. During the voyage the urine began to clear, became
normal, continued so at Groa, and he returned to Bombay in perfect health in about a
year and a half. After about a year's residence in Bombay, the chylo-serous urine,
impaired health, and occasional fever returned ; and he went again to Groa in May
1857. The urine became clear on the voyage, and continued so when I last saw him,
on the 3rd November, 1857, five days after his second return to Bombay.

Section III. — Saccharine Diabetes. — Infrequent in India. —

Diuresis.

In this abnormal state of the urine we have another illustration
of disease depending on faulty, primary, or secondary assimilation ;
differing, however, from that which has just been considered, in
that the defect is in the processes by which the non-azotised
principles of food are converted to their purposes of usefulness in
the system. The result is, that sugar exists in excess in the
blood, and is excreted with the urine ; hence the great abundance of
this secretion, its saccharine quality, and its high specific gravity.

For details on these points, and on the cachectic phenomena
which are associated with saccharine diabetes, I must refer
to the many excellent treatises which have been written on this
disease.

Prout, during the period in which he had seen only thirteen
cases of chylo-serous urine, witnessed 500 of diabetes. From
this fact some idea may be formed of the comparative frequency
of the two affections in European countries. The number of cases
of diabetes in India, of which I have liad personal knowledge,
amounts to six. The first occurred about the year 1836, in the
Hindoo Jemadar of the Governor's escort at Dharpooree, in the

SACCirARINE DIABETES. 503

Deccan. This officer died two or three months afterwards. Another,
in the person of a Mahomedan gentleman of advanced age, about
whom I was consulted in 1854, by Mr. Atmaram Pandurang. The
remaining four cases are narrated in this section : three, two males
and one female, were Parsees ; the fourth was a native of Groa.
I have no reason for supposing that in the experience of others,
diabetes has been found a more common disease than it has proved
to be in my own. Prout was disposed to relate diabetes to mala-
rious influence. The infrequency of the disease in India is not in
conformity with this opinion; nor does it countenance the idea
that abuse of mercury, or syphilitic taint, have much to do with
the etiology of diabetes. When we recollect that numerous classes
subsist chiefly on cereals and other vegetable food, we, in theory,
might anticipate that diabetes would be a more common disease
in India than in those coimtries in which animal food is more
generally consumed. This, however, does not seem to be the case.
Such facts tend to show that much of the pathology of saccharine
diabetes is still unknown.

224. Diabetes. — Sijmptoms improved somewhat under the use of creosote and muriate
of morphia. — ^Muncherjee Ruttoiijee, aParsee cook, of twonty-ciglit years of age, whilst
on his return from China, about twenty-three months before he came under observation,
landed at Singapore, and there, without appreciable cause, for the first time experienced
extreme thirst and frequent desire to micturate. Since that time both these symptoms
have continued and increased. After his return from China, he resided for three months
in Bombay ; then proceeded to his native town, Surat ; and, aft^r a residence there of
about eight months, he again set off for China, unrelieved of his complaint. Twenty days
before admission into the clinical ward, on the 9th March, 1850, he had returned from
China to Bombay. He was a good deal emaciated, was affected with urgent thirst and
dryness of the fauces, and micturated frequently and copiously. The gums were swollen
and the teeth loose, the appetite was keen, the tongue dryish and slightly florid at the
tip, and the bowels rather slow. The skin was of natural* temperature, and dry ; the
pulse 100, of tolerable volume, and soft. There were no signs of pulmonary or
cardiac disease. The abdomen was full, but soft, without uneasiness or abnormal
dulness. He complained of a general sense of weakness, slept badly, from uneasiness
in the course of the tibiae, burning in the soles of the feet, and frequent calls to pass
his urine. He stated that the urine increased in quantity after oleaginous articles of
food and vegetables, and that when voided on the same place for two or three succes-
sive days, the spot appeared as if whitewashed. He was unable to assign any par-
ticular cause of the complaint ; but a sister had died, after two years' illness, with
similar symptoms. No other member of his family, however, had been thus affected.
Much variety of medicine had been used, and he had been salivated about a year
before admission. He continued under observation till the 4th April. The urine was
generally of amber colour, and of specific gravity from 1'035 to 1'040. On admission
twenty- four pints were passed during the night ; but it gradually decreased, and after
the 14th March ranged from seven to three pints in the night. The thirst lessened,
and he improved somewhat in appearance. He was treated chiefly with creosote in
two- minim doses thrice daily, a draught with the solution o:frthe muriate of morphia
at bed-time, and the occasional use of the hot-air bath. The diet consisted of milk,
eggs, mutton, mth succulent vegetables.

K K 4

504 ABNORMAL STATES OF THE UKINE.

225. — Biahetcs. — No improvenmitfrom 'preparations of iron, permanganate of potass,
and opitim. — Ruttonjee Dhuiijeebho}^ a Parsce sweet-meat seller, of twenty-five years
of age, and using spirits to the extent of two ounces daily, was admitted into the clinical
ward on the 1 0th October, 1853. He was much reduced and complained of pain of loins,
weakness of the lower extremities, and frequent micturition. The countenance was
anxious, the pulse small, and slightly jerking; the skin of natural temperature, and
dry ; the tongue thinly coated, and somewhat florid at the tip ; the gums slightly
swollen, and tender; and the bowels confined. With exception of* an occasional
bronchitic rale, there was no sign of pulmonary or cardiac disease. The abdomen was
retracted and free of induration or dvdness. He rested badly at nights. He stated
that he had suffered from dysenteric symptoms for about two years, for which much
variety of treatment had been unsuccessfully folloAved till three months ago, when he
was treated in the hospital with opiates and stimulants, and the dysenteric symptoms
were removed. Then, for the first time, he observed an increase in the urine, and
attributed it to the remedies which had been used. These, he said, had caused thirst,
and led him to drink much water. On the 12th eight pints of urine had been passed
during the night ; it was clear, of pale amber colour, neutral, of specific gravity 1'033,
and on addition of sulphate of copper, liquor potassse, and application of lieat, a
yellowish brown precipitate was thrown down. He continued under treatment till the
7th November. The urine ranged from three to eight pints in the night, and con-
tinued of high specific gravity. The asthenia increased. He was discharged at his
own earnest desire. He was treated first with preparations of iron and opium, and
then the permanganate of potass was substitvited for the iron, and a diet of eggs, mutton,
and a limited portion of bread, and two ounces of arrack daily was given.

226. Diabetes. — Not improved by treatment. — Sorabye, a Parsee female, of twenty-
six years of age, much emaciated, and affected with boils, was, after a year's illness,
admitted into hospital on the 20th May, 1850. The tongue was florid. The pulse
feeble and quick. The urine ranged from six to twelve pints, and was of specific
gravity from 1-030 to 1-036, and yielded sugar on evaporation. The thirst was urgent,
and the appetite voracious. Opium, quinine, creosote, and Dover's powder were used,
and a diet of milk, eg^s, chicken, and little bread was given. She gained somewhat
in flesh, and the tongu6 was less florid, but in other respects was at the time of her
discharge, on the 29th July, in the same state as on admission. I saw her again in
the month of October, when the symptoms remained unchanged.

227. — Diabetes. — No improvement from permanganate of potass, or from creosote
alone, but marked benefit from addition of opium. — Cosmo de Souza, a native Christian,
of forty-five years of age, an inhabitant of Goa, a cook by occupation, and habitually
using spirits, was admitted into the clinical ward on the 10th November, 1852. Ho
was reduced in strength, the pulse was small and jerking. He complained of dimness
of vision, sleepless nights, frequent and copious micturition. The tongue was moist
and clean, the bowels slow, the appetite keen, and the thirst urgent. No signs of
thoracic or abdominal disease. He stated that these symptoms had first made their
appearance at Belgaum five years before, and had persisted with little intermission.
The urine on the 12th was five pints, of specific gravity 1-033, and gave a scanty brown
precipitate with sulphate of copper and liquor potassse. The patient seemed to have
discovered, and alluded to, the sweet taste of his urine. He continued under treat-
ment till the 21st December, when he was discharged at his own request; the urine
having decreased to about fifty ounces, and specific gravity to 1-022 ; his general state had
also improved. He was again seen on the 28th December, and the urine was examined.
It was of specific gravity 1-025, and gave merely a trace of sugar with Trommer's
test. He was afterwards seen on the 24th January, when the specific gravity of the
urine was 1-028, and a considerable brown precipitate was thrown down with the
sulphate of copper and liquor potasste. During his stay in hospital he was treated

URIC, OXALIC, AND PIIOSPIIATIC DIATHESIS. 505

first with permanganate of potass without improvement, then with creosote, also without
any change in the urine ; but on the addition of a grain of opium at bed-time, the
urine decreased from 100 to 60 ounces, and during the twenty days that he sub-
sequently continued in hospital ranged from forty to eighty ounces. He had full diet,
but without any special arrangement.

Diuresis. — Cases of abundant limpid urine, of low specific
gravity, are occasionally, though rarely, observed in India. I re-
collect two well-marked instances of this affection. The first, a
European, employed in the government remount stables, who,
about the year 1837, consulted me for this affection, and for par-
tial amaurosis of one of his eyes. The urine was very copious and
limpid, and was about 1*005 or lower in specific gravity. The
abnormal state of the urine, unaffected by medical treatment, after
a time reverted to its normal standard, and some improvement
took place in the amaurosis. This individual is still (1860) in
Bombay, and for many years subsequent to the period adverted to
has enjoyed good health.

The second case was of an Indo-Briton, who applied at the
Jamsetjee Jejeebhoy Hospital, towards the end of 1853. The
urine was very copious, of low specific gravity, and gave no traces
of sugar. He was much emaciated and out of health. I have no
notes of the particulars of this case, or of its further course.

Section IV. — Uric, Oxalic, and Pliosphatic Diathesis,

The presence of insoluble urates, oxalates, and phosphates in the
urine, is also a consequence of faulty primary or secondary assimi-
lation, sometimes due to error in the quantity or quality of the
food, at others to defect in the processes themselves. The sub-
ject has of late years received much attention, and the risk
is, that too much importance may be attached to the ascer-
tained facts, both in reference to pathology and therapeutics.
The probability is, that further investigation of the morbid
states of the urine in India will lead to results similar in
kind to those which have already been obtained in European
countries.

These abnormal conditions of the urine may be practically con-
sidered from two points of view.

1. As leading to the formation of urinary calculi, and all their
attendant evils. The opinion at one time entertained that these
were of rare occurrence in India, has been long since disproved in
Bengal, by the experience of Burnard, Brett, Twining, Darby,

506 ABNOBMAL STATES OF THE URINE.

ra^^^^

Cole, and many skilful lithotomists, graduates* of the Bengal
Medical College; in the Nizam's territories, by Dr. W. C. Maclean ;
and in Bombay, by Peet, Ballingall, Ritchie, and Bhawoo Dajee.f WM

* Of the many skilful lithotomists trained in the Bengal Medical College, I would
name Ram Narain Doss, the present teacher of surgery in the military class of the
college, as the most conspicuous. He has performed the operation above two hundred
times with good success. Also Mr. C. E. Raddock, who has communicated an in-
teresting report of his cases of lithotomy in the 4th number of the "Indian Annals of
Medical Science."

t On this subject I quote the following extract from my retrospective address to
Grant College Medical Society for the year 1857: —

*' Mr. Bhawoo Dajee, in continuation of a former paper published in the 2nd number of
the 2nd Series of the ' Transactions of the Medical and Physical Society,' communicated
five additional cases of lithotomy. In four the operation was performed by the author ;
in one by Mr. Narrayen Dajee. Two were of Mahomedans, three of Hindoos. The
ages of three ranged from 7 to 10 ; of the remaining two the ages were 55 and 60.
In all, the symptoms of calculus had been present from 3 to 6 years ; in all the opera-
tion was successful. The calculi extracted weighed from 3 to 4| drachms. But neither
in the six cases previously reported, nor in those now under notice, is there any account
given of the chemical composition of the calculi.

" Mr. Sadashcw Hemraj contributed three cases of lithotomy successfully performed
at Bhooj. Two in children 4 years of age ; one of 12. The composition of the calculi
is not stated. The same defective information exists relative to 41 of the 50 calculi
now in the Grant College Museum.

"The etiology of urinary calculus is imperfectly understood. It is, therefore, very
important that, in the investigation of this form of disease, information should be
carefully sought in regard to all points which may serve to elucidate the causes which
produce it. It is very desirable that the place of birth and of residence, varieties in
modes of life from habits of caste or diiference of circumstances, and the chemical
composition of the calculi, should be inquired into and recorded. Mr. Bransby Cooper,
in the year 1851, in a paper published in the 7th volume of the 2nd series of Guy's
Hospital Reports, relative to the cases of lithotomy performed by Mr. Coles of the
Bengal army in the Punjaub, remarks on the importance of determining whether a
relation existed between the climate and peculiar systems of diet and the composition
of urinary calculi ; and he throws out the suggestion, that in theory it may be ex-
pected that in India, where vegetable food is more exclusively used by large numbers
of the people, a greater proportion of oxalate of lime calculi would be found to exist.
With the view of setting before you the results which may be deduced from existing
records of Indian calculous disease, I have referred to the several sources of information
within my reach. There are cases recorded, with chemical analysis, in the ' Transac-
tions of the Medical and Physical Society of Calcutta,' by Burnard, SjDry, Twining, Brett,
and Darby ; in Guy's Hospital Reports by Coles ; and in the catalogue of the Grant
College Museum there is an analysis by Dr. Watson of nine calculi extracted by Dr.
Ritchie at Mooltan. The cases adverted to amount to 77. Eleven consisted of uric
acid, or urate of ammonia ; 48 of uric acid associated with oxalate of lime or phos-
phates ; 7 of oxalate of lime alone ; 7 of oxalate of lime and phosphates ; one of phos-
phates alone.

" Dr. Simpson, of Tirrhoot, in the 3rd number of the ' Indian Annals of Medicine,'
gives the analysis of 186 cases, with a mortality of 4-8 per cent. He makes no allusion
to mixed calculi, but classes them all under the heads of urates, phosphates, oxalates. Of
the first 76 ; of the second 68 ; of the third 42 ; which gives aper-centage of 40*8 urates;
36-6 phosphates; 22*6 oxalates.

URIC, OXALIC, AND PIIOSPIIATIC DIATHESIS. 507

2. As indications of mal-assimilation, the urates being often
related to excess of food and sthenic states, the oxalates and
phosphates to asthenic and cachectic states. They are signs of
deranged actions, very useful to note in practice, but often serving
merely to confirm an inference already sufficiently evident from
other symptoms. They indicate the propriety of the regimen and
remedies which are calculated on general principles to remove the
deranged constitutional states on which they depend. They do
not indicate the use of chemical remedies with the view of alterinof
the state of the urine, unless the formation of urinary calculus be
apprehended; and, then even, such remedies are not entitled to
rank higher than temporary palliatives.

The presence of blood, pus, and mucus in this secretion, in their
relation to disease of the urinary organs, and the decomposition of
urea, is well understood and need not be described in this work.

"Mr Ruddock, Sub-Assistant Surgeon of tlie Bengal Service, in the 4tli number of
the 'Indian Annals of Medicine,' reports 77 cases of lithotomy, with amortality of 6-7
per cent. ; but he is silent on the chemical composition of the calculi.

"These data show that uric acid entered into the composition of 135 out of 263
calculi ; but this is, doubtless, far short of the truth, for it is very improbable that Dr.
Simpson's 68 phosphates and 42 oxalates were, all of them, free of uric acid.

" In Dr. Golding Bird's work there is an analysis of 374 calculi in Guy's Hospital
Museum. Uric acid entered into the composition of 269. So far, then, as inquiry
has as yet gone, there are no grounds for believing that oxalate of lime calculi occur
in greater proportion in the natives of India than in those of England, yet the
question cannot be viewed as settled without more extended and more careful investi-
gation."

Since these remarks were written, Mr. H. Vandyke Carter, Professor of Anatomy
and Physiology, Grant Medical College, has carefully analysed the urinary calculi in
the Museum and arrived at the following conclusions : —

"1. That in the Bombay Presidency the proportion of calculi having oxalate of
lime for their nucleus, or wholly composed of it, is about twice as great as in Eng-
land, taking for comparison certain standard collections there. 2. That the propor-
tion of calculi having uric acid, or a urate for their nucleus or entire substance, is
considerably less in India tlian in England ; in the former, urate of ammonia calculi
are somewhat more frequent than uric acid calculi : the opposite is the case in Eng-
land. 3. That the number of calculi wholly composed of earthy phosphates, or having
them for a nucleus, is proportionately much fewer in India than in England : the dif-
ference being chiefly owing to the rarity of mixed phosphates in the former." ^

* " Transactions, Medical and Physical Society of Bombay," No. 5, New Series, p. 147.

508

CHAP. XXI.

ON PNEUMONIA.

Section I. — Pneuononia. — Rare in Europeans in Bombay. —
Asthenic Foi^m coramon in Natives.

Pneumonia is a rare disease in Europeans in Bombay. I am un-
able for the six years of my own service in the European Greneral
Hospital to separate the admissions of pneumonia from those of
bronchitis and pleuritis: they have all been recorded in the
hospital returns under the head " Thoracic Inflammations." The
register of admissions might supply the means of subdivision, but
it is not at present within my reach. On referring to my " Cases *
illustrative of the Pathology of the Diseases of Bombay," chiefly
observed in the European Greneral Hospital, I find only eight of
pneumonia, and five of them were consecutive on measles. Of the
three other cases, one occurred in a dissipated clerk serving in a
public ofiice, and the attack came on obscurely during a series of
successive days of intemperance ; the second in a seaman suffering
from delirium tremens ; the third in a warrant officer of the garri-
son, terminated in red and grey induration, with several gangrenous
excavations. In the returns of the European Greneral Hospital for
the succeeding ten years, from 1844 to 1853, kindly supplied to
me by Dr. Stovell, twenty-two admissions of pneumonia are re-
corded : of these, two died. On examining my notes of cases of
sick officers, it appears that of 1,699 cases which passed under my
review, only five of pneumonia are noted: four of these proved
fatal ; in one there w^as a gangrenous excavation, and in the
remaining three the disease had passed on to induration or he-
patisation.

In respect to the natives of India, however, the results are very
different. In them pneumonia, of asthenic type, is sufficiently

* " Transactions, Medical and Physical Society of BomI)ay," 1st Series, Nos. 2, 6, 7.

ETIOLOGY, 509

common. Mr. Allen Webb has published* an account of this
disease, as observed in 1845, at the dispensary of Cawnpore, in
the upper provinces of Hindostan, by Dr. Edward Groodeve; and in
the jail at Midnapore, in Bengal, by Mr. Grreen, in the same year.
Mr. Webb had also himself frequently observed pneumonia in
natives in the lower belt of the Himalayan range. During the six
years, from 1848 to 1853, 313 admissions of pneumonia took place
in the Jamsetjee Jejeebhoy Hospital. Of these 103 were under my
immediate care in the clinical ward; and the following remarks
will chiefly relate to the pathological and therapeutic deductions
which these cases have suggested.

Seventy-six of the cases were of primary pneumonia, and
twenty-seven f were of pneumonia complicating intermittent or
remittent fever.

In the chapter on Eemittent Fever it was stated that primary
pneumonia, and that which complicates malarious fever, would
be considered together. When this arrangement was originally
adopted, it seemed to me that questions relative to the pathology,
symptoms, and treatment of inflammation of the lungs might
arise, in the consideration of which a comparison of the two
forms might be found useful. In the observations which I am
about to make I shall use the term primary pneumonia in its
generally received sense ; while for convenience sake, I shall de-
signate by the term febrile, the pneumonia which complicates
intermittent and remittent fever. In this restricted sense, then,
the word febrile, when applied to pneumonia, has been used in
this chapter.

My comments on these clinical cases have been arranged under
the heads — 1. Etiology. 2. Pathology. 3. Symptoms. 4. Treat-
ment.

Section II. — Etiology. — Relation to Sex, Age, Caste, Habits
Constitution, and Season.

Sex. — The question of the influence of difference of sex in pre-
disposing to pneumonia is not affected by these cases — they were
all of males.

Age. — The greater or less prevalence and mortality of this dis-
ease at different periods of life is a subject of interesting inquiry;

* "Pathologia Indica," by Allan Webb, B. M. S., 2ncl edition: Calcutta, 1848.
t Of these, twenty- thxee complicated remittent fever, and four intermittent fever.

OlU PNEUMONIA.

but the class of inmates of the Jamsetjee Jejeehhoy Hospital is not
calculated to advance it. They are chiefly adults, and consist for
the most part of day-labourers, peons, cart-drivers, domestic ser-
vants, and sailors. Many of them are natives of other parts of the
country, resorting to Bombay, for a season, in pursuit of the
means of subsistence. They are generally individuals in the vigour
of life. Of the subjects of the present cases, fifty-seven were
between the ages of twenty-one and thirty ; twenty-two between
thirty-one and forty ; eleven between ten and twenty ; and nine
above forty.

Caste, — The castes from which these patients were selected
have been, with one exception, Hindoo, Mussulman, and native
Christian: there were forty-nine Hindoos, forty Mussulmans,
and thirteen native Christians. This is about the ratio of the
total hospital admissions of these several castes. In this state-
ment, then, there is no evidence of liability to pneumonia being
caused by peculiarities in the customs of these different classes.
Yet there is an interesting fact observable in these cases, which is
probably related to caste-customs. The mortality among the
Hindoos and Mussulmans has been about one in three ; that of the
native Christians not quite one in six. On referring to the
duration of the disease before admission, I find that of the seventy-
one recovered cases, only twenty were admitted within five days of
the commencement of the attack : of these, nine were native
Christians. From this statement it is a fair inference, that
though pneumonia has been as prevalent among native Christians
as the other two castes, yet it has been much more successfully
treated, in consequence of their earlier application for relief.*

Habits and state of constitution, — The state of constitution
and the habits of these patients, have in all probability assisted in
causing the disease. Of one hundred and one individuals whose
state of constitution on admission is noted, sixty-three were
asthenic, and the condition of thirty-eight is stated to have been
good or tolerable. Of the asthenic patients, about one in three
died ; of the others about one in four.

The habits of seventy-seven are stated : of these, forty-six ad-
mitted that they were in the practice of using spirituous liquors ;
thirty -one denied it.

Seasons. — On referring to the total hospital admissions of pri-

* That the difference of the rate of mortality from pneumonia in Christians extends
to all forms of disease is shown by the fact — that the general hospital mortality is,
in Hindoos, 19-4:8, in Mussulmans, 15-56, and in Christians, 9-93.

ETIOLOGY.

511

mary pneumonia during the six years to which these remarks
relate, it is found that in the year 1849 the number was one-third
more than the average of the other years. On comparing the
monthly admissions for the whole period, it appears that in the six
months from December to May, the admissions were 182; but
in the six months from June to November, they were 131 — a
difference of fifty-one in favour of the winter and spring. These
results are deduced from the consideration of 313 cases.

In M. Grrisolle's elaborate work on pneumonia, there is a table
which exhibits the months of admission in Paris of 296 cases.
It will be useful to compare these two statements *, with the view
of determining to what extent there is correspondence or difference
in the seasons of greatest prevalence of pneumonia in the climates
of Paris and Bombay. In both we find the disease more common
in the six months from December to May than in those from June
to November. But the difference is more marked in one climate
than in the other: in Paris it is 190, in Bombay fifty-one. When
the month of November is excluded, and the admissions in the two
places from June to October are compared, it appears that in Bom-
bay they amount to one hundred, in Paris to thirty-one.

There is, then, in Bombay, a greater proportion of admissions
in summer and the first half of autumn than in Paris. The reason
is evident. June, July, August, and September are the monsoon
months in Bombay — the season of the periodical rains. We have
at this time wet, a moist atmosphere, and high winds, as causes of
reduction of the temperature of the surface of the body.

These remarks have had reference to prhnary pneumonia. But
when we regard the periods of admission of the twenty-seven cases
of febrile pneumonia, we find that the greatest monthly number

* The statements in detail are subjoined : —

Bombay. Paris.

January . . . . 30 . . . .20

February . . . . 39 . . . .40

March . . , . 32 . . . .47

April 21 . . . .62

May 27 . . . .40

June 23 . . . .8

July 9 .... 13

August .... 18 .... 3

September . . . . 21 . . . .5

October . . . . 29 . . . .2

November . . . . 31 . . . .22

December . . . . 33 . . . .34

313 296

512 PNEUMONIA.

was in July. When we compare the six months from June to
November with those from December to May, we find that the
admissions in the former amounted to twenty-two, in the latter
only to five. The difference between the seasons of greatest pre-
valence of primary and febrile pneumonia in Bombay would seem
to be well marked. The explanation is clear. Primary pneumonia
is most common iti the cold months of the year ; but febrile pneu-
monia, on the other hand, is necessarily most common in the
months in which malarious fevers chiefly prevail. This fact is
important, as it tends to facilitate the diagnosis of the two forms,
and affects the principles of treatment.

Causes assigned. — The patients generally have not attributed
the attack to any particular cause. Nine traced it to cold or wet,
eight to fatigue and exposure, and ten to blows more or les.« re-
cently received. When we consider the season of greatest pre-
valence of the primary form, the occupations of the inmates
of the hospital, their exposure to vicissitudes of weather, their
scanty clothing, and defective habitations, we are justified in
regarding reduction of the temperature of the surface of the body
as the common exciting cause of pneumonia in India, as else-
where.

Section III. — Pathology. — Preliminary Question relative to the
affected Capillaries. — Rate of Mortality. — Duration of Illness
before Admission. — Stage of the Disease. — Which Lung most
frequently affected. — Period of Residence in Hospital. — State
of the Lung on Discharge. — Morbid Anatomy.

Preliminary Remarks. — The first question which naturally
arises, relative to the pathology of pneumonia, is the deter-
mination of the precise seat of the inflammation. I do not
mean, whether the walls of the pulmonary air cells or their
connecting areolar tissue are the structures affected : this,
though much discussed by pathologists, has never appeared to me
a very important or difficult point to establish. If in inflam-
mation of mucous and serous membranes we generally find that
the deranged action tends to extend to and cause exudation in the
areolar tissue subjacent to them, it is improbable that inflamma-
tion of the pulmonary cell-wall can exist without tending to ex-
tend and to cause exudation in the areolar tissue which connects
the cells together, as well as into the cells themselves. The ques-
tion to which I allude is, whether the capillaries of the bronchial

PATHOLOGY — GENERAL REMARIvS. 513

arteries, or those of the pulmonary artery, are the seat of inflam-
mation. The answer appears to me simple and evident. If we
adopt the opinion, at present generally received, that inflammation
is an altered state of the nutritive processes of the affected part,
depending upon something faulty in one or other of the conditions
of normal nutrition, then the capillaries concerned in inflamma-
tion must necessarily be only those which circulate, in their normal
state, arterial blood for purposes of nutrition. The capillaries of
the bronchial arteries are the nutrient vessels of the visceral pleura,
of the mucous lining and other structures of the bronchial tubes,
and of the connecting areolar tissue of the constituent parts of the
lung ; and we can hardly avoid the conclusion that they are also
the nutrient vessels of the pulmonary cell-walls. These capil-
laries are unquestionably those involved in visceral pleuritis, and
in bronchitis ; and when we regard the frequent relation of these
affections to pneumonia, it is reasonable to conclude that the
same kind of capillaries are concerned when the inflammation is
of the pulmonary cell-walls, and of the areolar tissue which con-
nects the cells to each other.*

The capillaries of the pulmonary artery, on the other hand,
convey venous blood to the air cells, for distribution on their walls,
in order that the physical process of endosmosis and exosmosis
may take place between the gases of the blood and the atmospheric
air. It does not seem probable that the blood in these capillaries
takes any part in the nutrition of the cell-walls. It is, therefore, a
just conclusion that these capillaries and their blood cannot be
agents in the altered state of nutrition of the pulmonary cell-walls,
and their connecting areolar tissue, which we designate by the
term pneumonia. Though the capillaries of the pulmonary artery
are not the capillaries directly engaged in inflammation, yet their
deranged action has much to do with the pathology of pneumonia.

The phenomena which attend on the first inspiration after birth,
on asphyxia, vesicular emphysema, and other pathological states of
the lungs, teach us the following facts : —

1. That the pulmonary capillary circulation is contingent on

* I am, of course, aware that some physiologists hold that the blood in the pulmo-
nary capillaries, passing into the arterial state, becomes nutrient of the cell-walls.
The subject is not susceptible of demonstrative proof; but surely the argument from
analogy supports the opinion that the bronchial are the nutrient capillaries. It seems
to me quite as reasonable to suppose that the blood flowing in the channel of the aorta
is nutrient of its walls, as that the arterialised blood of the pulmonary capillaries is
nutrient of the tissues around it. Both bloods are flowing in their respective channels
with objects in view, special, and not related to the nutrition of the tissues imme-
diately adjoining to them.

L L

514 PNEUMONIA.

the processes between the blood in the pulmonary capillaries and
the air in the pulmonary air cells being in action.

2. If this aeration of the blood is impeded from want of suf-
ficient air or from thickening of the cell-walls^ or the cells
becoming filled with liquid or solid deposits, the pulmonary
capillary circulation on such cell-walls becomes languid, and soon
stops: — the blood distends the vessels, and stagnates in them.
Now, additional blood is no longer sent into the branches of the
pulmonary artery which conduct to these defective cells; but it
passes in excessive quantity into adjoining branches, to be con-
veyed to the capillaries of adjoining healthy "cells, in order that
it may be aerated there. If, however, the blood thus sent in ex-
cessive quantity to these adjacent healthy cells be greater than
their extent of surface can readily aerate, dyspnoea is caused.
Short and hurried respirations merely express the fact that all the
cells of the lungs are not admitting air, and that the diminished
extent of surface thus arising is being compensated for by the
greater frequency of the respiratory acts. Difficulty of breathing
is only experienced when there is want of harmony between the
quantity of blood in the vascular system and the extent of the
effective pulmonary surface.

Let us now endeavour to apply these principles to the pathology
of the disease before us.

When the pulmonary cell-walls become somewhat thickened
from the turgescent state of the bronchial capillaries, and when
secretions are present in the cells, in the degree which interferes
with, bp.t does not altogether prevent, the admission of air, then
we may believe that some degree of aeration is still carried on,
that the pulmonary capillaries become somewhat distended, and
that the circulation of the blood is impeded in them, but as yet
is not altogether obstructed. Such I believe to be the condition
of the lung in the first stage of pneumonia. The inflammation
continues, the thickening of the cell-walls increases, the inflam-
matory deposits take place in greater abundance into the cells,
and now the aeration of the blood at these cells is physically
impracticable : the pulmonary capillaries become turgid with stag-
nated blood, and the circulation in them becomes altogether ob-
structed. Such I believe to be the state of the lung in the second
stage of pneumonia: its spongy structure has become solid; the
solidification depending, in part, it may be assumed, on inflamma-
tory exudation into the cells, in part also, however, on the stag-

PATHOLOaY — KATE OF MORTALITY, 515

nated blood in the close-set meshes of the pulmonary capillaries.
This latter condition of consolidation is not stated with sufficient
prominence by pathological Avriters on this disease. It explains
well how the consolidation of the lung sometimes takes place
rapidly, and how it sometimes is very speedily removed. It
is evident that if part of the consolidated condition has de-
pended on pulmonary capillaries turgid with blood stagnated,
but not coagulated, and aeration becomes re-established in the
affected cells by reduction of the inflammation, then this stagna-
ting blood will at once be set in motion, and the consolidation
that depended upon it be speedily removed.

My belief, then, is, that the capillaries of the pulmonary artery
are not the inflamed capillaries of pneumonia; but that conse-
quent on inflammation of the pulmonary cell-walls, the action of
the pulmonary capillaries becomes deranged in the manner ex-
plained. This derangement constitutes the danger of pneumonia,
as of all other forms of pulmonary disease. Moreover, the de-
ranged action of the pulmonary capillaries takes a part in pro-
ducing the striking morbid appearance of the lung in pneumonia
— I mean its hepatisation.

In this view of the pathology of pneumonia, we have also a
satisfactory explanation of the relation between hypostatic con-
solidation of the lung, and the hepatisation of pneumonia. In
hepatisation, there is in the pulmonary capillary turgescence
which is present, the condition of hypostatic consolidation; but
there are also, in addition, the consolidating conditions derived
from the direct products of inflammation.

These are not mere idle speculations, for, as we shall presently
find, they have an important reference to symptoms, as well as to
questions of treatment. The subject is analogous to that which
has been previously discussed, relative to the capillaries engaged
in hepatitis.*

Rate of Mortality. — There were 76 cases of primai^y pneu-
monia. Of these 24 died — a mortality of nearly 29 per cent.,f if
two cases fatal from cholera be excluded. |

* Page 325.

t In my subsequent statements regarding the rates of mortality, I shall not exclude
these cholera cases.

I It will be obser^'ed, that the tabrdar statement at the end of this chapter gires
for the total hospital admissions of pneumonia a mortality of 38'6 per cent. This is
in part explained by the supposition that there may have been, cases admitted in such
an advanced and hopeless state of disease as to be unsuited for clinical instruction,

L L 2

516 PNEUMONIA.

There were twenty-seven cases of febrile pneumonia : of these
eight died ; in two the fatal result was caused more from co-exist-
ing meningitis than pneumonia; yet, in estimating the rate of
mortality of this form, we may not exclude any of the usual con-
tingencies of malarious fever. The rate of mortality of the febrile
cases was not quite 30 per cent.

The rate of mortality of primary pneumonia has been nearly as
high as that of the febrile form : hence we are probably justified in
assuming that this inflammation, complicating' malarious fever, is
not so severe as when it occurs in its primary form. Were it other-
wise, the mortality of the febrile form would be higher, for in it we
must always attribute death, in part, to other conditions of idio-
pathic fever as well as to the pneumonia.

But 29 per cent, seems a large mortality from primary pneu-
monia. We have already found in the diatheses of a large propor-
tion of the patients one condition favourable to high mortality
from disease. Still it is very necessary, with the view of satisfac-
torily testing the success or failure of treatment, to inquire into the
following points : —

1. The duration of illness before admission.

2. The stage of the disease on admission.

3. The extent and part of the lung affected.

4. The length of time under treatment before recovery or
death.

5. The state of the lung on discharge, in the cases discharged
from hospital.

Duration of illness before admission. — The following tabular

and therefore to have been excluded from my selection for the clinical ward. Allow-
ance must also be made for errors of diagnosis, liable to occur in large hospitals served
by different medical men often overtasked with duty. This latter observation, pro-
bably more or less true of all countries, is correct of civil and military hospitals in
India — more especially in seasons of unusual sickness, or amid the distractions and
labours of active service. It is also particularly applicable to those forms of disease —
of the chest for example — in which much care, time, and patience are required to
establish the diagnosis with that precision and accuracy of which the present state of
the science is capable.

I am most desirous of impressing on the Indian practitioner the injury which is
likely to result to pathology and therapeutics, by applying to their elucidation data
which are unsuited for the purpose. The least reflection must convince any one that
there is little in common between the figured statements of disease in hospitals, as
usually compiled, and the results of the scrutiny of a series of attentively considered
and carefully recorded clinical cases. Most certainly nothing in common, but the use
of figures, between pathological and therapeutic deductions, from military and naval
hospital statistics, and the inferences from the numerical method as practised by Louis
and those who are truly his followers.

PATHOLOGY — RATE OF MORTALITY.

517

statement exhibits the duration of illness of the patients before
admission.

Duration of Elness of Patients before Admission.

Recovered.

Died.

1 to 5 days ....

Total.

Primary

Febrile.

Primary.

Febrile.

6 to 10 „

—

11 to 15 „

16 to 20 „

—

21 to 30 „

31 and upwards ....

—

Total .

103

The mortality of the ^rimfiary form, admitted within five days
from the commencement of illness, was 6'6 per cent. The single
fatal case occurred in a Parsee of intemperate habits ; was in the
second stage, and complicated with pleuritic effusion and albu-
minuria.

The mortality of the febrile form, admitted within five days
from the commencement of illness, was 25 per cent. The single
fatal case occurred in an individual affected with fever and bron-
chitis : pneumonia came on subsequently, and proved fatal seven-
teen days after admission.

The mortality of primary pneumonia, admitted between six and
ten days from the commencement of illness, was 30 per cent. In
seven of the eight fatal cases the disease was in the second stage on
admission. In four the pneumonia was double, and in three of
them the disease was in the second stage, in one in the first.

Of the eight cases oi febrile pneumonia, admitted between six and
ten days from the commencement of illness, none proved fatal.

The mortality of both forms, admitted above ten days from the
commencement of illness, was nearly 47 per cent.

When we regard all the admissions of jprimary pneumonia,
within ten days from the commencement of illness, the rate of
mortality is found to be 20 per cent. But when we consider the
febrile cases from the same point of view, the mortality falls to 8
per cent. Yet for the periods above ten days, the mortality of
both forms is the same, — 47 per cent. The lower mortality of
febrile pneumonia, within ten days from the commencement of
illness, is of interest : it seems to show that the pneumonia does
not come on till some time after the commencement of the fever.
It is, therefore, probable, that in all the cases of febrile pneumonia

L L 3

518 PNEUMONIA.

admitted within ten days from the commencement of illness, the
pneumonia has generally been either in the first stage, or only
passing into the second.

Stage of the Disease. — Of the primary form eight were in the
first stage. Of these two died ; in one the pneumonia was double, in
the other it was complicated with much bronchitis in a man of
sixty years of age.

Sixty-four cases of primary pneumonia were admitted in the
second stage. Of these twenty-seven were double, thirty-four were
single, and confined to part of a lung, and three were of one entire
lung. If we class together the cases of double pneumonia and
those of one entire lung in the second stage, we find that the mor-
tality was 36*6 per cent. ; but the mortality of single pneumonia
in the second stage, involving only part of a lung, has been 17*6
per cent. The mortality of the aggregate admissions of primary
pneumonia in the second stage, has been 26*5 per cent.

Four admissions of primary pneumonia took place in the third
stage : all were fatal.

Oi the febrile form, five cases were admitted in the first stage:
one proved fatal, admitted after twenty days from the commence-
ment of the fever, complicated with muttering delirium and
drowsiness.

Twenty-two of this form were admitted in the second stage. Of
these, fourteen were double, eight single. The mortality of the
former was 35 per cent., of the latter 25 per cent.

Lung affected. — In comparing the frequency of pneumonia in
the lung of the different sides, and in the different parts of the
lung, I shall class the primary and febrile forms together. Of
both lungs (double pneumonia) there were forty-six cases, with
a mortality of 32*6 per cent. Of the right lung there were
thirty-nine cases, with a mortality of 33*3 per cent. Of the
left lung there were eighteen cases, w^ith a mortality of 22*2 per
cent. Of the cases in which the right lung was affected, the entire
organ was involved in three : this did not occur in any of the in-
stances in which the disease was confined to the left side, there-
fore, when these three cases are deducted, the mortality for the
right side is reduced to 25-3.

In regarding these rates of mortality, we must always bear in
mind that they relate to a series of cases of which the admissions in
the first stage were only about 13 per cent.

In this statement the proportion of double pneumonia appears
much greater than has usually been observed. This is, in part.

PATHOLOGY. 519

owing to the two forms having been classed together. Of the
twenty-seven cases of febrile pneumonia, we had the disease double
in seventeen. When we consider the primary form alone, we find of
double pneumonia twenty-nine; of the right lung thirty-three;
of the left lung fourteen. This is still an unusual proportion
of double pneumonia.

When we direct our attention to the part of the lung affected in
these cases, it appears that in seventy-nine the lower or middle parts,
or both, were engaged, and of these the mortality was 26 per cent.
In fifteen cases the upper lobe was affected, and of these the mor-
tality was 26 per cent. In nine the entire lung, double or single,
was affected, and the rate of mortality was 77 per cent.

The greater liability of the lower part of the lung to become
affected with pneumonia is well shown in these cases. The great
mortality of the disease when an entire lung is involved also ap-
pears ; but the opinion that pneumonia of the upper part of the
lung is more fatal than that of the lower, is not confirmed by these
cases. It was believed by Louis, that individuals above the age
of fifty were more liable to pneumonia of the upper lobe than those
of earlier periods of life: but eleven of my fifteen cases were under
the age of thirty-one.*

* Subsequent observation in India has tended to confirm my opinion that pneumonia
of the upper lobe is more frequent than is generally supposed, is not more dangerous,
and is not most common in individuals above the age of fifty. It also shows that,
in India at least, there is a greater liability to error of diagnosis between pneumonia
and phthisis in their second stages, than would exist under the generally received
opinion that pneumonia is seldom exclusively in the upper lobes. I am satisfied that
a too ready belief in the common opinion has led me, on more than one occasion, to
diagnose phthisis in the second stage instead of pneumonia in the second stage.

The subject is so important, that I do not hesitate to submit a short summary of
the additional cases which have come under my notice since the remarks in the
text were written ; the aggregate thus amounts to twenty-one cases.

1. Bapoo Eawa, a Maratha, twenty-five years of age, admitted with remittent fever
attended with delirium, on the 5th December, 1856. There was cough. Dulness and
coarse crepitus were detected in the right infra- clavicular region on the 1 1th, and
phthisis was diagnosed. The fever ceased. The dulness lessened, and he was dis-
charged on the 16th December without any trace of disease in the right infra-clavicular
region.

2. Chota Padren, aged twelve, was, after three days' illness, admitted on the 5th
January, 1857. He was out of condition, there was much fever with pain of limbs.
The dorsal regions were examined, and no pulmonary disease detected. Continuance
of febrile exacerbation with cough led to a more thorough examination, and on the
7th there was found dulness of the left infra-clavicular, mammary and axillary regions
with bronchial respiration. Acetate of ammonia and nitre were given, and water com-
presses applied to the affected regions. The febrile symptoms lessened, crepitus ap-
peared in the dull regions, and on the 22nd the state of the upper part of the left lung
was normal and he was discharged well on the 31st.

L L 4

520 PNEUMONIA.

Residence in hospital. — In considering the duration of residence
in hospital, let us separate the recovered from the fatal cases.

Of recovered cases, twelve primary and two febrile were dis-
charged within ten days ; twelve primary and eleven febrile between
eleven and twenty days ; thirteen primary and three febrile between
twenty-one and thirty days ; fifteen primary and three febrile above
thirfcy-one days.

There were fifty-seven cases discharged at different periods above
ten days ; eighteen of them, indeed, above thirty-one days. From
this statement we may infer, that though pneumonia in the second
stage is frequently recovered from, yet a considerable time is gene-
rally required to ensure the restoration of the lung to a healthy or
useful state.

Of the fatal cases, fourteen primary and five febrile died within
ten days from admission, three primary and two febrile between
eleven and twenty days, two primary and one febrile between
twenty-one and thirty days, and five primary upwards of thirty-
one days. The fact of nineteen of the thirty-two fatal cases
having proved fatal within ten days of admission shows the ad-
vanced stage at which a great portion of them must have come

3. Rama Itoo, a Hindoo, aged tliirtj, after six days' illness, was admitted on the 4th
January, 1858, with diilness, bronchial respiration, and crepitus of the left infra-cla-v-i-
cular, mammary and scapular regions. There was also crepitus in the right infra-
scapular region. Under the use of quinine, stimulants, nourishment, and a water
compress to the chest, the cough and fever lessened, the dulness and bronchial respira-
tion decreased, and he left the hospital contrary to adrice on the 12th, at which time
there was no fever nor cough, but the defective resonance and the bronchial respiration
on the left side were not altogether gone.

4. Pestonjee Dorabjee, aParsee, aged forty, had been in hospital two or three times
with fever and suspected tubercles in the upper right lung, but after discharge he had
gained so much in flesh as to remove the suspicion of phthisis. He was re-admitted
on tlie 4th February, 1857, with remittent fever. The tongue was florid at the edges,
and there was occasional vomiting and cough. On the 7th there was dulness and im-
perfect respiration in the right infra-clavicular region, with bronchial respiration and
crepitus in the scapular region. On the ninth the physical signs were the same, and
the sputa had a faint rusty tinge. The fever continued for two days with some delirium
and slight jaundice, then lessening of the fever and cough, and on the 12th there was
coarse general crepitus in the right infra-clavicular region. On the 14th the dulness
was less and the crepitus was being replaced by vesicular respiration. The fever no
longer recurred. He gradually improved and was discharged on the 23rd March in
good flesh, without cough, and with normal resonance and breath sounds in the right
infra-clavicular region.

5. Mahadoo Sawnut, a Mahratta sepoy of the 6th Eegiment, Bombay Infantry,
aged twenty-two, was admitted into hospital at Poona, on the 15th April, 1859. He
had fever with marked remissions and exacerbations. The chest was examined on the
17th, but nothing abnormal was detected. On the 19th the fever continued, the re-
spiration was hurried, and wandering delirium was present. I saw tliis patient for the

PATHOLOGY. 521

under treatment. It confirms the direct statement made on this
point in a former part of these remarks.

State of lung on discharge. — Seventy-one cases were discharged
from hospital. Of fifty-one cases of 'primary pneumonia the lung
was quite* restored in thirty -three, improved in thirteen, not im-
proved in five, and in one not recorded. Of nineteen febrile cases
the lung was restored in sixteen, improved in two, and in one not
recorded.

When we class the two forms together, we find that sixty-two
were admitted in the second stage, and only nine in the first stage.
It has appeared that in forty-nine of the discharged cases the lung
was restored. If we deduct from these the nine cases admitted
in the first stage, we have of sixty-two cases of pneumonia in
the second stage forty recoveries. Of the remaining twenty-two
the lung was improved in fifteen, not improved in five, and not
recorded in two.

Morbid anatomy. — There was a post-mortem examination made
in fifteen of the twenty-four fatal cases of primary pneumonia, and
in seven of the eight fatal cases of febrile pneumonia.

In eleven of the cases the solidified lung was in a state of

first time on the morning of the 20t]i, on the occasion of my weekly visit to the
hospital, and was struck with the hurried breathing and defective movement of the
left side. The subclavian, mammary and scapular regions of that side were didl, and
bronchial respiration was present. I called the attention of the medical officer to the
pneumonia in the second stage, complicating fever, which he had overlooked. A few
leeches were applied, and quinine, with one grain of calomel and antimonial powder,
was given every second hour, and sesquicarbonate of ammonia in the intervals. On the
21st the sputa, previously tenacious, had become less so, the respiration less hurried,
but the delirium still occasional. On the 23rd, the respiratory murmur began to
return ; and on the 28th, when I again saw him, the dvdness was gone and the
respiration quite restored. He was discharged on the 1st May. This case shows
very forcibly the importance of frequent systematic auscultation and percussion in
remittent fever in natives of India. The medical officer in this instance was a gentle-
man of much intelligence, and in general quite alive to the importance of these
methods of investigation, but in this case he had been satisfied with one cursory ex-
amination on the second day after admission,

6. John Dias, aged thirty, a cook, after five days' illness, was admitted, on the 18th
December, 1857, with fever, slight jaundice, delirium, adhesive yellow-tinged sputa,
and solidification of the left lung, chiefly noted in the axillary and scapular regions.
He died on the 14th, and on inspection the whole of the left upper lobe was in a state
of grey hepatisation, with friable lymph on its pleural surface. The upper part of the
lower lobe from above downwards passed from grey into red hepatisation, and the thin
part of the base of the lung was spongy and crepitating. The right lung was healthy.
There was commencing Bright' s disease. This was a case of pneumonia commencing
in the upper lobe, and passing downwards.

* By this I mean that the removal of the dulness on percussibn, and return of the vesi-
cular respiration, indicated that tlie lung had become permeable and fit for function.

522 PNEUMONIA.

induration, either red or grey. This condition, compared with
readily lacerable hepatisation, occurs in this hospital in a greater
proportion even than this series shows : it is related to asthenic
states, to a protracted course, and not un frequently to advanced
period of life. True hepatisation, on the other hand, usually
occurs in better states of the constitution, and after a more rapid
course : in the febrile form it has existed in greater proportion than
induration. Of the seven cases of febrile pneumonia there was he-
patisation in five, and induration in two ; whereas in the fifteen cases
of primary pneumonia there was induration in nine, and hepati-
sation in six. Whether the grey induration is to be regarded as an
advanced stage of the red or brown, or a distinct variety from the
commencement, has been a question: these cases rather counte-
nance the former view. Tubercular deposit was observed in only
one case, a febrile one : it was in small quantity in the upper lobe
of the left lung.

In three of the cases — two primary, and one febrile — the he-
patisation, in places, occurred in nodules : the pneumonia had- been
in part lobular ; but in all there were also hepatised portions of
considerable extent. There Avas no reason for supposing that these
instances of lobular pneumonia were dependent on pysemia: they
were more probably cases in which bronchitis had passed into
pneumonia, for in all of them increased redness of the bronchial
mucous lining was well marked.

Though there are no cases of pyaemic pulmonary abscesses in
this series, yet several have been observed in the hospital. Pysemia
will be considered in a subsequent chapter.

Pleural adhesions have generally proved the co-existence of
pleuritis, more or less recent. The absence of pleuritis occurs,
more frequently in febrile than in primary pneumonia; of
the seven fatal cases of the former, examined after death, it is
distinctly stated that in two of them there were no traces of
pleuritis, and yet in both there was much red hepatisation of
the lung.

Thick cacoplastic membranous, almost cartilaginous, deposits
were found in one or two cases, connecting the surfaces of the
pleura together. One case seemed to show that the deposit takes
place in the first instance on the surface of the pulmonary pleura,
and advances to some degree of thickness, before it forms adhesion
with the opposed costal pleura. In the case referred to, the an-
terior part of the upper lobe of the right lung adhered to the costal
surface by a thick membranous, almost cartilaginous, layer ; while

PATHOLOGY. 523

on the same part of the left lung there was an opaque membranous
deposit, but no adhesion.

Bronchitis, to greater or less extent, has also been noticed as a
frequent complication : it occurred in greater proportion in the
febrile form.

Cavities were found in the lungs in five* cases. They ranged
in size from a small orange to a split pea. In all there were
several cavities : they existed both in the upper and lower lobes,
and had formed in the midst of grey induration. In case 228
the different stages of the process were well shown ; in it, scattered
in the grey induration, were dark-red points, from the size of
a pin's head to that of a hemp seed ; and there were also
cavities from the size of a split pea to that of a pigeon's egg, with
an inner surface, moist, and of dark-red colour. In the gi'ey in-
durated part, inflammatory stasis of blood had probably taken
place, here and there followed by molecular loss of vitality, hence
softening, liquefaction, and the formation of cavities at these
points : this seemed to me to be the process by which in two
of these cases the cavities had been formed. In the three others
the appearance of the cavities, the foetor of their contents, or
of the sputa during life, indicated that the loss of vitality had
not been molecular merely, but of portions of tissue more or less
extensive: that the cavities had been formed by a process of
gangrene, f

* There was a sixth case, in which. cavernous respiration was present; but the body-
was not examined after death,

t The occurrence of gangrene of the lung, unpreeeded by inflammation, is not
common. There are two cases in my notes which seem to me to have been of this
nature.

The first was a marine of Her Majesty's ship Endi/mion, of twenty years of age.
He had suiFered from adynamic remittent fever, and was under treatment for consecu-
tive dysentery. Chest. — The lungs did not collapse, the anterior parts were inflated,
the posterior oedematous. On the posterior part of both lungs there was a green dis-
coloured portion, which broke down readily under the knife, and gave out much green-
ish frothy serum. The cellular tissue was plainly disorganised, and the serum seemed
to have been contained in a small cyst, rather than in the natural tissue of the lung
(gangrene with serous effusion into the cellular tissue of the lung, not preceded by
condensation of that portion of the lung). No hepatisation of any part of the lungs.
Heart healthy. Abdomen. — The stomach, much distended, occupied the entire space
between the ensiform cartilage and umbiKcus ; its mucous coat was lined with adhe-
sive mucus, and presented throughout a dusky rosy tint, without softening. The liver
was rather enlarged, olive-green in colour, and mottled ; no abscess. The transverse
portion of the colon was opened ; the mucous coat presented numerous ulcers in diffe-
rent stages, many of them cicatrising. Spleen natural ; kidneys healthy.

The second occurred in a destitute Mahomedan pilgrim, of fifty years of age, with
puffed face, oedematous feet, short and hurried respiration, puriform sputa, some degree

524 TNEDMONIA.

In none of the five cases in which cavities existed was tuber-
cular deposit observed in the lungs: three of them are here
detailed: —

228. Tneumonia, extensive of right lung. — Grey induration with cavities formed in
the tipper lobe by molecular gangrene. — Pandoo Gunnoo, a Hindoo, of thirty-five years
of age, a native of Carlee, following the occupation of a peon, and not addicted to the
use of spirits, was, after fifteen days' illness with fever, cough, pain of back and loins,
admitted into the clinical ward on the 5th September, 1849. He was emaciated. The
respiration was hurried. There was dulncss of the subclavian and lateral regions, and
of the whole posterior part of the right side of chest, greatest in degree in the supra-
spinous and dorsal regions. In all these situations occasional subcrepitus was heard,
with blowing respiration under the clavicle and under the spine of the scapula. In
the left side of chest no abnormal sign was detected ; but the respiration was puerile
in parts. The sounds and impulse of the heart were natural. There was elastic and
uneasy fulness of the abdomen, above the umbilicus. The feet were asdematous. The
skin was above the natural temperatvire. The pulse was small and somewhat frequent.
The tongue was slightly florid at the tip and coated posteriorly. The voice was hoarse,
and the breath very fetid. On the 8th the chest was again carefully examined : under
the acromial end of the right claAdcle and in the axilla, the respiration was cavernous,
sometimes almost amphoric, and pectoriloquy was distinct. In the right lateral and
dorsal regions the respiration was bronchial, with occasional crepitus and subcrepitus
in the former. He continued under treatment till the 21st, when he died. There was
hectic fever, frequent hard cough, with grey puriform sputa. Diarrhoea supervened
on the 16th, and hastened the fatal issue. He was treated with anodynes chiefly till
the diarrhoea came on, when acetate of lead with opium was given.

Inspection six hours after death. — The larynx and trachea were healthy. Chest. —
The left lung was crepitating and inflated : there were old adhesions between the
inferior lobe and the costal pleura and diaphragm. The right lung adhered firmly
on all sides to the parietes of the chest : the upper lobe was in a state of grey indura-
tion with many irregular excavations ; the largest was situated near the apex, of the
size of a small egg, and another, somewhat smaller, existed at the lower and outer part ;
the excavations in process of formation were surrounded by a dark-red layer, and the
contents of all consisted of dark grey, sero-puriform, very fetid fluid ; the lower lobe
was in a state of grey hepatisation, with the exception of its inner and lower half,
which was healthy and crepitating. Abdomen. — On opening the abdomen some fetid
gas escaped. Eirm adhesions connected the anterior parietes to the omentum and
colon, which passed horizontally across the abdomen from one side to the other, just
above the umbilicus. The liver had contracted firm adhesions with the stomach,
diaphragm, and anterior parietes of the abdomen ; and its outer covering appeared to
be denser than natural. The structure was healthy. Besides the adhesion with the
liver, the stomach was also adherent to the spleen ; its mucous surface was not ex-
amined. The spleen was not enlarged ; it adhered on all sides to the diaphragm,
abdominal parietes, and the stomach. The left kidney was larger than the right;
both were flabby, but of healthy structure. Other parts not examined.

of dulness of the right dorsal lateral and scapular regions, with occasional subcrepitus.
No albumen in the urine. Inspection.— 0\^ adhesions united the posterior part of the
right lung to the walls of the chest. The posterior part of this lung, for about four
inches in length and three in width, was in a state of gangrene — reduced to a dark-
grey fetid pulpy state. The surrounding pulmonary tissue was in part healthy, in
part cedematous ; but without trace of sanguineous engorgement or hepatisation.
The heart was healthy. Two pints of serous fluid were effused in the cavity of the
abdomen.

PATHOLOGY. 525

229. Grey, almost cartilaginous, induration of the lower part of the right lung, with
several excavations hy process of gangrenous molecular softening. — The several stages
of the process well shown. — Bright' s disease of the kidney. — Pandoo, a Hindoo
labourer, a native of Coorla, of thirty years age, was, after three months' illness, ad-
mitted into the clinical ward on the 11th September, 1848. He was much reduced,
affected with cough, puriform expectoration, and daily febrile accessions coming on at
irregular times. He had suffered thus for two months. He pointed to the right false
ribs as the seat of pain when he coughed, and this he believed to have been caused by
a fall from a horse some years before ; but he was wanting in intelligence, and not
distinct in his statements. The breathing was rather hurried, and the pulse feeble.
In consequence of disturbance from the cough, it was some days before a satisfactory
examination of the chest could be made. On the 17th, there was large mucous rale in
the right axilla. On the 27th, cavernous respiration in the right axilla, dulness of the
right scapula and dorsal regions, with occasional crepitus in the latter, were noted ;
also vesicTilar respiration general on the left side, with occasional crepitus in the dorsal
region. On the third October, cavernous respiration, and pectoriloquy, were reported
in the right axilla, and at the inside of the inferior angle of the right scapula. Vesi-
cular respiration was absent in the right lateral region, and bronchial sounds were
heard there. On the 8th, the right dorsal and lateral regions were completely dull,
and the signs of a cavity continued. There was very troublesome cough with copious
puriform expectoration and frequent hectic fever. On the 13th October, the urine
gave a flaky deposit with heat and nitric acid, and on several subsequent occasions
also evinced traces of albumen. The feet became oedematous, and he died on the 24th
October. Small blisters were applied to the right side of the chest. He was treated
with anodynes, expectorants, and tonics.

Inspection four hours after death. — Chest. — The left lung adhered firmly to the
costal pleura ; its upper lobe was emphysematous, but elsewhere it crepitated, was no-
where consolidated, and did not give out- much fluid of any kind when incised. The right
lung adhered very firmly to the costal pleura at the lateral and dorsal parts ; also to
the diaphragm. The upper lobe was crepitating, with, at its very apex, an emphyse-
matous bulla, the size of a walnut. The third lobe was consolidated throughout, and
covered by a membranous layer of lymph, at least quarter of an inch thick at
the base of the lung, where opposed to the diaphragm. This lobe was in a state of
grey induration, almost cartilaginous when incised, but branches of the pulmonary
artery and veins and bronchial tubes could be traced ramifying through the indurated
substance. At the very edge and back part of this lobe there was about an inch square
of crepitating tissue, and at the upper part were several irregular excavations, the
largest the size of a pigeon's egg, with moist dark red walls, and membranous investing
tissue. They had the character of gangrenous excavations, but wanted the gangrenous
foetor. On making a vertical incision in the indurated lobe, below and somewhat
posterior to these excavations, there was found at the upper part another cavity, the
size of a small bean, with dark red sides ; and a little lower down, one the size of a
split pea. Still lower in the lobe there existed dark red spots distinct, isolated with
considerable interspaces, from the size of a hemp-seed to a pin's head, evidently the
first stage of what would have formed excavations. The heart was healthy. Abdomen.
— The liver, enlarged, was not particularly examined. Both kidneys were somewhat
enlarged, the left most so, somewhat lobulated and mottled externally. Wlien incised,
the surface of the cortical part presented a granular appearance, very streaked and
mottled red and buff, and some of the bundles of the tubular part were surrounded by
a distinct buff-coloui-ed band. When examined through a lens, the surface of the in-
cision had a glistening fatty look.

230. Grey and red induration of the upper lobe of thcrright lung with gangrenous
excavation. — Dulla, a Hindoo servant, a native of Sawtint Waree, using spirits habit-

526 PNEUMONIA.

iially, was admitted into the clinical ward on the 27tli February, 1849. He stated
that, three years before, he had been struck with the stock of a musket at the lower
part of the sternum, and that immediately afterwards he vomited blood. Ho soon
recovered from the eflfects of the injury, and did not then suffer from cough. On admis-
sion he was a good deal emaciated, had frequent cough, with copious muco-puriform
sputa in roundish masses. The voice was hoarse, and the breath very fetid ; decubitus
was dorsal, and attempts to lie on the left side excited cough. He suffered from hectic
fever and diarrhoea. He had been affected with these sjonptoms for six weeks, and he
stated that his father, at an advanced age, had died of pulmonic disease. The respi-
ration was somewhat hurried and oppressed. There was dulness on percussion of the
right subclavian, mammary, and lateral regions, decreasing from above downwards.
The respiration was bronchial in these dull regions, and the resonance of voice was
very distinct below the right clavicle and a little below and internal to the nipple.
The respiration was puerile on the left side, but there was no dulness of that side,
nor any rales. He sank rapidly under the diarrhoea, and died on the 8th March.

Inspection five hours after death. — The left lung, with exception of a few hepatised
nodules the size of a horse-bean in the upper lobe, was soft and crepitated urider
pressure. The upper lobe of the right lung was in a state partly of grey and i tartly
of red induration, and there M^as a gangrenous excavation at the apex the size of a
large orange. In the indurated parts adjoining the cavity, there were a few dark grey
portions the size of a bean (commencing gangrene). The two lower lobes were in a
state of red induration, with exception of the posterior thin edge of the third lobe,
which was soft and crepitating. The heart was healthy. The kidneys were normal.
The end of the ileum and the large intestine, as far as the ascending colon, were
opened : the mucous membrane was not ulcerated.

In many of these cases, as may generally be noted when there
is solidification of a considerable part of a lung, a more or less
emphysematous or inflated state of the permeable parts of the lung
was observed.

Bright's disease of the kidney was present in only three of the
twenty-two cases examined after death : in two of them there
was red hepatisation, lobular in character in one, in the third case
there was grey induration, with cavities. On referring to my cases
of Bright's disease, it appears that pneumonia was present as a
secondary affection in five of twenty fatal cases. Of these, two were
in a state of induration, and three of hepatisation. Thus, then,
the observations made in this hospital tend to show a relation
between pneumonia and Bright's disease.

My investigations have not as yet confirmed the supposed
frequent relation between heart disease and pneumonia. Disease
of the heart was not present in any of the cases in this series, but
pneumonia was found in two of the seventeen fatal cases of cardiac
disease examined after death, and included in my remarks in a
subsequent chapter on disease of the heart.

In one case there had been circumscribed empyema of the right
side, and perforation of the under part of the middle lobe of the
lung at its fissure with the third lobe had taken place : this part of

SYMPTOMS. 527

the middle lobe had formed the vault of the sac. The purulent
effusion had also opened into the pericardium, and excited peri-
carditis. In the left lung there was grey induration, and cavities
by softening.

The complication of pleuritic effusion, serous or puriform, was
observed in only two of the fatal cases of this series. One, just
adverted to, was circumscribed empyema and primary pneumonia.
The other was febrile : the effusion was of red-tinged serum.
These results, however, by no means express the frequency of this
complication. It was present in five of the recovered cases, four
primary, and one febrile ; and I have met with it in several other
cases at different times. Defective vocal thrill, the appearance
of a friction murmur as the dulness lessened, the presence of
crepitus at some period or other, and of sputa more or less copious,
have been the signs on which the diagnosis of this complication has
been determined. On the whole, my experience tends to confirm
the generally received opinion relative to the combination of pneu-
monia, and some degree of pleuritic effusion, — that the prognosis
is more favourable in the combined than in the separate affections.
We may believe that both commence simultaneously, and may
suppose that they mutually influence each other : the solidification
of the lung may limit the amount of the pleuritic effusion ; the
pleuritic effusion may limit the degree of the solidification of the
lung. The advance of the morbid change in both is thus checked,
and a greater tendency to restoration results.

Section TV. — Symptoms. — Fever, Fain, Dyspnoea, Cough, De-
lirium., Character of the Sputa. — Fhysical Signs.

Fever, not hectic in character, was observed in ninety-two cases,
viz., in all of the febrile form, and sixty-five of the primary.

The remittent * character of the fever was well marked in all
the cases of the febrile form. It was also distinctly observed in a
considerable proportion of the cases of primary pneumonia. The
remittent character of symptomatic fever is of frequent occurrence,
both in the medical and surgical practice of this hospital, and may
be regarded as a feature of symptomatic febrile disturbance in the
natives of India generally, more particularly in the asthenic. It is
of practical importance to watch for the remission, for reasons
to be explained when the treatment of pneumonia comes under

* I do not think it necessary to separate the four cases inVhich the fever was inter-
mittent in type.

528 TiNEUMONIA.

consideration. This remittent type of symptomatic fever probably
depends on the influence of malaria pre-existing in the constitution,
and is excited by local inflammation, just as intermittent fever may
be excited by exposure to cold in the same state of the system.
The inflammation is the exciting cause of the fever. The state of
constitution, previously engendered by the influence of malaria,
determines the type which that fever assumes. These views we
shall find are confirmed by the results of treatment. But whatever
the true explanation may be, the fact is undoubted that symptom-
atic fever in asthenic natives affected with pneumonia in Bombay
is in many instances markedly remittent in type.* So much so,
indeed, that it is frequently a difficult question of diagnosis to
decide whether the particular instance ought to be classed as pri-
mary or febrile pneumonia.

In determining this diagnosis, the following considerations have
chiefly influenced me, in respect to the febrile form : —

1. The distinctness of the exacerbation and remission.

2. The history showing clearly that the febrile phenomena
had taken precedence by some days of the symptoms of pneumonia.

3. The state of the tongue, as regards fur, Acridity, dryness.

4. The presence of much restlessness at night, with some
degree of delirium when the pneumonia was not far advanced.

5. The fever presenting adynamic phenomena. This was,
however, an occurrence only of the advanced stages : it was observed
in five of the cases of this series.

Attention to these circumstances will in general suffice to estab-
lish this diagnosis. Still, with patients admitted in the advanced
stages of disease, with imperfect histories of their previous illness,
difficulty will be occasionally experienced.

When the pneumonia has existed for some time in the second
stage, very generally, the cessation of the febrile disturbance
takes precedence for a time — longer or shorter, according to the
previous duration of the disease — of the restoration of the lung to
its healthy state. The discontinuance of the fever, when not re-
placed by that of hectic type, is usually attended by improvement
of the other symptoms, as by lessening of the cough and dyspnoea.
It is, however, to the ^physical signs that we must turn for infor-
mation regarding the real condition of the lung. In many cases —
nearly all of the febrile form, and in a considerable proportion of
the primary form - - it will be found that the cessation of the fever,

* Eemarks of a similar tenor have already been made at p. 74. I now apply them
to a particular disease, as previously done in respect to hepatitis, p. 374.

SYMPTOMS. 529

and the lessening of the cough and dyspnoea, are attended by a
corresponding improvement in the physical signs. The dulness
becomes less, the bronchial respiration is gradually replaced by
vesicular murmur, the crepitus redux is sometimes heard, and after
a period more or less long the signs of complete recovery re-
appear. In other cases, however, of the primary form, in which the
lung has been for a longer time consolidated, we find that days
may pass before improvement in the general symptoms is followed
by signs of decrease of the consolidation : then these signs begin
to return, and by a slow process the lung is more or less com-
pletely restored.. It is reasonable to assume, that though in these
latter cases the process of recovery is so slow as to require some
time before, by a lessening of the signs of consolidation, it gives
evidence of its being in progress, yet its commencement, or its
tendency to commence, is coincident with the termination of the
fever and the improvement in the other symptoms. These facts
have an important bearing on treatment as I shall presently
endeavour to show.

Hectic fever was noted in eight cases. They were all of the
primary form; five of them were cases in which cavities ex-
isted, and which proved fatal. Three of them were discharged
cases, two with the lung somewhat improved, and one with no
change.

Pain. — When we inquire into the frequency with which pain in
some part of the chest has been complained of, we find that it was
present in only forty: thirty-four of these were primary, which
is rather more than half of this form; five were febrile, which is a
little less than a sixth of this form.

The less complaint of pain in the febrile form accords with the
results noted under the head Morbid Anatomy. There, it is stated
that pleuritis was more frequently absent in the febrile than in
the primary form.

Pain below the margin of the right false ribs was noticed in
thirteen cases : they were all of the primary form. In three there
was pain also at the margin of the left ribs. In six in which
there was pain below the margin of the right ribs, there was
also some degree of abnormal dulness on percussion in the same
situation.

In only one of these thirteen cases (a fatal one) was there reason
for connecting the pain with the existence of hepatic inflammation.
In this single instance abscess was found in the liver after death.
In my remarks on disease of the heart in a subsequent chapter

M M

530 PNEUMONIA.

(page 592), it will appear that in six of thirteen cases of that
affection there existed pain and some degree of abnormal dulness
at the margin of the right ribs. This was attributed to conges-
tion of the liver, consequent on obstructed passage of the blood
through the heart. That congestion of the liver is also apt
to occur consequent on obstruction to the passage of the blood
through the lungs in extensive pneumonia, is an old observation
of pathologists. That it is correct, I believe, from having wit-
nessed a congested state of the liver after death in several cases of
pneumonia.

When pain below the margin of the right ribs is present in
pneumonia, associated with abnormal dulness, we shall generally
be right in relating it to hepatic congestion. The pneumonia may-
be either of the right or the left side, but the hepatic congestion
probably indicates that it is extensive.

There are, however, other cases in which pain is experienced at
the margin of the right ribs, but which are unattended with ab-
normal dulness. In these the pain is probably sympathetic, like
that not unfrequently observed at the margin of the left ribs in
pericarditis. When the pneumonia is of the right lung, we shall
have this kind of pain, if present, at the margin of the right ribs ;
if the pneumonia, on the other hand, be of the left lung, the pain
will be at the margin of the left ribs. But we may expect to find
this symptom more frequently on the right side, because pneu-
monia of the right lung is more common than that of the left.
This sympathetic pain was noticed in seven cases of the present
series : but my remarks are not grounded on these cases alone, for
the symptom has been noticed by myself and others in other cases
in the general wards of the hospital.

The occurrence of hepatitis secondary on pneumonia doubtless
occasionally takes place ; therefore, when pain is felt at the margin
of the right ribs, this fact should be borne in mind. Still, these
cases observed in India would seem to justify the opinion that
the co-existence * of these diseases is not common. It was noticed
in one only of 103 cases of pneumonia, and that in an instance in
which the event was unlikely to occur, for the pneumonia was
of the upper part of the left lung. But pain at the margin of
the right ribs, unconnected with hepatitis, has been observed in
twelve of the 103 cases.

* It must be understood that I speak of hepatitis secondary on pneumonia : pneu-
monia secondary on hepatitis is more common. I do not now alhide to the co-existenco
of these diseases taking place in this hitter order, hut only in the former.

SYMPTOMS. 531

I have called attention to this symptom *, — and I shall follow
the same com-se in connection with heart disease, — in order that
an error in diagnosis may not be committed, and pneumonia be
mistaken for hepatitis. This I have known to occur ; therefore I
am satisfied that the caution is not uncalled for.

Dyspnoea, — Some degree of shortness and hurry of the respira-
tory acts was noticed in ninety-one cases: of these sixty-seven were
primary, and twenty-four were febrile. Thus there remain nine
of the first form, and three of the second in which this symptom
was not noted.

Though some degree of dyspnoea has been observed in so many
instances, yet in the great proportion of them it was by no means
urgent, and in many might have been overlooked, had not the
cases, from the circumstance of being collected together for pur-
poses of clinical instruction, been submitted to careful investi-
gation and record. The reason why the dyspnoea was slight,
and might readily have escaped notice in many of these cases, is
sufficiently explained by the asthenic state of so many of the
affected.

The degree of dyspnoea in this disease is always an expres-
sion of the degree in which there is disproportion between the
amount of blood to be aerated, and the extent of the pulmonary
surface.

In an individual of sthenic constitution, in whom the blood is
abundant and the full extent of the pulmonary surface is required
for aeration, pneumonia of a small extent of lung will be attended
with marked dyspnoea. But when the quantity of blood has been
for some time reduced, as always happens in asthenic states, then
the full extent of the pulmonary surface is in excess of what is
necessary : part of it may become unfitted for function by pneu-
monia, and yet dyspnoea be hardly noticeable. In these statements
we have the explanation of the latency or obscurity of the symp-
toms of impaired function of the lungs in asthenic pneumonia.

When the treatment of the sthenic forms of the disease comes
under consideration, we shall find that it is of importance to re-
member that dyspnoea indicates a want of proportion between the
quantity of the blood and the extent of the aerating surface ; and
that it may be lessened, or removed, in one or two ways — either

* It is hardly necessary to caution against the error of mistaking uneasiness at the
margin of the right ribs, with dulness, consequent on displacement of the liver
from pleuritic effusion, for the conditions to which referenc# has been made in these
remarks.

M M 2

532 PNEUMONIA.

by restoring the pulmonary surface to its structural fitness, or by
reducing the blood till it has become in proportion to the diminished
extent of that surface.*

Cough was present in ninety-eight cases, — seventy-two primary,
and twenty-six febrile.

The little urgency of the cough in pneumonia has been very
generally remarked by writers on this disease. The opinions which
I have ventured to express on the general pathology of pneumonia
seem to me to afford a ready explanation of this peculiarity. Cough
merely expresses the fact that there exists in the bronchial tubes some
obstacle to the free transmission of air to the cells beyond : it is a
forcible expiratory act, called into exercise to remove the cause
of the obstruction. It is reasonable to suppose that if the air cells
beyond become unfit for aeration, and the venous blood is no

* In some cursory notes on the thoracic inflammations in the European General
Hospital, presented by me to the Medical and Physical Society in May 1845, and
published in No. 6 of the "Transactions," the following remarks are made: — "Pneu-
monia is certainly a disease of infrequent occurrence in Bombay ; but it may not be
altogether misplaced to remark here, that partial and circumscribed pneumonia is by
no means a rare complication of the fevers to which natives are liable in the cold
season in the Deccan, and I believe in Guzerat. If the febrile symptoms persist
without intermission for two or three days, if the skin be dry, the tongue not furred
to the extent that might be expected, where the digestive organs are much deranged ;
then a careful stethoscopic examination will probably detect the existence of crepitous
rale in some part or other of the chest — most frequently in the neighbourhood of the
mammary region ; and this may be when there has been no complaint of pain, no
cough, and attention has not been called to any difficulty of respiration. In these
cases, attentive observation will detect an altered expression of countenance, not amount-
ing to anxiety, but which probably marks the implication of some important organ.
The person feels ill, but seems unable to explain to another the nature of his feelings ;
the body is inclined forwards, the lips are dry and parted, the respiration is somewhat
hurried, but often not more so than a general and uncomplicated febrile condition might
explain. The stethoscope wiU resolve the doubt, and the free use of tartar emetic,
combined with blood-letting, general or local, and blisters, according to circumstances,
wiU, if the disease has not been allowed to go too far, eiFect a cure, and prove the
accuracy of the diagnosis." These remarks were grounded on what I had seen of the
diseases of natives in former periods of my service in the Deccan, and on the Maha-
buleshwur Hills. My experience since in the Jamsetjee Jejeebhoy Hospital has cor-
rected my error in regard to the infrequency of pneumonia in Bombay. But my chief
object in reverting now to what I had previously written is, that I may have the oppor-
tunity of observing, that though there is nothing in my experience since at variance
with the tenor of these remarks on the obscurity and importance of febrile pneumonia,
yet we ought not to lay much stress on general symptoms such as those I have
detailed. In treating the malarious fevers of the natives of India, percussion and
auscultation of the chest should be invariably practised Tvith daily regularity. It is a
practical rule quite as important in the management of this class of disease, as the
search for the signs of pericarditis and endocarditis is in the course of acute rheuma-
tism. He is a careless observer of disease who finds himself taken by surprise by the
discovery of pneumonia in remittent fever, or pericarditis in acute rheumatism.

SYMPTOMS. 533

longer sent to them, but, instead, to the healthy adjacent cells, — •
then any obstruction existing in the tubes leading to the imper-
vious cells is no longer the same evil as when the cells were
efficient and blood was sent to them for aeration : hence there is
no longer the same demand for cough to clear them. The solidified
lung in pneumonia is in the state just described, and such seems
to me the best explanation of the little urgency of the cough in
this disease.

Delirium was observed in eleven cases. This symptom, when
present in primary pneumonia, occurs in the advanced stages : it
is of very unfavourable import. It was observed in three cases of
the primary form : they were all fatal, one with pneumonia of the
upper part of the left lung in the third stage with cavities, the
other two were double pneumonia in the second stage.

The remaining eight cases in which delirium, generally associated
with some degree of drowsiness, was noted, were of the febrile
form: in four there was recovery, and in four death. Therefore
this symptom, more particularly when occurring early in the
disease, and when not attended with adynamic phenomena, is
not of the same unfavourable import in febrile as in primary
pneumonia.

The character of the sputa, — The rusty adhesive sputa charac-
teristic of pneumonia were noted in only seventeen cases, — twelve
primary, and five febrile ; of these fourteen were recoveries, and
three proved fatal. In the other cases the sputa were untinged,
mucous, and more or less adhesive ; in a few cases none are re-
corded.

In seven cases red muco-puriform sputa are stated to have been
present : they were all of the primary form. Four proved fatal,
and in all of them there existed cavities in the lungs ; in two,
verified by post-mortem examination, but in two not examined
after death, cavities were believed to have been present, in conse-
quence of cavernous respiration having been recognised during
life. In three the patients were discharged: they were cases in
which hectic had been present ; in one there was no improvement of
the lung, but in two some degree of improvement had taken place.
In none of the three were cavities suspected to exist. From these
cases, then, and from another to which I shall presently advert,
the appearance of this character of sputa does not necessarily indi-
cate the existence of cavities in the lungs.*

•

* This is the red-tinged muco-puriform sputa, to which I have already alluded in
my remarks on hepatic abscess, as occurring in states of asthenic pneumonia, and

21 21 a

534 PNEUMONIA.

Physical signs. — It is unnecessary that I should enlarge on a
subject now so well understood as the physical signs of pneumonia.
The accuracy of the statement relative to the stage of the disease
on admission, and the state of the lung on discharge, depends
on these signs. On this point I would merely observe, that ab-
normal dulness on percussion, bronchial respiration, with some de-
gree of crepitus in the adjacent parts, and presence of vocal thrill,
were the signs held to indicate the existence of the second stage ;
while disappearance of the abnormal dulness, and replacement of
bronchial by vesicular respiration (even though the latter continued
somewhat feebler than on the sound side) have been held to signify
that the lung had become restored to functional fitness.

There is one caution which it may be useful to make. The
frequency with which enlargement of the spleen is met with in
India, makes it necessary that we should be careful not to mistake
abnormal dulness of the left dorsal region, caused by it, for dulness
from hepatisation of the lung.

Section V. — Treatment — General and Local Blood-letting,
Tartar Emetic, Mercury, Blisters, Quinine, Liquor Potassce,
Stimulants. — Concluding Remarks.

General blood-letting was held to be expedient in only three of
the 103 cases of pneumonia which form the subject of my present
remarks, and even in these it was adopted to a very limited ex-
tent. This fact shows clearly the general character of the consti-
tution of the persons affected, and the stage of the disease at
which they usually came under treatment. It is not to be ex-
plained on the supposition that I entertain peculiar views in re-
gard to the unsuitableness of general blood-letting in the treat-
ment of inflammatory disease. On the contrary I entirely agree
with those who think that a pulse above the natural frequency,
full and firm, associated with increased heat of skin, and co-exist-
ing with inflammation of an important organ, indicates the pro-
priety of general blood-letting. But we, at the same time, cannot
impress too firmly on our minds, that these are conditions of the
pulse which co-exist only with the early stages of inflammation in
individuals of sthenic constitution. Whilst thus, then, expressing
my belief in the efficacy of general blood-letting in appropriate

which is not to be distinguished, I believe, from that which I formerly considered to
be pathognomonic of hepatic abscess having opened into the lung. I would refer the
reader to those observations (p. 383).

TREATMENT. 535

circumstances, in the treatment of inflammatory disease, I am un-
able to concur in those views which regard it as a remedy ^peculiarly
appropriate in pneumonia. The opinion that blood-letting may be
carried to a greater extent in pneumonia than in other inflamma-
tions, rests, it may be supposed, on the observation of the great
relief to the dyspnoea which generally follows the loss of blood ;
and on the inference that this relief may be received as proof that
there has been a corresponding improvement in the inflamed lung.
Such an inference, however, may surely be erroneous. Dyspnoea,
as already explained, depends on a want of just proportion between
the quantity of blood in the vascular system, and the extent of the
pulmonary aerating surface. In pneumonia the extent of that sur-
face is lessened ; more blood is sent to the healthy part of the lung,
and dyspnoea results. By reducing, by venesection or other means,
the amount of blood circulating in the system, we necessarily re-
lieve the dyspnoea. But this may have been effected without any
improvement in the state of the inflamed part. Indeed, it is dis-
tinctly stated by Dr. Alison *, as a result of his clinical observa-
tion, that auscultation may indicate a continuance and even an
extension of the disease for a considerable time after the breathing
has been efl'ectually relieved by blood-letting. Let us admit, then,
that blood-letting in pneumonia may afford relief on two distinct
principles : one common to it with other inflammations, the other
peculiar to itself, and related to the function of the organ. But it
by no means follows on this account that the rules for its use
should in any respect differ from those which obtain in inflamma-
tion generally. Blood-letting, within certain limits, is a valuable
therapeutic means in certain states and stages of inflammation.
Carry it beyond these limits, use it in other states and stages of
inflammation, and it becomes injurious. This principle is equally
true of pneumonia as of other inflammations. When the circum-
stances, as indicated by the pulse and skin and stage of disease, are
inappropriate, we may not use blood-letting in pneumonia merely
to relieve dyspnoea : this would be the mere palliation of a
symptom, purchased by increasing the tendency to death by
syncope. It would be as if in idiopathic fever complicated with
diarrhoea and stupor, we were to give full opiates and check the
former, wdth the certainty of increasing the tendency to death by
coma.

The statement made, with the view of inculcating free blood-

* " Outlines of Pathology," p. 281.

M M 4

536 PNEUMONIA.

letting, by Andral*, and repeated by Dr. Watson f, that it is
useful in pneumonia on the principle applicable to all inflamma-
tions, and also on the principle in accordance with which the
exclusion of light is useful in ophthalmia, and rest in an inflamed
joint, is, I apprehend, in its latter part, of very doubtful accuracy.
If the opinions which I have ventured to express in a former part
of this chapter be correct, viz., that after the affected pulmonary
cells have, for a time, been the seat of inflammation, they become
unfit for function and no longer exercise it ; then blood-letting can
do no good to them, by relieving them from function, as the exclu-
sion of light and attention to rest do to the inflamed eye and
joint. It does good to the healthy cells by relieving them of part
of that excess of function which they had been required to assume.
But the only way in which the loss of blood can be of use to the
affected cells is by lessening the inflammation, in the way in which
other inflammations are lessened by the same means. The benefit
thus gained is augmented, not by the repose of these cells, but by
the resumption of function on their part setting the blood in their
pulmonary capillaries again in motion.

Local blood-letting. — Though there has been more scope for
the use of local than general blood-letting in these cases, still the
application of this means has also been limited in degree : not so
much as regards the proportion of instances as the extent to which
it was considered expedient to carry it.

In twenty-one of the cases cupping was used; in thirty-six,
leeches were applied. We have, then, an aggregate of fifty- seven
cases in which local blood-letting was practised : of these forty-six
recovered.

The total admissions within the fifth day from the commencement
of illness were twenty-two. Of these twenty recovered ; and in all
of them local blood-letting formed part of the treatment.

Between the sixth and tenth days there were thirty-four admis-
sions. Of these, twenty-six recovered : local blood-letting was used
in eighteen of them.

But if we confine our attention to primary pneumonia, this latter
statement gives too favourable an estimate of the success of treat-
ment. Of the twenty-six recoveries between the six and tenth days,
eight were of febrile pneumonia ; and I have already observed, that
though the fever had been of that duration on admission, the
pneumonia w^as probably of more recent origin.

* " Clinique Medicale," vol. ii. p. 378.

t "Lectures on the Principles and Practice of Phj-'sic," vol. ii. p. 91, 3rd edition.

TREATMENT. 537

From these data, then, we are justified in concluding that
when pneumonia is seen within five days, or a little over it, even
in the classes to which the inmates of this hospital belong, local
blood-letting to some extent is an appropriate and efficacious
remedy.

Of the forty-six recovered cases in which local blood-letting
was used, there remain eight admitted above the tenth day of
illness.

Of the eleven fatal cases in which there had been local blood-
letting, three were admitted between the sixth and tenth day, and
eight above the tenth day, dating from the commencement of
illness.

It appears, that of forty-seven cases of pneumonia admitted
after the tenth day, local blood-letting was had recourse to in six-
teen. Of these forty-seven cases, twenty-five recovered, and local
blood-letting had been used in eight of them. We find, then, that
for pneumonia admitted after the tenth day, the scope for local
blood-letting is very limited ; for even in those for whom at the
time it seemed admissible, there were as many deaths as recoveries.

The principles which have been observed in directing local
blood-letting have been the symptoms and signs of pneumonia
existing with that condition of pulse and skin which, on general
therapeutic principles, justifies the use of this means.

To those, who, by clinical experience, have yet to become fami-
liar with the varying conditions of the pulse and their indications,
it may be said that in the natives of India, generally, we are not
likely to meet with the state of pulse and skin which indicates
local blood-letting, co-existing with a primary pneumonia of
upwards of ten days' duration.

Tartar emetic. — We have found that in these cases there was
little opportunity of practising general blood-letting. There has
been also, and for the same reasons, little opportunity of giving
tartar emetic in free doses. I am, however, from former experi-
ence, perfectly sensible of its efficacy in suitable cases.

This remedy, however, has been used to some extent * in sixty-six
of the cases : of these, forty-nine were recoveries, and seventeen
proved fatal.

Thirty-three of the recoveries were admitted under ten days'
illness, and in twenty-four of them local blood-letting had also been
used. Sixteen were admitted above ten days' illness : in five of

* From a sixth to half a grain every second, third, or fourth hour.

538 PNEUMONIA.

these tartar emetic was given alone, and in eleven it was combined
with quinine.

It may be inferred then, from these statements, that in many of
the recovered cases for which local blood-letting was considered
appropriate, the moderate use of tartar emetic was also held to be
indicated, and that it assisted the cure. That in some, in which
local blood-letting was had recourse to, tartar emetic was omitted,
either in consequence of co-existing gastro-enteric irritation,
or from the treatment with mercury having been preferred.
Further, that in some cases, for which local blood-letting was not
considered appropriate, tartar emetic was used, generally in
combination with quinine, on a principle to be subsequently
explained.

The principles which have been stated relative to local blood-
letting, may be also applied to this moderate use of tartar emetic,
viz., that those states of pulse and skin and symptoms, which
indicate the propriety of local blood-letting, justify the use of tartar
emetic, provided it be not contra-indicated by the presence of an
irritable state of the gastro-intestinal lining. But we may probably
go further than this, and say that, if we are careful to guard against
the tartar emetic causing increased evacuation from the bowels, we
may use it in instances of pneumonia with febrile disturbance, in
which the small volume and compressibility of the pulse are such
as to contra-indicate local blood-letting or other evacuation. We
may act thus because, by this cautious use of tartar emetic, we are
not adding directly to the asthenia ; and if by its use we can
reduce the degree of febrile disturbance, we thereby certainly lessen
an influence which tends rapidly to induce asthenia.

Mercury. — Calomel and opium were given with the view of
inducing mercurial influence, in twenty-one cases. Of these, twenty
were of the primary form, and the following remarks have exclu-
sive reference to them.

Fourteen were recoveries, six proved fatal. The constitutional
effect of mercury was produced in eleven of the recovered cases,
and in two of the fatal ones. In the remaining seven it was neces-
sary to omit the remedy, from some cause or other adverse to its
continuance. The cases in which mercury was used were in the
second stage of the disease. In the fourteen recovered cases,
seven were admitted within five days from the commencement
of illness, five between the sixth and tenth day, and two after the
tenth day.

TREATMENT. 539

Of the eleven recovered cases in which mercurial influence was
induced, there was complete restoration of the lung in seven ; but
in four only improvement. Of the seven restored cases, four were
admitted within five days, and three between the sixth and tenth
day. Of the four improved cases, two were admitted within five
days, and two above that period.

Let us now take eight of the cases in which mercury was used,
and regard them from another point of view. In three the com-
mencement of improvement in the lung was coincident with the
tenderness and swelling of the gums. In three the improvement
of the lung distinctly took precedence of the usual indications of
mercurial action. In two there was no improvement.

Let us now follow the six fatal cases in which mercury was given.
The two, in which mercurial influence was induced, had been ill
for upwards of twenty days before admission: in one of them
dysenteric symptoms with hectic fever came on, and in the other,
hepatitis ending in abscess. Of the four other fatal cases in
which it was necessary to discontinue the mercury, three were
admitted between the sixth and tenth day, and one within five
days.

Let us now address ourselves to the question, whether this series
of cases affords evidence favourable to the mercurial treatment of
pneumonia.

Of the seventy-one cases discharged from hospital, the lung was
restored in forty-nine, and improved in fifteen. Of the restored
cases seven had been brought under the influence of mercury, and
forty-two had been cured without it ; and of these latter cases thirty-
seven had been admitted in the second stage. Of the improved
cases, in eleven the improvement was effected without mercmy ;
they were all in the second stage.

It may, however, be objected to this statement that the febrile
cases have been included, while, with one exception, mercury was
only used in the primary form.

Let us exclude, therefore, from the discharged cases admitted
in the second stage those that were of the febrile form, and there
will remain twenty-five cases of restored primary pneumonia,
with eighteen of them cured without mercury ; and of improved
cases thirteen, with nine of them without mercury. Further,
let us recollect that, of the seven cured cases in which mercurial
influence had been induced, in three the improvement in the lung
commenced before the usual evidence of the action of mercury had

540 PNEUMONIA.

appeared ; it may, therefore, be argued that the improvement was
independent of this remedy.*

From a careful consideration of these facts, it must be acknow-
ledged that in these cases there is little evidence of the therapeutic
value of mercury in the treatment of pneumonia. But because
we have found little proof, in a particular field of practice, of
the advantage of this agent, it by no means follows that it may
not be expedient and useful under some circumstances of the
disease. These cases have borne no testimony to the efficacy of
general blood-letting, or the free use of tartar emetic, but the
utility of these means in suitable instances has not on this account
been called in question. Nor may we doubt the advantages
to be derived from mercury when the conditions are appropriate
for its use. It is most important that we should endeavour to
determine the states of pneumonia in which mercury is likely
to be beneficial, in order that we may have recourse to it only
in these, and abstain from it in those for which it is unsuitable
and injurious.

For the treatment of sthenic pneumonia in its first stage, or as it
begins to pass into the second, general blood-letting and the free use
of tartar emetic are, I apprehend, the appropriate remedies, because
we are almost certain, under such circumstances, of finding the full
and firm pulse, and the increased heat of skin, which indicate the
propriety of these measures. But when the disease has gone on,
and passed into the second stage, or has come under treatment
at this period, then, in addition to the degree of local blood-
letting and of tartar emetic indicated by the state of the pulse
and skin, we should give calomel and opium in such manner as
shall most safely effect a gentle mercurial influence. But when
the failing volume and strength of pulse, and reduction of the
temperature of the skin, indicate a deficiency of blood, and a
feebly acting heart, then, whether this state be consequent on
long duration of the disease, or on too antiphlogistic treat-
ment in a constitution originally sthenic, or co-exist with the
earlier stages of the disease in a constitution originally asthenic,
we must abstain from the use of mercury, because in this
condition of the blood, and of the heart, it will increase
the exhaustion : instead of favouring the removal of lymph-

^ This argument has been generally used, but its force may be doubted. There is
nothing unreasonable in assuming that the mercury may have influence on the blood
and the diseased action which it is intended to remedy before it has been carried
to the degree of causing tender and swollen gums.

TREATMENT. 541

deposits, mercury will favour their degeneration into pus or
sero-pus.

If I were asked to state a rule on this point of practice which
might be applied to clinical purposes, I should be disposed to
say that calomel and opium should only be given in the second
stage of pneumonia, in addition to tartar emetic; but that
when the pulse and skin contra-indicate the use of tai'tar
emetic, mercury is also contra-indicated. In sthenic pneumonia
it will be found, that after the tenth or twelfth day this
remedy will no longer be appropriate; while, for the asthenic
form, it is altogether unsuitable. It not only increases the
asthenia, and favours softening or gangrene of the indurated
lung, but the calomel and opium are very apt to cause irrita-
tion of the intestinal mucous lining, and lead to dysentery
or diarrhoea : this is a most unfortunate complication of asthenic
pneumonia, and ought most carefully to be guarded against. The
result in several of the fatal cases of this series was hastened by
exhausting diarrhoea.

For the treatment of the second stage of the febrile form,
mercurial action is most inexpedient. We have, as I shall pre-
sently show, a more powerful agent in the sulphate of quinine. '

Blisters, — Blisters have been used in eighty-two cases ; of these
fifty-two recovered. It appears, then, that this remedy has been
had recourse to in a greater number of cases than any other of the
means which have been noticed. This has occurred, because
blisters are applicable to a greater variety of circumstances, — to
the more advanced stages of those cases in which local blood-
letting and antimony have been used, as well as to those for which
these means have been considered inappropriate.

This greater experience of the use of blisters might seem to
justify a positive opinion on their therapeutic value; but such
is not the case. It is difficult to come to a satisfactory con-
clusion on this point of practice. They are used in those more
advanced stages of disease in which we cannot look for marked
and speedy improvement from any remedies, and in which
we must be satisfied with steady, progressive, though slow
amendment. When the stage of pneumonia suitable for local
blood-letting has passed, blisters may be had recourse to with
some prospect of advantage. If applied too early in the disease,
they are apt to re-excite febrile disturbance and to be injurious.
If used in very asthenic states, they are sometimes followed by
troublesome ulceration, and the continued imtation thus arising

542 PNEUMONU.

does harm, by increasing the asthenia. For these reasons, then,
we must be cautious. The blisters in these cases have never been
larger than four inches square. The liquor lyttae has been the
preparation generally selected.*

Quinine, — The sulphate of quinine has been given in fifty-
six cases: of these thirty-seven were primary and nineteen
febrile ; of the former twenty-seven were recoveries, of the latter
fifteen.

In the treatment of febrile pneumonia, in addition to the local
blood-letting, tartar emetic and blisters, which the symptoms may
justify, quinine should be given in adequate doses during the
rennission. It may be combined with tartar emetic. From five to
eight grains of quinine, with from one-sixth to one-fourth of a
grain of tartar emetic, given at intervals of two or three hours for
five or six doses, will, in general, suffice to check and then stop the
febrile recurrences. When this effect on the febrile symptoms has
been produced, it will generally be found that improvement in the
pneumonia will at once commence; and in a large majority of
cases, if the recurrence of the febrile state be prevented for some
days, the inflammation of the lung will be speedily removed. That
this is a therapeutic fact I am satisfied from the observation of
many cases. Indeed, I am not acquainted with anything more
striking and satisfactory in the whole range of rational therapeutics
than the progressive but speedy restoration of a hepatised lung,
co-existing with fever of remittent type, when the exacerbations
have been controlled by the adequate use of quinine. It is true
that small local detractions of blood, the application of small
blisters, and the use of quarter-grain doses of tartar emetic, have
been generally used at the same time ; but it is quite impossible
for any one familiar with, disease, and the action of these means
in these degrees, to attribute the benefit chiefly to them, and
not to the prevention of the febrile exacerbation by the quinine.
But this is merely another illustration of a therapeutic principle
already explained, and inculcated in the chapters on intermittent
and remittent fever.

The same principle of treatment has been also applied to many
of the cases of primary pneumonia in asthenic subjects.

In my remarks on ^' Symptoms," I stated that the symptomatic
fever of primary pneumonia in asthenic natives is not unfrequently

* Though confining my observations to blisters, I by no means undervalue other
derivants, as turpentine, sinapisms, dry cupping, and water compresses. The last appli-
cation may be used with advantage in all stages.

TREATMENT. 543

distinctly remittent in type, and it seemed to me reasonable to
assume that it became so in consequence of the operative influence
of malaria. Actuated by these views I have latterly, in all cases
in which the remission was well marked, given quinine in com-
bination with antimony, in the same manner as in the febrile cases,
and very frequently with the same good effect ; though I think that
the improvement in the lung has taken place more slowly. It is
nevertheless true, that in some of the cases in which even the
remission has been well marked, we have met with disappoint-
ment ; the quinine failed to control the exacerbation. When this
occurs the remedy must be omitted, and the other usual means
appropriate for the case be trusted to.

Liquor potassce. — Some years since my attention was called to
the use of liquor potassse as a deobstruent remedy in the second
stage of pneumonia.* It has been used by me in many cases for
which mercury was considered unsuitable. It was given in doses
of from half a drachm to one drachm and a half every third or
fourth hour in ten of the recovered cases of this series, and was in
general continued for several days. In some the proportion of
liquor potassse was diminished, and from six to ten grains of ses-
quicarbonate of ammonia were added, when the state of the pulse
indicated the propriety of a stimulant. The general impression
left on my mind was favourable to the use of liquor potassae ; but
this impression has not been confirmed by a careful consideration,
not only of this series of cases but also of all other hospital cases in
which it had been used. I can only find two, and they are not
satisfactory, in which quinine on the principle just explained was
not at the same time given. Being already satisfied of the thera-
peutic value of quinine in appropriate cases, I cannot feel sure of
that of the liquor potassae, when the two remedies have been given
at the same time. Further careful clinical observation is therefore
necessary to satisfy me of the deobstruent efficacy of liquor
potassae in the second stage of pneumonia. The same remark
may be made of the internal use of iodide of potassium, and the
external application of the compound iodine ointment. I have
had recourse to both on several occasions, but am unable as yet
to offer any opinion on their utility.

Stimulants. — There often comes a period in the treatment of
pneumonia, and it may arrive very early in the asthenic form,

* I mucli regret that I am unable to refer to the publication in which the liquor
potassae was recommended. I omitted to make a note at the time, and I have been
unsuccessful in my search for it. It was in one of the periodicals.

544 PNEUMONIA.

when the failing pulse, the lowered temperature of the skin, and
the feeble expectorating efforts indicate the necessity for stimu-
lants. The earliest tendency to this must be watched for, and
stimulants be freely and assiduously given. The sesquicarbonate
of ammonia with tincture of squills, wine, and arrack, are the most
useful. At the same time chicken broth or beef tea must be
frequently administered; and sinapisms or warm turpentine applied
to the chest. By these means, if adopted in good time, cases
which appeared hopeless have been occasionally saved, more espe-
cially in youthful subjects.

Concluding Remarks, — In the review of these cases it has been
found that a large proportion of them came under treatment in the
second stage of pneumonia, and that when the disease was confined
to part of one lung, the rate of mortality was 17 per cent. I am
not acquainted with other recorded data exactly similar with
which to compare these results. But the impression on my mind
previous to my service in the Jamsetjee Jejeebhoy Hospital had
always been that pneumonia in the second stage was a more fatal
disease.

If, on the whole, success has attended the management of these
cases, it is very expedient to endeavour to explain all the principles
in accordance with which it has been directed. In a previous part
of these remarks I have stated, that in many of the cases a con-
siderable time was required for the restoration of the lung ; and
that in many the cessation of the febrile symptoms and the relief
of cough and dyspnoea, were not at once followed by lessening of
the signs of consolidation of the lung, but that several days elapsed
before this began to appear. The efficacy of local blood-letting, of
tartar emetic, of occasional mercurial influence, of blisters, and of
quinine, has been acknowledged, and an endeavour has been made
to explain the principles on which these remedies have been re-
spectively used. But we do not find in these principles anything
that provides for the management of that period in the course of
the disease when there is persisting consolidation of the lung, with
little or no febrile disturbance, and little or no cough or dyspnoea,
yet I am satisfied that it has been on the proper treatment of this
condition of the disease that the successful issue of many of these
cases has depended. If so, then, it is necessary that I should ex-
plain what the nature of this treatment has been, and the principles
on which it has been conducted. In this state of the disease, the
pulse will be found to be of small volume, and easily compressed

TREATMENT. 545

This character of the pulse, with absence of febrile * disturbance,
at once indicates the appropriate method of cure. Antiphlogistics
of every kind, especially mercury, should be abstained from ; and
the tonic regimen and remedies best fitted gradually to increase
the quantity of blood, improve its condition, and strengthen the
action of the heart should be used. A light nutritious diet with
suitable stimulants, pure air, nitric acid, quinine, and preparations
of iron, are the means most suitable.

That at different periods in the history of medicine there have
been great errors in practice, is a truth which, with a view to future
improvement, we are bound to keep steadily before us ; and perhaps
no better illustration can be found than the wavering principles
which have characterised the practice of medicine during the
last twenty years and more. Those of us who were familiar with
practice at the commencement of this period must have wit-
nessed the destructive freedom with which antiphlogistic remedies
were not unfrequently applied ; and must be sensible that there
then was a very general disregard of tonic means.

WTnen, on the other hand, we turn our attention to the present
state of practical medicine, we may discern a tendency to commit
the opposite error — to neglect antiphlogistic remedies and to
misapply tonics and stimulants ; to lose sight of great leading prin-
ciples, and to act too much under the guidance of a fragmentary,
and as yet very imperfect, knowledge of animal chemistry.

If this be true, it is peculiarly the province of those who have
practised during this period of vacillation and uncertainty, — who
have witnessed the advantages of the judicious use, and the evils of
the abuse, of antiphlogistics and tonics, — to endeavour to hold
the balance true between these two leading therapeutic principles,
by stating the impressions which these varied opportunities may
have left upon the mind.

Considerations of this nature induce me to explain, more
fully than may seem necessary, my reasons for attaching so much
importance, in certain states of pneumonia, to the decided inter-
mission of antiphlogistic, and the substitution of tonic treatment.
The principles which I am about to state are applicable, more or
less, to all inflammations.

It may be confidently affirmed, that when a tissue is inflamed, a

. * I have not thought it necessary to notice those cases in which, with continuance
of consolidated lung, we have hectic fever coming on, not cessation of the febrile dis-
ttirbance. Such cases must be managed on the ordinary piinciples observed in the
treatment of structural disease and co-existing hectic fever.

N N

546 PNEUMONIA.

leading aim in its cure is the maintenance of a normal state of the
capillary circulation in the structures around. It matters not
whether the restoration is to consist merely in stagnating blood
being again set in motion, or in serous or lymph effusions being
absorbed, or in the organisation of lymph, or in the change of
lymph into pus with organisation of a bounding sac and processes
for the evacuation of the pus and the after reparation of the ab-
scess, or in the granulation and cicatrisation of ulcers. Which-
ever of these actions must be gone through before the inflamed
structure can resume its state of integrity, it should be a main
object in the management of all to bring about and maintain a
normal quantity, quality, and rate of movement of the blood in
the capillaries around and in the general vascular system. If
there be symptomatic fever, with a pulse full, firm, and frequent, —
the quantity, quality, and rate of movement, of the blood in the
capillary system are abnormal, and our means of correcting this
derangement are blood-letting and other antiphlogistic remedies.
But when the pulse becomes soft and of moderate volume, im-
provement in the inflammation by general antiphlogistic treat-
ment will cease, for under its use the pulse will become small and
compressible, indicating a quantity, quality, and rate of movement
of the blood in the capillaries around the inflamed part and in the
system generally, as adverse to restoration, by whatever processes
it is to be effected, as the opposite conditions of sthenic sympto-
matic fever : under these circumstances of inflammation we cannot
hope to do good, unless our regimen and remedies be decidedly
tonic.

These may seem very narrow principles, yet they are very useful
in practice. They may seem trite and simple, yet they are often
lost sight of under the seductive influence of transcendental theories,
inapplicable in the present state of the science. But, after all,
they reach further than at first may appear.

In the state of pneumonia to which reference is now being made,
mercury is an injurious deobstruent, for it spoils the quality and
lessens the quantity of the blood. But it is probable enough that
a deobstruent may yet be discovered free from this defect, and
therefore applicable to the treatment of this kind of consolidation
of the lung ; still a tonic influence on the blood, and on the heart,
must be a leading indication of cure, for unless there be an adequate
capillary circulation immediately around the deposits, there can be
no absorption from the influence of any deobstruent. Again, the
idea that many inflammations are dependent on a materies morhi

STATISTICS.

547

in the blood is gaining ground as a pathological theory — very pro-
bably a true one ; if so, its elimination by the excreting organs may
become a chief object in the treatment. Still the maintenance of a
normal state of the capillary circulation by antiphlogistics or tonics,
as the case may be, must always be a leading aim, for without it we
can have no adequate action of the excreting organs, and conse-
quently no sufficient elimination from the blood. It would be easy
to multiply illustrations in proof, that whatever special therapeutic
indications may in after times arise in the treatment of particular
forms of disease, based on physiological or chemical facts as yet
undiscovered, there must always be the over-ruling principle of
maintaining, as far as practicable, a normal condition of the blood
and a sufficient capillary circulation general and local. This we
must endeavour to effect, in some forms of disease by antiphlogis-
tics, in others by tonics ; the state of the pulse, and of the general
system, determine the question.

Section VI. — Statistics of Pneumonia.

Table XXXV. — Admissions and Deaths, with Per-centage, from Pneu-
monia, in the Jamsetjee Jejeehhoy Hospital at Bombay, for the Six Years
from 1848 to 1853.

1848 to 1853.

Monthly Average.

Admissions.

Deaths.

Deaths on
Admissions.

Admissions
on total Ad-
missions.

Deaths on

total Deaths.

January

40-0

1-4

2-7

February

25-6

2-1

3-1

March .

531

1-5

4-4

April .

38-1

0-9

2-4

May .

51-9

1-2

4-8

June .

26-1

1-9

July .

•■^

55-5

0-4

1-6

August .

38-9

0-9

September

38-1

1-01

2-5

October

51-8

1-3

4-4

November

12-8

1-4

1-2

December

45-5

1-4

3-8

Total .

313

121

38-6

1-2

2-9

N N 2

548 PLEURITIS.

CHAP. XXII.

ON PLEUEITIS, BRONCHITIS, AND ASTHMA.

Section I. Pleuritis. — Symptoms, Causes, Fathology,
Treatment

Inflammation of the pleura is more common than that of the sub-
stance of the lung, because pneumonia seldom occurs without
co-existing pleuritis, and simple pleuritis is not an unfrequent
disease.

The admissions of pleuritis in the European Greneral Hospital
for the ten years, from 1844 to 1853, amounted to sixty-eight, with
one death, whereas those of pneumonia did not exceed twenty-two,
with two deaths. The admissions of pleuritis into the Jamsetjee
Jejeebhoy Hospital during the six years, from 1848 to 1853, were
sixty-one, with nineteen deaths, a mortality of 31*2 per cent. The
cases treated by me in the clinical ward during the same period,
numbered twenty-five, and the deaths seven. The admissions of
pneumonia into the hospital and the clinical ward, during the same
period, were respectively 313 and 103. These data would suggest
that, in Europeans in India, pleuritis is more common than pleuro-
pneumonia, but that in natives the converse obtains : they
are, however, too limited to justify a general inference of this
kind.

The following brief observations have reference to the twenty-five
cases which formed a subject of study in the clinical ward. They
are arranged under the heads. Symptoms, Causes, Pathology, and
Treatment.

Symptoms. — In cases admitted after the occurrence of pleuritic
effusion jpam was not usually complained of; but inquiry into the

SYMPTOMS— CAUSES, PATHOLOGY. 549

history generally led to the conclusion that this symptom had been
present at the commencement of the attack. Impaired respira-
tory movement of the affected side was noticed in all.

A distinct friction murmur was observed in ten cases. Its
most common situation was about the inferior angle of the scapula,
or in the lateral region. In eight the murmur was primary : I do
not mean that it occurred in that early stage which precedes
effusion, but that from the period of the disease and the degree
of co-existing dulness, it was judged not to be a redux friction
murmur. The redux murmur was noted in three cases : in two
it had not been present on admission, but had appeared as the
lessening dulness indicated absorption of the liquid effusion ; in the
third, the murmur was primary on admission, disappeared with
increasing effusion, but again reappeared in association with in-
creasing absorption. CEgophony was recorded in only one case of
pleuritis consequent on fracture of a rib. Bronchial respiration
was noticed in relation to the degree of effusion. Dulness on per-
cussion— more or less extensive, more or less complete — was
observed in every case. In some the shifting character was present,
in others it was absent. Defective vocal thrill generally co- existed
with the dulness.

In cases in which the effusion was considerable, the size of the
affected side was notably increased. In two of this class the
absorption of the fluid was followed by distinct contraction. In
the cases in which the effusion was in the left side — displacement
of the heart, in those of the right side — displacement of the
liver was noticed.

Causes. — Cold was doubtless the ordinary exciting cause. In
some, however, the affection was attributed to blows received in
squabbles, and in two to a strain while working. In two the
inflammation had probably depended on peculiarity of diathesis;
in one who had suffered from syphilitic rheumatism, all the cha-
racteristic physical signs were present, and recovery took place ; in
the other, cachectic from intermittent fever and long the subject of
diarrhoea, the bowel complaint was checked, pleuritis of the left
side with effusion, dulness, absence of vocal thrill, and displacement
of the heart, took place, and was removed on recurrence of the
diarrhoea, but death resulted from exhaustion.

Pathology. — These cases show that when the constitution is
good, and the management careful, recovery may be expected
Bven though the physical signs have proved the existence, for
several successive days, of considerable effusion. The left side was

N N 3

550 PLEURITIS.

affected in fourteen cases, and the right in eleven. In none was
it distinctly double. The seven fatal cases, with one exception
already noticed, occurred in asthenic individuals, admitted in
advanced stages of effusion. In four a communication existed
between the effusion and the lung, as was proved in three by
examination after death ; in one by several small openings, in
another by a large opening into a gangrenous excavation, and
in the third by direct communication with the left bronchus.
In this last case there was also perforation by ulceration of
the second, fourth, and sixth intercostal spaces, with a fluctuat-
ing swelling in these situations, and partial absorption of the
costal cartilages. In that case, which communicated with the
gangrenous excavation, there was a second collection, the size of a
cocoa-nut, circumscribed between the base of the left lung and the
diaphragm. In the fourth case there was no inspection after death ;
but the character of the sputa, the tympanitic resonance on percus-
sion, and the amphoric respiration, had left no doubt that com-
munication existed between the lung and the pleural sac.

I have seen two cases of recovery by discharge of the contents of
a circumscribed pleuritic effusion through the lung. One, a Hindoo
lad, in whom, while under treatment for adynamic remitt^ent fever,
pneumonia of the lower part of the left lung, as indicated by
crepitus and bronchial respiration, took place. This was followed
by circumscribed effusi o of the upper part of the left side,
proved by great dulness and absence of breath-sounds, then, by
perforation of the lung, shown by the sputa, the tympanitic reso-
nance in the previously dull regions, and the presence of amphoric
respiration. There wa-s gradual and slow restoration to health, with
permanent dulness of the upper part of the left side, very imper-
fect breath-sounds there, but no cognisable difference in the appear-
ance of the two sides. The second case was of a young European
female, of tubercular diathesis, who, after obscure pectoral symp-
toms, suddenly expectorated a large quantity of fetid pus. At this
stage of the affection I saw this patient. There were no signs of
consolidation, or cavities, of the upper part of either lung. About
the inferior angle of the left scapula, passing into the lateral region,
there was defective sound on percussion for a limited space, and
no breath-sounds. I concluded, not that tubercular excavations
existed in the lungs, but that a circumscribed pleuritic effusion had
opened into the lung. The opinion given, that gradual restoration
to tolerable health would take place, was verified. The expectora-
tion gradually ceased ; and when next I saw this patient, several

TREATMENT. 551

years afterwards, there had been absence of pulmonic disturbance
for a long period.

The few cases which have formed the subject of these remarks,
suffice to prove that pleuritic effusion is not unfrequently circum-
scribed, and that a considerable extent of pulmonary surface —
generally its anterior part — may become adherent to the costal
pleura. The facts are important because they serve to qualify the
import, in diagnosis, of the situation and shifting nature of the
dulness, and the character of the breath-sounds.

Further, there are two cases before me in which the circumscribed
effusion existed between the anterior wall of the chest and the
anterior surface of the lung, and extended into the infra-clavicular
region, causing dulness and leading to the erroneous diagnosis of
tubercular phthisis.

Treatment — The principles of treatment in pneumonia are also
applicable to pleuritis. Local blood-letting, small blisters, and
tartar emetic were the antiphlogistic remedies used in those cases.
Mercurial influence was induced in only one, but without benefit,
for the dulness continued when the patient was discharged. In
cases in which, from the state of constitution and the duration of
disease, it is reasonable to conclude that the existing effusion is
serous and removable, it must always be remembered that absorp-
tion is improbable before time has been allowed for the circulation
in the capillaries of the pleura to return to a normal state, and for
the exudations to become organised into areolar tissue. Whilst
waiting with this view, small blisters or other mild derivants may
be applied to the affected side. The further general treatment,
whether antiphlogistic, expectant, or tonic, will depend upon the
state of constitution, as explained in my remarks on the treatment
of pneumonia. But at this stage diuretic remedies also may
be used with advantage. In several of the cases now under
review, the decrease of the effusion, consecutive on an increased
flow of urine by diuretics, was well marked. Acetate of potass,
nitrous ether, and tincture of squills, were the remedies used. In
cases in which, from diathesis, duration of the disease, extent of
effusion, and hectic symptoms, empyema has become probable, the
general treatment must be regulated in accordance with the
principles applicable to a similar condition of the system, how-
ever induced.

A special practical question arises in the treatment of pleuritis,
viz., whether the effused fluid should be removed by paracentesis
or not. On this point I am without experience. Dr. Barlow,

N N 4

552 BRONCHITIS.

in his instructive "Manual of the Practice of Medicine," thus
remarks on this question of practice : — "In short, the ob-
jections to the operation may be thus summed up : where it is
safe and likely to be successful, it is unnecessary, but where it
seems to be called for by the permanence of the effusion, it is
more dangerous and generally unsuccessful." In estimating this
opinion, it should be borne in mind that it is grounded on
experieiice in a field — Gruy's Hospital, — in which this operation has
been practised on an extensive scale. Dr. Barlow is careful to
enjoin, that when the operation is considered expedient, it should
be performed in the manner recommended by Dr. Hughes and
Mr. Edward Cock, and to which I have already referred in my
remarks on the puncture of hepatic abscess.*

Section II. — Bronchitis. — Asthma.

Bronchitis. — The admissions from bronchitis into the European
Greneral Hospital at Bombay during the ten years, from 1844 to
1853, have amounted to 223, and the deaths to fourteen, which
gives a mortality of 6*2 per cent, on the admissions, and shows that
the proportion of cases of this disease to the total sick treated in
the hospital has been, for this period, 1*77 per cent.

The number of sick from bronchitis in the Jamsetjee Jejeebhoy
Hospital for the six years, from 1848 to 1853, has been more than
double that from pneumonia. The admissions amounted to 707,
and the deaths to 57, a mortality of 8*07 per cent. The ratio of
cases of bronchitis to total hospital sick, has been 2*7 per cent.

On instituting, in respect to bronchitis, the comparison, pre-
viously made regarding pneumonia, of the relative portion of
admissions at different periods of the year, it will be found that
there has been a great uniformity throughout the year. For
example : the admissions, from December to May, were 366, and
the deaths 29 ; those from June to November, were 341 and 28.
The probable inference from this statement is, that the rainy season,
included in the second half year, is as efficient an exciting cause of
bronchitis as the cold months of the first half year.f

* Page 410.

t For seventeen years, from 1837 to 1853, the "tlioracic inflammations," doubtless
cTiiefly bronchitis, in the BycuUa Schools, amounted to 518 with two deaths. For the
half year from December to May, the admissions were 227 ; from June to November,
291 ; but the greatest number in one month was in May, 85, — whereas, the number
in January was 21. I am unable to offer any explanation of the excess in May. It
has, however, not been uniform, because 48 of the 85, were in the Mays of 1840, 1844
and 1853, and none in 1841, 1847 and 1852.

ASTHMA.

553

It is unnecessary to enter into questions of practical detail
relative to a disease so well understood. It is sufficient that the
practitioner applies to bronchitis in India the lessons of watchful-
ness and care, more especially in regard to young children, which
have been inculcated by European writers.

Asthma. — The term asthma has been used in its common
acceptation, to signify that pathological state compounded of varying
proportions of bronchitis, emphysema, and bronchial spasm. It is
sufficiently common in natives of India, more particularly in the
cold and wet seasons of the year. I have already * expressed my
belief that this disease is occasionally related to malaria as a cause,
and is then most successfully treated with quinine and preparations
of iron; and above all by a prolonged residence in a non-malarious
climate of suitable temperature.

Vesicular emphysema of the lungs is often present in great
degree, and is indicated by the well-known physical signs, of
altered form of the chest, increased resonance on percussion, faint
vesicular respiration with rhonchi, prolonged expiratory acts, dis-
placement of the heart and liver, accompanied with general

anaemia.

Section III. — Statistics of Bronchitis,

Table XXXVI. — Admissions and Deaths, with Per-centage, from Bron-
chitis, in the Jamsetjee Jejeehhoy Hospital at Bombay, for the Six Years
from 1848 to 1853.

January
February-
March
April
May
June
July
August ,
September
October
November
December

Total

184S to 1853.

Admissions.

Deaths.

707

Monthly Average.

Deaths on
Admissions.

Admissions

on total
Admissions.

7-6
5-4
7-4
9-1
8-7

10-2
7-9
4-6
6-1
6-6

12-5
0-9

3-1
2-9
31
2-6
3-1
2-3
2-5
2-2
3-2
2-6
3-3
2-3

8-07

2-7

Death on
total Deaths

1-1
0-9
1-3
1-4
2-1
1-6
1-3
0-6
1-3
1-2
2-7
1-3

1-4

* Page 66.

554 PHTHISIS PULMONALIS.

CHAP. XXIIL

ON PHTHISIS PULMONALIS.

Section I. — Causes, Symptoms, Pathology, and Treatment.

In stating the result of my investigations, I shall keep in view the
researches of Louis, and other European writers on this disease.

During fifteen years, from 1838 to 1853, the admissions of
phthisis into the European Greneral Hospital at Bombay, amounted
to 184, and the deaths to 79, a ratio of 0*93 per cent, on the total
hospital admissions, and 6*1 per cent, on the aggregate deaths.

The admissions of natives with phthisis into the Jamsetjee
Jejeebhoy Hospital, during the six years from 1848 to 1853, have
amounted to 445, and the deaths to 268, a ratio of 1-7 per cent.
on the total hospital admissions, and 6'5 per cent, on the total
deaths. But this statement does not fully represent the proportion
of phthisical disease in the inmates of this hospital. The remark
made at page 465, relative to the admissions registered under the
title " Cachexia " is applicable to phthisis pulmonalis, equally as to
Bright's disease. Seventy-nine cases of phthisis have been treated
in the clinical ward during these six years. Of these forty-two
proved fatal, and inspection after death was made in thirty-one,

I have also before me the reports of seventeen fatal cases, noted
during my service in the European Greneral Hospital, and already
published.* In my notes of 311 fatal cases of European officers in
the Bombay Presidency, phthisis was the cause of death in eight.

I shall arrange the brief observations which these data suggest
under the heads : — 1. Causes. 2. Symptoms. 3. Pathology. 4.
Treatment.

Causes. — The erroneous opinion, at one time, entertained of the
rarity of phthisis pulmonalis in tropical countries, has been long

* " Transactions, Medical and Physical Society of Bombay," Nos. 2 and 6.

CAUSES. 555

since corrected by the medical statistical reports of the British
army, and information from other sources. I have witnessed the
disease in Europeans, Indo-Britons, and in many of the Asiatic
races. WTiether the access of phthisis is usually postponed to a
later period of life in warm climates, is a question which existing
data are insufficient to solve. Of nine European seamen who died
in the European Greneral Hospital, seven were upwards of thirty
years of age, and one of them had attained the age of fifty-two.
Two European pensioners also died at the ages of fifty-three and
forty-nine. In respect to the eight fatal cases of officers; in three
the age was above thirty, in one it was twenty-three, in another
seventeen, and in three it is not recorded. The ages of seventy-
eight of the clinical cases of natives have been given ; four were
below twenty years of age, fifty-eight between twenty and forty,
fifteen between forty and sixty, and one upwards of sixty.

These facts probably tend to indicate a later development of the
disease in India than in European countries; but they are too
limited to suggest more than the expediency of further inquiry.

The admissions of phthisis into both hospitals have been pretty
equally distributed throughout the different months of the year,
with, however, a slight excess in favour of the half year from June
to November. For example, the admissions into the European
Greneral Hospital and the Jamsetjee Jejeebhoy Hospital, for the
half year from December to May, were respectively 82 and 218 ;
whereas, for the half year from June to November, they were 102
and 227. The inference that the rainy season is unfavourable to
the course of phthisis, which may be drawn from this statement, is
confirmed by a remark made by Dr. E. H. Hunter relative to the
effect, on the health of Her Majesty's 2nd Eegiment, of change
from Poena to Bombay, at the commencement of the monsoon of
1836. Dr. Hunter says "all the phthisical cases began rapidly to
decline as the moist weather set in, and all proved fatal in the
course of the monsoon." *

Whether malarious cachexia favours the development of tuber-
cular disease, is a question of interest; and tropical countries
necessarily afford the best field for its investigation. In seven of
the seventy-nine clinical cases, attacks of intermittent fever were
reported to have preceded the pulmonary symptoms, and in four
others the febrile disturbance which co-existed with the phthisical
symptoms was rather malarious than hectic in character. Still

* " Transactions of the Metlical and Physical Society of Bombay," No. 1, p. 23.

556 niTiiisis ruLMONALis.

these facts do not justify the supposition of a predisposition to
tubercular disease from malarious influence; for in the classes who
resort to hospitals in India, it is very likely that the admissions of
any other form of disease would evince evidence of the taint in a
proportion quite as great. Nor does my experience in India afford
any support to the opinion of Lancisi and others, that malaria is
preventive of pulmonary phthisis.

The data before me relate exclusively to males, and, therefore
do not show whether the greater prevalence of phthisis in females
than in males, established in respect to European countries,
obtains in India or not.

Symjptoms. — The general symptoms and physical signs of
phthisis in India do not present any peculiarities.* Haemoptysis
had been present before admission in seventeen of the clinical
cases, and it was observed in three during the time they were
under treatment. In one of them the haemorrhage was consider-
able in quantity, and took place very shortly before death. A cavity
with red-tinged walls was found at the apex of the right limg, and
another the size of a walnut, filled with blood, existed at tbe upper
part of the left lung. Hoarseness of voice was present in eighteen
of the cases.

Pathology. — It has been supposed that phthisis runs a more
rapid course in warm than in cold climates, after it has fairly com-
menced. My cases are not of a nature to throw any light on this
question, for the record of the previous history is, in general, not
sufficiently precise, and probably unworthy of being fully depended
upon. Yet the general opinion may be safely hazarded, that in all
diseases which include destructive degeneration of structure and
co-existing hectic fever, the rapidity of the course will bear relation
to the number and degree of the debilitating influences to which
the individual is exposed. As in warm climates elevated tempe-
rature and malaria are causes of debility, additional to those ex-
isting in cold climates, it is a reasonable inference that, after tuber-
cular softening has fairly commenced, a fatal issue is likely to follow
sooner in a tropical than in a temperate climate. Moreover, as re-

* It has seemed to me that that the accuracy of diagnosis in cases, in which the
ordinary symptoms of cough, expectoration and dyspnoea are not well marked, is
sometimes prevented : — 1. By an emphysematous state of the adjoining pulmonary
tissues preventing dulness. 2. Many cavities, none sufficiently large or empty to
give a tympanitic sound on percussion, may lessen dulness. 3. In cases of general
ansemia, in which pulmonary expansion is diminished, there may be slight infra-clavi-
cular dxilness from defective expansion : this may suggest the suspicion of commencing
tubercular deposit, but it will disappear with the removal of the ansemia.

PATHOLOGY. 557

spects phthisis pulmonalis, it should be remembered that the course
of the disease is always very dependent on the early access and the
extent of intestinal ulceration, and that this is a morbid state to
which the residents in warm climates are particularly prone. On
the other hand, however, it may be argued, that inasmuch as the
rate of progress of tubercular phthisis may depend on intercurrent
pneumonia or bronchitis excited by cold, the resident in warm
climates has in this respect an advantage over the inhabitant of
colder climates. This may be true of the well-clothed and cared-
for European, but the argument has no application to the hospital-
frequenting Classes of the native community; they, from consti-
tution, from insufficient clothing and habitations, are as much
exposed to the injurious effects of cold and wet as the dwellers in
more northern latitudes.

In j&fty-two of the clinical cases, at the time of admission, the
disease had passed on to the stage of softening; in twenty-four the
tubercles were still in their solid state, and in three there was
doubt.

With one exception, both lungs were affected in all; and of
fifty-five of these, we have informatipn as to the side in which
the disease had made most progress. It was furthest advanced
on the left side in thirty-six; on the right side in nineteen.
The observation umversally made by European writers, that the
tubercular deposit commences in the upper lobes and travels
downwards, is equally true of the disease in India. I would
remark, however, that I have witnessed cases of transition, as
it were, between tubercular deposit and grey induration, in
which there seemed to be a blending of the position-cha^
racter of pneumonia and phthisis : the acme of the disease
was neither in the upper nor the lower part of the lung, but
rather midway between. This observation is not unimportant
as regards diagnosis, for we certainly meet in practice with cases
in which the signs of excavation are distinct at the inferior angle
of the scapula, without signs of consolidation in the upper part of
the lung. Such are, probably, of the pathological character just
adverted to.

In twenty-nine cases examined after death, in which the tuber-
cles had softened, a single cavity was found only in two ; in all the
others the cavities were numerous, and in different stages.

The deposits of tubercle usually take place at many points ;
these increase in size by accretion, and aggregate into nodules.
The same order of progress occurs in the process of softening:

658 PHTHISIS PULMONALIS.

commencing at points, increasing in size, and coalescing into exca-
vations of various forms and dimensions. It is important to keep
this fact before the mind, because it gives a significance to the
early and undoubted signs of tubercular softening — I mean the
variously sized but sharply defined moist ronchi. My cases exhibit
that constant co-existence of pleuritic adhesion with fatal tubercular
pulmonary disease, which has generally been noted by other ob-
servers. The adhesions have a distinct relation to the stage of the
disease. They are not unfrequently absent in the miliary stage,
but are invariably present when excavations have formed. They
take place in accordance with that protective law, which has in
view the prevention of the effusion of abnormal fluid collections
into serous sacs. Pleuritic adhesions were observed in all my in-
spections after death.

The morbid appearances of pneumonia have been less frequently
present. There was hepatisation in twelve cases, and sanguineous
engorgement in six. The frequent absence of the signs of inflam-
mation of the pulmonary tissue, affords conclusive evidence that
the deposition of tubercular matter is not necessarily a result of
inflammatory action. But, on the other hand, the not unfrequent
occurrence of intercurrent pneumonia requires to be carefully borne
in mind and regarded in treatment.

Louis found the larynx diseased in one fourth of his cases, and
the epiglottis in one sixth. My observations in India show fully
an equal proportion of this complication. In eighteen of seventy-
nine there was hoarseness of voice. In thirty- one cases inspected
after death, the larynx was ulcerated or abraded in nine, the epi-
glottis in six, and the trachea in 7.*

In fifteen cases, a turgid or ulcerated state of Peyer's glands, and
in sixteen, circular ulcers in the large intestine, were found after
death. In only one case was there reason for attributing the intestinal
ulceration to tubercular deposit and softening. My researches, as
already previously stated f, have not suggested to me that there is
any difference between the morbid process which leads to the for-
mation of circular ulcers in the large intestine in phthisis, and that
which causes the same form of ulcer in dysentery, consecutive on
hepatic abscess, or simple and primary.

Diarrhoea was absent in only five of the seventy-nine cases. Of
these five, only one proved fatal ; the tubercles were in a miliary

* I need hardly remark, tliat the morbid state of the different parts of the air tubes
was not unfrequently noticed in the same ease ; and that these numbers (nine, seven,
six) do not represent twenty-two instances of phthisis.

t Page 369 (foot note.)

TREATMENT. 559

state, and there was no intestinal ulceration ; death had been
caused by co-existing hepatisation of the lung and pleuritic
effusion. The mesenteric glands were noted as tubercular in seven
cases, but this probably does not represent the full proportion,
because in many there is no record of the state of these structures,
which gives rise to the impression, that they had occasionally been
overlooked.

In two, miliary tubercles existed in the subperitoneal tissue.
Case 195 is an additional instance of this morbid condition.

In one case perforation of the intestine took place. In two, the
liver was found in a state of cirrhosis.

Fatty liver was observed by Louis in one third of his cases, but
much more frequently in females than in males. This morbid
state has not been found to co-exist with phthisis in the same pro-
portion in England. It was noticed in only one of my thirty-one
fatal clinical cases, but they were all males, and probably my
attention has not been sufficiently fixed on this question of
pathology. I attach no weight, then, to my observations on this
point.

Bright's disease of the kidney has been noted in only one of the
cases.

Treatment — On this subject it is needless to enlarge. The
principle now generally admitted, — that the indication for the
prevention, cure, and stay of this disease, is the application of a
well-arranged system of tonic regimen and remedies — must com-
mand the assent of every practical physician. Cod-liver oil has of
late years been extensively used in phthisis in India as in other
countries, and though the cases, which have formed the principal
subject of my present remarks, were generally either admitted in
a stage too advanced, or were too short a time under observa-
vation, to afford evidence of the efficacy of this remedy, still proof
has not been wanting to me in other fields of practice. Though
I am fully persuaded that the diathetic treatment of phthisis,
as now generally pursued, is correct, still it is necessary to be
careful, and to guard against its tendency to withdraw the atten-
tion from the occasional occurrence of intercurrent pneumonia,
and the modification in treatment which this contingency neces-
sarily enjoins.

560

rilTHISIS PULMONALIS.

Section II. — Statistics of Phthisis Pul/monalis,

Table XXXVII. — Admissions and Deaths, with Per-centage,from Phthisis
Pulmonalis, in the Jamsetjee Jejeehhoy Hospital at Bombay, for the Six
Years from 1848 to 1853.

1848 to 1853.

Monthly Average.

Admissions.

Deaths.

Deaths on
Admissions.

Admissions

on total
Admissions.

Deaths on
total Deaths.

January

67-7

1-6

February-

52-9

1-8

5-6

March .

43-9

1-9

4-7

April .

52-5

1-9

6-6

May .

63-9

1-6

8-0

June .

68-7

1-5

7 ■'I

July .

66-6

1-9

8-5

August .

100-0

1-5

8-8

September

35-9

2-5

October

93-7

November

43-9

1-4

5-4

December

60-6

1-4

5-0

Total

445

268

60'1

1-7

6-5

561

CHAP. XXIV.

ON PERICARDITIS AND ENDOCARDITIS.

Section 1.^— Introductory Remarks.

In tliis and the following chapter I shall describe affections of
the heart and aorta, as observed by me in natives of India, and
shortly allude to these diseases in Europeans.

Fifty-six cases have been received into the clinical ward of the
Jamsetjee Jejeebhoy Hospital, during the six years from 1848 to
1853. I shall consider them under two heads. 1. Twenty-five
cases of pericarditis and endocarditis, in the present chapter.
2. Thirty-one cases of structural disease of the heart and aorta,
in the chapter which follows.

This inquiry will tend to correct the erroneous impression
which has existed, that acute rheumatism in India is rarely asso-
ciated with pericarditis or endocarditis. The relation of cardiac
disease to previously existing rheumatism is apparent in twenty-
nine of the fifty-six cases; and in all probability it would have
been evident in a still greater number, had the record of all been
equally complete.

When we compare the admissions under the head "Eheumatism"
into our Indian hospitals with those which take place into hospitals
in Europe, we may expect to find in the former a smaller propor-
tion of affections of the heart. The explanation, however, is
sufficiently simple. In the greater number of cases of rheuma-
tism treated in hospitals in India, the disease is chronic; it is
unattended with swelling of the joints or febrile disturbance, and
occurs for the most part in persons cachectic from malaria,
syphilis, scurvy, mercury, imperfect means of subsistence, &c. It
is not, I need hardly observe, in association with tJds form of
disease that pericarditis and endocarditis have been so frequently
noticed in European countries.

It may be that acute articular rheumatism is not so common in

0 0

562 PERICARDITIS AND ENDOCARDITIS.

India * as in colder climates, yet it is by no means rare ; and a
complicating pericarditis or endocarditis is, I believe, as frequent an
occurrence in the one countiy as in the other.

Of no rule in practice am I more thoroughly convinced than that it
is as incumbent on the practitioner in India as in Europe, carefully
to watch and search for the physical signs of pericarditis and endo-
carditis in every case of acute rheumatism. If this rule be neg-
lected, the co-existence of these diseases in India will necessarily
continue to be considered an unusual event. f

Section II. — Causes, Symptoms, and Treatment

The important practical facts deducible from the twenty-five
cases of pericarditis and endocarditis are arranged under the fol-
lowing heads : —

* This statement, written some years since in India, has been fully confirmed by recent
opportunities of observing the great frequency of acute articular rheumatism in hospi-
tals in London.

t In No. 11 of the "Indian Annals of Medical Science," for January 1859,
there is a very interesting communication from Dr. Gordon, Surgeon of the 10th
Regiment, on *' Rheumatism and allied diseases." The author concurs with me in
opinion that acute rheumatism is not so common in India as in colder climates, but
dissents from my statement that pericarditis and endocarditis are as frequent a com-
plication of acute rheumatism in the one country as the other. He justly explains the
discrepancy between us, by observing, that my results had reference to the inmates
of civil or general hospitals, — his, to regimental hospitals ; for it is a great error to
compare the statistics of communities so dilFerent as the inmates of civil, and military-
regimental hospitals. The greater proportion of men invalided for heart disease in
the United Kingdom than in India, seems to me to prove, as is explained in the text,
the comparative rarity of acute rheumatism in India, rather than the infrequency of
pericarditis, as a complication, as Dr. Gordon supposes.

The subject of cardiac disease in Europeans will come under consideration in the
concluding section of the next chapter, and I would only now remark that my oppor-
tunities of judging of its frequency in regimental hospitals, at different periods of my
service, have not been few, and that many cases have come under my observation.
Indeed the only case of acute endocarditis unconnected with rheumatism which I have
ever witnessed, was in the hospital of the 12th Lancers, at Kirkee, in June 1857.
The patient was admitted on the 16th with palpitation and uneasiness of the cardiac
region, but no abnormal sounds were detected ; and it so chanced that the day on
which I examined him, towards the end of the month, was the first on which a mitral
murmur was discovered. This patient was left behind when the regiment went on
service, and I had the opportunity of watching him in the depot hospital. The
murmur persisted, and on the 21st August, increased prsecordial dulness, not present
at first, indicated commencing hypertrophy and dilatation. There is no a priori reason
why acute articular rheumatism should be less accompanied with percarditis in soldiers
in India than in Europe. The kind of data necessary to prove the contrary must be
limited, and while tlie question is still sicb Judice, 1 would again urge that a careful
search for the physical signs of pericarditis and endocarditis should be the rule of prac-
tice in every case of acute rheumatism in India, both in civil and military hospitals.

COMPARATIVE PREVALENCE.

563

I. The proportion of cases of peri-
carditis and endocarditis, and
of both combined.
II. The result of the cases.

III. Relation to diiFerence of sex.

IV. The proportion of cases in dif-

ferent castes.
V. Classification, with reference to

Age.
VI. The different occupations of those

affected.
VII. Relation to habits of life.
VIII. The months of the year in which
most prevalent.
IX. Relation of the disease to rheu-
matism, cachexia, and pulmo-
nary inflammation.
X. The leading symptoms and signs
treated of under the following
subdivisions: —

1. Pain at margin of the left ribs.

2. Pain at the precordial region.

3. Increased action of the heart.

4. The state of the pulse.

5. The absence or presence of

fever.

6. Difficulty of breathing.

7. Anxiety of countenance.

8. Occurrence of delirium.

9. Increased prsecordial dulness.

10. Purring tremor.

11. Praecordial fulness.

12. Friction murmur.

13. Jogging movement of the

heart.
XI. On the treatment of the disease: — ■

1. Blood-letting, general and

local.

2. The application of blisters.

3. Mercurial influence.

I. The proportion of cases of Pericarditis and Endocarditis,
and of both combined. — Thirteen would seem to have been of
pericarditis alone. But in regard to six, the details are not suf-
ficiently stated to justify the exclusion of co-existing endocarditis;
they must, therefore, be regarded as doubtful, though the probability
is in favour of pericarditis alone.

There are four cases of endocarditis alone : of these, the mitral
valve was affected in three, and the tricuspid valve was believed to
be so in one.

There are eight of pericarditis and endocarditis combined: in
three the aortic valves, in four the mitral valve, and in one both
aortic and mitral valves were engaged. In seven, the pericarditis
took precedence of the endocarditis, and in the remaining case
the endocarditis was first observed.

II. The result of the cases. — Nine of the twenty-five cases
proved fatal. Of these eight are in the list of pericarditis, but five
of them are classed with those in which the co-existence of en-
docarditis was not disproved. One is in the list of pericarditis and
endocarditis combined. Two of the fatal cases occurred in asso-
ciation with rheumatism, two were present in individuals of very
cachectic habit, and four were instances of pericarditis secondary
on pneumonia, pleuritis, or phthisis pulmonalis.

Of these last four fatal cases, in two death took place from
pulmonic disease. In the first the pericardial inflammation had
terminated in adhesions, in the second in opaque patches on the
surface of the heart, and the endocarditis in valvular disease.

O O 2

564 PERICARDITIS AND ENDOCARDITIS.

It will subsequently appear, that of the twenty-five cases, seven-
teen were associated with rheumatism, two with cachexia; four
were secondary on pulmonic disease, and two primary or idiopathic.
It has just been stated, that of the rheumatic cases two were fatal,
of the cachectic all, of the pulmonic two *, and of the primary one.
The deduction from these cases is therefore comfirmatory of the
usual observation, that in pericarditis associated with rheumatism,
the prognosis is much more favourable than under the other cir-
cumstances in which the disease arises.

Of the sixteen discharged cases, in five no signs of cardiac
disease were left behind, and recovery was regarded as complete.
They were, with one exception, cases of pericarditis ; in the excep-
tional case endocarditis was also present. In three the signs of
valvular disease were so slight, that it is very probable they also
should be included in the list of perfect cures.

Of the eight cases in which complete restoration did not take
place, in one valvular disease was left, in six valvular disease and
pericardial adhesions, and in one pericardial adhesions alone. The
adhesions were in six inferred to exist from the severity of the
symptoms, and the distinctness and duration of the physical signs,
but in one there was greater certainty, in consequence of a well-
marked and persistent jogging motion of the heart.

III. Relation to difference of sex. — Of the cases under ex-
amination, four were females, but only three of these were hospital
patients. Of the four, two were Hindoos and two Parsees. These
data are much too limited to justify any attempt at precise com-
parison of the frequency of the disease in the two sexes. So far as
they go, they show as great a prevalence in females as in males.
The proportion of total female admissions into hospital during the
period to which these cases refer was about one to seven males,
and there is nearly the same proportion in the admissions from
pericarditis and endocarditis. Moreover, as the clinical ward was
for males only, I am satisfied, that in regard to the female inmates
of the hospital, there has not been the same care in looking for the
disease.

IV. The proportion of cases in the different castes. — The caste
of twenty-three of the cases only is stated, but from these I shall
exclude the females, so as to admit of a more accurate comparison
between the affected and the total hospital admissions of the dif-
ferent castes. The classification of the females according to caste

*■ Two in which death took place from piilmonic disease long after the pericarditis
are excluded.

CAUSES — RELATION TO CASTE.

565

lias not been attended to in the hospital returns of disease. There
are, therefore, nineteen cases to be considered under this head : of
these nine, nearly one half, are Hindoos. The proportion which the
Hindoo male hospital* admissions bear to the total male admis-
sions is not quite one half. There are four cases of Parsees, nearly
one fifth of the affected, but the proportion of the total male
Parsee hospital admissions is about one twelfth. There are four
cases classed under the head Christians in the hospital returns,
viz. three Portuguese and one European. The proportion of total
hospital Christian admissions is about one fifth. There are two
cases of Mussulmans, being one ninth and a half of the affected,
whereas the proportion of Mussulman hospital admissions is rather
more than one third.

From these data, then, it would seem that there is about an equal
liability to pericarditis and endocarditis in the Hindoo and native
Christian classes, but that compared with them, these affections aro
more than twice as common among Parsees, and not one fourth sa
frequent among Mussulmans. It will not fail to be observed that
of the four female cases, two were also Parsees, making six Parsees
affected out of a total of twenty-three. Under a subsequent head
it will appear that all the cases which occurred in Parsees were
in association with acute articular rheumatism. These facts con-
firm the general impression on my mind, that acute articular
rheumatism, with pericarditis and endocarditis, is more com-
mon among Parsees than any of the other classes of the native
community of Bombay. Of the comparative exemption of the
Mussulman population, as shown by these statements, I am unable
to suggest any explanation ; and it would be waste of time, and
might lead to error, were I to speculate on deductions from data
so limited.

* Total number of Hospital Admissions from 1848 to A^ril 1852.

J
s

1
S

i
1

1848-49.
1849-50.
1850-51.
1851-52.

Total.

3,045
3,653
4,133
3,543

487
589
713
583

3,532

4,242
4,846
4,126

1,154
1,335
1,712
1,486

1,064
1,377
1,347
1,064

482
681
715
629

145
260
359
364

487
589
713
583

3,532

4,242

' 4,846

4,126

14,374

2,372

16,746

5,687

4,852

2,707

1,128

2,372

16,746

O Q 3

5id6 PERICARDITIS AND ENDOCARDITIS.

V. Classification with reference to age, — The ages of only
twenty-three of the cases are recorded : —

From 10 to 20 7

„ 21 „ 30 . . . . .10

„ 31 „ 40 4

„ 41 „ 60 2

The lowest age is seventeen, and the highest fifty. Seventeen
cases were between the ages of seventeen and thirty, four between
thirty-one and forty, and two between forty-one and fifty. Of those
between seventeen and thirty, fourteen occurred in connection
with rheumatism, — a fact which goes to support the common
statement that rheumatism, with pericarditis and endocarditis, is a
disease rather of the earlier than the advanced periods of life.

YI. The different occupations of those affected. — Of five cases,
including three females, the nature of the occupation is not stated.
That of the remaining twenty was as follows : —

2 Sailors

1 Laboiirer.

3 Servants

1 Carpenter

3 Fruit, vegetable and fish

1 Grain seller

hawkers

1 Schoolmaster

2 Beggars

1 Oil seUer

2 Sepoys

1 Dyer.

1 Baker

1 Cook.

On examining this statement, it appears that of the twenty
persons, sixteen followed occupations which, more or less, lead to
exposure to wet or vicissitudes of temperature : this is the case
of sailors, hawkers, beggars, sepoys, bakers, cooks, dyers, and
labourers.

VII. Relation to habits of life. — It is stated of only five of the
twenty-five cases, that there was addiction to the use of spirituous
liquors ; of these two were Parsees, two Hindoos, and one a Portu-
guese ; one patient was habituated to opium smoking.

In regard to the remaining nineteen cases, it may be inferred of
the greater number that they were not of intemperate habits.

VIII. The months of the year in which most prevalent — The
admissions occurred in the followins: months : —

3 in January
2 ,, February

0 ,, March

1 „ April
0 „ May

4 „ June

3 in July

3 „ August

1 ,, September

4 ,, October

2 „ November
2 ,, December

CAUSES — KELATION TO SEASON, RHEUMATISM, ETC. 567

The relation of the disease to cold and wet is also very well
shown in this statement. There are nine cases in the cold months
of November, December, January, and February. Those of Fe-
bruary were admitted in its first half — one had been ill fifteen
days, the other eight days, they are therefore justly classed with
the occurrences of the cold season. There are fifteen in the rainy
season, in the months of June, July, August, September, and
October. Of the four which occurred in June, three were ad-
mitted after the 20th, and are consequently correctly classed as
admissions of the rainy season ; and of two the relation to wet
as a cause is distinctly recorded. Of the four cases in October,
three are correctly classed as admissions of the rainy season:
they were received into hospital before the 12th of the month,
and two of them had been ill fifteen and ten days respectively.
The fourth admission in October was of a very susceptible indi-
vidual, who had on a former occasion suffered from rheumatism.
The single case which occurred in the hot season, in the month of
April, was a Parsee female in good circumstances, who on previous
occasions had suffered from rheumatism.

IX. Relation of the disease to Rheumatism, Cachexia, and
Pulmonic Inflammation. — In seventeen cases the disease was
associated with acute articular rheumatism. In sixteen the rheu-
matism was present at the period when the cardiac symptoms
appeared, and afterwards co-existed with them. In one case the
rheumatic symptoms were not present with the cardiac symptoms,
which occurred in an individual who had some years previously
suffered from an attack of acute rheumatism, and in whom the
diathesis, at the period of the attack of pericarditis, may be assumed
to have been still present. Of these seventeen cases, eight were
Hindoos, six Parsees, two Christians, and one a Mussulman : six
were of pericarditis alone, four of endocarditis, and seven of peri-
carditis and endocarditis combined.

Of the remaining eight cases, in which rheumatism was ab-
sent, two occurred in very cachectic states of the system ; in one
the cachexia was distinctly syphilitic, and in both, pericarditis
alone was present. Four were extension of inflammation from
the lungs or pleura, and were with one exception cases of pericar-
ditis : in the exceptional one endocarditis also existed. Two must
be looked upon as instances of primary pericarditis.

Of the total cases of pericarditis and endocarditis there was only
one in which, so far as the record shows, Bright's disease of the
kidney existed.

o o 4

5G8 rERICAIlDITIS AND ENDOCARDITIS.

We notice distinctly in these cases the greater relation that
subsists between endocarditis and acute articular rheumatism, than
between pericarditis alone and rheumatism. All the cases of endo-
carditis, single or combined, were, with one exception, associated
with rheumatism ; whereas of the thirteen cases of pericarditis,
seven were unconnected with rheumatism ; and of the six cases in
the list of uncombined pericarditis noted as occurring in association
with rheumatism, it is not improbable that in two of them endo-
carditis was also present. Of the two cases of apparent primary-
pericarditis, one is peculiar in its nature, and will presently be
made the subject of comment.

X. The leading symptoms and signs observed. — In analysing
the symptoms, attention must be confined to twenty-two cases; for
of three the record is so incomplete as to render their exclusion
necessary.

Pain at the margin of the left ribs was present in seven cases,
in some extending to the prsecordial region, and in two or three to
the epigastrium and abdomen generally.

Prwcordial pain, either alone, or associated with pain at the
margin of the left ribs, existed in eight.

To consider this symptom from another point of view, pain
(prsecordial and hypochondriac) was observed in ten cases ; in two
it was confined to the margin of the left false ribs, in three
to the praecordial region, and in five it was common to both
situations. Of these ten, six were of pericarditis alone, thus
leaving four of this form in which pain was not observed ; two
were of endocarditis, leaving two of this form in which pain was
not present ; and two were of pericarditis and endocarditis com-
bined, leaving six of this form not characterised by pain.

From these statements, then, it appears that we are justified in
referring the symptom pain more to pericarditis than to endocar-
ditis ; for of the eighteen cases of pericarditis, simple and combined,
pain was present in eight ; but of the twelve of endocarditis, simple
or combined, pain was characteristic of only four. These cases also
confirm the now generally admitted fact, that in a considerable
proportion of instances of pericarditis and endocarditis pain is not
complained of. Of the twenty-two cases now under review, pain
was present in ten, but absent in twelve.

Increased action of the heart is noted as having existed in
eight cases. In five, pericarditis and endocarditis were com-
bined ; in two, endocarditis, and in one pericarditis existed alone :
thus there would seem to be a more frequent relation between

SYMPTOMS — PALPITATION, PULSE, FEVER. 569

increased action of the heart and endocarditis than between it and
pericarditis. Of the twelve cases in which endocarditis, simple
and combined, was present, palpitation existed in five ; but of
the ten cases in which there was pericarditis alone, palpitation is
noted of only one. It is further evident from this statement,
that in a large proportion of cases of pericarditis and endocarditis,
the action of the heart is not notably increased. Of the twenty-
two cases under review, of eight only is increased action recorded
as a symptom.

Impulse remote, — In one case the impulse of the heart is
stated to have seemed distant and obscure.

The state of the pulse. — In sixteen cases the character of the
pulse differed markedly from the healthy standard. In four it was
jerking ; of these, three were of pericarditis and endocarditis com-
bined, and one of pericarditis alone. As the jerking pulse is not
noted of any case of simple endocarditis, it may probably be inferred
that this character of pulse is more related to pericarditis than
endocarditis. It occurred only in simple or combined pericarditis.

In eleven cases the pulse is described as small, and in some it
was also sharpish ; six were of pericarditis, three of endocarditis,
and two of pericarditis and endocarditis combined. It may,
therefore, be inferred, that smallness of the pulse is as frequently
referable to endocarditis as to pericarditis.

In only one. case is the pulse stated to have intermitted, and
this feature was not observed till long after the acute symptoms of
pericarditis had ceased, and the disease was believed to have
terminated in adhesions.

From a consideration of these cases, then, we may infer that an
abnormal pulse is more frequently observed in pericarditis and
endocarditis than pain or palpitation ; that its most common
quality is smallness associated with occasional sharpness, then a
jerking character; but that an intermitting pulse, formerly looked
upon as symptomatic of pericarditis, is of infrequent occurrence,
and that we shall err, if we allow it weight in determining the
diagnosis.

Febrile symptoms were observed in fifteen cases : of these five
were of pericarditis alone, three of endocarditis, and seven of pericar-
ditis and endocarditis combined. Fever, then, would seem to be as
frequently related to endocarditis as to pericarditis. A reference
to the remaining eight cases, of which febrile disturbance is not
recorded, will show that in some of them fever had been present* in
the earlier stages of the illness, though it was»not noticed when the

570 PERICARDITIS AND ENDOCARDITIS.

patients were under observation in the hospital. In others, in
which the disease was consecutive on pulmonary inflammation, it
was impossible to relate the febrile symptoms to the pericarditis,
rather than to the previously existing pulmonary disease.

The review of these cases, in reference to the presence or
absence of fever, goes to show that pericarditis and endocarditis
rarely exist without some degree of pyrexia. This was par-
ticularly true of those associated with acute articular rheumatism,
and in them, no doubt, the fever was as much due to the
affection of the joints as to pericarditis and endocarditis. But
there is more than this ; for I am satisfied that a close observa-
tion of cases of acute articular rheumatism will very generally
show, that coincident with the commencement of pericarditis
or endocarditis, there is a marked exacerbation of the febrile
disturbance. The increase of fever in more than one cas^3 of
acute rheumatism (for some days under treatment, and in which
the state of the heart had been regularly inquired into), has led
me to suspect the occurrence of pericarditis or endocarditis ; and
on careful examination the physical signs have, in each instance,
confirmed the suspicion.

It is not improbable, that in acute rheumatism, in the sthenic
constitutions of the inhabitants of European countries, with fever
greater in degree and more continued, febrile exacerbations may
not be so significant as I believe them to be in acute rheumatism
in the asthenic constitutions of the natives of India, with fever,
less in degree, and remittent in type. It is when the exacerbation
becomes longer in duration, occurs at irregular periods, or is of
increased severity, that it becomes indicative of the access of
cardiac inflammation.

Some degree of hurry and shortness of breath were present
in eight of nineteen cases; for under this head I have also ex-
cluded those instances of pericarditis associated with pulmonic
disease. Of the eight cases, four were of pericarditis alone,
two of endocarditis, and two of pericarditis and endocarditis
combined. In none did the difficulty of breathing amount to
orthopnoea.

The expression of countenance was observed to be anxious in five
cases; two were of pericarditis, one of endocarditis, and two of
pericarditis and endocarditis combined.

The occurrence of delirium was noted only in one case. The
occasional presence of nervous symptoms in acute rheumatism
and pericarditis, independent of direct affection of the brain, first

PHYSICAL SIGNS. 571

pointed out by Dr. Watson, though not illustrated by these cases,
is practically very important. I can call to mind more than one
case of head symptoms misunderstood at the time, but which
were afterwards suspected to be of this nature.

The review which has just been made of the general and local
symptoms of pericarditis and endocarditis, goes to confirm the
now well-established fact that it is to physical signs we must trust
for the means of forming a precise diagnosis of these diseases;
that without these signs many cases will escape detection, and
very few will be recognised with certainty.

Physical Signs. — Increased prcecordial dulness was present in
nine cases : of these four were pericarditis alone, and five pericar-
ditis and endocarditis combined — in all, the dulness probably de-
pended on effusion into the pericardium. In two, the pyramidal
form of the dull region was well marked; in two, effusion was
found after death, and in a third, also fatal, no post mortem ex-
amination was made. In three of the six in which recovery took
place, the dulness disappeared by absorption of the effusion : this
was verified some time afterwards in one case by dissection. In
the three remaining recovered cases, there was persistence of
some degree of dulness, dependent, it was believed, on hypertrophy
and dilatation of the left ventricle of the heart : these were instances
in which considerable valvular disease existed.

Furring tremor was present in only three, and was accom-
panied with friction sound. The tremor, then, in these cases, was
probably consequent on pericarditis, and not on mitral valvular
disease.

Prcecordial fulness was observed in only two, and was, appa-
rently, caused by effusion into the pericardium.

Friction murraur, — The number of cases of pericarditis alone,
and combined with endocarditis, amount to twenty- one ; but from
these, four must be excluded, in which no examination of the
region of the heart had been made. Of the seventeen cases which
remain, friction sound was heard in fifteen : it was absent in two —
in one, consequent on the considerable effusion as indicated by the
extent of the dulness, but in the other it is not noted, because
I could not satisfy myself of its presence, though others at the
time thought that it existed.

The duration of the friction sound is stated in nine cases : in
two it was present upwards of thirty days, and the result was in all
probability adhesion of the surfaces ; in two the friction murmur
was heard for twenty and twenty-one days— in one adhesion was

572 PERICARDITIS AND ENDOCARDITIS.

suspected, in the other* it was proved to exist by subsequent dis-
section; in two the sound was present for fourteen days with
in one probably opaque patches, and in the other adhesions ; in
one case the murmur existed for seven days, and adhesions in all
likelihood resulted; in one the sound was heard for four days,
and probably some degree of opacity of the surface was left
behind ; in one the murmur was audible for three days only, and
in this case, on dissection many months after complete recovery,
opaque patches were found here and there on the surface of the
heart, but no adhesion.

In five of the cases in which friction murmur had been present,
there was the opportunity of examining the body after death. In
three a considerable time had elapsed between the period at which
the sound had been audible, and death'; in twof patches of organised
lymph existed on the surface of the heart, but there was no adhe-
sion of the surfaces ; in one firm adhesions united the heart to
the pericardium. In two cases death occurred at the time when
the friction sound existed ; in one i there were eight ounces of
reddish serum in the sac of the pericardium, and flakes and shreds
of lymph were deposited on the surfaces; in the other § twelve
ounces of clear fluid were found in the sac of the pericardium, three
hours after death, — this fluid spontaneously coagulated into a gela-
tinous mass when removed from the body, but there were no flakes
of lymph deposited on the surfaces, and no vascularity of the serous
covering of the heart, or lining of the pericardium.

Four of the fatal cases confirm the generally received, and no
doubt correct, opinion, that the friction murmur is for the most
part dependent on the roughening of the surfaces from l3rmph-de-
posits; but case 235, if correctly observed, would seem to show that
effusion of the liquor sanguinis (the tibrine being as yet undeposited
in the solid form) is adequate to cause a friction sound. The case
was for a very short time under observation, and that immediately
before death. Moreover, the abnormal sound may possibly have
proceeded from the great vessels compressed at their origin by the
fluid — a cause which has been suggested || as adequate to pro-
duce abnormal sound in pericardial effusion. For these reasons, I
am unwilling to attach undue importance to this case; yet it
seems to me to justify inquiry on the following points : —

1. Is it not probable that in exudations of liquor sanguinis
from the inflamed capillaries of serous linings of closed sacs, the

* Case 232. f Cases 231, 233. } Case 234. § Case 235.

II " Walslie on Diseases of the Lungs and Heart," p. 216, 1st edition.

PHYSICAL SIGNS — FRICTION MURMUE. 573

deposition of the fibrine, in the solid form, does not take place so
soon as is generally supposed ?

2. Whether the movement of the liquor sanguinis (the fibrine
as yet in the liquid form) between the serous surfaces is inadequate
to produce a friction murmur ; and whether, in considering this
question, we ought not to bear in mind those cases of pericarditis
in which this sound is present from the commencement, and to
account for which has always been a difficulty, — explained by
some on the supposition that the surfaces are roughened from the
turgid state of the capillaries which precedes effusion, by others,
as Dr. Hope *, on the improbable idea that lymph may be effused
in the dry state, as first suggested by Laennec ?

In twof of the fatal cases in which the friction sound was distinct,
death took place several months afterwards — in one from cholera,
in the other from pulmonary disease. In both, opaque patches
were found on the surface of the heart, but no adhesion between it
and the pericardium. In case 233 there was also valvular disease,
and it may be argued that an endocardial murmur may have been
mistaken for a friction sound. But this objection cannot be urged
against case 231 : in this, the friction murmur had been undoubted,
and the valves and heart were quite healthy, with the exception
of a few opaque patches on the surface of the right ventricle.
This case establishes the fact, that there may be friction sound,
then disappearance of it, and no greater structural change
than a few opaque patches on the surface of the heart.
Though this fact may now be admitted, still the statement made
relative to the duration of the friction murmur, as observed in
these cases, leaves little room for doubt, that when this sign
ceases, after having been present for fourteen days and upwards,
adhesion between the heart and pericardium has probably taken
place.

The followinof are the five fatal cases in which friction murmur
Avas observed : —

231. Pericarditis. — Friction mtirmur distinct, and then altogether disappearing. —
He was cured. — Eight months afterwards, death from cholera. — Opaque patches on the
surface of the heart.— No pericardial adhesions. — Tayjah Dongxir Sing, a Hindoo
fruit-seller, twenty-eight years of age, in tolerable condition, for six years addicted to
opium- smoking, was admitted into the clinical ward on the 28th June, 1850, having
been ill only since the day preceding. The countenance was somewhat anxious, the
respiration short and hurried (sixty-eight in a minute), and almost entirely abdo-
minal ; the skin was of natural temperature ; the pulse seventy-six, rather small, but

* Hope's Treatise on Disease of the Heart, 4th edit., p. 144.
t Cases 231, 233.

574 PERICAllDITIS AND ENDOCARDITIS.

sharpish ; and the tongue was a good deal furred. On percussion of the anterior part
of the chest no defective resonance was detected, and vesicular respiration was dis-
tinct and unmixed. In the praecordial region, over a spot aLout an inch and a half in
diameter, just internal to the nipple, there was heard a murmur, partly of a ruLbing,
partly of a creaking character. In this situation there was tenderness on pressure.
The sounds of the heart were distinctly audible, and the impulse was not much in-
creased. He pointed to the praecordial region, and to the margin of the left false ribs,
as the seats of pain, felt since the day preceding his admission. The pain did not
extend to the back or left shoulder. He was quite free of all pain of the limbs ; but
he stated that he had suffered eight years previously from a severe attack of swelling
and pain of the joints, chie% the knees and ankles ; and the marks of scarifications
were still visible on the knees. For this affection of the joints, he had also undergone
two long courses of mercury, and continued ill for seven months. Subsequently, how-
ever, he had enjoyed good health. The only circumstance to which he could attribute
his present illness was exposure to wet, to which he had been subjected ten days pre-
viously. Forty-eight leeches were applied to the prsecordial region, followed by a
blister ; three grain and then two-grain doses of calomel with one eighth of a grain of
tartar emetic, and one fourth of a grain of opium, were given every fourth hour. On
the 30th June the gums were tender, and the calomel was omitted ; on the 1st July the
mercurial influence was still more developed. On the 29th June the friction murmur
was still distinct ; on the 30th it had disappeared, and was not again heard. He was
discharged well from the ward on the 10th July. This patient again presented him-
self at the hospital on the 21st August, having experienced some uneasy sensations in
the praecordial region, but the sounds and impulse of the heart were natural ; and after
the action of some aperient medicine he was quite relieved, and left the hospital on the
22nd August. He was not again seen till the 7th of March, 1851, when he was ad-
mitted in the collapsed state of cholera, that disease being at the time prevalent:
re- action did not take place, and he died on the evening of the 10th.

Inspection. — Chest. — There was no increased quantity of fluid found in the pericar-
dium, and there were no adhesions between the pericardium and the heart. The inner
surface of the pericardium was pale, and without deposit of any kind. The heart was
rather small ; there was no dilatation of any of its cavities. Over the centre of the
anterior wall of the right ventricle there was an opaque patch, about half an inch long and
quarter of an inch in breadth, which, -with moderate traction with the forceps, could be
separated from the pericardial covering of the heart in the form of a thin firm layer of
areolar tissue. The free surface of the patch was quite smooth. At the upper part of
the left ventricle there was a smaller and a thinner patch. Elsewhere, here and there
on the surface of the heart, other opaque spots were noticed. The endocardium was
healthy, and so were also the valves. There were two or three small spots of com-
mencing deposit on the inner surface of the ascending aorta.

BemarJcs. — This case has been already published by me in the London Medical
Gazette, of the 16th May, 1851. It was so because at the time Dr. "W. S. Kirkes had
called in question the commonly received opinion, which maintains that when there
has been acute pericarditis, with friction murmur, followed by disappearance of the
murmur and restoration to tolerable health, this result has been effected by pericardial
adhesion. This case confirms Dr. Kirkes' opinion ; and, I think, definitely proves
that we may have friction murmur and recovery, without any other structural change
than the opaque white patches so frequently observed on parts of the surface of the
heart.

232. Phthisis 2>'i^^^nonalis. — Secondary 'pericarditis. — Friction murmur, distinct
for twenty days. — Death eighteen months afterwards. — Firin pericardial adhesions
— Bright s disease of the kidney. — Kannyah, a Hindoo baker, thirty-two years of age,
a native of Bangalore, and lately arrived in Bombay from Poena, was admitted, after

PHYSICAL SIGNS — FRICTION MURMUR. 575

eleven days' illness, into the clinical ward, on the 27th September, 1849. He was
reduced in flesh, and the respiration was short and hurried. The whole of the right
side of the chest was dull on percussion, the didness increasing from above down-
wards. In places there w£is crepitus rale, in others bronchial respiration. He con-
tinued under treatment tiU the Ilth December. There were febrile symptoms, with
evening exacerbations. The sputa, at first in part rusty and adhesive, frothy and
clear, subsequently became opaque, and were expectorated in detached masses. Tlie
dulness on the right side and bronchial respiration continued for some time unchanged,
but at the period of his discharge had considerably lessened. During his stay crepitus
was heard in the left dorsal region.

He was re-admitted on the 14th June, 1850. He had improved in health after
leaving the hospital, till five days before his re-admission, when, consequent on ex-
posure to cold, he had a return of febrile symptoms, cough, and dyspnoea. There wa«
dulness, with large crepitus, and bronchial respiration in the left mammary, lateral,
dorsal, and scapular regions. On the right side crepitus was also audible ; but nothing
is noted regarding the resonance on percussion. The sounds and rhythm of the heart
were natural. He continued suffering from febrile and pulmonic symptoms till the
23rd June, when a distinct friction murmur, synchronous with the heart's action, and
obscuring the soimds, was heard between the left nipple and the sternum. The pulse
was frequent and jerking. The murmur continued distinct till the 13th July, when it
ceased ; and there was left some degree of roughness and shortness of the first sound.
On the 3rd August, and for some time afterwards, the impulse of the heart was dis-
tinct between the third and fourth left costal cartilages, but it was not perceptible
below the nipple. The febrile and pulmonic symptoms continued, but became less in
severity; the dulness and bronchial respiration of the left side lessened in degree,
and he was discharged in improved health on the 20th September. He continued in
tolerable health for about a year, when he began again to suffer from cough and febrile
symptoms, and was re-admitted into the clinical ward on the 6th January, 1852. He
was a good deal emaciated. The respiration was short and hurried ; there was dul-
ness on percussion of the right scapular and dorsal regions, but undue resonance of the
subclavian region. In all these regions there was blowing respiration and increased
resonance of voice. The left subclavian and axillary regions were somewhat dull on
percussion, and there was bronchial respiration mixing with occasional subcrepitous rale.
There was no increased prsecordial dulness, and nothing abnormal was detected in the
sounds and impulse of the heart. There was dulness on percussion for an inch and a
half below the margin of the right false ribs, and some uneasiness on pressure there.
He complained of frequent cough. The sputa were copious, puriform,and in detached
masses. The pulse was small and frequent. There was no diarrhoea. He died on
the 10th January. During his second admission the urine gave no trace of albumen
on the one occasion on which it was examined. During his last admission it was
examined on the 9th January, when it was stated to be twenty ounces in quantity, of
bro-^vn colour, specific gravity r035, giving a deposit under heat and nitric acid, which
became of a brown colour.

Inspection fourteen hours after death. — Head. — The vessels of the pia mater were
congested, and about two ounces of serous fiuid were found at the base of the skull.
Chest. — The mucous membrane of the trachea presented here and there a blush of
redness : there were also small red points on that of the larynx. The lobes of the
right lung were firmly adherent to each other. The two upper ones were completely
solidified by aggregation of crude tubercles. About an inch and a half below the apex
of the upper lobe, and near to its posterior surface, there was a cavity the size of a
pigeon's egg, lined by a smooth membrane. The inferior lobe, also, had scattered
crude tubercles, with intercurrent sanguineous engorgement. Doth lobes of the
left lung were more or less solidified, but the upper one more so, from tubercular
deposit; there was no cavity. The internal surface of tlje pericardium was firmly,

576 PERICARDITIS AND ENDOCARDITIS.

closely, and generally adherent to the outer surface of the heart. The left ventricle of
the heart was slightly dilated, hut there was no hypertrophy of its walls. The valves
of both sides were healthy. Abdomen. — The external appearance and size of the liver
were natural. "When incised, it was found to be congested in the second degree. The
spleen was healthy. Both kidneys were slightly enlarged, somewhat lobulated, mot-
tled red and pale yellow, and finely granular externally ; their incised surfaces were in
general pale : the cortical portion of both was somewhat enlarged and encroached upon
the tubular. These changes were most marked in the left kidney. The stomach and
intestines were not examined.

233. Asthenic pneumonia, leading to red induration of the ujpper lobes. — In its
course, ^pericarditis and endocarditis of the left ventricle and auricle, causing structural
disease of the mitral valve. — Not traced to rheumatism. — Dilatation of all the cavities
of the heart. — Sebastian Fernandez, a native of Groa, thirty-one years of age, following
the occupation of a servant, and using spirituous liquors, was admitted into the clinical
ward on the 15th July, 1850. He was a good deal reduced, had been under treatment
in the hospital a month before for cough, from which on previous occasions he had
also suffered. Subsequent to his discharge from hospital, and about fifteen days
before his second admission, the cough had become more troublesome, and for the last
eight days had been attended with febrile symptoms, coming on with chills at irregular
times, and terminating with sweating ; and the sputa had been tinged with blood.
The respiration on admission was observed to be slightly hurried ; there was some de-
gree of dulness on percussion of the left subela\dan region, and the general character
of the respiration there, as well as in the left scapular region, was more bronchial
than normal. The sounds and impulse of the heart were natural. He continued
suffering from cough — the physical signs unchanged — occasional accessions of
fever, and slight dysenteric symptoms, with a pulse decreasing in strength, till
the 31st July, when, for the first time, some degree of preternatural prsecordial
dulness was observed. The dulness extended from the third to the fifth rib, and from
the left margin of the sternum to the nipple. At the foiu-th costal cartilage, internal
to the nipple, both sounds of the heart were distinct, and continued so in a direction
upwards. About an inch below and external to the nipple there was a rough murmur,
obscuring the first sound, but the second was tolerably clear. On moving the stetho-
scope downwards and outwards, about an inch and a half below and external to the
nipple, the murmur became louder, and obscured both sounds of the heart. The
features were contracted, and the pulse was scarcely perceptible. The bowels were
relaxed, and he had vomited frequently. He continued under treatment till the 29th
September, when he was transferred to another ward. Dm-ing this period occasional
febrile symptoms were present. The pulse was in general small, sometimes irritable.
The action of the heart was increased ; the prsecordial dulness somewhat extended.
The cardiac murmur continued as described, but latterly it was less rough, and some-
what fainter, and did not obscure both sounds. The pulmonic symptoms and signs
continued, and there was more or less gastro-enteric irritation present. The urine
showed no trace of albumen. He was treated with stimulants, tonics, and anodynes,
and small blisters were applied to the prsecordial region. Shortly afterwards he left
the hospital, and was not again heard of till the 24th February, 1851, when he applied
for re-admission, and was received into the clinical ward. He complained chiefly of
discomfort and distention of the abdomen after eating, and the breathing was hurried.
Dulness on percussion of the right subclavian and axillary regions was noted, with a
bronchial character of the respiration there, as well as in the left subclavian and
scapular regions. The prsecordial dulness extended from the third rib to the margin
of the left false ribs, and transversely from the right margin of the sternum to half
an inch external to the nipple. The action of the heart was increased. A little internal
to the nipple there was a blowing systolic murmur, which became more audible in a
direction downwards, but gradually disappeared in a direction upwards ; the second

PHYSICAL SIGNS — FRICTION MURMUR. 577

sound of the heart was distinct. The pulse was small and feeble, the dyspnoea in-
creased, and he died on the 5th March.

Inspection twelve hours after death. — Chest. — The lungs did not collapse. The
left lung adhered firmly to the costal pleura throughout its entire extent; the
greater part of the upper lobe was in a state of red induration, the lower lobe was
somewhat condensed, and a good deal of frothy serum oozed out when it was cut ;
there was no pleuritic effusion. The right lung was miconnected by abnormal adhe-
sion to the costal pleura ; the upper lobe was in a state of red induration similar to
that of the left side, but rather less in degree ; the posterior part of the third lobe
was also condensed, and the anterior crepitated feebly ; the bronchial tubes were
filled with frothy serum, and the mucous membrane was red ; there was no pleuritic
effusion. The heart extended from the third to the seventh left rib. There was
no fluid in the sac of the pericardium. Opaque thickened patches existed on
the surface of the heart, chiefly that of the right ventricle. The cavity of the left
ventricle was dilated, but the walls were of natural thickness; the mitral valve was
considerably thickened, and the auriculo-ventricular opening was so contracted as
not to allow the point of the little flnger to pass through. The free margins of the
aortic semi-lunar valves were thickened. The left auricle was also dilated, and its
lining membrane presented an opaque thickened appearance throughout, with granular
effiision here and there, in patches. There was considerable dilatation of the right
aiiricle and ventricle, and both contained firm fibrinous coagula. Abdomen. — The liver
was rather smaller than natural, but healthy in structure. The kidneys were healthy.

234. Empyema of the right side of the chest. — Secondary pericarditis. — Friction
Murmur. — Lymph effusions found after death, — Miguel Eozario, aged thirty -five, a

native of Goa, a cook by occupation, had been in bad health for some time before
his admission into the Jamsetjee Jejeebhoy^Hospital, on the 23rd July, 1852. He was
affected with cough, and with dyspnoea, and the indurated edge of the liver projected
for two or three inches below the margin of the right ribs. The dyspnoea increased
and there were occasional febrile symptoms, and on the 13th August a distinct friction
murmur was perceived in the prsecordial region, best heard at the apex. There was
slight increase of praecordial didness. The face became puffed, the feet and hands
cedematous, and he died on the 19th.

Inspection thirteen hours after death. — Chest. — The right sac of the pleura con-
tained several pints of purvdent fluid ; the lung was compressed, and the liver was
displaced downwards. The surfaces of the pleura were covered with flaky lymph.
The left lung was healthy. The pericardium contained about eight ounces of blood-
tinged serum, and flakes and shreds of lymph adhered generally to its inner surface.
The heart was of natural size, and there was no disease of the valves.

EemarJcs. — For this case I am indebted to Dr. Haines, under whose care the patient
was. I had not an opportunity of seeing the patient during life, nor the morbid
appearances after death.

235. Acute arachnitis and pericarditis, leading to considerable effusions, coagulating
into a jelly-like mass when removed from thebody. — Friction murmur. — In a pregnant
female. — Joomkee, a Hindoo female, a beggar, thirty years of age, was brought to the
Jamsetjee Jejeebhoy Hospital on the evening of the 9th August, 1852. She had
been found alone in a house by[the police, and was believed to have been ill for several
days. She was quite comatose, and the pupils were dilated ; the skin was somewhat
above the natural temperature : the breathing was hurried : the pulse was small and
frequent. The upper limit of the prsecordial dulness was the lower border of the
second left rib, the lower limit was the upper border of the sixth rib ; the inner the
middle of the sternum, and the outer a vertical line drawn along the external margin
of the nipple. The impidse of the heart was increased, and a thrilling sensation was
commxinicated to the hand when placed on the praecordial region. The action of the

P P

578 . rERICARDITIS AND ENDOCARDITIS.

heart was tumultuous, and the sounds confused. There was distinct induration below
the left false ribs. She was in about the sixth month of pregnancy, and the foetal
pulsations were audible to the left of the fundus of the uterus. During the 10th the
coma continued ; the pulse became feebler ; the breathing more hurried, and at the
evening visit a friction murmur was heard at the second left costal cartilage, but not
at the apex — here the sounds were still confused. She died early on the morning
of the 11th.

Inspection three hours after death. — Head. — About eight ^ ounces of fluid flowed
from the cavity of the arachnoid and base of the skull, and speedily coagulated
into a jelly-like mass. It was of red colour, but this was probably due to some ad-
mixture of blood which had escaped from the sinuses, wounded in removing the dura
mater. There was no increased vascularity of the membranes, or redness of the sub-
stance of the brain. The ventricles were empty. Chest. — The diaphragm rose high
in the chest. The lungs showed no traces of disease. The pericardium was distended,
and occupied a space extending from the first to the fifth left rib, reached to the right
border of the sternum, and on the left side half an inch beyond the nipple. It con-
tained about twelve ounces of clear greenish fluid, which speedily coagulated into a
tremulous jelly-like mass. There was no vascularity of any part of the inner surface
of the pericardium or outer surface of the heart, and no trace of lymph deposit. The
endocardium, the valves, and muscular tissue of the heart, presented no appearance of
disease, unless a greater degree than usual of redness of the muscular structure may
be so considered. There was no dilatation of any of the cavities, and they con-
tained little blood, and no fibrinous coagula. The spleen was considerably enlarged.
The liver was of natural size, and healthy. Both kidneys were somewhat larger than
natural, but their structure was healthy. The gravid uterus extended as high as the
umbilicus, and contained twins between the fifth and sixth month.

Jogging movement of the heart was noticed only in one case, and
in this the history pointed to pericardial adhesions as the probable
result : it may, therefore, be looked upon as tending to confirm
the opinion entertained by Dr. Hope relative to the import of this
sign.

XI. On the treatment of the disease, — The following obser-
vations have reference to seventeen cases : —

In none was general blood-letting required ; the constitutions of
the patients admitted into the Jamsetjee Hospital are for the most
part too asthenic to justify the use of this antiphlogistic means.

In eleven, local blood-letting by leeches was had recourse to.
The stage of the disease, and the state of the pulse and skin, were
the guides to the adoption and degree of this measure. Of its
efficacy, when the circumstances are appropriate, there can be no
doubt.

In fourteen cases, one or more blisters, from three to four inches
square, were applied to the prsecordial region. The liquor lyttse
was the preparation generally selected, and it was usually applied
after suitable local depletion, or in cases for which the latter mea-

* The character of the cerebral effusion is the only fact in this ease not witnessed
by myself. I am indebted to Mr. Sebastian Carvalho for the statement. The heart
and pericardial effusion were seen by me.

TREATMENT. 579

sure was considered inappropriate. Blisters were not used more
frequently, when liquid effusions were believed to be present,
th-an when they were supposed to be absent. Looking upon
the derivant action of a counter-irritant as a means which tends
to favour the restoration of normal circulation in the inflamed
capillaries, and believing that this is necessary to ensure the
absorption of liquid effusions, or the organisation of lymph-deposits,
it seems to me, as regards the application of blisters, an immaterial
question which of these processes must be brought into action
before recovery can take place : in both, a more or less complete
return to normal capillary circulation in the structures adjoining
the deposits, is essential.

Mercurial influence was induced in ten cases. In all, with
one exception, local blood-letting had also been used, and in all
blisters applied. Of these ten cases, three were of pericarditis
alone, one of endocarditis, and six of pericarditis and endocarditis
combined. Five of the ten cases in which mercury was used, re-
covered; but in the other five, though life was saved, structural change
remained behind. Of the eight cases classed under a former head as
recoveries (p. 564), mercurial influence was induced in five ; but in
three it formed no part of the treatment, which in one consisted
of local blood-letting and blisters, in another of blisters, in a third
of Dover's powder and nitre alone. The mercury was given every
third, fourth, or sixth hour, in the form of calomel, in two or three-
grain doses, combined with a quarter or half a grain of opium ;
and in cases in which there was much febrile disturbance, from a
quarter to a third of a grain of tartar emetic was added. The
calomel was used with caution, so as not to cause a greater effect
than slight swelling of the gums, and gentle ptyalism ; and this
state was maintained for several days. The mercurial treatment
was never had recourse to without a strict inquiry into the state of
the patient's constitution, with the view of ascertaining the like-
lihood of a scorbutic or other cachexia. This care is essential in
the treatment of the class of patients who resort to this hospital,
and indeed, I might add, of natives of India generally.

We find, then, that of ten cases brought under the influence
of mercury, five recovered, — but in these local blood-letting and
blisters had also been used ; and that of eight cases in which re-
covery took place, mercurial action, preceded by blisters and
leeches, had been induced in five, but in three mercury had not
been given. In this statement, then, we have no striking proof of
the efficacy of the mercurial treatment of pericarditis and endo-

p p 2

580 PERICARDITIS AND ENDOCARDITIS.

carditis : yet my impression is in favour of its cautious adoption in
suitable states of the constitution, and stages of the disease.

The present state of therapeutic science teaches us that mercury,
under some circumstances, favours the absorption of lymph-de-
posits; and so long as this doctrine remains unrefuted, it is the
course of prudence to yield to it some measure of our faith, and to
act in some degree under its guidance. At the same time, how-
ever, we must never forget, that if mercury may influence for
useful ends states of the blood well constituted as regards fibrine
and red corpuscles, it can hardly fail to cause harm in opposite
conditions. But these principles have been already fully explained
and enforced in various parts of this work.

In one case in which the use of mercury was contra-indicated,
liquor potassce was substituted, because in similar asthenic states
many good recoveries of pneumonia in the second stage seemed to
have been brought about by this remedy.

581

CHAP. XXV.

ON ORGANIC DISEASE OF THE HEAET AND AORTA.

Section I. — In Natives of India,

This section records the clinical history of twenty-eight cases of
structural disease of the heart, and three of aneurism of the aorta.
The important facts may be arranged under the following heads: —

I. The nature and situation of the

structural change.
II. Relation to difference of sex.

III. The proportion of cases in the

different castes.

IV. Classification with reference to

age.
V. The different occupations of those

affected.
VI. Relation to habits of life.
VII, Relation to the months of the
year.
VIII. Relation of the structural changes
to pericarditis, endocarditis,
and rheumatism.
IX. Relation to Bright's disease of the
kidney.
X. The leading symptoms and signs,

XI.

treated of under the following
heads : —

1. Dyspncea.

2. Dropsy.

3. Praecordial pain.

4. Pain below the margin of
the right ribs.

5. Scapular pain.

6. Character of the pulse.

7. Prsecordial fulness.
Increased impulse of the

heart.
Prsecordial dulness.
Dulness below the margin

of the right ribs.
Character of the murmurs.
12. Prsecordial thriU.
On medical treatment.

11.

I. The nature and situation of the structural changes. — Of
the thirty-one cases, eighteen proved fatal in hospital, and two in
all probability, shortly after discharge. Of the eighteen fatal cases
an examination of the body after death was made in seventeen.
Let us first notice the structural changes which existed in them.

In eleven there was dilatation of both ventricles of the heart ;
in six, associated with disease of both aortic and mitral valves ; in
four with disease of the mitral valve, and in one with disease of
the aortic valves alone.

In ten there was dilatation and hypertrophy of the left ven-
tricle. In these, with two exceptions, there was dilatation of the

p P 3

582 onaANic disease of the heart.

right ventricle also ; in five there was disease of both the aortic and
mitral valves, in three of the mitral valve, and in two of the
aortic valves only.

In one case there was hypertrophy of the right ventricle^ asso-
ciated with obstructive disease of the pulmonary semi-lunar valves.
It is here narrated : —

236. Contraction of the orifice of the pulmonary artery, probably congenital. — Mmh
hypertrophy, without dilatation of the right ventricle of the heart. — No disease of the
left side. — Mahadoo Babajee, a Hindoo beggar, fifteen years of age, of short statixre,
and disproportionately large head, a native of Alibag, in Angria's Colaba, and resident
in Bombay from his childhood, was admitted into the clinical ward on the 22nd Sep-
tember, 1850. He stated that from childhood he had suffered from dyspnoea, occasional
cough, and pain of the prsecordial region ; that he was liable to febrile attacks ; that
on one occasion his abdomen had become very tumid ; that for four months before ad-
mission he had experienced pain, without swelling, of the large joints, and to these
symptoms occasional headache had been added. On admission, the respiration was
observed to be slightly hurried ; the skin was cool ; the pulse small and easily com-
pressed ; the abdomen somewhat full, but supple ; the tongue coated with a white fur;
the bowels regular, and the urine free. The chest sounded well on percussion, with
exception of slight increase of the prsecordial dulness, which extended vertically from
the fourth to the sixth rib, and transversely from the middle of the sternum to the
left nipple. The respiratory murmur was somewhat puerile in character, and without
rales. The action of the heart was somewhat increased, and its apex beat in the in-
tercostal space between the fifth and sixth rib, at the left border of the sternum.
There was a systolic murmur, best heard a little below and internal to the nipple,
continuing distinct upwards and to the right side, and fading in the opposite direction.
The second sound was normal. No thrilling sensation was experienced on placing the
hand on the prsecordial region. He remained under treatment till the 26th November,
when he was discharged, little relieved. During his stay, the physical signs of heart
disease continued as on admission. He complained of dyspnoea, of cough, occasional
pain of the joints, of headache, and febrile disturbance from time to time. The pulse
was always small, and easily compressed; the urine free, specific gravity from 1-012
to 1-020, and without trace of albumen. This patient was re-admitted into the
hospital on the 19th March 1851, affected with febrile symptoms. The systolic murmur
was still present; also dry bronchitic rales. He was attacked with symptoms of
cholera on the 23rd, and died on the 24th.

Inspection twenty -four hours after 'death. — Head. — The calvarium, chiefly the
occipital and frontal portions, was very thick, being more than quarter of an inch, but
without any increase of the density of the diploe. The furrows of the middle menin-
geal artery were deeply grooved. The membranes of the brain were very much con-
gested. The substance of the brain was firm, showed more bloody points than usual,
and the cortical portion was of "darker tint than natural. Chest. — The heart weighed
seven ounces and a half. With exception of the right auricle there was no dilatation
of the cavities. The walls of the left ventricle were of natural thickness ; those of the
right ventricle were thicker than those of the left — they were rather more than half
an inch thick. The orifice of the pulmonary artery was of size only sufficient to permit
the passage of half the length of an ordinary dissecting case blow-pipe, and the surface
towards the cavity of the artery, and immediately surrounding the opening, had a
rough and papillated appearance, as of firm granular-lymph deposit. The orifice
seemed to be constructed by adhesion of the free edges of the semi-lunar valves, with
exception of their central part. The valves, however; were very little thickened, and
a probe passed readily into the little pouch between them and the internal surface

PATHOLOGY. 583

of the artery. The trunk of the pulmonary artery was of diminished capacity, and
the walls were thinner than natural. The aorta and its valves were healthy. The
lungs were not congested with blood ; in parts they were dry and wooUy, and the
surface somewhat irregular, from slight emphysema.

Remarks. — Presuming on the rarity of disease of the valves of the right side of the
heart, it was supposed that the aortic valves were the seat of disease in this case ; but
my belief is that a more careful inquiry into the situation at which the murmur was
best heard would during life have led to a correct diagnosis. The stunted growth,
the absence of dilatation of the cavities of the heart, the freedom from dropsical
symptoms or other signs of congestion, and the small pulse, all show that the blood
was maintained in very reduced quantity ; indeed, it was only by an adaptation of
the quantity to the very contracted pulmonary orifice that the circulation of the blood
could have been carried on. The complete absence of congestion of the lungs, so
diflferent from what obtains in most forms of heart disease, was interesting, but of easy
explanation.

In the four following cases there was aneurism of the left ven-
tricle. In all, the opaque state of the endocardium showed that
endocarditis had at a former period been present, and was pro-
bably the cause of the atrophy and impaired irritability of the
muscular fibre which had led to the formation of the aneurismal
pouches. In three of the cases there was disease of the mitral
valve, and in one, of the aortic valves.

237. Dilatation of both ventricles. — Hypertro^^hy of the left. — Disease of aortic valves
and the, well-marked results of pericarditis and endocarditis, consecutive mi rheumatism,
related to syphilis. — Ahmeenah, a Hindoo female, thirty-nine years of age, had, about
a year before she came under observation, been the subject of syphilis, followed by
pain and swelling of almost aU the joints, and latterly by dyspnoea, and fulness of the
epigastrium. She was admitted into the hospital on the 14th December, 1848, affected
with general anasarcous swellings, dyspnoea, and cough. There was praecordial dulness
from the third to the seventh rib, and from the middle of the sternum to an inch ex-
ternal to the left nipple. The impulse of the heart was increased, and a sawing murmxir
took the place of both sounds, and was loudest between the third and fourth rib, about
half an inch to the left of the sternum, continuing audible as the stethoscope was
moved towards the clavicle, but lessening in the direction of the apex. There was
occasional sibilus mixing with the respiration. The pulse was feeble. There was
fulness and uneasiness at the epigastrium, and hepatic dulness extended to within an
inch of the umbilicus. The urine was not albuminous. The dropsical symptoms and
the dyspnoea increased ; and she died on the 25th December.

Inspection. — On examining the body after death, the pericardium was found to ex-
tend from the second to the seventh rib, and its cavity contained about four ounces of
serum. It was connected to the surface of the heart, chiefly over the left ventricle, by
firm adhesions. The serous covering of the heart was for the most part thickened and
opaque. The heart was much enlarged — there was dilatation of both ventricles, with
hypertrophy of the left ; the tricuspid and mitral valves were healthy. The lining
membrane of the left ventricle, towards the aortic orifi.ce, was for a considerable extent
opaque, and much thickened. There existed at the upper part of the septum a thimble-
like depression about an inch in diameter, lined by thickened endocardium, roughened
by granules of lymph. The ring of the aortic valves felt cartilaginous and firm, but
there was no dilatation of the aorta.

238. Aneurism of the left ventricle of the heart, consequent on endocarditis and
pericarditis. — ^Mahomed Allee, aged forty, a Mussulman, » native of Bengal, resi-

p p 4

584 ORGANIC DISEASE OF THE HEART.

dent for fourteen years in Bombay, following the occupation of a sailor, and not in-
temperate in his habits, was admitted into the clinical ward on the 6th November,
1849, and died on the 12th of the same month. He was a good deal reduced ; the
countenance was anxious ; the respiration hurried ; the pulse feeble and intermitting.
He was easiest when on the right side, or in the sitting posture. Decubitus on the
back or the left side led to much aggravation of the dyspnoea, and anxiety ; and in conse-
quence of the suffering which they occasioned, minute and repeated examinations of
the chest were impracticable. The prseeordial dulness extended from the fovirth costal
cartilage to the seventh, and transversely from the middle of the sternum to just ex-
ternal to the left nipple. The impidse of the heart was somewhat increased. There was
a systolic murmur audible at the foiu'th costal cartilage, increasing in the direction of
the apex, decreasing above the base. The second sound was natural. He complained
of constant pain about the left scapula, but none of the prsecordial region. The pain
at the left scapular region had existed for about three months, but the dyspnoea came
on only nine days before his admission into the hospital. About two inches below
and external to the left nipple there was a depressed cicatrix — the mark, he said, of a
gun-shot wound received during the late war in Scinde. Was never affected with
rheumatism, or pain of the prsecordial region.

Ins-pection. — Chest. — The lungs collapsed on opening the chest, and there wa? about
a pint of serous efiusion in the sacs of the pleura. The upper lobes of both lungs,
more especially at their apices, contained many scattered miliary tubercles, with some
induration of the intervening pulmonary tissue ; the rest of the lung healthy and
crepitating, but somewhat congested. The pericardium contained about two ounces
of serum. The heart was much enlarged ; it occupied vertically a space between the
lower margin of the second rib and the level of the seventh, and transversely from the
sternal junction of the second right rib to the left nipple. There were firm close adhesions
between the pericardium and the posterior and upper part of the left ventricle ; also
general thickening and opacity of the serous covering of the heart. The left ventricle
was very much dilated. At its apex, and posteriorly below the mitral valve, it was
dilated into two distinct pouches. The latter pouch was large enough to hold a small
orange, its walls were membranous and opaque, and it contained fibrinous coagula.
The rest of the walls of the ventricle was of natural thickness. There was slight
thickening of the mitral valve ; the orifice of the aorta was dilated. The right ven-
tricle was also dilated ; the semi-lunar valves were healthy. There was no morbid
appearance found in the interior of the chest corresponding with the cicatrix on its
exterior. Abdomen. — There was about a pint of serum in the cavity of the peritoneum.
The free lower margin of the liver was about three inches below the ensiform cartilage,
and about an inch below the margin of the right ribs, and the organ was somewhat
congested. The kidneys were healthy.

239. JRheumatism, followed hy 'pericarditis and endocarditis. — Disease of the mitral
valve. — Dilatation of the right side of the heart. — Dilatation and hypertrophy, toith
circumscribed aneurism of the left ventricle. — Death expedited by acute general perito-
nitis. — Abdool Eahman, a Mussulman horsekeeper, fifty years of age, an inhabitant
of Hydrabad, in the Deccan, and a resident in Bombay for about six years, was ad-
mitted into the Jamsetjee Jejeebhoy Hospital on the 13th December, 1849. He had
been addicted to the use of spirituous liquors for several years, smoked ganja and
tobacco, and latterly also took opium. About three years before admission he had
suffered for a month from pain of the large joints, unattended with swelHng he said ;
but that since then there had been no recurrence. For a year and a half he had ex-
perienced more or less dyspnoea, easily increased by exertion, but unattended with
cough, till about eight days before admission, when cough began to be troublesome,
and the dyspnoea to be more urgent, followed in two or three days by puffiness of the
face and oedema of the feet and legs ; and in this state he was admitted into hospital.

PATHOLOGY. 585

The respirations were twenty-six, and ehiBfly abdominal. With exception of increased
prsecordial dulness, the chest sounded well on percussion ; but sibilous and subcrepitous
rales were present more or less in all parts of the lungs. The prsecordial dulness
extended vertically from the^thrrd costal cartilage to the margin of the left false ribs,
and tranversely from the middle of the sternum to about three inches external to the
nipple. The impulse was forcible, extensive, and heaving, and the apex beat between
the sixth and seventh ribs, an inch external to the nipple. There was a systolic
bellows murmur very distinct below the nipple, and in the direction of the apex, but
becoming faint above the base. The second soxind was distinct, but wanting in sharpness.
The skin was cool; the pulse 96 to 100, small, easily compressed, and slightly jerking
He complained of cough and dyspnoea, — both increased at night, the latter becoming
very urgent on slight exertion. The abdomen full and supple, without any sense
of fluctuation ; and there was dulness below the right false ribs for about two and a
half inches, and extending upwards as high as the level of the sixth right rib.
The bowels were slow, and the urine reported free. He continued under treatment till
the 4th March ; the dropsical symptoms disappeared, and the dyspnoea and cough
were much alleviated. The general character of the pulse was small, irregular
and unequal, and varying in frequency. The rhythm of the heart's action was often
observed to be irregular, two pulsations being succeeded by a period of considerable
repose, and a distinct thrill was in general perceptible on placing the hand on the
prsecordial region. The dulness of the prsecordial region, and the character
of the murmur and of the second sound, continued unchanged. The urine was
free, of varying density, and never albuminous. He was treated chiefly with com-
binations of camphor mixture, sesquicarbonate of ammonia, spiritus setheris nitrici,
tincture of hyosciamus, and preparations of squills. After his discharge from the
hospital, he from time to time presented himself at the morning visit, and the physical
signs of heart disease were found to continue without change. At length he was
re-admitted into the clinical ward on the 21st August, 1850. The abdomen was
tense, tender, and fluctuating ; the pulse frequent, and almost imperceptible ; dyspnoea
urgent. He died about twelve hours after admission.

Inspection nine hours after death. — Chest. — On opening the cavity of the chest,
the lungs collapsed, and were found crepitating. There were old adhesions of the
costal and pulmonary pleurae of the right side. The pericardium was in relation with
the anterior wall of the chest from the first to the sixth rib, and tranversely beyond the
right margin of the sternum to the right, and beyond the nipple to the left. There
was no adhesion of the pericardium to the heart, but the siirface of the heart, more
particularly of the left ventricle, was covered with opaque patches. The right auricle
was very much distended. There was also much dilatation of the right as well as of
the left ventricle, and in both were found coagula of blood. The walls of the left
ventricle were for the most part of natural thickness, with the exception of one place
in the internal wall, midway between the apex and the mitral valve, where the coats
were, much thinned, the muscular tissue being almost removed, so as to form a pouch
the size of a walnut. The endocardium surrounding the margin of the pouch for about
haK an inch was opaque and thick. The mitral valve was thickened, so as to permit
regiirgitation into the auricle. The aortic valve and the aorta were healthy. Ahdomen.
— About two pints of turbid serous fluid were found in the cavity of the peritoneum,
and an abundant effusion of coagulable lymph over the surface of the intestines formed
tender bands of adhesion between them and the parietes, and between the convolutions.
In several places the adhesions circumscribed collections of serum. The liver was
rather smaller than natural, and its substance felt hard under the knife ; its external
surface was granular, but there was no very distinct appearance of cirrhosis of its in-
cised surfaces ; the external surface was covered with patches of coagulable lymph ;
its anterior margin was firmly adherent to the ascending colon as well as to the
diaphragm. In the mucous membrane of the coecum there was an ulcer about the

586 ORGANIC DISEASE OF THE HEART.

size of a rupee ; and in that of the ascending colon there were three or four smaller
idcers, with patches of redness here and there. The other parts of the intestinal
canal wore healthy. Both kidneys were somewhat lobulated externally, and, when
incised, the cortical portion presented a slightly granular appearance ; the apices of
some of the pyramids seemed somewhat indurated and fibrous. The spleen and
stomach were healtliy.

240. The former subject of rheumatism. — Bilatation of the left ventricle. —
Disease of the mitral valve. — Much thickening of the endocardium. — An aneur-
ismal sac at the apex. — Also the marks of former pericarditis. — Shamoo, a female,
forty years of age, a Hindoo milk-seller, a native of Aurungabad, and resident a month
in Bombay, was admitted into the Jamsetjee Jejeebhoy Hospital on the 7th August,
1852. The face was puffed ; the feet and legs oedematous ; the respiration short and
hurried ; the skin coldish ; and the pulse small, and easily compressed. The prsecor-
dial dulness extended vertically from the second intercostal space to the margin of the
left false ribs, and transversely from the right border of the sternum to beyond the
left nipple. The impulse of the heart was feeble. There was a faint systolic murmur,
most distinct at the apex. At the base the sounds were confused, but the murmur was
hardly audible. The abdomen was rather full, and was dull on percussion for about
three inches below the right false ribs and the sternum, where there was uneafsiness
on pressure. She stated that three years before she had suffered from rheumatism,
and that fifteen days before admission there had been a severe febrile accession, pre-
ceded by chills, which continued for three days, and was followed by cedema of the
legs, and uneasiness of the abdomen. She continued with little change in the symp-
toms, and died on the morning of the 11th August,

Inspection three hours after death. — Chest. — Eight ounces of reddish serum were
found in the pericardium. The heart was considerably enlarged. There were opaque
patches on the anterior surface of the right ventricle, and at the apex of the heart there
was a patch the size of a dollar, of thick organised areolar tissue, somewhat reddened,
adherent firmly to the surface of the heart, but forming no adhesion with the inner
surface of the pericardium. The left ventricle was much dilated, and the walls were
in places somewhat thickened. The endocardium of the posterior surface of the left
ventricle was converted into an opaque thick membranous laj'er, with here and there
cacoplastic yeUow deposit, about two lines in thickness. There were also opaque
thickened patches of the endocardium of the anterior surface. At the apex there was
a pouch in the thickened endocardium, large enough to hold a walnut, corresponding
to the patch of adventitious tissue on the external surface ; the mu.scular covering of
the pouch was much thinned. The mitral valve was opaque and thickened, not ossified.
The aorta and valves were healthy. There was no dilatation of the right ventricle,
and the valves were healthy. The lungs were healthy and crepitating. The body was
not further examined.

In six there was both aortic and mitral valvular disease, in
six disease of the mitral valve only, in two of the aortic valves
alone, and in one * of the pulmonary semi-lunar valves.

The co-existence of dilatation of both or one of the ventricles of
the heart, with various stages of valvular disease has been shown.

In nine cases the existence of former pericarditis was proved by
the presence of opaque patches on the surface of the heart ; and
in two of these adhesion between the pericardium and the surface
of the heart also existed.

* Case 236.

PATHOLOGY. 587

In six there was in the opaque condition of the endocardium of
the left ventricle evidence of previous endocarditis.

Both the pericardium and endocardium had been affected in five
cases.

In five there was effusion of serum exceeding two ounces, in the
sac of the pericardium.

In the following case rupture of the left ventricle of the heart
had taken place : the muscular fibre had probably undergone fatty
degeneration,

241. Rupture of the heart from fatty degeneration. — John Amarago, a sailor, fifty-
five years of age, was admitted into the Jamsetjee Jejeebhoy Hospital on the 6 th
March, 1852, with bronchitic symptoms. The pulse was soft, and rather full, and
there was some heat of skin. He died suddenly and unexpectedly the day after ad-
mission, no information having been obtained in regard to his previous history.

Inspection. — The pericardium was distended with bloody serum, mixed with clots.
The left ventricle was ruptured longitudinally in two places, about an inch apart from
each other, in the upper and outer part of the ventricle. The fissures were one an
inch, the other half an inch in length ; one extended through the substance of the wall
of the ventricle, and opened into the cavity obliquely ; the other was a rupture of the
external fibres only. The walls of the ventricle were somewhat thickened, but
there was not any dilatation of the cavity. Over the right ventricle there was more
than the usual amount of adipose tissue, and in two situations in the substance of the
left ventricle were two distinct, defined, light yellow, granular-looking patches, occupy-
ing half the thickness of the wall, The aortic valves were healthy. There were
points of deposit on the inner surface of the ascending aorta.

EemarJcs. — Though unfortunately a microscopic examination was neglected, there
can be no doubt that the heart in this case was affected with fatty degeneration.

In three cases there was dilatation of the ascending portion of
the aorta, and in one the aorta was contracted. In three there
were thickened patches of athermatous deposit on the inner sur-
face of the aorta.

In two cases there was aneurism of the thoracic, and in one
of the abdominal aorta. One of the former and the latter are here
detailed.*

* I find in my notes the following two additional cases of aneurism of the aorta,
observ^ed subsequent to my return to India ; also one of perforation of the aorta and
death by haemorrhage.

1. A Hindoo admitted in November 1856. There was much dyspncea ; considerable
tumefaction with dulness at the epigastrium. The dulness extended above the ensi-
form cartilage. There was duhaess of the right dorsal region ; clearness but absence
of breath sounds in the right lateral and mammary regions. Dulness on percussion
at the sternal end of the right subchman region, with pulsation there greater than at
the heart, with single murmur at times, but disappearing when the pulse at the wrist
was faint. No abnormal cardiac sounds detected, but the heart action was feeble.
No difference of pulse. He died thirty-six hours after admission.

Inspection. — The upper lobe of the right lung was displaced by a large aneurismal
dilatation, the size of the fist, involving the whole of the ascending aorta, stopping at
the arch and not affecting the vessels given off from it. The aortic orifice was

588 ORGANIC DISEASE OF THE HEART.

242. Great dilatation of the ascending aorta and the arch. — An aneurismal tumour
at the commencement of the descending aorta. — There was no external swelling, but the
other signs of the disease were well marked. — Sungoor Seedee, a Mussulman sailor,
an inhabitant of Bahrein, and of African extraction, forty-one years of age, was ad-
mitted into the clinical ward on the 9th January, 1849. He was somewhat reduced in
strength, and the respiration was rather short and hiirried, and easiest in the sitting
posture. There was no marked dulness of the chest. He had occasional cough, with
scanty muco-puriform expectoration. Sonorous rale was audible in the left scapular
region, but elsewhere the vesicular respiration was good. There was no increased
impulse of the heart at the praecordial region, and the two soimds were distinct, but
from the third rib upwards in the line of the sternum, inclining to the right towards
the sternal junction of the right clavicle, there was a heaving impulse, very evident
under the stethoscope, indistinctly so to the hand, attended vrith a single sound, but
no murmur. When in the recumbent posture, there was occasional wheezing observ-
able in the respiration. The pulse at the left wrist was 104 in the sitting posture,
and of good strength ; the pulse at the right wrist, and in the right carotid artery, was
imperceptible. The abdomen was soft ; the tongue was moist and clean ; no difficulty

enlarged ; the valves slightly thickened. There was inadequacy of the valves, from
increased size of the orifice. Hypertrophy with dilatation of the left ventricle — dila-
tation of the right. Congestion of posterior parts of the lungs. Much congestion of
the liver, which explained the epigastric fulness.

2. Balloo Krishna, a Hindoo labourer, twenty-eight years of age, was under treatment
for supposed pleuritis in the early part of November 1856. He was discharged, and
some days afterwards when sleeping exposed, he became aiFected with great dyspnoea,
and was again admitted on the 28th November. There was urgent orthopncea, with
the face and trunk bent forwards. The dyspnoea, always great in degree, increased in
paroxysms, and was attended with muco-puriform expectoration. The voice was feeble,
and there was some difficulty of deglutition. The pulse feeble ; the skin coldish.
No disease of the heart or aorta detected, though carefully sought for. He experi-
enced slight relief from the cautious inhalation of chloroform in small quantities. He
died on the 7th December.

Inspection, — An aneurismal tumour, the size of a hen's egg, communicating by an
opening, the size of a rupee, with the posterior wall of the aorta at the commencement
of the arch, was found crossed obliquely by the innominate artery, and also by the left
carotid and subclavian, both displaced somewhat to the left. The sac was filled with a
eoagulum, from which a fibrinous band extended down the ascending aorta into the
left ventricle. The inner surface of the ascending aorta was roughened and thickened
from atheromatous deposit. Some dilatation of the left ventricle. No other cardiac
disease. There was congestion of the liver, and the thin edges of the lungs were
solidified from collapse.

A curious case of perforation of the aorta was kindly communicated to me by Dr.
Crawford, who also allowed me to examine the morbid structures : —

3. A soldier of the 18th Eoyal Irish swallowed a piece of chicken bone — came to
hospital — pain at lower part of sternum, and symptoms of gastric irritation ; very
little difficulty of swallowing. On the sixth day profuse hsematemesis and death.

Inspection. — A narrow (two lines broad) piece of bone, one and a half inch long, very
pointed and sharp, lay in a'sloughy depression, two inches long, three quarters wide, of
the lower and back part of the oesophagus ; it had penetrated the aorta. The sloughy
state extended to the tissues between the oesophagus and aorta, but had not reached
to those of the aorta. Under an effijrt of vomiting, the sharp point impacted
vertically in the mucous membrane, had penetrated the aorta, then a process of ulcer-
ation and sloughing, by which the bone was loosened, and haemorrhage the conse-
quence.

PATHOLOGY.

589

in deglutition. When sitting he experienced uneasiness at the epigastrium ; when
recumbent the uneasiness extended over the chest and shoulders. He had first
observed these symptoms two months before he came under observation, and they
had gradually increased. He attributed his illness to his having often been obliged
to lift heavy weights on board ship. During his stay in hospital, his nights were
restless ; he had occasional cough, and uneasiness about the sternum. On the 13th
there was a slight murmur audible at the top of the sternum, but it was not again
heard. Decubitus was easiest on the right side. He complained of difficulty of
swallowing on the 25th, and there was some degree of febrile excitement. The
breathing became disturbed, and the pulse feeble. He gradually sank and died,
without any marked change in the symptoms, on the 30th January.

Inspection twenty-five hours after death. — Chest. — Just above the semi-lunar
valves the aorta became dilated to about four times its natural calibre. The dilata-
tion involved the ascending aorta, the arch, and commencement of the descending
aorta ; it included all the coats of the artery, with probably an exception at the com-
mencement of the descending aorta, where there seemed to be a separate pouch,
closely adherent to the bodies of the fourth, fifth, and sixth dorsal vertebrae, and filled
by firm and fibrinous coagula. In the ascending portion of the aorta there was a loose
coagulum, and at the commencement of the arteria innominata there was thickening,
with irregularity of the surface of the lining membrane. The dilated arch of the aorta
pressed upon the trachea just above its bifurcation. The dilated pouch at the com-
mencement of the descending aorta made pressure on the oesophagus. The lower lobe
of the left lung adhered by recent adhesions to the costal pleura, and hepatised
nodules were felt on pressing it. The heart was healthy.

243. Aneurism of the abdominal aorta. — Death hy rupture. — Soorga Chunderbund, a
Mahratta washerman, forty years of age, in the habit of smoking tobacco and drinking
moderately, was admitted into the clinical ward on the 21st March, 1848. He was
considerably reduced in fiesh ; the countenance was anxious ; and he moved about
with a stooping gait. In the epigastric region, chiefly, but not altogether, to the left
of the median line, reaching to the umbilicus, and extending below the arch of the left
false ribs, from the ensiform cartilage downwards, there was a round indistinctly
circumscribed swelling, becoming more prominent on decubitus on the right side. The
swelling was strongly pulsating anteriorly and laterally, but there was no bruit
audible under the stethoscope. In the rest of the abdomen, along the margin of the
right ribs and the ensiform cartilage, and in the left hypochondrium above the upper
margin of the tumour, the sound was tympanitic on percussion. The action and
sounds of the heart were natural. He complained of pain of the loins, of impaired
appetite, and uneasiness after food. The pulse was somewhat foil, and the bowels
slow. He stated that about a year previously, whilst engaged in ironing clothes,
he felt a slight pain, first at the epigastrium, and that six months after he perceived a
small pulsating swelHng, which gradually attained the size which it presented on his
admission. He died suddenly the day after admission.

Inspection eight hours after death. — There was a large quantity of blood (several
pints) between the layers and at the root of the mesentery. Just below the superior
mesenteric artery, and extending below the giving oflf of the renal arteries, there
arose from the anterior surface of the aorta a tumour larger than a goose's egg, filled
with coagula, and ruptured at its apex, which extended between the folds of the
mesentery. The vena cava was pushed before the tumour, and was apparently com-
pressed.

Of the seventeen cases examined after death, the state of the
lungs is not mentioned in the report of two. In six there was
congestion of part of the hmgs : five of these were cases in which

590 ORaANIC DISEASE OF THE HEART.

there was dilatation of both ventricles, and one dilatation with hyper-
trophy of the left ventricle. In five there was oedema of the lungs,
and in all of them dilatation of both ventricles was present. In
four there was more or less serous effusion into the sacs of the
pleura, and in these there was also dilatation of both ventricles;
in three the pleural effusion was associated with oedema of the lungs.
In five, old pleural adhesions existed. In two there were hepatised
nodules here and there in the substance of the lungs. In one
tubercles existed ; in one emphysema. In one the lungs were re-
ported to be healthy. In these statements we find the relation between
congestion of the lungs, serous effusion into the sacs of the pleura,
or into the pulmonary air cells, and heart disease, well illustrated.

Cases not fatal in hospital, — There were thirteen of this class :
two, as already stated, were believed to prove fatal shortly after
the patients were discharged.

Of these thirteen cases, in eight there was hypertrophy and
dilatation of the left ventricle.

In seven there was mitral valvular disease, in one aortic val-
vular disease, in one disease of the tricuspid valve, and in one
aneurism of the arch of the aorta.

II. Relation to difference of sex. • — Of the twenty-four cases,
there are only three females. The observations made under this
head, in reference to pericarditis and endocarditis, are equally
applicable to the present division of the subject (p. 564).

III. Proportion of cases in the different castes. — Of the
thirty-one persons, fifteen were Hindoos, nine Mussulmans, six
Christians, and one a Parsee. On comparing this statement with
the corresponding one in the preceding chapter* it will be ob-
served that the proportions of Hindoos and Christians are very
similar, but those of Mussulmans and Parsees are altogether
opposed. This result makes it evident that the data have been too
limited to justify any general conclusion on this point.

IV. Classification with reference to age. — The ages were as
follows : —

[•om 10 to

» 21 „

» 31 „

» 41 „

M 51 „

„ 61 „

3
10
11
5
1
1

Page 504.

RELATION TO AGE AND OCCUPATION. 591

The lowest age was fourteen, and the highest sixty-five. Be-
tween the ages of fourteen and thirty there were thirteen cases,
and of these, five were in individuals who were reported to have
suffered from rheumatism. Between the ages of thirty-one and
forty there were eleven cases, and of these, four had been afi'ected
with rheumatism. Between the ages of forty-one and fifty there
were five cases, and of these, two had suffered from rheumatism.
Of the two cases between fifty-one and sixty-five, one had also
been affected with rheumatism.

When we compare this statement with that under the same head
relative to pericarditis and endocarditis *, we find that in the pre-
sent, the range is considerably more extensive — it is between the
ages of fourteen and sixty-five instead of seventeen and fifty.
We observe, also, that the cases below twenty are considerably
fewer — less than one half; that between twenty-one and thirty
they are also less numerous, but between thirty-one and forty the
proportion is more than double.

Of the thirty-one cases, twenty-one occurred between the ages
of twenty-one and forty, and of these, nine had suffered from
rheumatism ; of the remaining ten cases, three had suffered from
rheumatism.

V. The different occupations of the a^ec^ec^. — Excluding the
three females, and four whose occupations are not mentioned, the
remaining may be classed in the following manner : —

Servants 4

Beggar 1

Plasterer 1

Tailor 1

Sailors. .

. 9

Labourers

. 4

Horsekeepers .

. 2

"Washermen .

. 2

7=24

There may be observed in this statement the same relation be-
tween probable exposure to cold and wet and heart affections, as was
noted relative to these influences, and pericarditis and endocarditis:
the reason is evident. But there is another point of interest in
the etiology of heart disease, which is also illustrated — the
frequency of the affection in individuals whose occupations
require active muscular exertion. Of the twenty-four cases, the
seventeen in the first column were thus circumstanced, and it is
worthy of note that of the three cases of aortic aneurism, two
occurred in washermen f, the third in a sailor.

* Page 566.

t It is unnecessary to state for the information of the Indian reader, but it may be
for that of the European, that the method of clothes-washing in India necessitates
considerable, violent muscular exertion of the arms and upper parts of the body.

692 onaANic disease of the heart.

VI. Relation to habits of life. — The habits of only' twelve are
mentioned : of these four were not addicted to the use of spirits,
but eight were ; four of them were Hindoos, two Mussulmans, one
Parsee, one native Christian.

VII. Relation to the months of the year, — The admissions
occurred in the following months : —

2 in January

2 „ February

3 „ March

1 „ April
0 „ May

2 „ June

4 in July

4 „ Axigust

5 „ September
0 „ October

4 „ November
4 „ December.

As regards structural disease of the heart itself, it is not pro-
bable that we shall find any connection between admission into
hospital and the season of the year. But when we recollect that
admission is generally sought for relief from the secondary affec-
tions— dropsical effusions, and bronchitic attacks — we may be
prepared to find the same relation between cold and wet and
admission for heart disease, that we found to obtain between
these states of the weather and pericarditis and endocarditis.*
This statement confirms such expectation; eleven cases were
admitted in the cold months of November, December, January,
and February, and fifteen in the wet months of July, August, and
September ; in the hot months of April, May, and October only
one case was admitted.

VIII. Relation of the structural changes to Pericarditis, Endo-
carditis and Rheumatism. — Excluding the three cases of aortic
aneurism, and confining my observations to the twenty-eight cases
of heart-disease, it appears that the existence or not of previous
rheumatism has been stated of twenty cases ; of these twelve had
experienced, but eight never, an attack of this disease.

IX. Relation to Brighfs disease of the kidney. — There are
seventeen cases in which examination of the body after death was
made: in seven of them the condition of the kidneys is not
mentioned; of the ten remaining cases, in six the kidneys were
healthy; in four there was some degree of Bright's disease, but
in none had it proceeded to any great extent. This statement, so
far as it goes, shows a more frequent association of structural
disease of the heart and Bright's disease, than the corresponding
one in the' preceding chapter f did between this affection of the
kidney and pericarditis and endocarditis. In my notice of Bright's
disease i, it appeared that cardiac disease had been noted in six

* Page 566. f Page 567. t I'age 482.

SYMPTOMS AND PHYSICAL SIGNS. ,593

cases. Thus^ we have an aggregate of ten cases in which these
two affections were combined. But in four, the cardiac disease
was fairly traceable to rheumatism; and in the remaining six,
though rheumatism was not mentioned in the history, yet the
evidences of pericarditis and endocarditis were found after death,
and the kidney-disease was apparently of later date than the heart-
disease. Therefore my cases do not tend to confirm the relation
of antecedence and sequence between Bright's disease and disease
of the heart.

X. The leading symptoms and signs. — Dyspnoea. — The breath-
ing was somewhat short and hurried in twenty cases. Of these,
thirteen were fatal : in eleven there was dilatation of both ventri-
cles, in one dilatation and hypertrophy of the left ventricle, and in
one hypertrophy of the right ventricle. In three of the fatal cases
the lungs were found more or less congested after death, in five
there was oedema, in one pleural effusion, in one emphysema, in
one old pleuritic adhesions, in one the lungs were reported to be
healthy, and in one there was no note of the appearances. Thus
in eight of the twelve cases the dyspnoea was accounted for
by the presence of pulmonary congestion or oedema.

Of the ten cases not fatal, there was in seven, it was believed,
dilatation with hypertrophy of the left ventricle and disease of the
mitral valve, in two there was disease of the aortic valves, and in
the third of the tricuspid valve.

From these data, it would appear that dyspnoea has been gene-
rally associated with dilatation of the ventricles, and consequent
congestion and oedema of the lungs.

Dropsical symptoms were more or less present in sixteen cases :
of these ten were fatal ; in nine of them dilatation of both ventri-
cles, in one dilatation and hypertrophy of the left ventricle were
found after death. In the six not fatal there was dilatation and
hypertrophy of the left ventricle, and disease of the mitral valve.

We find, in this statement, a close relation between dropsical
symptoms and conditions of the heart which must involve more
or less systemic venous obstruction.

Prcecordial pain was not noted in any case.

Pain below the m^argin of the right ribs was present in six, and
was attended with dulness on percussion in the same situation. In
four there was dilatation of both ventricles, and in two dilatation
and hypertrophy of the left ventricle. The pain and abnormal
dulness were undoubtedly due to congestion of the liver. These
symptoms are practically important from the risk of mistaking

Q Q

594 ORGANIC DISEASE OF THE HEART.

them for indications of hepatic inflammation. This error was com-
mitted in one instance, and I am satisfied that the caution now given
is not uncalled for. (See p. 529.)

Scapular pain was present in one case, in which aneurism of
the left ventricle was found after death.

Character' of the pulse. — The state of the pulse is distinctly
noted in eighteen cases. In fourteen it was small : of these,
there was disease of the mitral valve alone in nine, of both
aortic and mitral valves in three, of the aortic valves alone in
one, and of the pulmonary semi-lunar valves in one. The
pulse was reported to be irritable in two cases : in one there
was disease of both mitral and aortic valves — in the other
of the mitral valve alone, and in this case the pulse was also
sometimes characterised as small. It was jerking in nine cases ;
of these, four were fatal, and in all there had been diastolic
mm*mur during life, and aortic valvular disease was found after
death ; of the five not fatal, there was diastolic murmur in three.
In the remaining two the jerking pulse was noted only at the left
wrist — it was small at the right ; in one dilatation of the aorta was
suspected, in the other this character might have been due to the
anaemic condition of the patient, for it had ceased before he left
the hospital. The pulse was intermitting in one case, and in this
there was disease of the mitral valve, dilated aortic orifice, and
ventricular aneurism. In two cases the pulse was irregular: in
one there was aortic and mitral valvular disease, and in the other
mitral disease alone.

From this statement it appears that smallness is the cha-
racter of pulse generally met with in cardiac valvular lesion, and
that it may be held to indicate mitral regurgitation, or obstructive
aortic disease. In four of the cases in which the pulse was jerking,
the existence of aortic regurgitation was not only made clear, by
the discovery of aortic valvular affection after death, but also by the
presence of aortic diastolic murmur during life. In three of the
cases not fatal, diastolic murmur was present, and hence aortic
valvular regurgitation was diagnosed.

In my observations on the pulse in the preceding chapter*, I have
pointed to the rarity of an intermitting pulse in pericarditis and
endocarditis ; and now in the cases of structural disease, we find
this character of pulse present only in one. The pulse, then, has
been observed to intermit in only two of fifty-six cases of varied
affections of the heart. It is therefore evident, that intermittence

* Page 569.

SYMPTOMS AND PHYSICAL SIGNS.

59^

of the pulse is a symptom of little value in the diagnosis of cardiac
disease.

Prcecordial fulness was noted in only one case, in which there
was dilatation of both ventricles, hypertrophy of the left, and
disease of the aortic and mitral valves.

There was increased impulse of the heart in thirteen cases — of
these eight were fatal : in six of them there was dilatation of both
ventricles, and hypertrophy of the left, in one dilatation of both
ventricles, with aneurism of the left, and in one hypertrophy of
the right ventricle. In the five not fatal, there was probably —
judging from the prsecordial dulness — dilatation and hypertrophy
of the left ventricle.

There was abnormal prcecordial dulness noted in twenty-two
cases : of these twelve proved fatal, and in nine of them there
was dilatation of both ventricles, in two dilatation and hyper-
trophy of the left ventricle, and in one h3rpertrophy of the right
ventricle.

Of the ten cases not fatal, there was in eight believed to be
dilatation and hypertrophy of the left ventricle, in one dilatation
of the right ventricle, and in one aortic valvular disease, with,
probably, some degree of dilatation of the left ventricle.

In twelve there was increased dulness below the margin of
the right ribs. Of these, seven were fatal ; in five there was dila-
tation of both ventricles, and in two dilatation and hypertrophy
of the left ventricle alone. In three of these cases the condition of
the liver after death is not mentioned, in two it was increased in
size and the substance mottled red and white from congestion, in
one there was mottling but no increase of size, and in one there was
no increase of size noted but tendency to cirrhosis. Of the five
cases of hepatic dulness, not fatal, in four there was dilatation and
hypertrophy of the left ventricle, and in the other dilatation of the
right ventricle. Under this head might also have been included a
case in which there was dulness below the margin of the right
ribs, from displacement of the liver downwards by pleuritic
effusion.

Character of the murmur.'^ — There was a mitral systolic mur-

* It is very necessary, more particularly in natiA^e hospitals, to remember the fact
of ansemic cardiac raiirmurs, so as to avoid errors in diagnosis. The state of constitu-
tion, the basic systolic character of the murmur, the absence of prsecordial dulness, the
occasional presence of venous hum, and the disappearance of the sound with improve-
ment in the general system, ought in general to suffice. I do not allude to this su.bject
without good reason. About three years ago, cardiac disease was reported to be very
common among the native workmen at Aden. Then followed a period of wonder and

Q Q 2

596 ORGANIC DISEASE OP THE HEART.

mur alone observed in ten cases, and of these the termination was
fatal in five. There was found after death in one slight thickening
of the mitral valve and aneurismal dilatation close to it, in one
the mitral valve was thickened, and permitted regurgitation and
an aneurismal pouch existed between this valve and the apex of
the heart, in one there was no thickening of the mitral valve but
the auriculo-ventricular opening was of greater than natural dia-
meter and must have permitted regurgitation, in one the mitral
valve was opaque and thickened with an aneurismal pouch at the
apex of the heart, and in one thero was general thickening of the
mitral valve with ossific deposit chiefly at the free margin. In
all these cases the aortic valves were healthy.

There was in three cases a mitral systolic and a diastolic mur-
mur: the result was fatal in one, and much thickening of the
mitral valve was found after death. In this case there was also an
aortic systolic murmur, and disease of the aortic valves.

There was a mitral systolic and diastolic murmur, with both
sounds of the heart audible at the base, observed in three cases :
one, narrated below, proved fatal, and much ossific thickening of
the mitral valve and some degree of thickening of the aortic
valves were found after death.

244. — Acute rJieumaiism. — Pericarditis, and endocarditis. — Dilatation of the right
side of the heart. — Dilatation and hyjpertrophy of the left ventricle. — Ossific state of
the mitral valve. — He'patic congestion. — Maliadoo Euggoo, aged twenty-four, a Hindoo
labourer, of originally robust frame, a native of Sattara, but resident in Bombay for
a period of three years, following the occupation of a boatman, addicted to the us^ of
spirits for a year, was admitted into the clinical ward on the 10th August, 1849.
About twelve months before, consequent on exposure to wet and cold, he became
aiFected with febrile symptoms, pain and swelling of the large joints, succeeded by
uneasiness of the chest, dyspnoea, and cough. The pectoral symptoms and the af-
fection of the joints had continued more or less. On admission, the breathing was
short and hurried ; the pulse irregular and feeble ; the skin of natural temperature ;
the bowels reported to be regular. The only abnormal dulness of the chest was of
the prsecordial region— it reached from the third to the seventh rib, vertically, and
transversely from the left border of the sternum external to the nipple. The impulse
of the heart was feeble ; the sounds were distinct, but distant, and there was no mur-
mur. Dry bronchitic rales, with occasional crepitus, were heard here and there
throughout both lungs. The abdomen was full, but not resistant. There was dulness
on percussion two inches below the margin of the right ribs, and midway between the
ensiform cartilage and the umbilicus, and uneasiness was complained of on pressure
of the dull parts. With little alteration in these symptoms, he continued till the 2nd
of September, when the impulse of the heart was observed to be somewhat increased,

correspondence and the final solution, that anaemic had been mistaken for organic
murmur. The mistake was the less excusable, because the tendency to a scorbutic
taint had always existed more or less in the Indian native troops and workmen at
Aden.

SYMPTOMS AND PHYSICAL SIGNS. 597

mid a distinct rough munnur was audible just below the nipple, external to it, and
obscuring both the sounds of the heart ; but the sounds of the heart were both heard at
the third costal cartilage and upwards. The cough, the dyspnoea, pain of joints from time
to time, the heart signs last noted, the bronchitic rales, and occasional crepitus, the
hepatic dulness and tenderness, with occasionally pale intestinal evacuations, continued
with little change, and on the 20th September there were added puffiness of the face,
oedema of the feet and ankles, and some degree of drowsiness. At this time cholera was
prevalent in Bombay, and this patient became affected for several days with vomiting
and watery purging, and considerable collapse, during which the dropsical symptoms
much decreased. They recurred on cessation of the purging; the dyspnoea continued;
he became delirious and drowsy, and died comatose on the 5th October. The cardiac
murmur was last heard on the 1st October. The urine was frequently tested ; at
first it was free and of low density ; latterly it was scanty ; it never showed any
trace of albumen. Leeches were on one or two occasions applied to the epigastrium,
and blisters to the prsecordial region. An attempt was made to induce the consti-
tutional effect of mercury, but it was necessary to desist, in consequence of the
irritable state of the bowels. The rest of the treatment consisted of diuretics, or
stimulants, or depressants, according to the indications.

Inspection nine hours after death. — Head. — The inner surface of the scalp was
slightly tinged yellow. The brain and the membranes were not congested with blood,
and were in every respect healthy. There was about one ounce and a half of serous
fluid at the base of the brain. Chest. — The lungs did not collapse very freely. In
places there were a few bands of recent adhesion between the costal and pulmonary
pleurae, and there was very little serous effusion in the sacs of the pleura. The
situation of the heart corresponded to the dull space noted on admission. The peri-
cardium contained about five ounces of serum, but there was no perceptible alteration
in the appearance of its serous surface. The heart was larger than natural ; its
serous covering to a considerable extent, particularly over the right ventricle, presented
an opaque appearance, but nowhere were there traces of recent lymph; a considerable
quantity of dark coloured liquid blood flowed from the divided vessels of the right
side; the right ventricle was considerably dilated; the tricuspid and pulmonary
valves were healthy ; the left ventricle was dilated, and its walls, perhaps, of little
more than natural thickness, the mitral valve was converted into a thick ossific irre-
gular mass, and the aortic valves were somewhat thickened but not by earthy deposit.
The ascending aorta and the arch were narrower, and their coats somewhat more
attenuated than natural. The left auricle was considerably dilated, and yellow opaque
patches, somewhat raised above the surface, were seen on its serous covering. The
posterior part of the left lung was very much congested, and somewhat indurated, but
not distinctly hepatised. There were several red indurated nodules, the largest the
size of an egg, in different parts of the right lung, especially in the upper lobe.
Abdomen. — About a pint of dark-coloured serous fluid was found in the peritoneal
cavity. The liver was almost of natural size ; when incised, it presented a mottled
red and buff-coloured appearance, and was somewhat indurated. The kidneys were
healthy.

Remarks. — This case is of interest in many points of view. The heart-disease was
clearly related to an attack of acute rheumatism. On admission, a feulty diagnosis
was formed from the presence, but faintness, of the sounds of the heart, and the
absence of all murmur. The dulness of the prsecordial region, and the feeble pulse,
were attributed to pericardial effusion. Increased bulk of the heart and disease of
the valves were not suspected. Again, when increased impulse of the heart, Avith a
rough murmur at the nipple, obscuring both sounds of the heart, were noted, a fresh
accession of pericarditis, with lymph effusion, was suspected — for I was not then
aware of what this case and subsequent ones have since taught me, that a mitral
murmur may obscure both sounds at the apex, but leave them distinct at the base.

Q Q 3

598 onaANic disease of the heart.

There was aortic systolic murmur alone in one case ; also dia-
stolic murmur in one. Neither were fatal.

Aortic systolic and diastolic murmyUr was present in four cases,
and in all the result was fatal : in one the aortic valves were dis-
eased, and the mitral healthy ; in one the aortic valves were
much thickened, the mitral valve also, and in this, as already men-
tioned, a mitral systolic and a diastolic murmur were also present ;
in one there were warty-like deposits of lymph on the aortic
valves, with disease of the mitral valve, but no mitral murmur
had been recognised during life; in one the aortic valves were
thickened, and the orifice patulous, and there was very slight dis-
ease of the mitral valve. In three of these cases the pulse was
jerking ; in one it was small.

The sounds of the heart were confused, without distinct murmur,
in three cases, both fatal : in one there was hypertrophy and dilata-
tion of the left ventricle, with disease of the mitral and aortic
valves, — but the murmurs were not heard, on account of the dis-
turbed and laboured action of the heart. In the other there was
considerable dilatation of the cavities of both sides, and some
thickening of the aortic and mitral valves.

These statements support the opinions generally entertained
in regard to cardiac murmurs. They show the relation between
murmurs best heard at the base, and aortic valvular disease,
and that of murmurs best heard at the apex, and mitral valvular
disease. The fact that a mitral murmur obscuring both sounds
at the apex may co-exist with audible first and second sounds at
the base was first taught me by case 244. I am not acquainted
with any writer on the physical signs of heart-disease who states
this fact, with the exception of Dr. Walshe.* The case to which I
have just referred occurred to me some time before the publication
of this excellent work. The fact that a mitral murmur may co-exist
with audible first and second sounds at the base is not only of
diagnostic value, but seems to me to favour those views of the
sources of the sounds of the heart which do not attribute much of
the first sound to tension of the mitral valve. The sounds of the
heart being confused, and murmur being absent, though valvular
disease is present, is practically important as regards the diagnosis
of cases first submitted to observation in very advanced stages,
when the feebly acting heart is oppressed and transmits imperfectly
the blood through the orifices.f

* Walshe on the Diseases of the Lungs and Heart, pp. 223—226.

t Dr. Stokes, in his Treatise on Diseases of the Heart and Aorta, has some excel-

TREATMENT. 599

Prcecordial thrill was observed in only two cases ; one proved
fatal ; and there was hypertrophy and dilatation of the left ventricle
with aneurism, and mitral valvular disease. The other was not
fatal, and mitral valvular disease was believed to be present.

XI. Medical treatment, — Dilatation of the cavities, hypertrophy
of the muscular fibre of the heart, associated with structural change
of the valves, is an incurable form of disease. All that we can
attempt is to regulate the bodily and mental states in such manner
as shall maintain the actions of the heart as unembarrassed as
possible ; and to remove, by appropriate means, the secondary
dropsical and bronchitic affections when they occur. The only
practical points to which I shall advert are, — 1. The signal benefit
frequently derived, under failing action of the heart in valvular
disease, from preparations of iron, and the free assiduous use of
ammonia and other stimulants. I have witnessed several cases in
which imminent peril was averted, and life prolonged, by these
means. On the other hand, I have never met with a case of con-
firmed valvular disease in which digitalis or other sedatives were
not distinctly contra-indicated ; and I look upon the association
which used to exist in the minds of practical men between digitalis
and heart-disease as a very serious, and, I believe, now generally
admitted, error in therapeutics.* 2. A comparison of the
dropsical effusions from cardiac-disease, and those from Bright's dis-
ease, shows the greater scope for the exhibition of hydragogue
cathartics and diuretics in the former. The following case is a
good illustration of the efficacy of elaterium in this form of
disease : —

245. Aortic and mitral valvular disease. — Hy'pertro'phy , with dilatation of the left
ventricle. — General dropsy. — Bapid relief from elaterium. — Discharged. — Moorbariick
Seedee, an African sailor, of twenty-five years of age, and large frame, but reduced by

lent observations on an error of another kind — that of mistaking the murmur of old-
standing valvular disease for that depending on recent endocarditis. This involves a
question of diagnosis, which should never be absent from the mind in the investigation
of cardiac disease.

* The contents of this chapter were presented very much in their present form to
the Medical and Physical Society of Bombay in 1852, and published in the first num-
ber of the second series of the Society's "Transactions." Since then, Dr. Stokes's work on
the Diseases of the Heart has been published. The perusal of this admirable treatise
has not suggested to me the expediency of, in any respect, modifying this analysis of
my own clinical experience. In regard to the observation to which this note is re-
ferred— on the value of stimulants and the danger of depressants of tlie muscular fibre
of the heart — I would direct the attention of the clinical student to the valuable prac-
tical principle on which Dr. Stokes insists in various passages of his work— that the
important question in organic valvular disease is the quality of the action of the mus-
cular fibre, not the mere condition of the valves.

Q Q 4

600 ORGANIC DISEASE OF THE HEART.

sickness, was received, on the 3rd September, 1852, into the clinical ward. The face
was puffed, and the breathing was short, hurried, and oppressed. There was general
anasarca, a swollen and fluctuating abdomen, and shifting dulness on both sides of the
chest to above the lower limit of the subclavian regions. The pulse was of moderate
volume, of natural frequency, with a peculiar thrill. The prsecordial dulness could not
be distinguished from the general dulness. The impulse of the heart, though extended,
was very feeble, and the apex beat two inches directly below the left nipple. Both
sounds of the heart were obscured by murmurs ; one, bloAving, best heard at the base
and in tlie line of the aorta ; the other, musical, best heard at the apex and to its left.
The only history he gave was, that ten months before, while on the voyage from Muscat
to Aden, the dropsical symptoms came on and had persisted. He was treated for
three days with elaterium, which acted well, and rapidly reduced the dropsical effu-
sions. A diuretic of acetate of potass, spiritus setheris nitrici, and tincture of squills,
was then used. The urine increased to upwards of fifty ounces daily, and gave no
trace of albumen. The dropsy was altogether removed, and he was discharged on the
18th September. The pulse had lost its thrilling feel, was of moderate volume, and
compressible. The breathing was easy. The prsecordial dulness extended from the
lower margin of the third costal cartilage to the seventh rib, and from the median line
to one vertical from the nipple. The two murmurs continued distinct, and posciessed
the same characters as on admission. The hepatic dulness reached upwards to the
fifth rib, and inferiorly to a line extended from the tenth right to the seventh left
rib.

He was re-admitted on the 16th November. The dropsical symptoms had returned,
but not to the same degree. The cardiac signs were unchanged, but the pulse was
feebler and again jerking, and bronchitic dry rhonchi were present. A similar course
of treatment was followed again, with removal of the dropsy, and he was discharged
on the 1st December. The pulse, however, had not resumed its former volume, and
continued jerking. The mitral murmur had lost its musical character and become
rough.

BemarJcs. — An African sailor, sailing along the coast of Arabia, becomes affected
with general dropsy and marked symptoms of hydrothorax. This case a few years
ago would have been called, in the language of Indian nosology, beriberi, and an air
of mystery have been thus thrown over one of the simplest events in pathology.

Section II. — In Europeans in India.

Disease of the heart and aorta is not uncommon in Europeans in
India. Many years ago Dr. E. H. Hunter*, in a series of interest-
ing reports, addressed to the Medical and Physical Society of Bom-
bay, directed the attention of the profession in India to the fre-
quency of cardiac-disease in Her Majesty's 2nd or Queen's Royal
Eegiment, and suggested the probability that it was owing to
undue parading in the tight thick dress of the European soldier,
so unsuitable for the climate of India. At the period now referred
to, I enjoyed the privilege of frequent communication with
Dr. Hunter, and on many occasions had the opportunity of wit-
nessing his cases, and appreciating the accuracy and care with

* "Transactions, Medical and Physical Society of Bombay," No. 1, p. 239; No. 2,
p. 222 ; No. 5, p. 47.

IN EUROPEANS IN INDIA.* 601

whicli he diagnosed cardiac and pulmonary disease, at a time when
the physical signs of these affections were not so well understood,
or so generally studied, as at present.

In the European General Hospital also many instances of cardiac
and aortic disease in sailors and others came under my observation.
Seven of the former and two of the latter have been elsewhere
detailed by me.*

The subject, however, requires further careful clinical and
statistical investigation, for the following reasons : —

1 . Dr. Grordon f is of opinion that disease of the heart bears
an inconsiderable ratio to the admissions of acute J rheumatism ;
but the exact ratio is not stated. He further thinks that the num-
ber of men invalided in consequence of disease of the heart in
India, is not a tithe so large as in the United Kingdom. No
precise data are given, but my own experience, as stated above, as
well as subsequently, convinces me that the disease is not very
unfrequent.

2. Facts for determining the ratio of heart-disease to acute rheu-
matism, and of invaliding from heart-disease in India, do not, I
believe, as yet exist — not only from a want of clinical infor-
mation on the disease itself, but also because cases are not
unfrequently returned " Carditis," in which the derangement of
the heart's action is merely functional. I make this latter state-
ment with much confidence ; not only of Europeans in the Indian
army, but in the British army also. In respect to the former, I
some years since satisfied myself by carefully examining the invalids
sent to Bombay with " disease of the heart ; " in several it did not
exist: in respect to the latter — in 1857, 1858, and 1859 — when,
as superintending surgeon at Poona, I weekly visited all the
European hospitals at the station.

3. Palpitation, increased at night and by mental and physical
excitement, without cardiac pain, dulness, or murmur, generally in
pale young soldiers, is surely not unusual in hospitals in India,
and is not unfrequently erroneously returned " carditis." It may
often be traced to drinking or smoking in excess, to exposure to
the sun, and to the debilitating effects of elevated temperature and
frequent recurrences of fever or other forms of disease augmented
by medical treatment unduly depressing. It is also sometimes

^ " Transactions, Medical and Physical Society of Bombay," No. 6.
t " Indian Annals of Medical Science," No. 11, p. 7.

X The word "acute" does not occur in the passage adverted to, but it is evidently
implied by the context ; in fact, the question entirely rests upon it.

602 onaANic disease of the heart.

feigned. If these be the causes it necessarily follows, that the
affection will vary much in different regiments : I am acquainted
with some in which it was hardly known, and others in which it
was very common.

Dr. Grordon remarks*: "As far as my experience goes, there is, as
already stated, no want of care among medical officers in making
minute examination of the cases under their care." To this state-
ment a large part of my experience leads me cordially to assent ;
but there remains behind a portion which tells me that it is not
invariably applicable.

It is on these grounds that I conclude, that, cardiac disease
in Europeans in India has still to be clinically and statistically
investigated.

* " Indian Annals of Medical Science," No. 11, p. 16.

603

CHAP. XXVI.

ON SUN-STROKE.*

The influence of high atmospheric temperature in exciting or
modifying febrile and other forms of disease, has been elsewhere
explained in this work.f In the present chapter I propose to
describe effects of direct or indirect solar heat — more immediate,
often very urgent — which have less of the character of unmixed
fever, and evince earlier and greater disturbance of the brain, the
heart, and the lungs.

But as in inflammatory remittent, ardent continued fever, and
the type compounded of these, there is often disturbance of the
brain, heart, and lungs ; and, as in sun-stroke, there is the heat of
skin, the frequency of pulse and defective secrections, characteristic
of fever, — difficulty has been sometimes experienced in drawing the
line between fever and sun-stroke, and in keeping distinct the pa-
thology, etiology, and therapeutics of these two forms of disease.
In the first edition of this work sun-stroke was treated very briefly f,

* Of the many names applied to this affection — insolation, coup de soleil, ictus
solis, heat apoplexy, heat asphyxia, sun feyer, calenture, erethismus tropicus — I
have, after much consideration, selected the simplest, because it involves no patho-
logical theory, and expresses merely, what all admit, that the chief exciting cause
is great solar heat, direct or indirect, and that the attack is often sudden and
dangerous.

t Pages 8, 57, 61, 81, 162, 164, 363, 437, 642, 650.

I Not only very briefly, but I fear, also, very unintelligibly, if I may judge from
the manner in which my opinions have been misunderstood and misrepresented.

Mr. Scriven in a paper on " Sun Fever," in the 4th volume of the "Indian
Annals of Medical Science," at pages 502 and 503, notices my remarks on the effects
of elevated temperature, and misstates my opinions in the following instances : —

1. By combining statements in the 3rd chapter of the 1st volume on ardent
continued fever with others in the 19th chapter of the 2nd volume on sun-stroke,
he represents me to say, that, the blood is unduly heated in ardent fever, and that
undue heating produces no chemical change of the blood. Whereas there is no
allusion to a heated state of the blood in my chapter on ardent fever ; and the manner
in which "materies" is used, in contrasting the causes o| remittent fever, and of
ardent fever, must satisfy the most casual reader that a " materies " introduced from

604 sun-sthoke.

because, though occasional cases occurring in my hospital practi
had made me sufficiently familiar with the general clinical characters

without was referred to. The words are "in the former (ardent fever*) there is no
'materies' in the blood, as in the latter (remittent fever), exercising a sedative influence
on vital actions and requiring time for elimination " (vol. i. p. 264). The only
observation on undue heating of the blood, is in the following words at page 585 of
the 2nd volume. " From a review of all the attendant circumstances, it seems to me
not an unreasonable suggestion to offer that the temperature of the blood may become
much increased, and that to this altered condition of the blood the deranged actions
may in part be due."

2. Mr. Scriven writes: "Dr. Morehead I see still looks upon it (sun-stroke) as an
inflammatory disease, and recommends early bleeding, tartar emetic, &c., and this too,
under the head of diseases ' to the extreme degree ' of which ' the terms coup de
soleil, &c., have been given;' and amongst which he considers encephalitis and phrenitis
may be included. On the post-mortem appearances, however, of those extreme cases
in which the brain is found healthy, he does not touch, and, seems not to entertain
the idea of such patients dying from cerebral syncope."

Whereas (a) the word "inflammation" is not once used in my remarks on sun-stroke.
It was purposely avoided, because I do not consider the disease to be an inflammation.
(b) The early bleeding and tartar emetic are recommended by me in ardent fever.
The only allusion made to them in connection with sun-stroke, is in the following
words. " In the commencement of the second degree" (that is the stage of cases
of sun-stroke in which the pulse is frequent, full, and firm), " the same means are
still indicated." (c) Blood-letting &c., are not recommended by me in the extreme
degree of sun-stroke ; on the contrary, my words are " but in the advanced stages of
this degree (second), and in the third degree from its commencement when coma co-
exists with a rapid feeble pulse, blood-letting, and free purging, if had recourse to,
will necessarily expedite the fatal issue;" and again, " cold effusion frequently applied,
and the exhibition when practicable of ammoniated stimulants, from time to time,
are the means which hold out the fairest prospect of good." (d) The object of my
incidental allusion to encephalitis or phrenitis is to express my belief, that, if there is
such a disease as the phrenitis of Cullen in tropical climates, it is those occasional
eases of sun -stroke in which the delirium is violent. The logical inference from my
remarks is, not that sun-stroke is an inflammation but that the phrenitis of Cullen is
not an inflammation, (e) The term cerebral syncope is not used by me, because I
think it objectionable ; but if it be implied that the depression of the action of the
heart, and the tendency to death by syncope in extreme cases, are not recognised by
me, I can only remark, that in the description of symptoms and treatment much
prominence is given to them ; indeed, in the latter, it is twice emphasised by italics.
The words are, " as soon as the impairment of the cerebral functions sets in, the pulse
begins to fail in strength, and when coma is fairly established it becomes small and
rapid. In the most aggravated form, that in which there is coma at the outset, the
pulse is small and rapid from the beginning. It appears then that co-existent with
the oppression of the brain, there is always a marked sedative influence operating on
the action of the heart."

To a medical writer, whose sole object ought to be to elicit truth, the free and
fair criticism of others must always be very acceptable. But when he finds his
opinions on important questions of pathology and treatment perverted by garbled
references and inaccurate statements, it is a duty which he owes to himself and to the
character of medical literature to enter his protest against the proceeding.

* This and other parenthetical passages in this note are not in the original text, but
their introduction is necessary, to render the quotations intelligible when separated
from the context.

PRELIMINAEY EEMAEKS. 605

of the disease, still it seemed to me inexpedient to enlarge upon
my own limited experience, in a work professing to be chiefly
the record of personal research. The late contingencies of
public service in India have, however, enhanced the importance
of sun-stroke as a disease of our armies ; and my altered official
position on my return to that country has afforded me the oppor-
tunity of collecting information, and thus in a measure participating
in the experience of others. The following clinical history is
drawn from these and other sources*, as well as from my own pre-
vious practical knowledge of the disease.

* The papers before me, to which chief attention has been given, are : —

1. A short sketch of the medical topography of the fortress of Bukkur, and the
cantonment of Sukkur, &c., in 1839, by I. Don, M.D., staflf surgeon. "Transactions,
Medical and Physical Society of Bombay," No. 3.

2. Some remarks upon the climate of Sukkur in Upper Scinde, during the months
of April, May, June, and July 1846, with an account of the fever prevailing there
during these months, by N. HeiFerman, M.B., H.M's 60th Eifles. " Transactions,
Medical and Physical Society," No. 10.

3. Manuscript notes, by Dr. Crawford, 18th Koyal Irish, on coup de soleil, as
observed by him in H.M's 51st Eegt., in operations at Kangoon, in April 1852,
kindly lent for perusal.

4. Eeport of a board of medical officers, assembled by order of Major-General
Sir Hugh Eose, K.C.B., commanding Central India Field Force, dated 18th May,
1858, to investigate circumstances connected with the death of several men of H.M's.
71st Highlanders, before Koonch, on the 7th May, 1858, as well as other points re-
ferred to in a letter from the superintending surgeon of the force No. 65 of 1858,
dated 8th May, 1858, to the chief of the Staff. President: Surgeon A. Stewart, 14th
Light Dragoons. Members: Surgeon W. Simpson, 7th Eegt.; Assist. Surgeon O'Brien,
3rd Bombay European Eegt.

5. Eeports on coup de soleil in H.M's 71st Eegt. (right wing) in Central India,
1858, by W. Simpson, M.D., Surgeon, H.M's. 71st Eegt.

6. Cases of coup de soleil, in the 3rd European Eegt., Central India Field Force,
by T. W. W. Ward, Esq.

7. Cases of coup de soleil, at Shikarpoor, by Assistant Surgeon, A. K. Simpson, M.D.

8. Cases of coup de soleil, in the 3rd troop H. A., by Assistant Surgeon J. H.
Wilmot, M.D. The last five papers are in the " Transactions, Medical and Physical
Society, Bombay," No. 4, new series.

9. Major-General Sir Hugh Eose's despatch on the operations attending the
capture of Calpee, dated Grwalior, 22nd June, 1858.

10. The summaries of twenty-seven cases fatal in Eajpootana and Central India kindly
shown to the author by C.White, Esq., Deputylnspector-General of hospitals in Bombay.

11. Manuscript report by Assistant Surgeon Lofthouse, 14th Light Dragoons, lent
for the author's perusal, by the Deputy Inspector- General.

12. Queries issued to medical officers of the Central India Field Force, by
Superintending Surgeon Arnott, with replies thereto from Assistant Surgeon Nay lor,
Field Hospital, Jhansi ; Assistant Surgeon Lofthouse, 14th Light Dragoons ; Surgeon
Ward, B. European Eegiment ; Surgeon Ewing, 95th Eegiment, and Assistant Surgeon
Sylvester, forwarded by Dr. Arnott, for the author's perusal.

13. Manuscript report of the 25th Eegiment, N.I. for the year 1858-9, while in
Central India, by Dr. W. Stuart, Surgeon of the Eegimen]^.

14. Manuscript case of an engineer at Kotra, in Scinde, by Assistant Surgeon Niven.

G06 SUN-STROKE.

I shall class my remarks under the heads: — 1. Symptoms.
2. Pathology. 3. Etiology. 4. Treatment.

Symptoms. — When the various descriptions of sun-stroke are
carefully considered, a want of uniformity in the symptoms is
apparent ; and when the investigation is still further pursued, it is
evident that the discrepancy depends upon the circumstance that in
sun-stroke the tendency to death is by three different ways: (1)
by coma ; (2) by syncope ; (3) by coma and syncope combined.
I shall succeed best in rendering the symptoms intelligible by
describing those which, though not all present in every instance,
may be regarded as typical of these three varieties, and then re-
marking more particularly on the phenomena which have chiefly
attracted the attention of observers as characteristic of the disease^

With the view of rendering my own remarks more easily under-
stood, and of obviating the necessity of frequent circumlocution,
I shall designate the first variety — that in which there is death, or
tendency to death, by coma— the cerebrospinal ; the second — that
in which there is death, or tendency to death, by syncope — the
cardiac; and the third — in which there is death, or tendency to
death, b}^ coma and syncope combined — the mixed,

1. The cerebrospinal variety, — In this the premonitory symp-
toms are headache, more or less severe, delirium, tendency to drowsi-

15. Private notes on this and allied subjects, from Deputy Inspector- General
W. M. Muir, M.D.

16. Eemarks on the disease termed insolatio^or heat apoplexy, with observations
on its pathology by Marcus G-. Hill, Officiating Assistant Garrison Surgeon, Calcutta.
"Indian Annals of Medical Science," vol. iii. p. 188.

17. On Sun Fever, by J. B. Scriven, Esq. " Indian Annals of Medical Science,"
vol. iv. p. 496.

18. On erethismus tropicus, by J. K. Taylor, Esq., Deputy Inspector of Hospitals.
"Lancet," 2ist and 28th August, 1858.

19. Coup de soleil in India, by R. H. A. Hunter, Esq., 1st Class Staff Surgeon.
"Medical Times and Gazette," December 18th, 1858.

20. On heat apoplexy, coup de soleil, or sun fever, by James Ranald Martin, Esq.,
F.R.S. "Lancet," 1st, 8th, and 15th January, 1859.

21. Heat apoplexy, summary of a report of sixteen cases in H.M's. Regiment,
Barrackpore, by Thomas Longmore, Esq., Surgeon, 19th Regiment. "Lancet," March
26th, 1859.

22. On insolatio, sun-stroke, or coup de soleil, by W. Pirrie, M.D., Assistant Surgeon,
II.M.'s 71st Regiment. "Lancet," May 20, 1859.

23. Brief notice of a paper on coup de soleil by Dr. Peet, Professor of Medicine,
Grant Medical College. " Transactions, Medical and Physical Society of Bombay,"
No. 4, new series, Appendix, p. xxix.

24. Manuscript report on sun-stroke, occurring in K Batter}^, Royal Artillery,
at Baroda, in May 1859,

Numbers 13 and 24 have since been published. " Transactions Medical and Physical
Society," No, 5, new series.

SYMPTOMS. 607

ness, flushing of the face, increased vascularity of the conjunctivas,
and a dry hot skin. The pulse is accelerated, full, occasionally
jerking, but generally easily compressed ; there is much thirst, and
the urine is scanty and high coloured, with sometimes a frequent
desire to micturate. More or less of such symptoms as these may
continue for some hours, and then, without further aggravation,
may be gradually removed by appropriate treatment, or, after vary-
ing periods, sometimes, indeed, so transient as to escape notice, they
assume the following characters: — The drowsiness increases, the
pupils contract, convulsive twitching of the muscles is observed,
the respiration becomes somewhat hurried and oppressed, the action
of the heart is tumultuous, the pulse still frequent becomes
smaller and more compressible, and the heat of skin increases in
pungency. Now succeed coma and dilated pupils, sometimes pre-
ceded by convulsion ; the respiration becomes more oppressed and
slower, and often stertorous, the countenance swollen and livid,
the action of the heart still tumultuous, but feebler, and the pulse
rapidly sinks. Death may thus take place in from two to nine
hours from the commencement of the attack, and the skin continues
pungently hot to the close, and even for some time after death.

2. Cardiac variety. — Sometimes without premonitory warning,
generally consequent on direct exposure to the sun, the individual
falls down insensible, makes a few hurried gasping respirations,
and instantly expires.* This is death by syncope. Or a sense
of faintness and prostration is experienced, with vertigo, dimness
of vision, dilated pupils, drowsiness, from which the patient may
be roused by pinching, loud speaking, or sprinkling the face with
water. There is constriction of the chest, with sighing respiration,
a sense of weight or sinking at the epigastrium, with nausea and
sometimes vomiting. The face and lips are pale, the skin is
generally cold and clammy, with exception of the head, which is
somewhat hot. The pulse is feeble, and generally slow. In a
large proportion recovery will take place from these symptoms
under judicious management; on the other hand the pulse may
sink, the respiration become more sighing and irregular, and death
result, sometimes preceded by convulsion.

3. The mixed variety. — The premonitory symptoms — of longer or
shorter duration — are headache, delirium, drowsiness, vertigo, pro-
stration with tendency to weep or to laugh on being questioned f ;
a sense of constriction of the chest, nausea, vomiting, palpitation,
the pulse frequent, soft, small, and compressible ; the countenance

* Dr. Pirrie. t Dr. Simpson.

608 SUN-STROKE.

is pale, the skin sometimes hot, at others rather cold. Such symp-
toms may be gradually recovered from, or aggravation may take
place, characterised by convulsion, coma, oppressed breathing,
lividity of lips and nails, failing pulse, a skin sometimes hot but
moist, at others cold and clammy, with death, partly by coma, partly
by syncope.

Remarks on some of the principal symptoms, — Delirium is
sometimes present in the premonitory stage of the cerebrospinal
and mixed forms. It is occasionally though rarely violent, and
when so, is generally of short duration ; for, unless subdued, it
speedily terminates in convulsion and coma.

Convulsion is liable to occur in all the forms, preceding the
coma in the first and third, and occurring very shortly before
death in the second.

Coma. — The insensibility of syncope, which attends more or less
the cardiac variety, is pathologically distinct from the coma of the
other two. It ceases with the reviving action of the heart, and
does not return unless on a recurrence of the syncope. Eecovery
from incomplete coma, in the first and third forms, is not unfre-
quent ; but such cases require to be watched with great care, for
the tendency to relapse is great. The patient may have seemed
alert in the comparative coolness of the morning, but as the day
advances, the drowsiness may recur and pass into complete coma
sometimes preceded by convulsion. Dr. Simpson truly observes, —
" No patient can be considered out of danger till the skin becomes
cool and moist." Eecovery from complete coma would seem to be
occasional, but rare. Dr. Taylor expresses himself with more
confidence on this point than any other writer. In the cases
which he witnessed at Grhazeepore in 1843, recovery from deep
coma was rare ; but in his subsequent experience at Eangoon in
1852, he found that in cases of insensibility, sometimes lasting
from one to three hours, and in some instances attended with one
or more epileptic fits or convulsions, cold affusion in the shade was
successful — not one case terminated fatally. The difference he
attributed to the treatment. At Grhazeepore there was copious
abstraction of blood in all the cases ; — at Eangoon blood-letting
was abstained from, and cold affusion used.

The pupils are generally contracted when the drowsiness of the
first and third forms is passing into coma, or when convulsion im-
pends ; but they become dilated when the coma is complete.
There is also some degree of dilatation with the insensibility of
the second form.

SYMPTOMS. 609

The respiration in the cardiac and mixed varieties has the
irregular, gasping character of syncope, with a sense of constriction
of the chest. Coincident with the coma of the first and third forms,
the breathing becomes laboured and slow, and in cases in which
the access of coma is speedy and complete, it is a striking symp-
tom from the outset of the attack.

The tumultuous action of the heart — greatest in degree in the
cerebro-spinal variety —is also present in the mixed, and is most
marked in the stage of coma ; but it is not then regarded merely
as a consequence of the impeded pulmonary function, but as due
to a more direct influence on the heart itself. This view is pro-
bably con-ect, because cardiac disturbance of this kind is not
unfrequently observed as a single derangement, after undue ex-
posure to solar heat : it very likely precedes in many cases the
attack of the cardiac form.

The pulse is frequently full, sometimes firm, at the commence-
ment of the first form, when the premonitory symptoms have been
of considerable duration ; but as the drowsiness advances it becomes
compressible, and sinks as the coma increases. In the third variety,
the pulse is wanting in volume and power from the very commence-
ment ; and in the second it is always small and often slow.

The peculiar, dry, pungent heat of skin is observed chiefly in the
coma and premonitory stage of the cerebro-spinal and mixed forms ;
and is always in greatest degree in sthenic Europeans recently
arrived from colder latitudes.

A cold clammy skin, usually, though I believe not invariably,
attends the syncope of the cardiac form : it is also noticed some-
times in the mixed form, and in this too the skin is occasionally
hot and moist. It is not improbable that in this latter form
the skin will be hot and dry in Europeans recently arrived,
as was the case in the 71st Kegiment; but occasionally cold
and clammy in natives, and asthenic Europeans long resident, as
happened in the 14th Light Dragoons. Both these regiments
suffered in Central India in the same field: the first had been
only three months in India, having reached it by the overland
route ; the second had served about twenty years.

Colour of the skin. — During the premonitory stage of the first
variety, the face is flushed and the general surface redder than
natural, but when coma and oppressed breathing supervene, it
becomes swollen, more or less purplish and finally livid. In the
second variety, the face and general surface are pale. This is also
often the case at the commencement of the third form, but iti

R R

610 SUN-STllOKE.

this, towards the close, when coma and dyspnoea are established, the
lips and nails become purplish and Uvid.

Nausea and voTYiiting, preceded by giddiness and dimness of
vision, are most common in the cardiac and mixed forms, and are
related to the syncopal condition.

But as is well known, nausea and vomiting are also not unfre-
quently indications of cerebral disturbance. It is important to
remember that in occasional cases of the cerebro-spinal form, the
premonitory symptoms may be uneasiness of head, slight suffusion
of the eyes, listlessness and fretfulness of manner, with irritability
of stomach so great as almost exclusively to engage the attention of
the observer. These are often perplexing. The vomiting is sympto-
matic of cerebral disturbance, and if it be rightly understood, and
the appropriate remedies used, the result will be satisfactory ; but
a grave error will be committed if the principal derangement is
overlooked, and the treatment directed to the secondary and sym-
pathetic disorder.

The botvels are not affected with any characteristic derangement;
they are often natural, sometimes constipated, at others relaxed.
This last condition when present will in general, probably, be
found to have preceded the attack of the second variety.

The urine is high coloured and scanty, in association with the
increased heat and cerebral disturbance of the first and third forms.
A frequent desire to micturate is sometimes a premonitory symp-
tom, to which Mr. Longmore has specially called attention: in
referring to it he very justly observes, "If this symptom should
prove to be a general precursor of the attack it might be rendered
valuable as an indication of the approaching danger, which, by
early and proper care, might then probably be averted ; and its
presence at a time when heat apoplexy was prevalent would make
the surgeon alert to obviate the more serious symptoms which might
be expected to follow."

Convalescence. — In the milder attacks of the cardiac forai, re-
covery, when no abiding state of debility is present, is often rapid.
During the operations of the Central India Field Force in May and
June 1858, it was not unusual for officers and men struck down to
be recovered by cold affusion on the field and to return to duty.

The premonitory symptoms of the other two varieties, when
dight and brought under treatment at the commencement, may
be recovered from by two or three days of careful management.
But when these symptoms have been greater in degree, or of
longer duration, or have partially merged into those of the more

TATHOLOaY. 611

advanced stages, then recovery may be characterised by pros-
tration of strength^ partial paralysis, blunted sensation, imperfect
respiration, and deranged secretions.

Pathology. — The post-mortem appearances in the cerebro-spinal
and mixed forms are varying degrees of congestion of the cerebral
vessels and of serous effusion in the sub- arachnoid space and ven-
tricles, varying degrees of engorgement of the lungs, of the right side
of the heart, and of the general venous system, with more or less
congestion of the abdominal viscera. The blood is always fluid. The
post-mortem appearances referable to the cardiac form have not
yet been carefully studied, but doubtless they are those which fol-
low death by syncope, from paralysis of the fibre of the heart,
when the cavities of both sides are filled with blood; or from spasm
of the heart, when the so-called concentric hypertrophy is found.

I concur with those who think that the phenomena of sun-stroke
are produced by depressed function more or less complete, and vary-
ing in degree, of the cerebro-spinal and sympathetic nervous systems.
Whilst as yet there are only head symptoms, the derangement is con-
fined to the cerebrum ; when the respiration becomes implicated, the
medulla oblongata has become involved. In those cases of sudden
death by syncope there is an influence, similar to concussion from
a blow or a copious cerebral haemorrhage, which not only destroys
consciousness and respiration, but at the same time paralyses the
fibre of the heart. In the slighter degrees of syncope it is not
improbable that the ganglia or periphery of the sympathetic system
are primarily affected; and it is further not unlikely that the
slighter degrees of deranged respiration may be caused in some
cases also through the same nervous channel by an influence un-
favourable to circulation exercised on the pulmonary capillaries, as
suggested by Dr. Wood*, or by an influence exercised on the
bronchial fibres, leading to some amount of spasm.

In the mixed form there is from the commencement depression
to some extent of the nervous influence which regulates the action
of the heart ; it is in this fact that resides the difference between it
and the first form. The nature of the proximate cause of this dis-
turbance of the nervous system will be considered in connection
with the etiology.

It has been conceived by several recent observers, that in a large
proportion of cases death is caused by asphyxia — apnoea — induced
by insufficiency of oxygen in the atmospheric air consequent on
rarefaction by heat.

^ "Practice of Medicine," vol. ii. p. 108.

R B 2

612 SUN-STKOKE.

The principal fact adduced in favour of this opinion is the en-
gorged state of the lungs, the right side of the heart, and venous
system found after death.

The arguments against it, are: — 1. The fact, that when death
takes place speedily by coma, that is, when great depression of the
nervous influence of the medulla oblongata is coincident with or
follows closely upon that of the cerebrum, the post-mortem ap-
pearances are identical with those of death by asphyxia, viz.
engorged lungs, right side of heart, and venous system. The
reason is evident. Failure of the medulla oblongata as effectually
puts a stop to respiration as irrespirable air or mechanical occlusion
of the air passages ; but in correct pathological language this is not
death by asphyxia, but by coma*, and it is important that this
distinction should be carefully observed.

2. Atmospheric air is in a more rarefied state by elevation at
ordinary Hill Sanitaria than it ever is by the heat of the hot season
in the plains, in any part of India.t Consequently, asphyxia from
insufficiency of oxygen resulting from rarefaction of the air by
heat is an untenable proposition.

* I am aware that there may be exceptional cases in which the medulla oblongata
suffers first, nnpreceded by insensibilty, and that, strictly speaking, in these cases,
when fatal, death cannot be said to occur by coma ; yet such are few and practically
unimportant. It is well to regard the expression "death by coma" as synonymous
with death by failure of the nervous influence of the medulla oblongata in respiration.

t To make this assertion more evident, let me state the physical facts which bear
upon it, and then suggest certain probable inferences : — (a) Normal respiration in man
may be assumed to consist of sixteen respirations in the minute, with each of which
30 cubic inches of air are inhaled, which is equivalent to 400 cubic feet in twenty-four
hours, (b) 400 cubic feet of dry air at 32^ F, contains 83'2 cubic feet of oxygen.
(c) 400 cubic feet of air at 32° F. will, at 80° F., expand to 441-21 cubic feet;
and the proportion of oxygen in 400 cubic feet of this expanded air is 75 '428
cubic feet, (d) 400 cubic feet of air at 32° F. will, at 100° F., expand to 459 cubic
feet; and the proportion of oxygen in 400 cubic feet of this expanded air is 72*51
cubic feet, (e) In latitudes of temperature 80"^ F. at the sea level, there is at a height
of 5000 feet a decrease of temperature to 60° F. ; and 400 cubic feet of this air, ren-
dered less dense by elevation, contains 74*19 cubic feet of oxygen. At a height of
10,000 feet the temperature falls to 40° F., and the proportion of oxygen in 400 cubic
feet of this still more rarefied air decreases to 63-294.

From these data it may be inferred : —

1. That as the temperature of the pulmonary air-cells in man is about 100° F., it
is improbable, whatever the external atmospheric temperature may be, that air with a
larger proportion of oxygen than 72-51 cubic feet in 400 cubic feet ever reaches the air-
cells ; and therefore the conclusion is erroneous, that the air of a climate at 100° F., when
in the air-cells oxygenating the blood, contains a less proportion of oxygen than that
supplied by a climate at 32° F. 2. In tropical countries, at elevations of 5000 and
10,000 feet, with atmospheric temperatures at 60° F. and 40° F., and proportions of
oxygen (in 400 cubic feet) of 74-19 and 63-294 cubic feet, there must, when the air raised
to 100° F. reaches the air-cells, be still more rarefaction, from heat, and consequently

RATE OF MORTALITY.

6ia

3. Air so deficient in oxygen as to asphyxiate would operate
generally, not partially, on all the warm-blooded animals exposed
to its influence; and there could be no recovery from the asphyxia
without removal into a more respirable atmosphere. We have an
illustration of this in the blast of the simoom, affecting not a few
individuals but an entire kafila.

Rate of mortality. — On this point satisfactory data are wanting,
in consequence of the different system of classification, followed by
different observers. Some include under the term " sun-stroke" all
degrees of the immediate effects of solar heat, others merely the
severer forms.

The following are the results taken from the reports before me: —

Mr. Hill's collected Cases ....

Dr. Taylor's, Ghazeepore ....

Mr. Longmore, Barrackpore, (IQth Eegiment)

Mr. Lofthouse, (14tli Lt. Dragoons)

Dr. Simpson (71st Regiment)

Mr. Waxd (3rd Bombay European Regiment)

Mr. Ewing (95tli Regiment)

Sir Hugh Rose and Dr. Stuart* (25tli Regt. B.N.I

Field Hospital, Jhansi . . . . ,

Treated.

504
115
16
80
89
25
60
200
29

Deaths.

259
16

10
24

6
17

further decrease in the proportion of oxygen. Hence there is in the air in the air-cells
at heights a considerably less proportion of oxygen than in the air in the air-cells in
the plains. 3. But in tropical climates there is undoubtedly less oxygenation of the
blood, because there is less necessity for, and less generation of, animal heat. At
elevations of 10,000 feet the temperature is 40°, and man is found healthy and robtist;
therefore there must be sufficient oxygenation of the blood — to generate animal heat —
to meet the demand of the low external temperature. By what means is respiration
so adjusted as to satisfy the different requirements of a tropical climate at the sea
level, and of an elevated locality ? certainly not by a different proportion of oxygen in
the air respired, for that at the elevation where more oxygenation is necessary con-
tains much less oxygen than that at the sea level in the tropics, where the degree of
oxygenation is diminished. The adjustment is effected by the varying amount of air
received into the lungs at each respiration, and by the varying number of inspirations
taken in the minute. In the warm climate at the sea level the respiratory function is
reduced by lessened expansion of the lungs. In the elevated locality the respiratoiy
function is increased, to meet the diminished proportion of oxygen and the greater
demand for animal heat, by {a) augmented pulmonary expansion, {b) increased
number of respirations : this obtains within certain limits. If there be no longer
capacity of air-cells, or increase of respiratory movements to compensate for the
diminished proportion of oxygen, then symptoms of asphyxia begin.

For the calculations on which this note is based, and for the suggestion that the
air in the air-cells must always be at a temperature of about 100° F., whatever that
of the external air may be, I am indebted to the kindness of Dr. Forbes Watson.

* The number 200 is from Sir Hugh Rose's dispatch. Dr. Stuart, in his report,
says, " Sixteen cases only admitted into hospital, none fatal; but of course many in
the field, none of them fatal." ^

R R 3

614

SUN-STKOKE.

Etiology. — The documents before me supply the following
facts in reference to season, age, period of service in India, and
duration of attack. The months of prevalence have been almost
exclusively April, May, and June, but chiefly May and the first
half of June.

In respect to age, my only data are derived from twenty-seven
fatal cases of the Eajpootana and Central India Field Forces, and
ten of the K Battery of Eoyal Artillery fatal at Baroda.

Age.

Rajpootana,

and Central

India Field

Forces.

K Battery.

19 years and under

20 to 25
26 to 30
31 to 35
36 to 40

Total

2
2
6

The period of service in India of twenty-seven fatal cases was,
in ten, six months and under ; in twelve, seven to nine months ; in
four, four to sixteen years, and in one it was not noted.

The 71st Eegiment arrived in India at the end of February
1858, and had eighty-nine men attacked with sun-stroke, be-
tween the 5th May and 15th August. The K Battery had also
been only six months in India, when it suffered at Baroda. These
corps then illustrate the relation of sun-stroke to recent arrival
from colder latitudes.

Death occurred at varying periods from the commencement of
the attack, thus: —

Rajpootana

;ind Central

India Field

Forces.

Day of admission .

Following day

Upwards of five days

Not Noted ....

19
4
3
1

K Battery.

1 to 3 hours ....
4 to 6 ., .
7 to 12 „ .
13 to 24 „ .

2
1
6
1

CAUSES — PREDISPOSING AND EXCITING. 615

Sun-stroke is not confined to Europeans. In Dr. Don's report on
the Medical Topography of Sukkur, there is an interesting account
of the sufferings of an escort of Bengal and Bombay Native Infantry,
when marching in the latter half of May 1839 from Sukkur to
Dadur. The 25th Regiment Bombay Native Infantry, during the
campaign in Central India, in 1858, was, as already stated, tem-
porarily crippled by sun-stroke; and I have it from the best authority,
that the appearance presented by the corpses of many of the rebel
troops opposed to the Central India Field Force showed that death
had resulted from sun-stroke and not from wounds. The meteoro-
logical observations made during the seasons of prevalence of sun-
stroke are very meagre, but the temperature would seem to have
ranged from 96° to 120° in the shade. This high atmospheric heat,
chiefly observed on the Coromandel coast. Central India, the north-
west provinces, Scinde, and the Punjab, may be received as the
chief exciting cause.

But predisposing causes are also very influential. There is a very
general concurrence of opinion that the sthenic constitution of the
recently arrived European predisposes to the cerebro-spinal form
of the disease, and this predisposition may be greatly increased by
the intemperate use of alcoholic drinks. Then, as predisposing
conditions of the cardiac and mixed forms may be named the asthenic
constitution of the natives of India, and of long resident Europeans,
increased by fatigue and other exhausting causes, also, a diathesis
cachectic from malaria, scurvy, or from degeneration of the fibre
of the heart or secreting structure of the liver or kidney.

The * high atmospheric heat probably excites the cerebro-spinal
form of sun-stroke by increasing the temperature of the blood some
degrees above its normal standard ; and it produces this effect, not
so much by direct conduction to the body, as by impaired evapora-
tion from the cutaneous surface, leading to an undue accumulation
of animal heat in the following ways : —

1. A still or moist atmosphere of 94° F. and upwards. Dr. Taylor
remarks of sun-stroke at Grhazeepore : — " This epidemic was
undoubtedly the direct morbid effect of the high temperature
of the season. Instead of the regular hot winds from the N.W.
the wind during the month of May had been constantly N.E.
and the tatties were consequently of little service. The ther-

* In restricting my observations to the temperature, moisture, and moyement of
the atmosphere, I by no means wish to express a belief that there may not be other
states, electrical, &c., also influential ; but on these questions it is idle to speculate.
Observation, not speculation, is the desideratum.

B R 4 •

616 SUN-STROKE.

mometer at the end of May averaged 105° in the shade, and
from the unfavourable direction of the wind for working the tatties,
the heat in the barracks could be but little diminished. On the
1st of June the wind was still N.E. and light with the thermometer
at 104°. The sensation of heat was intense. On the morning of
the 2nd, the day of the outbreak of the epidemic, the wind came
round to the N.W. and was strong and scorching. The thermo-
meter in a covered passage facing N.E. showed a temperature of
108° at two P.M."

Mr. Naylor observes of the Field Hospital at Jhansi, — in which,
during six weeks, the thermometer ranged at noon from 110° to
120°, — "but it was observable that it was not in the hottest days
that the affection showed itself, the most favourable periods of its
occurrence being rather those cloudy days, accompanied with a
moist condition of the atmosphere, when even the water in the
cooja could not be rendered cool." It is to the stillness and
moisture of the heated air, favoured by some degree of vitiation,
that are due the attacks in barracks and hospitals. Dr. Taylor
alludes to the injurious influence of the crowding of masses of
infantry, during the march and on parade, compared to what ob-
tains in artillery and cavalry; and Dr. Lofthouse attributes the
greater immunity from sun-stroke of the cavalry of the Central
India Field Force to the less exhaustion of men on horseback, and
to the air currents caused by the rapidity of their movements.

2. The refrigerating effect of evaporation must be lessened when
the due proportion of water in the blood is not kept up by a suf-
ficient and regular supply of drinking water. The importance of
this consideration is universally admitted. It is stated by Dr. Don
that the much greater exemption from mortality in the Bombay
than in the Bengal Eegiment of the Sukkur escort was attributed
by the commanding officer to the men of the former " being sup-
plied, as is the custom in the Bombay army, with canteens of
water, with which they refreshed themselves on the march, as well
as at all times on duty, when water could not otherwise have been
readily procured."

3. If the opinion of physiologists relative to the influence of the
vaso-motor nerves on the size of the capillaries, and consequently on
the quantity and movement of the blood in them, be correct, then
it is very likely that a sequence of the action of direct solar heat
on the cutaneous surface may be such diminished secretion by the
sudoriferous glands as shall materially lessen refrigeration by
evaporation.

CAUSES— PREDISPOSINa AND EXCITINa. 617

In these three ways — the first having reference to still moist
hot air, the two last equally to hot dry air — the temperature of
the blood may become increased by accumulation of animal heat
from defective cutaneous evaporation.* On this point Dr. Simpson
makes the following valuable practical remark : — " Every man
seized with sun-stroke, and who could answer questions, informed
me that he had not perspired for a greater or less extent of time,
sometimes not for days, previous to being attacked, and that he
had enjoyed good health as long as he perspired, but that on the
perspiration being checked he felt dull and listless, and unable to
take much exertion without making a great effort.'"

But there is still another circumstance which favours the increase
of heat in the subjects of sun-stroke.

We have already seen that recent arrival from colder latitudes
predisposes to the cerebrospinal form. Dr. Crawford, in his " Notes
on Coup de Soleil in the 51st Eegiment at Eangoon," says, that
obesity was present in all the fatal cases. Dr. Taylor remarks:
" The subjects of the disease were with few exceptions large-
chested, muscular, and fat men." These conditions of the system
favour undue generation and retention of animal heat.

It is not, however, only by increasing the heat of th^? blood, in
the manner explained, to a degree incompatible with the mainte-
nance of the functions of the nervous system, that elevated tem-
perature acts as the exciting cause of sun-stroke. In the cardiac
form, we must look for another explanation; because in these
speedily fatal attacks, the sudden violence of the onset, and in the
milder attacks, the cold and clammy skin, are inconsistent with the
idea of a gradual heating of the blood as the proximate cause. The
action must therefore be direct either on the nervous centre near
to the origin of the vagus nerve, or on the general periphery of the
cutaneous nerves, as supposed by Dr. Alison. His f words are :
*' The effect of very intense heat applied to a pretty large surface
of the body, as in an extensive burn, or to the whole body, as in
the case of a coup de soleil, is also quite similar to that of con-
cussion."

To recapitulate. 1. The cerebro-spinal form, commencing with
cerebral symptoms, without much depression of the pulse in the
first instance, characterised by pungent heat of skin, and proving

* When eyaporation is deficient, and tlie external air above 100, tlien there will be
increased heat of the body, not only from accumulation of animal heat, but also by
conduction from the air.

t "Outlines of Pathology and Practice of Medicine," p, 13.

618 SUN-STROKE.

fatal by coma, is due to increased heat of the blood disturbing
and depressing the functions of the cerebro-spinal nervous system.
2. The cardiac form, with small or imperceptible pulse, cold and
clammy skin — often suddenly coming on and proving speedily
fatal — is due to a direct depressing influence, probably on the entire
nervous system, irrespective of the condition of the blood. 3. In
the mixed form there are varying proportions of both conditions,
viz. — overheated blood and direct influence on the nervous system.

It is at present a favourite doctrine with many pathologists that
sun-stroke is in part due to a supposed venous condition of the
arterial blood. I am not acquainted with any facts or any sound
arguments which go to justify this hypothesis. The explanation of
asphyxia given by Kay, and universally assented to by physiolo-
gists for the last thirty years, is, that death takes place in conse-
quence of the stagnation of blood in the pulmonary capillaries,
leading to general congestion of the vascular system behind, and
permitting but a scanty stream of blood to pass to the left side of
the heart. Little, if any, of the deranged phenomena can be
reasonably attributed to the poisonous influence of the small quan-
tity of venous blood which for a minute or two before death passes
to the left ventricle, and thence through the systemic arteries.*

Again, it follows from Kay's experiments, that venous blood will
not circulate through the pulmonary capillaries, and that therefore
the supposed continued circulation of venous blood poisoning the
tissues generally is inconsistent with ascertained facts.

The idea of the assumed pathological import of venous blood
would seem to have originated — 1. In forgetfulness that Bichat's
opinion that venous blood is poisonous has been long since dis-
proved ; and that the phenomena of asphyxia are little, if at all,
dependent on the circumstance of the blood in the arteries being

* It is very remarkable that though there is a universal assent to Kay's theory,
and a general dissent from the doctrines of Bichat that the venous blood is poison-
ous ; still, this latter erroneous view is freely applied by pathologists at the present
day. I woidd instance Dr. Watson's fifth lecture, in which, speaking of Dr. Kay, he
says, *' His experiments tend moreover to prove, that venous blood, circulating through
the arteries has no direct poisonous operation " (p. 69, vol. i.). But further on, at p. 73,
drawing the distinction between death by syncope and apnoea, he attaches an im-
portance to the venous character of the blood which reaches the left side of the heart
more consistent with the theory of Bichat than that of Kay. If in asphyxia the blood
stagnates at the lungs, at first incompletely and shortly afterwards completely, we have
in the general congestion from venous obstruction, and in the insufficient quantity of
blood in the arteries in the first instance, and shortly afterwards its absence altogether,
an adequate explanation of the phenomena without attributing anything to the venous
(Condition of the slender and transient stream which for a few minutes may circu-
late through the arterial system.

PREVENTION AND TREATMENT. 619

venous. 2. In the erroneous inference that persisting diminished
respiration, either from elevated temperature, or slight vitiation of
the atmospheric air, from small quantities of carbonic acid, as in
cities, crowded rooms, &c. leads to a venous condition of the blood
in the arteries : there is no evidence of this in an altered colom' of
any part of the surface of the body. The effect of the diminished
respiration is altogether different. The appetite for food, digestion,
assimilation, and the quantity of blood, are brought into harmony
with the diminished respiration, and there results not venous blood
and purple lips, but anaemia more or less, as shown in the pallid
countenance of the tropical resident and of the dweller in the
impure air of crowded cities.

The passage of venous blood from the venous into the arterial sys-
tem takes place only when its complete aeration has become impos-
sible, either from an insufficiency of oxygen or defect of the lung, or
of nervous influence ; and the immediate sequence of this is the com-
mencement of stagnation in the pulmonary circulation. There is
no fact, so far as I am aware, which can justify the assumption that
venous blood can continue to circulate in the arterial system, and
in consequence of its venous character excite derangement. A
venous condition of the blood in the arteries must, it seems to me,
be always consecutive on defective aeration, be 'preceded by pul-
monary stagnation, attended by the symptoms of apnoea, and,
if not speedily removed, followed by death.

The opinion that malaria is an exciting cause of sun-stroke
appears to rest on no sufficient grounds. The occurrence of death
by coma in a proportion of the severer forms of remittent fever is
no reason for concluding that sun-stroke is caused by malaria, the
more especially as this latter disease prevails most at seasons which
hitherto have not been regarded as those in which malaria is
chiefly generated.

Prevention and Treatment. — The prevention of sun-stroke by
avoiding as far as practicable the predisposing and exciting causes,
is of essential importance.

The following influences must be carefully guarded against : —
{a) Needless exposure to the sun. (6) Exhaustion from fatiguing
duties, defective commissariat arrangements, and other causes,
(c) Intemperance from the excessive use of alcoholic drinks.

A full and well-regulated supply of good drinking water, under
all the circumstances of military service in the hot season, is an
essential measure for the prevention of sun-stroke. It ministers
to the cooling effect of evaporation from the cutaneous surface, and

620 SUN-STROKE.

materially assists in warding off that state of exhaustion which
leads to syncope.

Protection of the body from direct, reflected or radiated solar
heat by suitable clothing, is a subject to which of late much
attention has been justly given.* The object in view is to devise
the best practicable means of obstructing the transmission of
external heat to the body without interfering with free cuta-
neous evaporation. The non-conducting head-dress with ventilat-
ing arrangements, and the loose tunics of suitable light wadded
material, are constructed on this principle. If the pathological
views which attribute much to the implication of the medulla
oblongata be correct, the importance of a neck-piece to the
head-dress, already established by ample experience, is very intel-
ligible ; and a similar observation may be made relative to the
spinal cord, the solar plexus and the general nervous periphery,
and the necessity of providing for their protection by suitable
clothing. The great importance of space, of the interception of
external heat, of ventilation, and of means, as wet tatties and pun-
kahs, of reducing the temperature, and of agitating and maintain-
ing pure the atmosphere in tents, barracks, and hospitals cannot be
too strongly insisted upon ; while the injurious effect of crowding
men in masses during the march and on parade should receive
its just measure of attention. f

In the medical treatment of sun-stroke there is now great
■unanimity of opinion ; and the conclusions so generally admitted
are in accordance with the views entertained of the pathology and
etiology of the disease. Greneral blood-letting has few supporters.

* I would refer the reader to the following sources among others of much useful
information on this and other subjects, relating to the health of the soldier in
India : — " The British Army in India," by Julius Jeffreys ; " The British Soldier in
India," by Dr. F. Mouat ; " Eeports on Coup de Soleil," by a Board of Medical Officers,
and by Dr. Simpson ; " Transactions, Medical and Physical Society of Bombay," No. 4.
New Series.

t It may happen that troops are so circumstanced, that a slight change of air may
exercise a very beneficial effect. The following is an illustration : —

In May 1859, K Battery, Royal Artillery, and two companies of the 4th Regiment
were stationed at Baroda, in Guzerat. The atmosphere was still, and the ther-
mometer rose to 110° in the shade. Both corps were housed in equally good barracks,
with punkahs day and night. The stable duties of the battery entailed however
greater exposure, and the canteen reports showed a large daily consumption of arrack,
which increased after sickness commenced on the 27th May ; between which day and
the 2nd June ten men died of sun-stroke, and there was amongst the men a general
dread of the disease. The men were now moved out in tents to Dubka, on the banks
of the Myhee, fourteen miles from Baroda, and witliin the influence of the sea breeze,
and with space for recreation and amusement. No more deaths occurred. The
health of the men improved, and they returned to Baroda with fewer sick than they

PREVENTION AND TREATMENT. 621

Though it may be admitted that an occasional case occurs in
which cautious venesection might be useful, yet the evidence of
the great injury usually resulting from it is so conclusive that
there should be no hesitation in altogether interdicting this pro-
ceeding in the treatment of sun-stroke. The cause of the ill
success of blood-letting is not difficult to understand. The proof,
occurring more or less early, but certainly at some period or
other in all attacks, of a sedative influence on the heart, distinctly
contra-indicates its use. The affusion of cold water over the head,
neck, and chest has been proved to be the most efficacious means of
treatment; and as its power is greater the earlier it is resorted
to, well arranged methods of applying it should be always
ready at hand. It acts in two ways. 1. By reducing the heat of
the body. 2. By stimulating the nervous system through the
impression made on the periphery of the cutaneous nerves. The
first is the mode of action which is probably most beneficial in the
cerebro-spinal form ; the second in the cardiac form.

The extent and continuance of the affusion must be regulated by
the temperature of the surface of the body and the state of the
pulse. While the skin is hot and dry, and the pulse of good
volume, water may be freely poured over the head, neck, spine, and
chest, and frequently repeated ; but when the cold, clammy skin, the
sighing respiration, and the small pulse, indicative of syncope,
are present, the water should be merely dashed, or sprinkled from
time to time, on the face and chest. It should never be forgotten
that after the temperature of the body has been reduced, and the
skin become accustomed to the impression, the affusion of cold water
soon begins to exercise a sedative influence on the heart. In using
this remedy, therefore, the distinction between the cerebro-spinal
and the cardiac form of the disease should be borne in mind, and
the state of the pulse and skin should be carefully watched and
noted.

These cautions are very necessary, for if they be disregarded,
and a routine system be adopted, it may be safely predicted that
cold affusion in sun-stroke will share the fate of all powerful
remedies used without discrimination and judgment, and soon cease
to maintain the high place to which it is justly entitled in the treat-
ment of this disease.

had had for some time. There was only one death from sun-stroke in the detachment
of the 4th Kegiment, and little sickness of any kind.

The improvement in the men of the battery was doubtless due to greater tem-
perance, relief from stable duties, the cooler locality, and mental interest and occupation.

622 SUN-STROKE.

When the patient is able to swallow, stimulants and nourishment
should be given, with a frequency and in quantities according to
the state of the pulse.*

It is, moreover, of great importance in the treatment of sun-
stroke to supply the patient freely with good drinking water. Dr.
Crawford, of the 18th Koyal Irish, in the notes of his experience
in Kangoon, attaches more weight to this indication than any
other writer with whose works I am acquainted. If the view
taken of a deficient supply of good water, as a predisposing
cause, be correct, the necessity of diluents in the treatment is
self-evident.

When the tendency to death by coma or syncope has been over-
come, and febrile reaction and some degree of local congestion
remain, the treatment should be conducted on ordinary prin-
ciples. Moderate local blood-letting, mercurial and other purga-
tives, and diuretics, may be used with much advantage. But in
applying this principle of treatment it should be remembered that
the patient has lately passed from a state of which a sedative
influence on the heart was a constituent, and that this condition
may easily be reproduced by injudicious evacuation and the neglect
of appropriate nourishment.

Concluding Remarhs. — This important subject has been very
inadequately explained by me, but this, in fact, is unavoidable, and
only to be remedied by further careful clinical observation and
description. The following are the points on which information is
chiefly to be desir.ed : —

1. A more careful and precise observation of the symptoms with
reference to the different tendency to death in different cases.

2. Carefully conducted post-mortem examinations with the view
of determining whether the division into cases fatal by coma and
by syncope is correct.

3. Meteorological observations on the temperature, moisture,
pressure, movement, and electrical states of the atmosphere.

^' In an anonymous letter, dated May 1859, published in the "Lancet," and also in
a private letter from a friend whose judgment I respect, it has been suggested that
Marshall Hall's ready method might be of use in the treatment of sun-stroke. The
idea rests on the belief that death takes place by asphyxia, from defect of the aerating
medium. I have already expressed my dissent from this pathology, but nevertheless
I think the suggestion ought not to be lost sight of, for, as in some eases of narcotic
poisoning, the influence on the medulla oblongata may be so transient in an occa-
sional case of sun-stroke, as not to preclude the idea of advantage from artificially
assisting respiration. But, irrespective of this, the change from dorsal decubitus,
involved in the acts of the "ready method," is likely to retard the pulmonary con-
gestion, and thus postpone death.

PEEVENTION AND TREATMENT.

623

4. Precise facts, bearing on the state of predisposition, having
reference to exposure, clothing, diathesis, habits, exhausting con-
ditions, supply of water, accommodation, age, residence in India,
and previous disease.

5. Precise clinical notes on the condition of the patient
before the use of remedies, and on the effects produced by the
remedies.

624

DELIKIUM TREMENS.

CHAP. XXVII.

ON DELIRIUM TREMENS.

Section I. — On the Symptoms and Treatment of Delirium
Tremens in the European General Hospital at Bombay,

As my clinical knowledge of this important disease has been chiefly
acquired in the European G-eneral Hospital at Bombay, 1 shall
confine my present observations, in a great measure, to my experi-
ence in that institution.

During the five years, from July 1838 to June 1843, 237
patients were under treatment for delirium tremens, being 3*1 per
cent, of the total hospital admissions. Forty-one cases terminated
fatally, being 17*8 per cent, of the admissions from delirium tremens,
and 7*5 per cent, of the aggregate deaths in the hospital.

Though 17*8 per cent, was the average annual rate of mortality
for the five years, it varied considerably in different years, and very
strikingly in different months. In the years 1839 and 1841, the
deaths were above 20 per cent, of the admissions, whereas in the
year 1842 they were only 7. Throughout the five years, there
was not a singly fatal case of delirium tremens recorded in the
months of January and February, though the admissions from the
disease were respectively 3*2 and 5*3 per cent, of the total hospital
admissions ; whereas in the months of May and October the rate of
mortality from delirium tremens was above 40 per cent., though
the admissions were not above 4*7 and 1*2 per cent, of the aggre-
gate hospital admissions. In the month of May the admissions
were also numerically considerably above those of any other month
of the year.

The data from which these statements have been made, will be
found, with additional statistical details of a similar character, in
the tables which are annexed to this chapter.*

* "When wc compare the statistical facts of these five years with those of the ten
which sxicceed, it is found that in the latter there were 453 admissions of delirium

SYMPTOMS AND TREATMENT. 625

Persons admitted into the Greneral Hospital, affected with deUrium
tremens, have belonged generally to one of the following classes : —
1. Engineers and boilermakers connected with the Steam Flotilla,
or works in the dockyard — men not long resident in India, and
whose ages may range from twenty to thirty-five. 2. Non-com-
missioned officers and soldiers attached to the different branches
of the military department at the presidency — men of various
periods of service in India. 3. Seamen belonging to the public
service or to merchant ships, who have been on shore on liberty,
and have for a succession of days been dissipating in the bazaar ;
or seamen and others out of employment who have been lodging
in taverns.

From the class of seamen, however, the admissions have been
considerably the most numerous.

Sym'ptoins and Treatment. — The division of delirium tremens
into two species, which has been made by some writers *, is clini-
cally correct. The first in general immediately succeeds the
excitement of hard drinking without an intermediate period of
abstinence from the accustomed stimulus, and is characterised by a
flushed countenance, full pulse, slight tremors, a tongue coated in
the centre and frequently florid at the tip, with, generally but not
invariably, more or less irritability of stomach. In the second
the symptoms come on in the habitually dissipated, after the

tremens into the European General Hospital, equivalent to 37 per cent, of the total
hospital admissions. Of these thirty-eight died, being a mortality-rate from this
disease of 8*4 per cent. Though 8 "4 per cent, was the average mortality for the ten
years, it has varied considerably in diiFerent years, and very strikingly in different
months. In the year 1848 the deaths were 20-4 per cent, of the admissions, whereas,
in the year 1853, they were only 2-2. Tliroughout the ten years there is only one
death from delirium tremens in the months of January and February, though the ad-
missions were respectively 2-5 and 2*4 per cent, of the total admissions. The month
of greatest mortality has been October, viz., 26'6 per cent., when the admissions per
cent, of the total hospital admissions were not more than 3 '7. Though the great
mortality of the month of May does not appear to the same extent in these ten years
as in the five which preceded, yet the aggravation in the hot months (April and May)
is sufficiently apparent.

The striking difference between these statements and those in the text is the much
lower rate of mortality from 1844 to 1853 than from 1838 to 1843. Particular
reference will be made to this in the sequel. The tabular returns for these ten years
are also annexed to this chapter. On this subject I would further refer to Dr. Stovell's
"Decennial Eeport of the European General Hospital," published subsequently to the
1st edition of this work, in No. 3, new series, " Transactions, Medical and Physical
Society of Bombay."

* " Copland's Dictionary of Practical Medicine, and British and Foreign Medical
Review," vol. ix. p. 475. _

S S

626 DELIRIUM TREMENS.

accustomed stimulus has, from some cause or other, been for a
time withheld.*

* As my remarks on delirium tremens have reference to a particular series of cases,
and were "svritten at a time (1843) wlien the diaries were before me, and the clinical im-
pressions fresh on my mind, I am unwilling to alter the statements made in the text,
though I believe that a fuller explanation respecting the division into species is neces-
sary to prevent misapprehension. The first species probably includes cases that now
would be classed as " ebrietas," The definition of the second species leaves it to be im-
plied that it comes on in the habitually dissipated, only after the accustomed stimulus
has been withdrawn : but this is an error, and not consistent with the toxsemic theory
of the pathology. In the " British and Foreign Medico-Chirurgical Review" for
October 1859, the subject of delirium tremens is fully considered as respects its
pathology and causes, and partially as respects its treatment. The principal doctrines
inculcated are : — 1. Delii-ium tremens is a toxaemia from alcohol, and becomes devel-
oped when the poisoned condition of the blood and of the nervous matter is sufficient
in degree. 2. The idea that the attack comes on in the habitually dissipated, when
the use of alcohol has been suddenly discontinued, is an error; and therefore to with-
hold this stimulus cannot be injurious, but, on the contrary, must be beneficial, {a.)
The erroneous idea has arisen in consequence of delirium tremens occurring ''n indi-
viduals admitted into hospitals with injuries, and it is maintained that the explanation
of this event is not as hitherto supposed — the suspension of the use of alcohol — but the
shock of the injury, acting as a determining cause in constitutions in which the toxaemia
is considerable, but not of itself sufficient to excite the disease, {b.) It is argued that the
withdrawal of alcohol cannot be the cause, because observation shows that in gaols and
houses of correction, into which the dissipated are received in large numbers, delirium
tremens rarely occurs in the recently admitted, though, as a matter of course, the use
of alcohol has in them been discontinued. 3. Not only is the treatment by free opiates
and alcoholic stimulants condemned, but it is maintained that, as the patient is
alcoholised when suffering from delirium tremens, to propose the use of more alcohol
in the treatment is irrational.

These doctrines are in part correct, but they do not embrace the whole subject, and
are therefore, it seems to me, in part erroneous. The following appear to me to be
the defects : — 1. The distinction between the toxsemic effect on the nervous system
of the continued use of alcohol, and the stimulant effect on the heart of regulated
quantities occasionally given, is not observed. 2. Though the disease often comes on
when the toxaemia is complete, without any suspension of the use of alcohol, yet
when the toxaemia is not complete, it may be determined by the sudden withdrawal
of alcohol ; and the error has consisted merely in a too general application of this
occasional fact, {a.) The explanation would seem to be, that the removal of the
stimulant effect of the alcohol by depressing the action of the heart determines the
attack, just as the shock does in the case of injury, or depletion in a co-existing
inflammatory disease, {h.) The argument that deliiium tremens is rare in the
inmates of gaols, is not of much force ; for the evident answer is, that though the
i;se of alcohol was suspended on admission, the disease did not become developed
because the toxaemia was insufficient. Indeed, it might be anticipated that delirium
tremens would not frequently attack the recent admissions into gaols, for a person on
tlie verge of delirium tremens cannot be said to be in a state well fitted for the com-
mission of general crime. 3. When the toxaemia is great, the withdi*awal of alcohol
may determine the attack. In this state the general tremor, the small pulse, the
damp and coldish surface, indicate the necessity of stimulants, and alcohol, used with
this view, will under these circumstances sometimes prevent the attack. But it does
not follow that in less degrees of the toxaemia, where the same necessity for a stimu-
lant does not exist, it may not be withdrawn with perfect safety: this measure is, then,

FIRST SPECIES SYMPTOMS AND TREATMENT. 627

Of the first species, cases are occasionally admitted into the
Greneral Hospital, occurring, usually, in steam-engineers, and not
unfrequently terminating by convulsion unexpectedly coming on,
passing into complete coma, with rapid pulse, pungent heat of skin,
and proving fatal in a few hours after the accession of convulsion.
Symptoms of gastric irritation, in this form of the disease, are
common, and require to be specially attended to in directing the
treatment. Many cases do well under the use of cold affusion fre-
quently repeated, attention to rest and quietness, the exhibition of
effervescing draughts with a few minims of tincture of opium, and
the application of sinapisms to the epigastrium, or a blister, if the
symptoms are more urgent. Six or seven grains of calomel, with
one grain of muriate of morphia, and one of ipecacuanha, given at
bed-time, preceded by cold affusion to the head and a hot foot-bath,
are often beneficial.

It is only in this species that the question of the local detraction
of blood, can, with advantage, be entertained ; and probably the best
guides to its successful use are the diathesis of the individual,
— whether plethoric or not — the knowledge of the length of time
to which he has been addicted to habits of dissipation, and the
duration of the symptoms. In young men of robust constitution,
not long resident in India, and not confirmed drunkards, it is often
useful, at the commencement of the attack, to detract blood locally
by cupping the nape of the neck, or leeching the temples ; but it is
only under these circumstances that this practice holds out any
prospect of benefit. In regard to the general abstraction of blood,
it is even in these cases very seldom expedient, and, if ever had
recourse to, should be carried into effect with very great caution.

Stimulants (wine, &c.) in this form of delirium tremens are not
usually required, — but the state of the pulse and skin sometimes
calls for their exhibition. When symptoms of gastric irritation are
not present (and such cases occasionally occur), tartar emetic com-
bined with more or less opium, according to the character of the

the only method by which the attack can be prevented. 4. In the treatment of
delirium tremens, alcohol should not be used without good reason, because the
tendency of its frequent repetition must be to increase the alcoholism ; but when the
skin and pulse indicate on general therapeutic principles the necessity of stimulants,
then they must be used in this as in other diseases, and wine and brandy are the best
at our command. Tendency to death by syncope must not be neglected in delirium
tremens, because the stimulants used temporarily to aA^crt an immediate and pressing
danger are by frequent repetition likely to increase the toxsemia, and lead to a remoter
evil. Here as in the practice of medicine generally, the physician's science lies in a
correct appreciation of the good and the evil of his remedies ; and his art in the skill
with which the first quality is sifted from the other, and usgfully applied.

s s 2

628 DELIRIUM TREMENS.

head symptoms, in the manner to be subsequently more particularly
adverted to, is perfectly applicable.

But the second species of the disease is the one of greatest
importance, and most frequent occurrence ; the other being com-
paratively rare.

The division of the second species into three stages, first, I
believe, suggested by Dr. Blake *, is in accordance with the cha-
racter of the disease as observed in the European Greneral Hos-
pital at Bombay, viz. : — 1. A stage of depression, characterised by
tremors (in some cases excessive), a feeble pulse, sleepless nights,
but no delirium, anorexia, and frequently irritability of stomach.
2. The stage of active delirium. 3. The third stage, in cases which
have gone on favourably, is one of lengthened sleep, followed by
recovery; in cases which have progressed unfavourably, it is a state
of low muttering delirium, with contracted pupils, tremulous
agitation, feeble and rapid pulse, and generally terminates fatally
by convulsion and coma, or by coma unpreceded by convulsion. It
is to this train of symptoms, that throughout these remarks I shall
apply the designation " third stage.''^

First stage. — By treating this stage with stimulants, wine,
brandy, ammonia, and occasionally f an opiate at bed-time pre-
ceded by cold affusion to the head, — the occurrence of the second
stage is sometimes prevented, and recovery takes place ; or, if not
prevented, it is much lessened in severity.

When there is irritability of stomach with slimy and florid
tongue, effervescing draughts with a few minims of laudanum,
sinapisms or a blister to the epigastrium, with stimulants according
to the state of the skin, pulse and tremors ; also a grain of muriate
of morphia, with two or three grains of calomel, and an effervescing
draught at bed-time, preceded by a hot foot-bath, — constitute the
best method of treatment. In the management of this stage,
stimulants ought never to be abruptly stoj^ped, but always gradu-
ally lessened, and an adequate diet should be reverted to as soon
as practicable.

* " Edinburgh Medical and Surgical Journal for October 1823." I regret that
I have not had the opportunity of consulting Dr. Blake's " Practical Treatise on
Delirium Tremens," published in 1830; or the second edition of 1840.

1 1 have said occasionally an opiate at bed-time advisedly, because it requires to be
given with discrimination ; for not unfrequently the first symptoms of the second stage
come on after an opiate given at bed-time — whether in consequence of the opiate, or
because it has chanced to have been given at the period when the commencement of
the second stage was to be looked for in the regular course of the disease, is a question
which I do not pretend to resolve. Of the fact as now stated I have no doubt.

SECOND SPECIES SECOND STAGE — SYMPTOMS. 629

The second stage, or that of active mental excitement. — It is
unnecessary to enter into any particular description of the delirium
of this stage : it is the symptom which most particularly charac-
terises the disease, and is fully and accurately delineated in all the
best works on practical medicine.* There are, however, certain
particulars which, though noted by some observers, have not re-
ceived that attention which their importance (as bearing on treat-
ment) seems to me to require ; and on these points I shall somewhat
extend my remarks.

It has been observed by Dr. Hoeg Gruldberg, physician to the
hospital at Frederickstadt, that the critical sleep occurs in the
greater number of cases on the fourth day ; but it does not appear
whether he dates from the commencement of the first stage, or
from that of the second. In all probability from the former ; for,
on carefully examining a great many of the diaries of cases treated
in the European General Hospital, I find, that of twenty-six cases
in which the access of the second stage, and its termination, were
distinctly recorded, the average duration of this stage was forty-six
hours — the shortest period being twenty-four, and the longest
sixty.

It is stated by Dr. Blake, that the mental irritation requires a
given time to subside ; and it is also the opinion of Dr. Ware of
Boston, that this disease runs a certain course. From considering
the cases which had passed under my own observation, I had
arrived at a similar conclusion, when not aware that the same view
had been entertained by previous observers.

The circumstances which suggested this opinion to me, were : —
1. The frequently observed fact, that the quantity of opium which
on one day failed to induce sleep, succeeded on the following ; a
circumstance to be explained, either on the supposition, that the
natural tendency of the symptoms was to abate, after a certain
course, or that the effect of the opium was cumulative — a con-
clusion which would be contrary to our experience of the action of
this medicine in all other forms of disease. 2. In cases treated
with full opiates frequently repeated, I have several times remarked,
that sleep was induced for three or four hours, but that the patient
afterwards woke up delirious as before ; and some of these cases
terminated fatally.

It is the circumstance of the second stage running a certain

* Dr. Stovell, at page 68 of his Decennial Eeport, gives an excellent summary of
his observations on the character of the illusions of patients with delirium tremens
in the European General Hospital.

630 DELIRIUM TKEMENS.

course, — which seem8 to me not to have received its full conside
ration in relation to treatment. For, if acknowledged, it may be
safely affirmed, that the indication of cure is not by full doses of
narcotics to force a state of sleep, but to conduct the patient
through the period of delirium, by withdrawing all sources of
irritation, by moderating or sustaining the circulation, and by
calming the nervous excitement. Though a similar opinion is
expressed by Dr. Blake in the following words ; " It does not
appear to me to be of any service to attempt to break the chain of
morbid concatenation too abruptly, as the stage of mental irrita-
tion seems to require a given time to subside, in proportion to the
stage of exhaustion, to the mode of treatment adopted, and to its
previous causes," I am not aware that any subsequent writer has
given to this feature of the disease that prominence which its im-
portance demands.

The indications of cure, as thus stated, are best effected by
cold affusion, tartar emetic combined with opium or other narcotic,
and stimulants.

In regard to cold affusion, it may be used with excellent effect
three or four times in the course of the twenty-four hours, — the
most important, however, being that before bed-time, — in all cases
in which the circulation is steady, the skin not covered with per-
spiration, or its temperature not reduced below the natural standard ;
or, in which there are not present any of the local complications
which usually contra-indicate the use of this remedy. In cases
in which, from the state of the pulse, there may be doubt of
the propriety of the cold affusion, it frequently becomes quite
admissible by preceding its application, by a stimulant (as brandy) ;
and in the still more doubtful cases, — even in instances in which
the measure may be decidedly contra-indicated, — there is good
effect from using cold affusion to the head, and at the same time
a hot foot-bath.

There has not been much difficulty experienced in inducing
patients to submit to this remedy, and it is hardly necessary to
add that the employment of coercive measures to effect it is alto-
gether inadmissible. In considering this statement, however, it
must be borne in mind, that I .write of the disease in a climate
whose mean temperature is about 80°, that the water used has
never been artificially cooled, and that the practice of frequent
bathing is habitual to many of the patients. The first considera-
tion is important, as bearing on the question of the temperature
of the water ; and the second, as, in all probability, explaining

SECOND SPECIES — SECOND STAGE — TREATMENT. 631

the little difficulty which has been experienced from the opposition
of the patients.

But the exhibition of tartar emetic with opium or other nar-
cotic, first introduced into practice by Dr. Law, of Dublin*,
and followed by Dr. Grraves f. Dr. Clendinning J, and others,
constitutes the most successful means of controlling the symp-
toms of this stage of the disease. This mode of treatment was,
during the five years to which my remarks apply, much followed
in delirium tremens, in the European Greneral Hospital at
Bombay; and there was also, during the same period, ample
opportunity of comparing it with that by free opiates frequently
repeated.

Tartar emetic and opium, in proportions modified according to
the symptoms, and associated with the use of cold affusion and
stimulants, is, in my judgment, a much more successful and satis-
factory method of treating the second stage of delirium tremens than
the more common plan of giving free opiates uncombined, or in
combination with stimulants alone ; and is moreover devoid of the
risk of positive injury, which more or less -attends the latter system
of treatment.

Tartar emetic was given in doses from half a grain to a grain
in an ounce and a half of camphor mixture, with from twenty
to thirty minims of tincture of opium or tincture of hyosci-
amus, repeated every hour, second, or third hour § ; the variations
in the dose, and the intervals, being dependent on the state of the
circulation, the condition of the skin, and the degree of mental ex-
citement. Though in determining these variations, there is room
for the exercise of discretion in each particular case, still, it will
be found, that the greater number are sufficiently controlled
by three quarters of a grain of tartar emetic and thirty minims
of tincture of opium or tincture of hyosciamus every second
hour, continued till sleep is induced, — with intermissions of
several hours, at times, if the sinking of the pulse or reduction of

* " London Medical Gazette for 2nd July and 30th July, 1835."

t " The Dublin Journal of Medical Science for May, 1836."

\ " London Medical G-azette," January 14th, 1842.

§ In regarding the proportion of opium here recommended, in reference to my ob-
jections to an exclusive opiate treatment of delirium tremens, the clinical student must
bear in mind the well-established therapeutic fact, that the narcotic effect of opium is
lessened by antimony. But I would add, that Dr. Stovell, in applying these prin-
ciples, has usually reduced the quantity of tincture of opium to ten minims ; and in
the expediency of this modification I am disposed to concur. I would therefore re-
commend it, as the rule, instead of the larger quantity stated in the text to have been
given in the series of cases to which these remarks specially refer.

s 8 4

G32 DELIRIUM TREMENS.

the temperature of the skin, should indicate the expediency of
this measure. The tincture of opium is the more useful ; the
tincture of hyosciamus was used in milder cases, and chiefly with
the view of avoiding the constipating effect of the opium. Tartar
emetic thus combined and repeated every hour, very seldom, even
in grain-doses, causes nausea or vomiting. In fact, it has seemed
to me that in the second stage of delirium tremens, there is as
complete a tolerance of the emetic action of tartar emetic as in
pneumonia ; and this I have remarked, even in cases in which there
had been irritability of stomach during the first stage, — an observa-
tion which accords with Dr. Law's experience.*

In cases treated in this manner for about twenty-four hours,
without tendency to sleep, it is often useful to intermit the
medicine for a few hours before bed-time, then to use cold affusion,
preceded, if the pulse and skin indicate the expediency, by a
stimulant ; and after the affusion to give one dose of the an+imo-
nial with a drachm of tincture of opium. By this means, sleep
is often induced in cases in which, without this fuller opiate, it
might have been still postponed for several hours. It is, how-
ever, very generally of no avail to adopt this course within the
first twenty-four hours of the second stage.

Stimulants, as wine, brandy, ammonia, are more or less required
throughout the treatment of this stage of the disease; and their use
is perfectly compatible with that of cold affusion, tartar emetic, and
opium. The degree to which these stimulants are required in in-
dividual cases, must vary according to what may be known of the
previous history of the patient ; and the state of the pulse and skin
at different periods ought to be the principal guide. From six to
eight ounces of port wine in the twenty-four hours will generally
be sufficient, though the necessity of adding brandy to the extent
of from four to six ounces, not unfrequently occurs ; and it follows,
that the cases in which there is the greatest necessity for stimu-
lants, are those in which the utility of tartar emetic is least appa-
rent, and in which it is most frequently necessary to intermit its
use. But cases of this nature constitute a small proportion of the
admissions, and occur for the most part only in those whose career
of dissipation has been protracted, and who have suffered from
several former attacks of the disease.

* On this point Dr. Stovell writes : — " I am in the habit of giving antimony with-
out reference to the presence or absence of irritability of stomach ; for not only is
there marked tolerance of this medicine in those cases in which there is no irritability
of stomach, but its use has often appeared to allay this irritability in cases where it
existed."

SECOND SPECIES — SECOND STAGE — TREATMENT. 633

It has been well remarked by Dr. Budd*, that in the manage-
ment of the second stage of delirium tremens, it is of consequence
to attend to the diet of the patient, with the view of encouraging
any desire for solid animal food that he may evince. This sug-
gestion is very important ; and it will frequently be found that
there is during this stage no great disinclination for food on
the part of the patient, — such being rather a feature of the first
stage.

The not unfrequent injurious effects of opium, too often repeated,
or given in doses too large, in the treatment of the second stage of
delirium tremens did not escape the observation of Dr. Pearson f
and Dr. Blake ; and has been brought forward of late years very
prominently by Dr. Wright, of Baltimore, and Dr. Ware, of Boston. J
On no point of practice is my conviction more decided, than that
opium in full^doses requires to be used in delirium tremens with
very considerable caution, — much more, indeed, than is generally
believed ; — and that it is liable, under some circumstances, to hasten
a fatal result by convulsion and coma, or to aggravate and modify
the train of symptoms which characterise the third stage. The fol-
lowing have seemed to me the leading objections which may be
urged against the treatment by opium, as frequently followed,

1. If there be good grounds for supposing that the tendency
of the second stage is to run a certain course and terminate
in sleep, then the indication of cure is, surely, not to attempt
to cut short this stage abruptly, by large doses of narcotics ; for it
would be as sound practice to attempt to obviate the hot stage
of an intermittent fever, or the febrile or eruptive stages of the
exanthemata.

2. In support of the opinion that the treatment of the second
stage, by free opiates, may tend to interfere with its regular course,
I would state that in selecting from the cases treated in the Greneral
Hospital those which illustrated the duration of this stage §, I con-
fined myself to those in which the change from the first to the
second stage was well marked, and in which the occurrence of
sleep was critical and followed by recovery; and almost without
exception, these cases proved to be instances in which the treat-
ment with tartar emetic and opium, or hyosciamus, cold affusion,
and stimulants had been used. In those in which the treat-

* "London Medical aazette," May 13th, 1843.

t " Copland's Dictionary of Practical Medicine."

I " British and Foreign Medical Eeview," vol. rii. p. 268.

§ The result of which is stated at page 629.

634 DELIRIUM TREMENS.

ment by free and frequently repeated opiates had been followed,
and in which the issue had also been successful, I experienced a
difficulty in determining the commencement and termination of
the second stage ; because opium had very generally been given
more or less freely during the first stage, and had plainly masked
the period of transition; and again, very frequently during the
course of the second stage, sleep had been produced for some hours,
but been succeeded by a recurrence of delirium, again to be checked,
and perhaps again to return. It is not disputed that a full opiate
given during the period of excitement is frequently followed by
sleep, but if the law as stated be just, the probability of this
result depends on the time of the stage at which the remedy has
chanced to be given; and then it acts favourably merely in con-
formity with the natural tendency of the disease, and, not because
there has been an accurate adaptation of the quantity to the degree
of excitement.

3. It has seemed to me, that in cases treated with free opiates
there is a greater tendency to pass into the third stage, and that
a greater number terminate by convulsion and coma. I have
not attempted, by a scrutiny of the cases, to offer a numerical
statement in support of this opinion ; for, in all questions of
medical treatment, such data are open to evident sources of
fallacy, — the principal of which is, that there are many important
circumstances bearing on success which do not admit of expression
by numbers. Still, however, the opinion, as stated, is the result
of the impression left on my mind by the cases when under obser-
vation, strengthened by a careful review of a great many of the
diaries.

4. As has already been remarked, it was the opinion of Dr.
Pearson, that after a certain time it is injurious to persist in the
use of opium, for the action of the medicine confuses the symp-
toms of the disease ; and a similar conviction is still more strongly
expressed by Dr. Wright, of Baltimore. My suspicion on this
point was excited — when it was not known to me, that such
views had been already entertained — by the following circum-
stances:— A man under treatment for delirium tremens in the
second stage, took one grain of tartar emetic, and one drachm of
tincture of hyosciamus, every hour for ten successive times, after
which there succeeded convulsive agitation of the hands, which
moved about as if in search of objects; there was a rolling motion
of the tongue about the teeth and the cheeks, as if in search of
something in the mouth; the pulse was 108, of moderate strength ;

SECOND SPECIES — THIRD STAGE — SYMPTOMS. 635

there was constant incoherent low muttering ; the pupils were very
Tnuch dilated. Under the use of blisters, tartar emetic in smaller
doses, with spiritus setheris nitrici, this patient recovered. The symp-
toms just detailed are those of the commencement of the third stage
of the disease, with the exception that the pupils were much dilated
instead of being contracted. It is hardly necessary to observe that
henbane in poisonous doses dilates the pupils, and opium contracts
them.

The mode of exhibiting opium to which these remarks are
intended to apply is, not only the unusually large quantities
recommended by some American practitioners, but — 1. The use
of tincture of opium in doses of one drachm or one drachm
and a half, with stimulants, given every hour or every two hours
for many times. 2. The exhibition of from a drachm and a half
to three drachms of tincture of opium at bed-time, followed by
a half dose every hour or second hour, for two, three, or more
times. 3. One and a half-grain doses of muriate of morphia
with a few grains of blue pill at bed-time, repeated every second
hour in grain doses for two, three, or more times, if required.
The first mode I have witnessed, the second and third I have fre-
quently practised, using at the same time cold affusion.

Before proceeding to consider the symptoms characteristic of
the tJiird stage of the disease, there are signs which mark as
it were, in unfavourable cases, the approaching transition of the
second into the third stage ; and which, as bearing on treatment,
it has seemed to me of much moment carefully to note. After
the second stage has gone on for some time, without sleep,
the pulse begins to increase in frequency, rising above 100 and
becoming more compressible, the skin is damp, the expres-
sion of countenance vacant, and the pupils begin to contract* ;

^ Dr. Barlow, in his "Manual of the Practice of Medicine," p. 541, Avrites : —
" The diagnosis of delirium tremens, in its perfect form, is not difficult ; from
phrenitis it may be distinguished by the softer pulse, the moist tongue, perspiring
skin, scanty urine, and, by what is perhaps a still more important sign, the dilated
pupil." That dilatation of the pupil is characteristic of delirium tremens, is, I appre-
hend, not a usual belief. Copland and Wood state that it is contracted in the second
stage. My own opinion is that it presents no peculiarity in the second stage, but
that its contraction is to be viewed as a sign of the impending dangers of the third
stage.

On my return to India, I requested Dr. Leith, who had succeeded to the surgeoncy
of the European G-eneral Hospital, to favour me by noticing the state of the pupil in
the second stage of delirium tremens. The following is his reply, dated 21st January,
1858 :— " With reference to the question whether or not the pupil is contracted or
dilated during delirium tremens, I find I have noted the symptom in eighteen of the
cases treated in my wards during last year without any opium, and find that in nine

636 DELIRIUM TREMENS.

the tremors increase and assume more tlie character of subsultus
tendinum than in the earlier period of the disease, and the patient
catches at objects, not so much, apparently, from fancying them
present when not so, as from miscalculating the distance when
they are really before him.

On the occurrence of these symptoms, danger impends either
from the sudden access of convulsion with succeeding coma and
death, or the passing of the disease into the third stage, character-
ised by still increased frequency (120), and feebleness of pulse,
constant agitation, low muttering delirium, contracted pupils, roll-
ing of the tongue within the lips and cheeks as if in search of
objects in the mouth, — passing gradually into coma, and termi-
nating fatally in a few hours.

When these symptoms which indicate the transition of the
second stage into the third become developed, then all narcotic
medicines should be completely intermitted ; the head should be

it was dilated, in seven it was of natural or moderate size, and in none was it stated
to be contracted. With regard to the statement 'natural' size, or 'moderate' size,
it is indefinite ; and, latterly, I have compared the size during the attack with the
size after recovery."

Dr. Leith, in his report of the hospital for the year 1858-59, published in No. 5,
new series, " Transactions, Medical and Physical Society of Bombay," thus states his
latest conclusions : — " For some time past I have attended to the state of the pupil of
the eye in all cases of delirium tremens that have come under my care, and the result
of my observations is, that the pupil is dilated in this disease, but that at the same time
the iris is sensitive, readily obeying the stimulus of light ; the pupil oscillates about a
mean diameter abnormally large." Dr. Leith also explains " a diagram, in which
there is a row of disks of uniform size, each having in its centre a smaller black disk
which represents the pupil of the eye," by means of which he gave precision to his
observations. He further states, — "With the aid of this diagram or scale, I estimate
and note the relative size of the pupil on admission and during delirium ; and again,
after all signs of delirium have for some time ceased, — the patient being also free
from the influence of opium or other medicine. I take care that the circumstances as
to light are the same at each observation ; and to secure this, I find it best that the
patient's eyes should be directed to the sky and not to the observer, and that the time
of day be always the same."

The inference which I draw from these statements, though it is not distinctly
stated, is, that the dilatation of the pupil, observed in the second stage of delirium
tremens, was not great in degree. The following circumstance (doubtless not over-
looked by Dr. Leith) renders additional caution necessary in conducting an inquiry of
this nature in this hospital. During my time, the cases of delirium tremens were
treated in the ordinary light wards ; they are now treated in darkened cells, badly
constructed and situated in the basement floor. I still incline to the opinion, that in
patients in the second stage of delirium tremens, undrugged with narcotics, and not
secluded in small darkened rooms, but placed in ordinary light, the diagnosis is not
assisted by an abnormal state of the pupil, dilatation or contraction, but that the pupil
is usually what may be fairly termed natural. Further inquiry is, I think, still
necessary.

SECOND SPECIES — THIKD STAGE — TREATMENT. 637

shaved, a blister should be placed on the nucha, the hot foot-bath
should be used, and if the scalp be hot, cold cloths should be ap-
plied to it; camphor mixture should be exhibited every second
hour, either with a small portion of tartar emetic or spiritus setheris
nitrici, according to the state of the pulse and skin ; wine should
also be given, and the importance of mild nourishment, as beef-
tea and chicken soup, is very great. These means, if adopted at
the proper time, and assiduously pursued, are not unfrequently
successful, — the patient falls asleep, and awakes comparatively well.
It is under these particular circumstances, and also at. times earlier
in the disease, while all these conditions are not yet present,
that the application of a blister to the nape of the neck is of
g"reat utility. This is a point of practice which, so far as I know,
has not been estimated according to its just importance; for it is
generally stated, that blisters ought to be confined to the first stage
of the disease, a remark in all probability correct as regards their
application to the epigastrium, but not to the nape of the neck or
to the head.

In the course of these observations, I have anticipated the de-
scription of the symptoms ; but it remains that a few words be said
of the treatment of the third stage. Supposing that the course
above recommended has been gone through, a blister should now
be applied to the scalp, camphor mixture one ounce and a half
wuth half a drachm of spiritus setheris nitrici, should be given every
second hour with wine and light nourishment. Under this treat-
ment, in instances in which the symptoms of the third stage were
fully formed, I have known recovery to take place ; but in them
there was frequently room for suspicion that the symptoms had,
to a certain extent, been caused by the free exhibition of nar-
cotics;— and the fact of recovery from a combination of symp-
toms which, resulting in the natural course of the disease, is usually,
if not always, followed by death, is an additional argument in sup-
port of the opinion that the too free use of narcotics is apt to
complicate and modify the symptoms of the third stage.

It has been stated by Dr. Blake that when the pulse rises
above 100, there is room for apprehension. This remark is in
accordance with my experience ; care however being taken not to'
mistake a frequency of pulse caused by muscular exertions which
the patient in his excitement may have been just undergoing, —
for that frequency which is permanent, and which takes place
when the disease is progressing unfavourably.

General Remarks on Treatment, Blood-letting, general and local.

638 DELIKIUM TREMENS.

Purgatives , Emetics, &c. — It is unnecessary to notice particularly
the use of general or local blood-letting in the treatment of deli-
rium tremens, for with the exception of local depletion, in a few
cases of the first species, I believe that all are agreed in consider-
ing it inadmissible. It is not often, indeed, (so rarely is it had
recourse to), that there exists the occasion of witnessing positive
injury from general or local blood-letting in the second species
of the disease. The opportunity, however, sometimes occurs,
when the application of leeches may have been thought necessary,
in consequence of the complication of local inflammatory dis-
ease, as dysentery ; and it may be very safely affirmed, that this
measure is never adopted without a positive aggravation of the
characteristic symptoms of delirium tremens.

Laxatives or purgatives have not been used by me in the second
species of delirium tremens, except with the view of removing ex-
isting constipation. Griven with this object they are of courfc3 fre-
quently required, but further than this, their exhibition does not
constitute any part of the treatment, for free purging in this form
of the disease must generally be injurious. I am aware that these
opinions are opposed to the statements of several very excellent
writers * ; but it must be recollected that I write of the disease as
observed in a climate in which affections of the bowels are common,
and easily excited ; and in which that free use of purgatives, often
safe, and perhaps necessary, in the management of the diseases of
extra-tropical countries, is generally injurious.

Emetics may occasionally be useful in the first stage, when the
tongue is coated and white, and symptoms of gastric irritation are
not present. Cases of this nature are, however, rare, and there-
fore the utility of emetics, in the treatment of delirium tremens,
is very limited.

There are other points of general management on which I have
thought it unnecessary to dwell, because it may be presumed that
there is little difference of opinion in regard to them. They are —

1. The advantage of secluding the patient in a quiet, and par-
tially darkened room, under the care of a trustworthy attendant.

2. The injurious effects of strait-jackets, or bonds of any kind,
and the extreme rarity of any necessity for their use, when the
management of the patient is conducted with ordinary intelligence
and tact. 3. The necessity of guarding against the risk of injury
to the patient, either from the suicidal tendency, which is not unfre-

* " Copland's Dictionary of Practical Medicine," &c.

GENERAL REMAEKS ON TREATMENT. 639

qiiently present, or from the efforts made by him to escape from
some imaginary danger.*

This account of the symptoms and treatment of delirium tre-
mens was presented to the Medical and Physical Society of Bombay,
in 1843, and published in the Transactions of the Society f, in the
form in which it is now reproduced. I expressed myself then,
with confidence, on the superiority of the treatment here recom-
mended, over that with opium and stimulants, because my oppor-
tunities of forming an opinion had been ample, and because I felt
the practical question to be one of very great importance in the
treatment of European Hospital sick in India. It has therefore
been to me a source of great satisfaction, to find these views fully
corroborated, daring the last ten years, by the experience of the
medical officers who have succeeded me in the European Greneral
Hospital, more especially by Dr. Stovell, who has borne repeated |

* The fulfilment of these indications ought never to be aimed at by the construc-
tion of darkened, barred, and secluded cells in the basement or other parts of a
building not deemed suitable for other sick. The necessary protection of the patient '
from self-injury, " and of the other inmates of an hospital from disturbance, ought to
be eifected without adding to the alarm characteristic of the disease — the idea of im-
prisonment and forcible restraint.

t No. vi. p. 139.

]. " Transactions, Medical and Physical Society of Bombay," No. 9, p. 53 ; No. 10,
p. 861 ; Second Series, No. 2, p. 66 ; and No. 3, p. 70.

Since these remarks were written, I have seen two reports, in which a diiferent
system of treatment has been advocated. Dr. Laycock, in the "Edinburgh Medical
Journal" for October 1858, recommends an almost exclusive expectant treatment —
by food, occasional cold affusion, and the soporific influence on the mind of a placebo,
given at bed-time as an anodyne. Dr. Leith, in his report of the European General
Hospital, Bombay, for the year 1857-58, published in the fourth number of the new
series of the " Transactions of the Medical and Physical Society," states : — " The
treatment of delirium tremens during the year has been chiefly expectant, and in the
uncomplicated cases that have been under my own immediate care no medicine what-
ever has been given. The patient is secluded, and kept as quiet as the present im-
perfect hospital accommodation will allow ; and where there is any heat of head, the
cold afflision is used, and sometimes along with it the hot pediluvium. In many cases,
however, even these remedies are not employed. Attention is always paid to alimen-
tation, and strong broth is given at regular intervals. I had followed this plan for
many years in the cases that from time to time came under my care, and now that I
have had trial of it in a more abundant field of observation, I continue to be satisfied
with it." On referring to the return, I find that the mortality was 8 per cent.

These two reports are of much interest, for they confirm the toxgemic view of the
pathology of the disease, and the correctness of the general principles of treatment
recommended in this chapter. But it no more follows that an expectant treatment is
the best in delirium tremens because cases very generally recover under it, than that an
expectant treatment is the best in all other forms of toxsemic disease. In treating
delirium tremens there is not merely the question of recovery, but — 1. Can the duration

640 DELIiaUM T11EMEN8.

testimony to the success of the system here advocated. Though,
as I have elsewhere remarked, figured statements, as data from
which alone to judge of the success of medical treatment, are open
to very evident sources of fallacy, and must be used with much
caution, yet I feel satisfied that I run no risk of misleading others,
when I point to the statistics of the European General Hospital, in
proof of the greater efficacy of the treatment of delirium tremens,
by the means, and in accordance with the principles, here incul-
cated. From 1838 to 1841 — the years during which I became
convinced, from careful clinical observation of the evils of an exclu-
sive opiate and stimulant treatment —the mortality from delirium
tremens was 24*5 per cent. Whereas, from 1842 to 1853 — a period
during which I know that the disease was chiefly treated in the
manner recommended by me — the mortality was 9*4 per cent.
Why, the year 1848, in which the mortality again rose to 20*4 per
cent., is the single exceptional year of these twelve, I am uaable,
from the data before me, to explain ; but it would be interesting
to inquire, by examination of the diaries of the cases of that year,

of the delirium be shortened ? 2. Can the delirium be moderated, and thus the
general management be much facilitated, and exhaustion in a measure ob\aated ?
The answer to these questions is affirmative. It is these objects which the treat-
ment by tartar emetic and small opiates with alimentation effects,- and the neglect of
which is the objection to an exclusive expectant method.

It may be gathered from Dr. Laycock's cases, that the average duration of treat-
ment was seven days ; and allusions to strait-jackets show that in cases there was
much violence, for which restraint was used. Dr. Leith gives no details either in
respect to the duration of the attack or the character of the delirium, but seclusion in
the small barred rooms of the hospital of necessity supplied restraint.

The tartar emetic treatment tends to shorten the attack, and so to moderate the
delirium as very materially to facilitate the control and management of the patient
without strait-jackets, and small, barred, darkened rooms. But the chief advantage
of moderating the delirium is not the convenience to the attendants, but the protec-
tion of the patient from direct injury, and, above all, from the exhausting effects of
the constant muscular exercise which attends the unmitigated delirium of this disease.
Of the importance of this, any one who feels the pulse and skin of a patient affected
with delirium tremens, after a paroxysm of restless movement and great alarm, may
satisfy himself. Alimentation is a very essential part of treatment, but surely much
of its value is lost if the patient be allowed to exhaust himself by uncontrolled excite-
ment. Tartar emetic with small opiates, proportioned to the degree of excitement,
prevent much of the exhaustion which results from muscular waste, and does not' in-
terfere with the taking of food : hence its utility in the treatment of delirium tremens.

I have dwelt at length on this question, because, not only is it of great importance
in reference to the treatment of delirium tremens, but also to those general princij^les
which are unfortunately gaining ground — that because recovery follows, expectant
treatment is necessarily the best. This conclusion is neither logical nor consonant to
rational pathology or therapeutics.

REVIEW OF PATHOLOGY AND PRINCIPLES OF TREATMENT. 641

whether there had not been a backsliding into the old, and I fear,
still too common, system of treatment.*

Section II. — On the Pathology, the Principles of Treatment, and

Diagnosis.

I propose in this section to extend the observations of my origi-
nal paper, in the hope of reconciling the discrepancies which exist
in the treatment of delirium tremens. The following statements
relative to the general pathology of the brain, may be received as
probably true.

1. The functions of the brain may be deranged by toxoemia.
It is very likely that the symptoms peculiar to this disease —
the busy, apprehensive delirium, the sleeplessness, the muscular
tremors — are of this nature. The poison may be " alcohol accu-
mulated slowly in the blood, incorporated, if we may so speak,
with the nervous matter of the brain," as suggested by me in
1848t, or a "compound formed of alcohol, and perhaps some
morbid matter generated in the system," as advanced by Dr.
Todd, in 1850. J

* On my return to Bombay, in August, 1856, I requested Dr. Leith to have the
kindness to cause the diaries of the cases of delirium tremens for the year 1848 to be
examined, with the view of ascertaining whether the surmise hinted in the text was
coi-rect or not. The following is the reply: — "I at last have got the diaries of the
delirium .tremens cases of 1848 searched out, and I have gone over them, and the fol-
lowing is the result : of those entered in the register, the diaries of eight cannot be
found— of these two died, six recovered ; of the thirty-six that have been by me ex-
amined, thirty were treated with free use of opiates and brandy — of these six died and
twenty-six recovered ; six were treated with mist, antimon. c. opio chiefly — of these
one died and five recovered," It is evident that the treatment with free opiates and
stimulants was the ruling system of the year 1848.

t "Transactions, Medical and Physical Society of Bombay," No. 9, p. 127.

I "London Medical Gazette," vol. xiv., new series, p. 1078.

As bearing upon this subject, I may allude to the cases of poisoning with Datura
which are from time to time received into the Jamsetjee Jejeebhoy Hospital. The
symptoms are in many respects allied to those of delirium tremens. The delirium is
more muttering, not so busy as that of delirium tremens ; but there is the same
rambling of the mind on subjects not present to the senses. There is the same power
of controlling the thoughts for a few moments, the same desire to appear rational, and,
above all, the same picking at small objects, as if they were indistinctly seen, which is
often obser\'ed in the advanced stages of, delirium tremens.

AVhere the quantity taken has been large, there is coma with agitated movements
of the hands and lips, and picking movements of the fingers: in fact, the same class of
deranged nervous actions which characterise the third stage of delirium tremens.
There is, however, this great difference in these latter phenomena when caused by
datura ; they are very generally recovered from, not by a retiu-n from coma to a state of
health, but the coma ceases, and then succeed the delirium and the other phenomena
which attend those slighter cases which have never passed into coma.

What is the indication of cure in these cases of datura poisoning after the time has

T T

642 DELIIUUM TREMENS.

2. The functions of the brain may be deranged from excess or
defect of blood in the cerebral capillaries, without reference to its
quality.

3. Determination of blood in the capillaries of the brain is of
common occurrence in Europeans in India, characterised by sense
of fulness or pain in the head, flushed countenance, injected con-
junctivae, heat of scalp, confusion of thought, or some degree of
delirium, liable in its more aggravated forms to pass into con-
vulsion and coma. The appearances found in fatal cases are more
or less vascular turgescence of the membranes and substance of
the brain, with more or less serous effusion. The more ordmary
exciting causes, are elevated temperature, and immediate excesses
in drinking. As proof of the influence of these causes, it may be
stated, that of twenty-nine cases, with head symptoms, noted by me
in the European General Hospital,* in which there was found after
death, increased serous effusion in the cavity of the cranium with
or without increased vascularity, twenty-six occurred in the hot
months of the year, and twenty-one in individuals addicted to
drinking.

4. The subjects of the toxoemia which induces delirium tremens,
are very likely to be exposed to the causes of, and to be affected

passed for the exhibition of emetics and purgatives, with the view of removing the
poison from the alimentary canal ? Certainly not an attempt to destroy the delirium
of datura by the sopor of opium, or to remove the coma of datura by the means of
treatment applicable to idiopathic apoplexy.

They are viewed as deranged states of the nervous system, caused by the presence
of a poison in the blood, and which will not cease till time has been given for its eli-
mination. If the delirium be troublesome and active, and the pulse does not contra-
indicate, antimonials and cold affusion are appropriate means for moderating these
deranged actions. If the pulse be feeble and the skin cold, which is often the case,
then stimulants are used to counteract this tendency to death by syncope. If coma
comes on, then it is recollected that the suspended action of the brain, consequent on
narcotic poisons, is attended by a degree of congestion, and (the state of the pulse and
skin permitting) a few leeches, cold douche, and a blister to the nucha are used to
lessen this congestion. It is not to be doubted that these means of treatment are often
very useful and conducive to the successful issue of many of these cases.

The similarity of many of the phenomena of poisoning by datura and those charac-
teristic of delirium tremens is a circumstance which seems to me to afford a reasonable
confirmation of the idea that delirium tremens is nothing but one form of poisoning by
alcohol ; and to explain the practical fact, that we most successfully treat the disease
when we observe the same indications of cure, i. e. moderate the symptoms, oppose the
tendency to death, and allow time for the elimination of the poison from the blood,
before we hope for perfect recovery.

A very interesting account of datura poisoning, as observed in the Jamsetjee
Jejeebhoy Hospital, has been published by Dr. Criraud in the Ninth Number of the
*' Transactions of the Medical and Physical Society of Bombay."

* " Transactions, Medical and Physical Society," No. ix. pp. 120 and 121.

REVIEW OF PATHOLOaY AND PRINCIPLES OF TREATMENT. 643

with, cerebral determination. In them we may expect to find
symptoms indicative of both deranged states — that is, symptoms
of delirium tremens, and of cerebral determination — combined in
varying proportions, according as the one or the other predomi-
nates. Allusion has been made to this fact, in reference to the
pathology of cerebral complication in remittent fever (p. 57), and
it is an important consideration in the pathology and treatment
of delirium tremens. It is because there is some amount of this
combination of cerebral determination, in by far the larger pro-
portion of cases of delirium tremens met with in Em-opean
hospitals in India, that tartar emetic and cold affusion are so
valuable, and the free use of opium and stimulants so dangerous,
in the treatment.

5. In the early stages of the mixed cases, the danger is from the
cerebral capillary derangement ; there is seldom risk from failure
of the action of the heart : therefore antimony and cold affusion
may be freely used, but opium very cautiously. But as the
duration increases, the cerebral danger may still continue, and
indications of exhaustion begin to appear ; and now we must be
still cautious with opium, use antimony and cold affusion with
more reserve, and direct our attention to stimulants and nourish-
ment.

6. In pure unmixed delirium tremens, the danger is from
exhaustion, therefore stimulants, nourishment, and opium are indi-
cated. But they should be used in that moderate expectant
manner, which is a therapeutic rule in the treatment of all forms
of toxoemic disease. The coma, and serous effusion of unmixed
delirium tremens, are probably related to general anaemia with
watery blood, and not to local hypersemia. It is because this form
of disease is rare in Europeans in India, that the treatment exclu-
sively appropriate to it is generally inapplicable. This remark
must be viewed in connection with what has been written at the
concluding part of the preceding head — that in the advanced
stages of the mixed cases, there is also hazard from exhaustion. It
is probably because unmixed delirium tremens occurs more fre-
quently in the asthenic inmates of civil hospitals in the large cities
of Europe, that the exclusive treatment with opium and stimulants
still finds acceptance in these institutions.

In these statements I have endeavoured to explain the prin-
ciples of the treatment which I have advised, and to account for
the apparent discrepancy in the results of clinical experience in
India and in other countries, in respect to this disease. The same

T T 2

G44 DELIIUUM TREMENS

doctrines will be found to pervade the more desultory observations
of my original paper.

Morbid Anatomy. — The appearances found after death are
sometimes trifling and insufficient to explain the phenomena of
the disease. There is in a proportion of cases, but not in all, some
degree of vascular turgescence of the membranes of the brain, with
frequently more or less serous effusion between the arachnoid and
the pia-mater, into the ventricles, or at the base of the skull,
and occasionally slight opacity of the membranes. 2. There is
often dotted redness at the cardiac end of the mucous lining
of the stomach, frequently without alteration of texture, but some-
times with a mammillated state at the pyloric end or body of the
organ. Admitting, however, the frequency of this appearance,
it does not support the view originating with Broussais, and sub-
sequently supported by Dr. Hannay * of Grlasgow and others, that
delirium tremens is caused by gastritis. On the contrary, this
appearance of the mucous coat of a stomach exposed to the
habitual action of the strong stimulus of alcohol, is what might be
expected, and doubtless exists in individuals with these habits,
even when delirium tremens is absent. The circumstances most
important to remember as bearing on the prognosis, are the cere-
bral determination, the frequency of previous attacks, and the
existence of some local complication — dysentery being that which
is most common in delirium tremens in India.

Diagnosis. — The diagnosis between simple delirium tremens
and cerebral determination or inflammation is easily stated. The
characteristic delirium, the tremors, the pale countenance and the
compressible pulse of the one ; the flushed face, hot head, active
delirium, headache, and firm pulse of the other, are sufficiently in
contrast. But I have already explained that this picture does not
represent the realities of practice. At the bedside of the sick we
may readily recognise the peculiar delirium and the tremors of
delirium tremens, but we shall generally find something more ;
and the practical question which ought always to arise is, does any
derangement exist in addition to the toxoemia which causes the
symptoms peculiar to delirium tremens, if so, what is its nature ?
On the frequency of cerebral determination I have already
enlarged. The complication of inflammations, — as pneumonia,
pleuritis, dysentery — has been often the subject of comment. Dr.
Wood f alludes to the complication of meningitis and delirium

* "London Medical Gazette," March 3, 1838.

t " Treatise on the Practice of Medicine," by George B. Wood, M.D., vol. ii. p. 737.

IN NATIVES OF INDIA. 645

tremens ; this is important and very liable to be misunderstood.
The following is an illustrative case.

246. Meningitis. — Effusion of lymph and serum in the sub-arachnoid space. —
Symptoms of delirium tremens, — John Rechlin, a discharged European soldier, desti-
tute, drinking in the bazaar, and exposing himself to the sun, came to the Jamsetjee
Jejeebhoy Hospital in a state of intoxication on the loth April. The stomach was
irritable, and he was delirious in the evening. He was bled to twelve ounces ; three
dozen leeches were applied to the temples, and a purgative given. The delirium con-
tinued, and the illusions were of the character of those of delirium tremens. The con-
junctivae were yellow. On the evening of the 17th, the 18th, and 19th he was treated
with potassio-tartrate of antimony, and tincture of opium in repeated but moderate
doses. After this there was drowsiness and picking at objects without sleep. The
yellowness of the conjunctivae continued. He was now treated with moderate mercu-
rial purgatives, diuretics, a blister to the nucha, and afterwards to the scalp. The
drowsiness continued, with twitching of the arms, and the pulse lost strength. He
died on the evening of the 22nd.

Inspection fifteen hours after death. — There were about four ounces of serum in the
cavity of the cranium, chiefly at the base. There was also some serous eflfusion in the
sub-arachnoid space at the convex surface of the brain. The vessels of the pia mater
were somewhat congested. The pia mater and arachnoid were in parts opaque, and
much thickened, chiefly from lymph deposit between them : this was most marked near
the longitudinal fissure about its middle. The substance of the brain was healthy.
There was no increased effusion in the ventricles. The cerebellum, pons Varolii, and
medulla oblongata were healthy. The lungs and heart were normal. The liver was
nearly of natural size, of pale yellow colom* from biliary congestion ; under the
microscope the cells were visible here and there, they contained many fat globules,
and were surrounded by granidar amorphous matter and free fat globules. The
structure of both kidneys was healthy.

Section III. — Delirium Tremens in the natives of India,

Dm-ing the six years from 1848 to 1853, forty-one cases were ad-
mitted into the Jamsetjee Jejeebhoy Hospital; of these, two proved
fatal, one being a European whose case has just been detailed.
The classes chiefly affected were Hindoos and native Christians.
Though the lower classes of the Parsee community drink spirits to
great excess, and though I have often seen them tremulous, and
exhibiting other indications of intemperance, I have never witnessed
one in the second stage of delirium tremens: the cause of this
fact I am unable to explain. In respect to the treatment of the
disease in natives, I have followed the principles which have been
so fully set forth in this chapter, and found them as applicable
to natives as to Europeans.

t T 3

DELIllIUM TEEMENS.

Section IV. — Statistics of Delirium Tremens.

Table XXXVIII. — Admissions and Deaths j with Per-centage, from Delirium
Tremens, in the European General Hospital at Bombay, for the Five Years
from 1838 to 1843.

1838 to 1843.

Monthlj Average.

Admissions

Deaths on

Admissions.

Deaths.

Admissions.

on total
Admissions.

total
Deaths.

January-

3-2

February

—

5-3

—

March .

18-1

April .

3-8

4-4

2-4

May

42-8'

4-7

22-4

June .

8-3

3-1

3-9

July .

11-7

2-3

5-4

August .

8-3

1-9

2-8

September

33-3

3-3

11-5

October

44-4

1-2

14-8

November

6-2

2-3

2-1

December

18-1

3-5

•6

Total

237

17-8

3-1

7-5

Table XXXIX. — Admissions and Deaths, with Per-centage, from Delirium
Tremens, in the European General Hospital at Bomhay, for the Five Years
from 1844 to 1848.

1844 to 1848.

Monthly Average.

Admissions.

Deaths.

Deaths on
Admissions.

Admissions

on total
Admissions.

Deaths on

total
Deaths.

January
February
March.
April .
May .
June .
July .
August
September
October
November
December

17
14
23
23
18
22
18
18
18
15
13
16

3
2
1

2
2
2
5
2
2

5-8

13-0
8-7
5-5

11-1
11-1
111
33-3
15-4
12-5

2-7
2-7
4-8
4-5
3-1
3-1
2-7
3-3
3-9
2-5
2-3
31

2-2

10-0
6-4
3-3

56
13-3
91
1-3
6-4
5-0

Total

215

10-2

3-2

5-6

STATISTICS.

647

Table XL. — Admissions and Deaths, with Per-centage, from Delirium
Tremens, in the European General Hospital at Bombay, for the Five Years
from 1849 to 1853.

1849 to 1853.

Monthly Average.

Deaths on
Admissions.

Admissions

Deaths on

Admissions.

Deaths.

on total
Admissions.

total
Deaths.

January

2-4

February-

—

2-2

— •

March .

—

5-2

—

April .

22-8

4-2

•0

May .

4-3

4-4

4-2

June .

3-4

July .

5-8

3-2

3-0

August

13-3

3-0

5-3

September

— •

—

3-9

—

October

20-0

17-4

November

4-2

4-6

3-3 .

December

3-1

5-2

2-5

Total

238

6-7

4-1

4-5

T T 4

048 CEKEBIUL DISEASE.

CHAP. XXVIII.

ON CEREBRAL DISEASE AND PARALYSIS.

Section I. — General Preliminary Remarks on tlie Pathology
and Treatment of Cerebral Disease,

The situation of the brain and spinal cord and the nature of their
physiological actions prevent our ascertaining the morbid states of
these organs by physical signs. It is therefore on derangement of
function that we are mainly dependent for a knowledge of their
diseases ; and the investigation is materially assisted by the variety
of the actions in which these nervous centres are engaged, and
by the distinctness of the phenomena which attend them. In
order to facilitate this inquiry it may be well to state in general
terms, the kind of symptoms which indicate deranged function,
and then attempt to relate them to conditions of the nervous
matter. In following this course, I shall, with the view of sim-
plifying the subject, confine my observations to the brain.

It may be sufficient for clinical purposes, to divide the symptoms
of cerebral disease into (a) Those which indicate excess of action.
(U) Those which indicate defect of action. Under the first, may
be ranged active delirium, convulsion, pain of head, and of peri-
phery of nerves, intolerance of light and of sound. Under the
second, may be included muttering delirium, drowsiness, coma,
irregular spasmodic action, paralysis, anaesthesia, blindness, and
deafness.

When death takes place from cerebral disease, it is usually pre-
ceded by the passage of the first class of phenomena into the
second. When we investigate the pathological states of the brain
— that is, the proximate causes — in these two classes of symptoms,
our practical knowledge is advanced, by simply remembering that
they are generally related to different conditions of the capilla,ry
circulation, as respects the quantity and quality of the blood, and
its rate of movement through the vessels.

PEELIMINAKY REMARKS. 649

In the first set of symptoms, there is probably always either that
active state of capillary circulation termed determination of blood,
present also in the early stage of inflammation ; or the quality of
the blood is altered by the introduction of some external agent
of which alcohol may be taken as a type.

In the second set there is probably a state of capillary circula-
tion, in which the blood moves imperfectly, in which, therefore,
the processes between the blood and the nervous tissue are inade-
quately carried on, — as obtains in passive congestion, in the stasis-
stage of inflammation, in anaemia, also when the cerebral substance
is partially unfit for function from organic lesion, haemorrhage,
laceration, exudation and degeneration of lymph, &c. Or the im-
perfect action between the blood and nervous tissue may depend
on the quality of the former being altered by foreign agents, as
narcotic poisons, or the materies of cachexise. This class of sym-
ptoms also often co-exists with evident pressure on the cerebral
mass, as from depressed fracture, considerable effusion of blood, or
other fluids. Without denying that the nervous matter itself may,
in some manner or other, be affected by these mechanical influences,
still I would suggest that the primary effect of pressure is exer-
cised on the capillary vessels, obstructing the passage of the
blood through them, and therefore impairing the functions of the
brain from deficiency of the processes between the blood and
tissue, just as obtains in passive congestion and anaemia.

This reference to the general pathology of the brain would be
incomplete without an allusion to the influence of concussion, as
evincing my belief that a condition distinct from that of disordered
capillary circulation, or changed states of the blood, may be opera-
tive in some of the deranged actions of the brain. But it is not
my intention to enter into the discussion of this question.

Assuming that these general pathological doctrines are correct —
what is their bearing on principles of treatment ?

1. If it be true that the first class of symptoms — those of excess
of cerebral action — tend to pass into the second, and then to end
in death, it is very evident that the prompt recognition and treat-
ment of these symptoms must be very important. Setting aside
for the present toxoemic cases, they are caused by active determi-
nation, or commencing inflammation, and are to be controlled by
the appropriate use of blood-letting, cold to the head, tartar emetic,
and purgatives.

2. In the treatment of the second class of symptoms much dis-
crimination is requisite. When they depend on general cerebral

650 CEREBRAL DISEASE.

congestion — apoplexy — blood-letting, and purgatives are often use-
ful. When they depend on destruction of structure from extra-
vasated blood or the results of inflammation, on anaemia, or
cachexia, remedies which reduce the action of the heart and
lessen the quantity of blood are no longer applicable, because these
conditions of cerebral disease are always characterised by failing
action of the heart, and require the use of tonics and stimulants.

The treatment of narcotic poisoning is a consideration apart
from my present inquiry.

The remarks in this chapter are classed under the heads : —
1. Apoplexy; 2. Meningitis; 3. Acute Hydrocephalus; 4. Chronic
Hydrocephalus; 5. Morbid growths within the cranium ; 6. Hemi-
plegia; 7. Facial Palsy; 8. Paraplegia; 9. Paralysis from arsenic.

Section II. — Apoplexy. — Meningitis. — Acute and Chronic
Hydrocephalus. — Morbid Growths within the Cranium. —
Paroxysmal Headache.

In pathology, the term cerebral apoplexy is only correctly
applied to sudden coma, caused by general cerebral congestion,
with or without serous effusion or haemorrhage. But in hospital
returns, it is sometimes us^d to designate sudden coma, caused
by general cerebral determination, with or without serous effusion,
excited by elevated temperature or alcoholic excess. In this looser
acceptation, the term must be understood in the following statis-
tical remarks.

The admissions from apoplexy, into the European Greneral Hos-
pital during the fifteen years, from 1838 to 1853, amounted to
twenty-nine, and of these twenty-five proved fatal. The subjects
of these attacks were chiefly seamen, or others who had been
leading lives of dissipation and exposure to the sun, and who
had been brought to hospital some hours after the access of the
attack. These circumstances explain the great mortality.

Of the 311 fatal cases of European officers so frequently alluded
to, eighteen deaths took place from sudden coma, viz., seven from
true apoplexy ; nine from elevated temperature, and two from
alcohol. It has already been shown (p. 76) that of ninety fatal
cases of remittent fever, thirty-three took place with coma, preceded
by delirium or convulsion. A scrutiny of all these cases, both
febrile and idiopathic, would doubtless show a relation between
this train of symptoms and imprudence of one kind or other.
Thus, it appears that of the European officers who have died in

APOPLEXY.

651

the Bombay Presidency, from 1830 to 1850, death has been
caused in one sixth by forms of cerebral disease, towards the pre-
vention of which ordinary prudence and cai*e exercise an undoubted
and considerable influence.

The admissions from apoplexy into the Jamsetjee Jejeebhoy
Hospital during the six years from 1848 to 1853 amounted to
forty-five, and the deaths to forty-three.

In the following table the admissions in different months in
both hospitals are shown.

European General Hospital.

Jamsetjee Jejeebhoy Hospital.

Admissions.

Deaths.

Admissions.

Deaths.

January .
February .
March . .

1
3

4
1
5

5
1

April . .
May . .
June . .

1
9
5

1
9
4

4
4

July ....

August . .
September .
October

1
2

1
1
2

3
2
6
3

3
2
5
3

November .

• 3

December .

Total .

Though it is w<

3ll to abstf

lin from d

rawing coi

iclusions on

the causes of apoplexy from numbers so limited as these, and
stated with so little pathological precision, yet we cannot fail to
notice the striking contrast in the months of seizure of Europeans
and natives. In the former, one-half of the attacks took place
in the hot months May and June ; whereas in the latter, the ad-
missions are pretty equally distributed throughout the year. The
inference from this fact is, that of the admissions into the European
Greneral Hospital a proportion was not true congestive apoplexy,
but sudden coma, related to elevated temperature, in other words,
sun-stroke.

With respect to the symptoms and pathology of true apoplexy,
I would refer the clinical student to Abercombie's classical work for
information equally applicable to India as to European countries.*

• * I would venture to counsel the graduates of the Indian colleges who are fixing
the foundations of medical science and of rational medical practice in a new and great
country, to study well the writings of this eminent physician, not only on account of
the numerous valuable facts with which they are enriched, but also on account of the

652 CEREBIIAL DISEASE.

I have nothing to add to the lucid descriptions and philosophic
deductions of this distinguished pathologist.

Meningitis. — Inflammation of the pia mater and arachnoid,
marked by opacity and thickening of these membranes, by deposits
of lymph, or by serous effusion containing flaky flocculi, existed
in cases 10, 11, 29, 30, 31, 133, 246 ; and the notes of others,
some caused by injuries of the head, might have been added.
On the whole, then, it would appear that this form of disease
has not very frequently come under my notice in hospital prac-
tice in India. In the present defective state of hospital medical
statistics, there are no records calculated to show whether men-
ingitis is of more frequent occurrence in hospitals in European
countries than it seems to be in India. Of the 311 fatal cases
of sick officers, meningitis was the reputed cause of death in
six.

Acute Hydrocephalus. — During the four years that I held
medical charge of the BycuUa Schools, the number of children was
about 235, and with exception of 25, their ages ranged from five
to fifteen, yet case 29 is the only one of cerebral inflammation
which came under my observation. During the succeeding eight
years, when the medical charge of these, schools had passed into
other hands, and during which there had been a considerable in-
crease in the number of children, the only case with symptoms of
acute hydrocephalus which has come to my knowledge, was one
which occurred to Mr. Carter, who has kindly favoured me with
the following statement of the symptoms and the morbid- appear-
ances found after death.

simplicity and accuracy of the diction, and the correct application of principles of
reasoning to medical science and observation. The " Pathological and Practical
Researches on the Diseases of the Abdomen," though meagre on several subjects of
great interest to the Indian practitioner, still contain very much that is valuable to
the student of medicine in all countries. The work more particularly alluded to here,
" Pathological and Practical Eesearches on the Diseases of the Brain and the Spinal
Cord," is not open to the same objection ; for, — if we except the microscopic discrimi-
nation of inflammatory from degenerative softening, a more precise knowledge of the
pathological changes in diseased cerebral arteries, speculations relative to the influ-
ence of cardiac and renal disease, and the correction by Dr. Burrows of Dr. Kellie's
faulty experiments relative to the cerebral circulation, — I am not aware of any
great addition to our knowledge of the pathology of the brain since Abercrombie
wrote.

The little allusion to diathetic conditions, and the activity of the treatment, are to
be in a great part attributed to the fact that the subjects were not hospital patients,'
but from classes of the community less influenced by diathetic states, and more likely
to be benefited by depletion. The hospital physician, in comparing his own results
with Abercrombi43's statements, should bear this fact in recollection.

HYDROCEPHALUS. 65S

247. Acute Hydrocephalus. — A boy, twelve years of age, after being under treat-
ment with febrile symptoms from the 8th to the 23rd August, 1848, complained
of pain increased by pressure at the margin of the right ribs. On the 26th he
had headache, became drowsy, and screamed occasionally. On the 27th and
28th there was more or less delirium ; there was drowsiness, slight strabismus, im-
paired vision, and a pulse ranging from 68 to 80, and a remission of febrile heat of
skin. During the 29th, 30th, and 31st, the drowsiness increased, the heat of skin
was more marked, the pulse became very frequent, and lost strength ; and he died
comatose on the 1st of September.

Inspection. — The arachnoid membrane over the hemispheres of the brain presented
rather an opaque appearance ; it had also, where investing the cerebellum, an opaque,
lymphy, almost puriform character, and was much thickened at the base of the brain.
The lateral ventricles were much distended with serum, and the cerebral substance in
contact with the ventricles was softened. The fourth ventricle was also much dis-
tended, and the membranes about it and around the spinal cord were opaque. The
peritoneal surface of the liver was opaque, and studded chiefly at its lower edges with
gTanular lymphy deposit.

Thus it would seem that in Bombay, during twelve years, in
a body of children, in number from 255 to 350, partly Indo-
British, partly descended from European parents, and the greater
number ranging in age from five to fifteen, only one case of un-
doubted strumous meningitis has been observed. How far this
result accords with, or differs from, that of similar circumstances in
other countries I am unable to judge.*

When my attention is turned to the other fields of practice, in
which I have been engaged, only one case of acute hydrocephalus
in a European child of about ten months old, of strumous parents,
who died in the Jamsetjee Jejeebhoy Hospital, comes to my recol-
lection. There was no examination after death.

* In regard to the eight years during which I did not hold medical charge of the
Byculla Schools, my statement must be looked upon as an accurate approximation to
the truth. A reference to the Returns and Registers of Disease in the Schools for
this period, does not show any fatal case referable to hydrocephalus. I have referred
to two of the medical officers who have been in medical charge during the period
adverted to. Dr. Leith, in reply, observes, " I am certain I did not see a case of acute
hydrocephalus in the Byculla Schools"; and Dr. Coles states, "I do not recoUect
any case of any description of hydrocephalus happening whilst I was in attendance
in the schools." Dr. Graham, who has also been in charge of the schools during this
period, has returned to England, and I have been unable to make a similar reference
to him.

The question of the comparative greater or less degree of prevalence of acute hydro-
cephalus in the children of these schools, is probably part of a more general question
of the degree of prevalence of the strumous diathesis. I do not know what might be
the result of the application of the test suggested by Mr. Phillips in his work on
Scrofula — viz., " Enlarged Cervical Glands discoverable by touch"; but I believe that
I am correct in saying that scrofulous disease of the joints, suppurating lymphatic or
tubercular mesenteric disease, is of infrequent occurrence. On the other hand, if the
history of these children be traced after they have grown up and left the schools, it
will be found that phthisis pulmonalis is a cause of death sufficiently common : I can
bring to my recollection several cases in proof of this.

654 CEREBI5AL DISEASE.

Chronic Hydrocephalus, I have seen only two cases, both patients
of Dr. Peet. In one the head was three times tapped : the parti-
culars of the case, which terminated fatally, have been reported by
Dr. Peet.*

Morbid Growths within the Cranium, — The following is the
only instance of this pathological state in my notes.

248. Amaurosis ofhoth eyes, headache, fatuity , convulsions, tumour in the brain, with
much softening of the cerebral substance. — Joshua Paterson, aged twenty-five, seaman
of the ship Bon Pascoa, was admitted into the European Greneral Hospital on the 25th
April, 1841, affected with complete amaurosis of both eyes, and complaining of pain
of the right side of the head, fixed at the temple and shooting in different directions.
He was somewhat reduced in flesh and strength. He stated that about fifteen months
before, he became affected with headache, and had continued subject to it ever since.
About seven months before admission the pain was confined to the left temple, and
was followed by amaurosis of the left eye. Whilst at sea, about two months since,
the pain affected the right side of the head, and the amaurosis of the right eye took
place about a fortnight before admission. He continued in hospital till the 2nd
December, 1842, (a period of nineteen months,) when he died. During the first month
or two there was more or less pain of head. Leeches, blisters, &c., were used. Diu'ing
the greater part of his residence in hospital, he was in a fatuous state, and made
little complaint. On two occasions he experienced comndsive fits, followed by sopor,
and twice extensive sloughing ulcers formed on the sacrum. Some days before his
death he lay in a drowsy state, with twitching movements of the fingers, and refused
all food.

Inspection eight hours after death. — Head. — The lower part of the anterior lobes
and the anterior part of the middle lobes of the brain adhered to the calvarium, and
were separated from it with difiiculty. The brain in these sites, but chiefly the an-
terior part of the middle lobe of the left side, was in a very pulpy state; in the latter
site there was imbedded a tumour, the size of a small walnut, partly schirrous and
partly tubercular in its character. The rest of the brain appeared to be normal.

Paroxysmal Headache. — There is a circumstance relating to
the symptomatology of cerebral disease, to which my attention
was directed at a very early period of my service in India, and to
which a brief allusion may be useful. Cases of paroxysmal
headache related to malarious influence, mercurial or syphilitic
cachexia, came under my observation from time to time ; f but
others in which organic cerebral disease was apprehended were
also of occasional occurrence : of the latter I may instance three,
in which this suspicion proved ultimately correct. The first, an
officer seen by me on the Mahubuleshwur Hills, whose case is
quoted by Mr. Murray, in his first report en the climate of that
sanitarium! : this officer died of hypertrophy of the brain at Shola-
pore. The second, a much esteemed officer, who, after suffering

* "Transactions, Medical and Physical Society of Bombay," No. 7, p. 97.

t Such cases have certainly been of less frequent occurrence of late years, and this
I attribute to the greater caution observed in the use of mercury in the general treat-
ment of disease in India.

X " Transactions, Medical and Physical Society of Bombay," No. 1, p. 143.

PAROXYSMAL HEADACHE. 655

for a considerable time from attacks of acute periodic headache,
became subject to occasional convulsion, and ultimately died, also
of hypertrophy of the brain. The third, an officer of the royal
army, under my care at Mahnbuleshwur, subsequently died in
Dublin of cerebral disease, of the precise nature of which I have
not been informed.

In the year 1836, a communication on this question of diagnosis
was submitted by me to the Medical and Physical Society of Bom-
bay, in which I brought together the doubtful cases which had
occurred in my own practice ; and then quoted a series of instances
of cerebral disease characterised, with one exception, by paroxysmal
pain of head, extracted from the Fifth Volume of Andral's Clinique
Medical, and Abercrombie's work on Diseases of the Brain. The
diagnosis of functional from organic paroxysmal headache is
sometimes difficult, and depends on a careful consideration of the
history, and of the associated symptoms. The beneficial effect of
treatment directed under a belief in the functional character of the
headache is not always to be relied upon as a means of diagnosis :
in two of the three cases above adverted to — those of hypertrophy
of the brain — the headache was at times alleviated by the use of
antiperiodic remedies.

The cases of fatal cerebral disease characterised by paroxysmal
pain of head, reported by Andral and Abercrombie, submitted by
me to analysis, amount to thirty-four, and the conclusions which
were drawn from them may now be briefly stated. The following
were the lesions found after death : —

1, Softening of some part of the Lrain or cerebellum . . 9

2, Tumours, chiefly encephaloid and scirrhous . . .13

3, Hypertrophy and induration of the whole cerebral mass . 3

4, Tubercles in different parts of the brain and cerebellum . 8

5, Patch of effused lymph on the arachnoid membrane . . 1

Total 34

1. Softening of some parts of the Brain or Cerebellum. — The
duration of these cases was generally very much under a year, dating
from the commencement of the illness. In one it was only ten
days, and in another twenty.

The pain was usually confined to a particular part of the head,
and in eight of the cases it existed on the side in which the lesion
was found after death. In all the pain was persistent, in some
obtuse, in others severe, but in all acuter paroxysms took place
from time to time. In one case there was no pain of head, but
pain of the extremities of the side opposite to that in which the

656 CEREBRAL DISEASE.

lesion was found after death : the pain was followed by spasmod
twitching and paralysis. In one case there was pain of head at the
site of lesion, and also pain of the neck and of the upper extremity
of the opposite side, which gradually ended in paralysis.

After the pain of head had persisted for some days a sense of
diminished power of the extremities of the opposite side began to
be experienced. This generally commenced in the upper extre-
mity, then extended to the lower, and ended in complete paralysis.
Sometimes the diminution of power was preceded by spasmodic
twitching, or permanent contraction, of some of the joints ; and in
these cases the spasms were preceded by paroxysmal pain of the
extremities. In none of the cases under notice did spasm precede
the paralysis, without itself having been preceded by paroxysmal
pain of the affected parts.

After paralysis had existed for some time, spasmodic contractions
again recurred in some cases, but in these there was reason for
believing that there had been aggression of fresh inflammatory
action.

It was usually observed in these cases that with the gradual
access of the paralysis there was remission of the pain of the head.

In these nine cases the fatal result took place in the following
manner : —

By sudden apoplexy from cerebral hsemorrliage .... 2

By gradual exhaustion ......... 1

By pneumonia 1

By gradual coma 2

By conyulsion . 1

By access of general inflammation of brain and membranes . . 2

Total 9

From this statement it would appear that there is not much
likelihood of mistaking pain of head symptomatic of inflamma-
tory softening of the brain for functional headache. When the
pain — obtuse or severe — is confined to a particular part of the
head, is permanent but liable to occasional acute paroxysms, there
are grounds for apprehension. When, after the persistence of such
headache for some days, there is sense of tingling or pain, spas-
modic twitching or awkwardness in using the arm of the opposite
side, the existence of serious cerebral disease becomes almost cer-
tain, unless the individual affected is evidently the subject of
malarious cachexia. I make this latter reservation, because I have
witnessed at least one very striking case, in which recurrences of
intermittent fever with occasional periodic headache were followed

PAROXYSMAL HEADACHE. 657

by spasmodic twitcliing of one of the arms and of the muscles of
the face. In this case, in consequence of the history, the periodic
character of the headache, the cachectic state of the patient, and
the choreic character of the muscular action, the affection was
attributed to malaria and not to cerebral disease. This patient
quite regained his health after return to England.*

In the relation just stated between inflammatory softening of the
brain and pain of head, it will be understood that my observa-
tions apply to a certain series of cases ; for it must be well known
that softening of the brain often runs its course without pain of
head, and is then indicated by the kind of symptoms which have
been here described as having taken place in successian to
headache.

2. Tumours in the hvain. — In the thirteen cases classed under
this head the duration of the disease was considerable. In seven
it extended to two or three years, in one to ten, and in another
to fifteen. The ages of the individuals affected with encephaloid
degeneration ranged from thirty to sixty years. The pain in
these cases was more decidedly intermittent than in those of soft-
ening ; but it generally became permanent towards the close of
the affection. When paralysis of the opposite extremities was
present, it generally occurred in the advanced stages, and after the
headache had existed for a length of time. The manner of termi-
nation was, in several, by the aggression of varying degrees of
inflammation of the membranes or substance of the brain.

3. General hypertrophy of the brain. — The three subjects of
this lesion were iinder thirty years of age, and the duration of
illness, dating from the commencement of cerebral symptoms to

^ I have, since this passage was written, seen another case in which the diagnosis
was still more doubtful, because there was no influence of malaria to explain it. An
officer of about twenty-one years of age, of good constitution, with whom I had
travelled to India in July and August of 1856, not long after his arrival accompanied
the force to the Persian Gulf, whence he returned about May 1857, after suffering
from headache and pain of limbs, looked upon as rheumatic. I saw him at Poona in
June, when he was affected with irregular spasmodic movements somewhat choreic in
character. They commenced in the right side, became less there and passed to the
left side, but subsequently became general, and were sometimes to such a degree as to
seem to threaten an attack of general convulsion. The articulation was imperfect, and
there was slight facial twitching. The pulse was of good strength, the face flushed,
and no notable periodicity of the symptoms. I apprehended organic lesion probably
of the cerebellum. He was leeched, and an attempt made to affect the system with
mercury without success. There was no marked effect from the treatment, but after
upwards of a month he began gradually to improve, and the irregular movements had
ceased before the middle of September. He subsequently came to England, and has
quite recovered his health. I saw him last in July 1860.

U U

658 PARALYSIS.

the period of death, was respectively fifteen, twelve, and ten years.
In all, paroxysmal headache had been present for some years ; it
did not, however, present the fixed and limited character of that
usually related to other lesions, but extended over the whole head.
In one case there was complication of epilepsy from the commence-
ment, and in the other two convulsion towards the close. The
headache related to hypertrophy of the brain was frequently
attended with irritability of stomach.

4. Tubercles in different parts of the brain and cerebellum, —
The eight subjects of this morbid state were under thirty years of
age, and tubercles were generally found present in other organs.
In one death took place from pulmonary phthisis. The symptoms
which attended the development and progress of tubercles in the
brain in these cases were very similar to those already stated in
regard to the formation of tumours.

Section III. — Paralysis. — Hemiplegia, — Myelitis. — Para-
plegia.— Paralysis from Arsenic. — Facial Palsy.

The admissions from paralysis into the Jamsetjee Jejeebhoy
Hospital, during the six years from 1848 to 1853, amounted to
288, and the deaths to forty-two. They exhibit a mortality of 14*6
per cent., and a ratio of 0*01 per cent, of the total hospital ad-
missions, and 1*02 per cent, of the total hospital deaths. The
admissions are pretty equally divided throughout the year.

In my brief remarks on this class of disease, I shall allude to —
1. Hemiplegia; 2. Paraplegia; 3. Paralysis from arsenic; and
4. Facial Palsy.

Hemiplegia.— Of the 288 cases of paralysis, by far the greater
number have been hemiplegia. I regret, however, that my notes
do not supply data for determining with precision the proportion
of hemiplegia to the other forms of paralysis. The diaries of forty-
seven cases of hemiplegia treated in the clinical ward are before
me, and the few practical observations about to be offered have
reference to these cases, and are, arranged under the heads —
1. Causes; 2. Pathology; 3. Symptoms; 4. Treatment.

Causes. — The ages of the forty-seven c^

20 to 30 years
31 „ 40 „
41 „ 50 „
51 „ 60 „

Upwards of 60 years

inical patients were :-

13
6
5
1

HEMIPLEGIA — dAUSES. 659

In this statement, we find that three-fourths of the affected with
hemiplegia were below the age of forty. Whether a result so dif-
ferent from that which is usually asserted of the relation of age to
this disease is sufficiently explained by the fluctuating character of
the population of Bombay, and the probable abnormal proportion
of individuals in the prime of life ; or whether the influence of
advancing years is less operative in causing hemiplegia in the
natives of India than of Europeaji countries, is a question which,
for the present, must be left sub judice.

The caste of these clinical patients is stated in respect to forty-
five ; viz : —

Hindoos . . . . , , .19

Mussulmans . . , , . .12

Parsees . . . . . . .10

Native Christians . . . . .4

In the chapter on Pericarditis and Endocarditis it is shown (p.
565) that the proportion of Parsees to the total hospital inmates is
only about one-twelfth ; but this statement makes the proportion of
Parsees affected with hemiplegia only a little less than one-fourth.
Though, from arrangements connected with my clinical ward, the
proportion of Parsees affected with hemiplegia to the other castes
is here represented in excess, still, from hospital experience and
from cases seen in consultation with the College Graduates, I
entertain the belief that Parsees are more subject to hemiplegia
than the other native classes in Bombay.

The record of the habits of these clinical patients has not been
sufficiently attended to. Seven are mentioned as addicted to the
use of spirits, opium, or bhang.

Of late years it has been maintained by pathologists, that struc-
tural disease of the heart, and Bright's disease of the kidney, play
an important part in the causation of hemiplegia as well as in that
of other forms of cerebral disease. The condition of the heart,
judged of by physical signs, is distinctly noticed in thirty-three of
these cases, and in thirty of them the organ was considered healthy.*
In Chap. XXV., twenty-eight cases of heart-disease are treated
of, and cerebral affection was absent in all. In twenty- five of the
forty-seven clinical cases of hemiplegia, the condition of the urine
was carefully observed, and in none did it present traces of albu-
men. It has been already shown in Chap. XIX., p. 481, that

* The remaining three cases are narrated in this chapter, 251, 254, 255. If my
results were arrived at from fatal cases alone they would conform more nearly to those
usually stated; but on a question open to clinical as well as to post mortem observation
is it not an error to generalise exclusively from the records of the dissecting room ?

U u 2

660 TARALYSIP.

my cases of Briglit's disease do not tend to confirm the etiological
relation usually supposed to exist between affections of the brain
and albuminuria.

On these results it may be remarked that they at least suffice to
justify a suspicion that it will ultimately be proved that patholo-
gists have, on these questions, indulged in a premature and hasty
generalisation. The investigations of others have doubtless shown
that a coincidence of the diseases is not uncommon ; but that the
relation is one of cause and effect, is, I would submit, as yet
problematical.

Pathology. — As hemiplegia depends upon a deranged condition
of a limited portion of the nervous matter of the brain, it may be
assumed that the derangement is generally of a kind which involves
structural lesion. The destruction of tissue may be caused by
laceration, by a blood-clot, by inflammation ending in softening or
abscess, or by degeneration from mal-nutrition conseque'jt on
deficient blood-supply from mechanical arterial obstruction or from
a general cachectic state. Twenty-nine of my clinical cases were
considered to be dependent on cerebral haemorrhage, fourteen
on structural lesion from inflammation, and one on degenerative
softening. The diagnosis of the hsemorrhagic cases chiefly rested
on the suddenness of the seizure, the absence of headache, febrile
disturbance, soreness of the affected side, and contraction of the
joints; that of the inflammatory cases, on the presence of more or
less of these symptoms, preceded sometimes by pain of head and
febrile excitement. The single case of degenerative softening was
proved by inspection after death (255).*

Of the cases about to be narrated, six f illustrate inflammatory
softening; and one (255) degenerative softening. Case 256 shows
well the obscurity with which abscess in the brain may form,
and case 94 also illustrates this truth. Of the nine cases just
referred to, the lesion in four was in a corpus striatum, and in the
others was situated elsewhere in a hemisphere. In the eight in
which hemiplegia had been present, the lesion was, it need hardly
be observed, on the side of the brain opposite to the paralysed
extremities. In case 257, not examined after death, there was
hemiplegia of the right side, caused as was supposed by haemor-
rhage ; but the occurrence of gangrene of the left leg, from obstruc-
tion of the femoral artery, afterwards suggested the suspicion that

* The reader will bear in mind that Glnge and Bennett have lately pointed out
that the distinction of inflammatory from degenerative softening, may be facilitated
by the detection with the microscope of exudation corpuscles in the former.

t Cases 249 to 254.

IIEMIPLEGIl — PATHOLOGY. 66 1

the paralysis might have been produced by obstruction of a
cerebral arterial branch by a blood-clot or fibrinous coagulum. In
case 258" there had been hemiplegia of the left side for four years,
followed by transient palsy of the muscles, ruled by the portio dura,
on the right side ; so that the case formed no exception to the
almost universal, but not well-explained, fact, that in hemiplegia,
the portio dura of the affected side remains intact.

249. Hemiplegia of the right side. — Softening of the left corpus striatum. — Crushna
Govind, a Hindoo cart driver, of thirty years of age, after twelve days' illness, was
admitted into the clinical ward, on the 24th September, 1849, There was paralysis
of the right side, face included, indistinct articulation, and deviation of the tongue to
the affected side. The right elbow and wrist were permanently flexed. There was
no ansesthesia. The right side of the chest moved less than the left on inspiration.
He was leeched on the temples, a small blister applied, and diuretics and laxatives
exhibited. He was comatose on the 2nd October, and died on the 3rd.

Inspection nine hours after death. — Head. — There was some degree of turgesccnce
of the vessels of the dura mater ; and those of the pia mater were very turgid with
blood even to their minute ramifications. The cortical substance of the brain was of
darker colour than natural ; and the white substance, when incised, presented
numerous bleeding points. There was dark-red softening in the centre of the anterior
and the posterior parts of the left coi-pus striatum. The posterior softened portion
was the size of a small bean : the anterior was considerably larger. There was no
increased serous eiFusion in the ventricles, nor at the base of the skull. The cortical
substance of the cerebellum was also darker than natural, and the white substance
presented numerous bleeding points on incision. No coagulum of effused blood, old or
recent, could be detected in any part of the brain. The kidneys were healthy,

250. Apoplexy. — Hemiplegia of the right side. — Death. — General congestion of the
membranes of the brain. — Eed softening of the left corpus striatum. — Munchee, a
Portuguese sailor, of foi-ty-four years of age, was brought to hospital on the 11th
December, 1848. He was in a comatose state. The pupils were contracted. There
was paralysis of the right side, with tremors of the left leg and arm. After excesses-
in drinking, he had been found on board ship in this condition, two days before he
was brought to hospital. He died on the 12th.

Inspection twenty hours after death. — Head. — On separating the skull-cap from
the diu'a mater, dark-coloured blood oozed in small quantity from the vessels. The
glandulse Pacchioni were more developed in parts, and caused a firmer than natural
adhesion between the surfaces of the arachnoid, where it dips between the hemispheres
to line the falx. The vessels of the pia mater were congested, and a thin veil of
serum was here and there effused between the arachnoid and pia mater on the convex
surface of the brain. The anterior part of tlie left corpus striatum was, compared to
that of the other side, considerably softened, pulpy, and of dark -red colour, but there
was no trace of distinct extravasation of blood. The substance of the brain and cere-
bellum did not present any other appearance worthy of note. The vessels at the base
were healthy. There was no increased effusion of serum in the ventricles. Slight
dotted vascularity of the mucous membrane of the stomach existed. The liver and
the kidneys appeared healthy.

251. Hemiplegia of the right side. — Softening of the left corpus striatum. — Disease
of the mitred valve. — Mahomed- Avad, a Mussulman beggar, of thirty years of age, was
brought to hospital by a police peon. He was paralytic of the right side, and very
drowsy. He died a few hours after admission.

Inspection. — The upper portion of the left corpus striatum was reduced to a creamy

u u 3

6f)2 PARALYSIS.

consistence, and was of darker colour,. The ventricles of the heart were dilated. The
mitral valve was thickened, and on its surface near the attachment of the chordae
tendineoe, there were two or three indurated granular bodies.

252. 8(/mptonis of injlammation of the hrain, followed hy hemi'plegia of the right
side, and death hy coma. — lied softening of the left corpus striatum found after death.

— Pandoo-Souza, a' washerman, of twenty-five years of age, a native of Goa, was
brought to the Jarasetjee Jejeebhoy Hospital, on the 30th September, 1830, in a state
of coma. His friends stated that he had been ill fourteen days with fever attended
with headache — that eight days before admission the extremities of the right side
had become paralysed. The coma had existed for three days. The pulse was small
and slow. He died on the 4th October.

Inspection made hy Mr. Leshoa. — Head. — An ounce of serum oozed out on sepa-
rating the calvarium, and an ounce and a half were found at the base of the skull.
The vessels of the pia mater were turgid, and a small point of the superior surface of
the left hemisphere at its middle part, and near to the longitudinal fissure, was opaque
from slight lymph effusion into the sub-arachnoid tissue, and a similar spot was ob-
served in the left Sylvian fissure at its commencement. Numerous bloody points
appeared on incising the brain. The left corpus striatum when cut into was found
darker than the right, and broke down readily into a soft pulpy substance on pressure.
There was no surrounding redness. The texture of the right corpus striatum and.
thalamus was healthy. The other cavities of the body were not examined.

253. Hemiplegia of the right side. — Meningitis and softening of the anterior and
middle lohes of the left cerehral hemisphere. — The premonitory sym,ptoms well marJced.

— An officer, of forty-two years of age, of corpulent and pletlioric habit, after twenty-
five years' residence in India, became, in April 1834, suddenly aifected with giddiness,
general but not severe pain of head, tingling sensation in the ring and little finger of
the right hand, and subsequently slight impairment of articulation. The senses were
undisturbed. He was actively treated and resumed his duties, which were frequently
of a harassing description. During one or two months subsequent to the above
attack, there was occasional numbness and tingling of the fingers of the right hand,
also at times a dragging of the right leg, and a constant and irresistible inclination to
sleep after dinner. In the course of the following monsoon all these symptoms were
removed, with the exception of the strong inclination to sleep. On returning to Bom-
bay in the ensuing cold season, from the Deccan, where the events above detailed had
occurred, the somnolency was still experienced, and there was frequent pain over the
left temple, with giddiness and feeling of numbness of the right arm. The somnolency
he attributed to increasing corpulence, the headache and other symptoms to bilioiisness,
aggravated by the harassing duties of his office ; and by the action of a smart purga-
tive, they were in general temporarily removed. This officer arrived on the Maliubu-
leshwur Hills, on the 4th May, 1835, to appearance in robust health. After having
felt an increase of headache and giddiness for two days, he was seized in the morning
of the 12th with hemiplegia of the right side and loss of speech without suspension
of consciousness. He continued without any improvement, and died on the 14t]i,
after having been comatose for only two hours.

Inspection. — Head. — There was much vascularity of the pia mater, with here and
there turbid Ijrniph effiised under the arachnoid. The substance of the brain, on being
sliced, showed a surface crowded with bloody points, A large portion of the central
part of the anterior and middle lobes of the left hemisphere was very markedly
softened and reduced to a pultaceous mass. There was no effusion into the ventricles.
The heart was healthy, but commencing deposit existed at the beginning of the aorta,

BemarJc. — I am indebted to Mr, Murray for the notes of this case, and the oppor-
tunity of witnessing the examination after death,

254. Incomplete paralysis of left side. — Improvement. — Disease of heart and valves.
■^ Death hastened hy diarrh(Ba. — Puriform softcnivg of part of anterior lohe of right

IIEMirLEGIA — rATirOLOGY. 663

cerebral hemisphere. — Bhao, a Hindoo liquor-seller, of thirty-five years of age, habit-
ually using spirits in moderate quantity, while evacuating the bowels at midnight,
suddenly fell down insensible. On becoming conscious he found the left extremities
deficient in power, and on the following day his speech was indistinct and he was
affected with headache. Four days afterwards he was admitted into the clinical ward,
on the 13th October, 1851. There was incomplete paralysis of the extremities and
face of the left side and indistinct articulation. He complained of pain of the right
temple, and suffered from febrile accessions coming on with chills at midnight. The
prsecordial dulness extending from the third intercostal space was continuous with the
hepatic dulness, and was bounded externally by a vertical line dropped from the left
nipple. There was a systolic murmur at base and apex, but of different tones, also
a slight diastolic murmur, most distinct at the apex. The systolic murmur was loudest
and roughest at the third right costal cartilage and continued so to the top of the
sternum. The pulse was of moderate volume and distinctly jerking in character. The
urine was frequently tested and gave no trace of albumen. The bowels tended
to be relaxed. He was treated with small blisters to the nucha and diuretics, and on
the 5 th November the paralysis of the limbs was reported to be removed, but that of
the face still to continue. The diarrhoea increased, became dysenteric in character ;
he lost strength, and on the morning of the 22nd November hs was found comatose
with dilated pupils, stertorous breathing, cold and clammy and imperceptible pulse,
and died an hour afterwards.

Inspection seven hours after death. — Brain. — There was increased vascularity of
the membranes of the brain, and on the com^ex surface considerable increased effusion
of serum into the sub-arachnoid space. There was slight opacity here and there of the
arachnoid, and firmer adhesion than usual between the surfaces at the dipping down
of the falx. There was about an ounce of serum at the base of the skull. At the anterior
part of the right anterior lobe of the brain there was a portion near the under sur-
face about the size of a pigeon's egg, soft, pulpy, and yellow, and in parts consisting
almost entirely of pus. There was no cyst and no traces of inflammation of the pia
mater or of the arachnoid in the neighbourhood of the abscess. Chest. — The heart
reached from the second to the seventh rib, and transversely almost to the junction of
the right costal cartilages with the ribs. About an ounce and a half of clear serum
was found in the pericardium. On the external surface of the heart there were three
or four opaque patches of organised lymph. The right auricle and ventricle were
distended with blood. The left ventricle contained a considerable quantity of dark
coagulated blood, was dilated, and its walls were somewhat thicker than natural. The
mitral valve was considerably thickened from firm warty -looking deposit, and there
was similar deposit on the chordae tendinese, which were rendered more friable. The
aortic valves were also thickened at their edges and the diameter of the aortic opening
increased. The right ventricle was also somewhat dilated. The tricuspid valves and
those of the pulmonary artery were healthy. The ascending aorta was considerably
dilated, and its inner surface and that of the arch was irregular and very rough from
firm organised deposit, which had become ossific just above the aortic orifice. The
coats of the aorta much thickened. The lungs were spongy and crepitating. Abdo-
7nen. — There was no morbid appearance of the mucous membrane of the intestines.
The liver was healthy. There was a little encroachment on the tubular portion of the
left kidney. The right kidney was healthy.

Eemark. — The examination after death confirmed the diagnosis of the heart disease,
as noted on admission, viz., " hypertrophy with dilatation of left ventricle, disease of
the mitral and aortic valves, the latter permitting regurgitation, dilatation of the aorta,
and roughing of its inner surface."

255. Hemiplegia of the left side. — White softening in the right cerebral hemisphere.
■ — Nickus, aged sixty, a beggar, an infirm old man, paralytic, and frequently in hos-
pital, was admitted on the 1st August, 1852, in a state of debility. On the 25th there

u u 4 *

661 TARALYSIS.

were couvulsh-e movcmonts of the left side, except the face, which was calm. Both
feet were flexed, pxipils unaffected, skin above natural temperature ; pulse rrither
freqiient : was perfectly sensible, but spoke with difficulty, and could not protrude the
tongue beyond the lips. He said that he felt pain in the head and nape of the neck,
chiefly the latter. On the 27th there was continuance of the symptoms, witli, how-
ever, towards evening, the convulsive movements affecting both sides. On the 28th
the convulsive movements were confined to the left side. He contimied to sink, and
died on the 4th September.

Inspection by Mr. Leshoa, fifteen hours after death. — Head. — There were about
seven ounces of turbid fluid at the base of the skull. In the substance of the posterior
lobe of the right hemisphere, immediately behind, and to the outer side of the pos-
terior cornu of the right ventricle, there was softening to the extent which would be
occupied by a pigeon's egg. The softened substance was very pulj^y, and of yellowish
white eoloiu'. The surrounding parts of the brain were healthy. The right lateral
ventricle was considerably enlarged, but there was no unusual quantity of fluid in it
or in the left. The arachnoid membrane, covering the cerebellum, was somewhat
thickened and opaque in some points, chiefly around and over the vermiform process.
No other morbid change in the brain was detected. Chest. — The lungs were healthy.
The aortic semi-lunar valves were thickened at their attached margins by some hard
deposits. In other respects the heart was healthy. The liver was smaller than natural;
the fibrous capsule was thickened, and the surface irregular and lobulated ; the sub-
stance was firm and indurated, and when cut into presented a distinct nodulated ap-
pearance. The nodules about the size of a small pea, with bands and streaks of white
fibrous tissue crossing between.

256. Abscess m the left hemisphere of the brain ; for some time general febrile
symptoms. — Hemiplegia of the right side some days before death. — Jeremiah Merit, an
African, aged twenty-four, after a month's illness was admitted into the European
General Hospital, on the 2nd September, 1842. He suffered from a mild attack of
dysentery, and was discharged well on the 9th October. Re-admitted on the 19th
October ill with quotidian fever, associated with pain of the left hj^pochondriura : he
was discharged well on the 1st November. Re-admitted on the 24th November, suf-
fering from irregular febrile accessions, but to no great extent : he made no complaint
of local uneasiness, and the suspicion was entertained that he was disposed to make
more of his ailments than their apparent importance justified. On the 20th December
his bowels were relaxed, and he complained of cramps of the limbs. On the 21st the
right arm and leg were weak. On the 22nd there was complete hemiplegia of that
side, with occasional twitching of the arm. There was heat of skin, and he was
manifestly losing flesh and strength ; no headache complained of. He continued in
this state, with generally a febrile accession towards evening. He died on the 28th.

Inspection seven hours after death. — Head. — There was considerable thickening
with an opaque state of the arachnoid membrane of the upper surface of the brain,
with yellow points here and there. In the left hemisphere of the brain, above the
lateral ventricle, there was an abscess, the size of a large walnut, filled with pus, and
surrounded by a pulpy state of the cerebral substance. The right side of the brain
was healthy. Chest. — Old adhesions of the lungs and pearly deposit on the surface
of the heart.

257. Apoplexy, followed by hemiplegia of the right side. — Gangrene of the left foot
and leg, apparently from obstruction of the femoral artery. — Kasoojee, a Hindoo, of
forty years of age, a native of Kattywar, but for many years resident in Bombay, fol-
lowing the occupation of sandal- wood seller, and temperate in his habits, was admitted
into the clinical ward on the 28th October, 1853. There was complete hemiplegia of
the right side, face included, attended with anaesthesia and absence of reflex action on
tickling the sole of the affected foot. He was drowsy and unable to speak, but seemed

HEMirLEGIA — SYMPTOMS. 6i)5

to apprehend what was said to him ; was unable to protrude his tongue. He was of
spare habit, but the pulse, was full. The sounds and impulse of the heart were normal.
It was reported that, three days before admission, he had been much exposed to the
sun, making preparations for an entertainment ; and that subsequently, after haA*ing
been for some time in a stooping posture serving his guests, he assumed the erect
position, then fell down suddenly in a state of complete coma, with stertorous breath-
ing, but without convulsion of any kind. After a time he vomited, recovered his con-
sciousness, but remained in the state present on admission. He continued in the hos-
pital till the 5th November, when he was removed by his friends. On the 30th there
was febrile heat of skin, and he began to complain of pain of the left leg ; and on
the 31st the pulse of the paralytic side was somewhat fuller than that of the left side.
On the 2nd November the upper part of the left leg was still painful, but the lower
part and the foot were cold and livid, somewhat swollen, and without sensation. No
signs of cardiac disease. No change in the paralytic symptoms of the right side. On
tlie 4th, absence of pulsation of the femoral artery at the left groin was noted. The
gangrene increased in degree, but not in extent. He suffered from epistaxis two or
three times, was restless, and at times wandering. The pulse lost strength and in-
creased in frequency, and in this state he was removed from hospital by his friends.
Treated with leeches to the head, a blister, and purgatives.

Bemarks. — The history and the symptoms seemed clearly to point to general cere-
bral congestion, with partial hsemorrhage, as the proximate cause of the attack. The
gangrene of the unparalysed foot and leg, apparently from obstruction of the femoral
artery, suggests the question, — whether the apoplectic and paralytic symptoms might
not also have been due to fibrinous coagula obstructing branches of the cerebral
arteries.

258. Hcmiflcgia of left side, persistent. — Facial palsy of the right side, consecutive
ayid transient. — Moorarjee, a Hindoo shopkeeper, of fifty years of age, was admitted
into the clinical ward on the 8th August, 1852. There was incomplete hemiplegia of
the ujDper and lower extremities of the left side ; but the portio dura of the right side
was also affected, as indicated by the open state of the right eye. The sounds and
impulse of the heart were normal. His statement was that the hemiplegia of the left
side had existed for four years, but that two days before admission, when cooking his
food, he suddenly fell, and that since then giddiness and the facial distortion had
been present. He remained under observation till the 15th September, using occa-
sional laxatives, diuretics, and small blisters to the nucha, and electro-galvanism to
the affected limbs. The urine, frequently tested, gave no trace of albumen. On dis-
charge he could close the right eye, and the distortion of face was almost gone ; but
the hemiplegia of the left side remained unchanged.

Symptoms. — The hemiplegia in these clinical cases has been
nearly equally divided between the two sides : there were twenty-
four of the right, and twenty-three of the left side. The face of
the same side was affected in thirty-six, articulation impaired in
twenty, and deviation of the tongue to the affected side, was usually
observed in the cases in which the face shared in the disease.
There was anaesthesia of the paralytic side in ten ; and in some it
disappeared under treatment, though no alleviation of the paralysis
had been effected.

There was a state of flexion more or less rigid of the elbow joint
of the affected side in seventeen cases ; sometimes accompanied with
a similar condition of the wrist or finger joints. This event gene-

666 PAKALYSIS.

rally occurred in cases which had been- considered inflammatory
from the commencement, or in which the after symptoms indicated
the probability of inflammation having affected the cerebral tissue
around a blood-clot.

Dr. Todd, in his clinical lectures on paralysis, has adverted to
great muscular rigidity, occurring both early and late. The first
related to inflammatory action. The second attributed to the
contraction of the cicatrices consequent on absorbed blood-clot
acting on the neighbouring healthy tissue, and keeping up a slow
and lingering irritation.

The presence or absence of reflex action in the affected limbs
was noted in some of the cases, but not with sufficient regularity
to merit notice here.

I have confined my remarks on hemiplegia to the desultory
suggestions, which my own observations have prompted, and have
made no attempt to enter upon a full consideration of this impor-
tant subject. The work of Abercrombie, abounding with interest-
ing facts and philosophic deductions, should be in the hands of
every clinical student of this branch of pathology.

Treatment — It is sufficiently easy to lay down abstract
principles of rational treatment for the different forms of hemi-
plegia. The difficulty is in the diagnosis, and consequently in
the application of the principles to particular instances. For
example, if the hemiplegia is due to recent cerebral haemorrhage,
and symptoms of general excess of blood in the cerebral capillaries
are present, it may be necessary to reduce this by general or topical
blood-letting, cold to the head, jjosition, and purgative medicines.
If, on the other hand, general cerebral congestion is absent, these
means are not required, and the removal of the clot, by absorption,
must be a work of time : in the management of such a case we musfc
be careful not to reduce the system too much, for this reparative
process is dependent on a certain vigour of the vital actions ; while,
at the same time, we must be watchful for the access of inflamma-
•tion of the surrounding cerebral tissue, in order that the appropriate
remedies may be used.

Should, however, the hemiplegia be attributable, not to haemor-
rhage, but to inflammation leading to lymph exudation and soften-
ing, then the remedies appropriate for this morbid action, in relation
to stage and constitutional state, must be had recourse to. It has
been usual — on a therapeutic principle generally acknowledged
and elsewhere fully explained — to give, in this state of cerebral
disease, mercury to the induction of its influence on the system : it

IIEMirLEGlA — TREATMENT. 667

lias generally been used in my clinical cases of this nature ; but
benefit consecutive on ptyalism has not occurred in a single instance
of paralysis under my care. I am unwilling to express with con-
fidence a dissuasive opinion on this point of practice, but I may
avow my belief that benefit from mercury in inflammatory hemi-
plegia is improbable, simply because the paralysis does not in all
likelihood occur till after degenerative softening of the lymph, and
of the tissue around, has already taken place. Eecovery from this
state can only be effected by absorption of the softened substance,
with subsequent cicatrisation and contraction : in processes of this
kind mercury is not even theoretically indicated ; for, to be use-
ful in inflammation of the brain, it should be given in those
early stages of the lymph-exudation which precede softening, and
in which, unfortunately, the symptoms are often obscure. I make
no reference to the use of mercury in the hsemorrhagic cases with
the view of favouring absorption of the clot, for I am not aware that
an idea so irrational has been entertained by any physician.*

Electro-galvanism and strychnine have been used in the ad-
vanced stages of many of my cases, but without results calculated
to inspire confidence in their efficacy.

It may, in conclusion, be assumed, that suspension of part
of the function of the brain consequent on destruction of struc-
titre is a state from which complete recovery can seldom be
looked for, that we should be satisfied with endeavouring to limit
and to stop the lesion, and then to favour its repair ; and should
always recollect that time, and judicious regimen — not medicines
— conduce most to this end.

I am very sensible that these observations on hemiplegia add
little or nothing to existing knowledge, and that there is much in
respect to this disease to which the medical inquirer in India may
turn his attention with interest and advantage, — as the relation of
hemiplegia to period of life, to heart and kidney-disease, to parti-
cular diathesis and habits, to h39morrhage, inflammatory and
degenerative softening, disease and obstruction of cerebral arte-
rial branches, to the frequency and import of reflex action and of
rigidity of the joints of the affected limbs, the existence of ana3s-
thesia, and the discrimination of the cerebral nerves which are
involved in the deranged processes.

Myelitis. — Idiopathic inflammation of the membranes or sub-

* I need hardly say that when symptoms indicate that inflammation is commencing
in the nervous matter around the clot, that mercury may be indicated; hut on a
principle quite distinct from that of absorption of the clot.

668 rAiiALYSis.

stance of the spiiifxl cord is a rare form of disease. I have notes
only of two cases. One a Hindoo, of thirty-five years of age, ad-
mitted on the 19th February, 1857, under Dr. Ballingall's care, —
with pain in the dorsal and lower cervical regions of the spine,
paralysis and ansesthesia of the lower extremities, heat of skin,
hurried and oppressed breathing, bronchitic rales and cough.
He had been ill four days, and attributed the attack to exposure
to cold at night in a boat. The paralysis had commenced in the
feet, and the evening after admission it had extended partially to
the right arm, with sense of formication in the left. There was
retention of urine. He continued with failing pulse, occasional
fever, no convulsion, till the 26th, when he died.

The upper part of the spinal cord, as far down as one fourth of
the dorsal portion, was healthy ; but from this to its termination it
was diffluent, mottled pink and yellowish in parts, and exhibited
under the microscope the exudation corpuscles of inflammation.
No trace of spinal meningitis.

The other case was under my own care. It occurred in a Persian
Parsee, who was admitted into hospital on the 14th December,
1856, ill, as it seemed, with gastric remittent fever. After six or
seven days he complained of pain about the sixth dorsal vertebra,
also of the chest and abdomen. The breathing was hurried ; then
succeeded paralysis of the upper and lower extremities, with im-
paired sensation, and a flexed state of the fingers. No retention
of urine. He continued thus till the 1st January, when an attack
of general convulsion, followed by coma, supervened. After re-
covery, there was more or less incoherence. On the 5th the con-
vulsion returned, and he died on the 6th. The catheter had not
been required. No inspection permitted.

Paraplegia. — Cases of paraplegia, consequent on injury of the
spine and caries of some of the vertebrae, have from time to time
come under my observation ; as well as paraplegia in females,
without cognizable spinal disease, and referable, in all probability,
to hysteria. I cite only the following case, in which there was
division of the left half of the spinal cord by a stabbed wound,
followed by paralysis and anaesthesia of the lower extremity of tlie
same side. This case is of interest in reference to the functions
of the cord, and to the opinions of M. Brown-Sequard, that divi-
sion of one segment of the cord causes paralysis of the side of sec-
tion, but loss of sensation on the opposite side not on that of the
section.

PARAPLEGIA. G69

259. Division of the left half of the spinal cord by a wound. — Paralysis and
anesthesia of the left lower extremity. — Joseph Gomez, aged forty-five, a painter,
was on the evening of the 2nd December, 1851, when sitting quietly in his house at
Mazagong, stabbed and wounded in three phices by a Malay seaman. The wounds
were about the level of the fifth and sixth dorsal vertebrse ; one was a foot in length,
and extended transversely across the middle of the back, reached to the muscles, and
partly divided some of them. A little above this and to the left of the backbone
there was a deep stabbed wound, about an inch in length, directed inwards towards
the spine ; its depth was not ascertained. There was a third small wound on the
back of the arm. When brought to the hospital shortly after the injury, there was
paralysis and anaesthesia of the left lower extremity. The ansesthesia extended down-
wards from the angle of the scapula. There was retention of urine, much diarrhoea
and involuntary discharge of faeces. He lingered in this state till the 12th December,
when he died.

Inspection. — The punctured wound had sliced off the left transverse process of the
fourth dorsal vertebra, and the point of the knife had penetrated the spinal canal and
divided transversely the left half of the cord, reaching almost to its median line.
Here there was no softening or lymph effusion. About two inches lower down, for
about the length of an inch, the cord seemed shrivelled, and to consist of little
else than the pia mater and vessels ; and below this it again became of natural
appearance.

Remark. — This case was the subject of inquiry before the coroner, and the above
are the notes from which my evidence was given. I am unable to understand the
shrivelled appearance of the cord below the injury. The difficulty occurred to me at
the time. There was therefore no apparent explanation, such as laceration of the
parts, in making the examination.

But paraplegia is of still further interest in India and other
tropical countries. Bontius, Lind, Clark, and Marshall have
described a form of it under the name " Barbiers." It is thus
defined by Copland : " Tremor with pricking, formicating pain ;
numbness of the extremities, principally of the lower, followed by
contractions and paralysis of the limbs ; inarticulation and hoarse-
ness of voice, emaciation, and sinking of all the vital powers."
This disease has been viewed as related to cachectic states, and ex-
posure to wet or cold, as predisposing and exciting causes. Bontius
confounded barbiers with beri-beri, and Marshall has accurately
pointed out the distinction of the two affections. But the affection
described under the former title, and answering to Copland's defi-
nition, has of late years been lost sight of. That paralysis, chiefly
paraplegic, related to cachectic diathesis and exposure to cold, and
independent of spinal structural disease, does occur in the natives
of India, is true : it is not common, but I have met with occasional
instances. The subject requires investigation; but no advantage
can result to science by retaining the name barbiers. It is suffi-
cient for the clinical inquirer in India to be aware that paraplegia,
related to cachexia, cold, and wet as causes, and independent of

670 PARALYSIS.

structural lesion of a nervous centre, is an occasional occurrence,
and that its pathology and etiology are imperfectly understood.*

Paralysis from Arsenic. — Paralysis caused by arsenic is not
merely a subject of interest, as a toxicological fact, but also from
its bearing on the general pathological question of the toxoemic
causation of some forms of disease of the nervous system.

The case which I now quote is a good illustration of this effect
from arsenic.

260. Paralysis from arsenical poisoning. — Pneumonia also present. — Cazee Ahmud,
a Mussulman, of seventeen years of age, was brought to the Jamsetjee Jejeebhoy
Hospital, on the 20th April, about noon. It was stated that having eaten of curds at
nine o'clock the previous night, he became affected two hours afterwards with vomit-
ing, which recurred several times during the night; also with purging. On admission
into hospital, the pulse was seventy-two, feeble ; the skin of natural temperature, the
respiration hurried, and rather thoracic, and the tongue somewhat florid at the tip.
There was no recurrence of vomiting after admission. The bowels, however, were
relaxed, but to no great extent, and on one occasion the evacuations consisted in
part of mucus. The tongue continued florid, and there was uneasiness at the epi-
gastrium. He was treated with leeches; and sinapisms to the epigastrium, and
effervescing draughts. He was discharged on the 30th April. He was re-admitted on
the 7th May. He had become considerably emaciated, and there was partial paralysis
of both upper and lower extremities. The hands dropped from the wrists, and the
fingers were bent somewhat backwards, and the hands were closed feebly and with
difficulty. He was able to bend the knee joints but imperfectly, and he lay stretched
with the feet extended, and the toes pointing downward. He was also affected with
cough, the breathing was somewhat short and hurried, and the left side of the chest,
both anteriorly and posteriorly, was dull on percussion, and the respiratory murmur
was inaudible. The pulse was 100, and feeble, the skin cool, the tongue whitish
in the centre, not florid at the edges, but there was tendency to diarrhoea, and the
evacuations were passed in bed. He stated that after his discharge from hospital on
the 30th April he attended several successive days at the police office. On the third

* In No. 12, of the " Indian Annals of Medical Science," published at Calcutta, July
1859, and received while these sheets are passing through the press, there is a very
interesting notice of this form of paralysis by Dr. J. Irving. It is stated that in
Pergunnah Barra, in the district of Allahabad, situated on the right bank of the
Jumna, 3'19 per cent, of the population are affected wdth this form of disease, and
that it is attributed by the people to habitual use of the kessaree dal {Lathyrxis
sativa) as an article of food, and to exposure to wet chiefly in the monsoon season
between July and October. The Pergunnah is described as swampy, and intersected
by numerous jheels and tanks. Males suffer more than females, and different villages
are affected in different proportions.

Dr. Irving further calls attention to notices of this form of paralysis, attributed
to kessaree by other observers, viz., by Dr. K. W. Kirk, in Upper Scinde, in his
" Topography of Upper Scinde ; " by Col. Sleeman, in the Saugor territories, in
" Eambles and EecoUections of an Indian Official; " and by Dr. Thomas Thompson in
Thibet, in his " Travels in the Himalayas." The subject is of great interest and
calls for further careful investigation. The native opinion on the influence of the
Lathyrus sativa is worthy of every attention, but it must be regarded as still suh
judice till submitted to logical and systematic inquiry.

STATISTICS.

671

day he had a febrile accession, attributed to having lain on the ground at the police
office. The accession came on in the evening, ceased the following morning, recurred
the subsequent night, continued three days without distinct intermission, and left
his legs in the state in which they were on re-admission. During his residence in
hospital he complained, at times, of pain of the arms and legs, and there was a good
deal of desquamation of the cuticle of the hands, and about the shoulders. The
pneumonia was treated successfully, with Dover's powder and quinine, and a blister
to the aifected side. He was discharged on the 4th September. The paralysis, though
less, still existed in considerable degree. He was unable to walk. The emaciation
was less, but still considerable. There had been no return of diarrhoea.

It appeared in evidence that the milkman had purchased arsenic, he said, at the
boy's request, for killing rats. The opinion of the judge was that the milkman's
story was true, and that the boy had taken the poison with suicidal intent. The
milkman was acquitted.

Facial Palsy. — Paralysis of the portio dura, first discriminated
by Sir Charles Bell and now well understood, occurs in India as in
other countries, presenting its usual characteristic phenomena, and
frequently traceable to exposure to cold. The cases which have
passed through the clinical ward during the six years do not, how-
ever, exceed three in number, and do not suggest anything worthy
of notice.

Section IV. — Statistics of Paralysis,

Table XLI. — Admissions and Deaths, with Per-centage, from Paralysis,
in the Jamsetjee Jejeehhoy Hospital, at Bombay, for the Six Years from
IMS to 1853..

1848 to 1853.

Monthly Average.

Admissions.

Deaths.

Deaths on
Admissions.

Admissions

on total
Admissions.

Deaths on
total Deaths.

January

12-0

1-2

0-7

February

1-1

0-7

March .

15-4

1-2

1-04

April .

10-0

0-9

0-6

May .

7-1

1-3

0-7

June

26-1

1-1

1-9

July .

25-0

1-18

1-9

August .

5-2

0-9

0-3

September

15-8

0-9

October

20-7

1-5

November

20-7

1-3

1-2

December

6-9

1-2

0-5

Total

288 42

14-6

1-11

1-02

672 TETANUS.

CHAP. XXIX.

ON TETANUS.

Section I. — The prevalence of Tetanus in certain classes of the

community in India.

That tetanus is a disease of frequent occurrence in certain classes
of the community in India, is sufficiently apparent from Dr. Leith's
Eegister of Deaths in Bombay, and from the records of the Jaraset-
jee Jejeebhoy Hospital,

During the five years from 1848 to 1852 there took place in
Bombay 1716 deaths from tetanus, which is in the ratio of 2*5 per
cent, of the total deaths during the period.

During the nine years from 1845 to 1853 the admissions from
tetanus into the Jamsetjee Jejeebhoy Hospital amounted to 289,
and the deaths to 186, or 64*3 per cent. The ratios of admissions
and deaths from tetanus to the total hospital admissions and deaths
may be learned in respect to six of the nine years, by reference to
the tabular statement at the end of the chapter : they are respec-
tively 0-8 and 3*9 per cent.

But it would be an error to conclude from the statements which
have just been made, that tetanus is a disease which will neces-
sarily come frequently under the observation of every practitioner
in India.

Between the years 1829 and 1838, while doing duty with Euro-
pean and native troops, and at the sanatory station on the Mahu-
buleshwur Hills, and habitually putting myself in the way of
observing disease, wherever it was to be witnessed, I did not meet
with a single case of tetanus.

Between the years 1838 and 1845, while attached to the Euro-
pean General Hospital at Bombay, and in medical charge of the
Jail, House of Correction, and Byculla Schools, only three cases of
tetanus came under my notice. Two of them were idiopathic: one

PATHOLOGY. 673

the son of the marshal of the House of Correction, a European boy
of about twelve years of age ; the other a sailor in the European
Greneral Hospital. The third case occurred in a young English
merchant, consequent on a lacerated wound over the tibia, caused
by a carriage wheel.

Thus during the first sixteen years of my service in India,
though actively engaged in varied fields of practice, I met with only
three cases of tetanus; but during the last nine years 289 have
come under my observation in one institution, and a considerable
number of them have been under my immediate care.

I have no data before me to show the proportion of tetanus in
the European and native armies of India, but it is probably small.
On referring to my notes of fatal cases of European officers, I find
two instances in a total of 311 : both were, traumatic, consequent
on lacerated wounds of the leg, by carriage wheels. The death
of a young English merchant in Bombay, from traumatic tetanus,
has already been alluded to; another instance occurred a year
or two afterwards in the same class of the community from a
wound close to the tibia, caused by the shaft of a buggy. Thus
all the instances of tetanus in the higher classes of Europeans,
of which I have notes, were consequent on injuries to the leg by
carriages. The only other case which I can bring to recollection
is that of a medical officer at Vingorla, after a compound fracture
of the leg from a fall.

The brief practical remarks which I have to make on this impor-
tant disease will have reference to my experience in the Jamsetjee
Jejeebhoy Hospital. In addition to notes of my general impres-
sions, the diaries of thirty-three cases, of which about one half was
treated in the clinical ward, are before me ; also a very valuable
report* on tetanus, as observed in the same hospital by my able and
experienced colleague, Dr. Peet.

I shall arrange my remarks under the heads: — 1. Pathology.
2. Causes. 3. Symptoms. 4. Treatment.

Section II. — Pathology. — Nature of the deranged action ivith
reference to the Physiology of the Sphial Cord. — Division
into Idiopathic and Traumatic, Acute and Chronic. —Morbid
Anatomy.

In the preliminary observations on the pathology of the brain, I
stated that it was sufficient for clinical purposes to divide the symp-

* " Transactions, Medical and Physical Society of Bombay," No. 1, new series.

X X

674 TETANUS.

toms of cerebral disease into, 1st, those which indicate excess in the
actions of the brain ; 2nd, those which indicate defect.

A similar classification may be made of the symptoms of disease
of the spinal cord. But when we confine our attention to the spinal
cord as a nervous centre^ it is necessary to limit the inquiry to
the symptoms which indicate excess of action; because those
which imply defect may be caused by change in the medullary
portion which conducts, as well as in the vesicular portion which
originates, nervous influence. In other words, we cannot separate
the defect of action of that part of the cord, which exercises the
function of a nervous centre, from that which exercises merely
the function of a nervous conductor.

Defect of action of the spinal cord has been already noticed
in that section of the preceding chapter which treats of Paralysis.

I would therefore now advert to the spinal cord as a nervous
centre, and confine my remarks to the symptoms which indicate
excess of action, and to the conditions on which this depends.

It is assumed that the clinical student is familiar with the
functions of the grey nervous matter of the spinal cord, as at
present taught by physiologists — that it receives impressions — ex-
cito-motor — made upon the peripheral extremities of afferent fibres,
and in respondence generates motor impulses — reflex — which are
conveyed by efferent fibres to muscular tissue ; and that the result-
ing action may be altogether irrespective of sensation and volition.
That in addition to the contraction of muscular fibre induced by
volition and reflex action, there is a permanent slight degree, to
which the terms antagonistic, muscular tension, tonicity have been
applied : it probably depends upon a continuous supply of nervous
influence, proceeding from the spinal cord as its centre of gene-
ration.

Excess of action of the spinal cord will then necessarily be indi-
cated, — 1. By forcible involuntary muscular contractions, often
originating without evident excito-motor impression, but always
readily excited by the slightest peripheral irritation. 2. By
excess of muscular tension, that is, by permanent rigidity of more
or less of muscular structure.

It is to phenomena of this kind that the term Tetanus has
been applied : they bear the same relation to the spinal cord as
a nervous centre that active delirium and excessive sensation do to
the brain as a nervous centre.

The subordiuate phrases, trismus, opisthotonos, emprosthotonos,
pleurostliotonos, merely express the fact that the phenomena are

PATnOLOGY. 675

prominently displayed in certain sets of muscles : they are unim-
jiortant in reference to pathology, and may be altogether set aside.

When inquiring into the proximate cause of excess of action of
the brain, I remarked that it probably always consisted either of
that active state of the capillary circulation termed determination
of blood, or of an altered quality of the blood from some external
agent, of which alcohol might be taken as a type.

It is reasonable and consistent to entertain the same views of
the pathology of the spinal cord and to relate tetanus to deter-
mination of blood, or to toxaemia. Strychnia may be named as
a typical agent of the latter.

But we experience a difficulty which was not felt in the
instance of the brain. Tetanus has been divided into idiopathic
and trauTYiatic, centric, and eccentric. The conditions of the
nervous centre just stated are sufficient for the explanation of the
idiopathic or centric ; but the traumatic or eccentric would seem
to imply that altered states of the periphery of afferent fibres may
so affect the quality of excito-motor impressions, as to lead to
excessive reflex action, irrespective of actual derangement of the
centre itself.

Without pretending to assert that injured periphery of nerves
may not be adequate, in some circumstances, to cause the pheno-
mena of tetanus, I would express my belief that derangement of
the spinal cord, similar to that in idiopathic tetanus, always plays
an important, often the principal, part in the pathology of trau-
matic tetanus also ; and for the following reasons : —

1. The rarity of tetanus after, compared with the frequency of,
injuries. 2. Tetanus after wounds is most frequent in countries
in which the idiopathic disease is not unusual. This fact seems to
imply that there exists something common in the causation of the
two forms. 3. Tetanus has been frequently observed after trifling
injuries ; but this has been chiefly, if not exclusively, in countries,
and in classes, in which the idiopathic form is of frequent occur-
rence. 4. Tetanus after wounds has not been usually noticed as
an early sequence of their infliction, but as an event coming on
after an interval of several, sometimes many, days, and in associa-
tion with quiescent as well as irritated conditions of the wound.*

* Dr. Peet mentions a circumstance which bears on this question. The only four
cases in which tetanus followed the operation of amputation, were, in persons affected
with traumatic gangrene ; in one, tetanus came on in ten hours after the operation ;
in the second, in twenty hours ; in the third, in forty-eight hours ; in the fourth, in
between three and four days.

Dr. Peet, referring to the first three cases, very justly remarks : " Are they not

X X 2

676 TETANUS.

These facts are more accordant with the idea of a diathetic influ-
ence extending to the spinal cord than of a mere respondence
to excito-motor impressions. 5. Permanent rigidity of muscular
structure is a symptom of traumatic as well as of idiopathic
tetanus ; and though we might admit that the paroxysms of spas-
modic action may be due to peripheral derangement alone, there
is no reason for believing that the action of the spinal cord in
respect to muscular tension is dependent on the reception of peri-
pheral impressions, or likely to be increased by alterations of their
quality.

The statement very generally made by writers on tetanus, that
the idiopathic form is not so severe and fatal as the traumatic,
is not supported by experience in Bombay. My belief is that
on these points there is no difference in the two forms.* If
there be little, if any, difference in the pathology of idiopathic
and traumatic tetanus, and none in the severity of the symp-
toms or in the principles of general treatment, then there is
little to be practically gained by dwelling on the distinction: it
is perhaps sufficient to say, that when a wound or other injury
co-exists with tetanus, it should be treated on ordinary surgical
principles.

Tetanus has also been divided into acute and chronic.

By the first is understood severity of form, and a fatal result
generally within nine days. By the second, less severity of symp-
toms, a protracted course, and often a successful termination.

These terms, which have been objected to by some writers, may
be viewed as synonymous with severe and Tnild, and as indicating
the influence of different degrees of the predisposing and exciting
conditions. In cases which terminate favourably, — whether they
have been mild from the commencement, or severe at first and
subsequently mild, — the course is always protracted, and recovery
slow and gradual: this fact seems to imply the influence of a
diathetic state.

In regard to the morbid anatomy of tetanus, the appearances

calculated to favour the idea that there is in this disease, as in most others, a period
of incubation ; a stage during which the efficient cause, or more correctly, perhaps, the
disease itself, is actually in existence, without its presence being manifested by any
appreciable signs or symptoms?" He further relates the tetanus to the original
injury, not to the surgical operation.

* Dr. Peet, in his interesting report, has already pointed out the discrepancy
between the result of observation in Bombay and recorded statements, and has nar-
rated cases illustrative of the severity of the idiopathic form of the disease. His
opinion is that the idiopathic form is more severe than the traumatic. My im-
pression, as just stated is, that there is no difference in this respect.

PATHOLOGY. 677

found in the spinal canal after death are analogous to those found
in the cranium, when death has followed close upon symptoms of
excessive action of the cerebral functions, viz., more or less
increased capillary turgescence, with or without increased serous
effusion. These are in fact the only anatomical changes which
may be looked for after death in organs which have been the
seats merely of active determination.

The question — whether inflammation of the membranes or sub-
stance of the cord is the proximate cause of tetanus, has been
discussed.

In cases which have terminated fatally after a few days' illness,
— and of such the records of morbid anatomy may be held exclu-
sively to consist, — the presence of only increased vascularity is not
conclusive against the idea of recent inflammation during life, for
in encephalitis, quickly fatal, no other appearance may be found.
But the improbability of tetanus being dependent on inflamma-
tion seems to me to rest on facts of another kind.

1. When inflammation of the cranial contents becomes pro-
tracted to those stages when blood-stasis or lesions of structure
take place, then excess of action of the brain ceases to be indi-
cated; but muttering delirium, drowsiness, coma, irregular mus-
cular contraction, and paralysis — the symptoms of defective action
— come on.

2. In chronic tetanus, though protracted for weeks, the symp-
toms of excess of action continue to the close. There is never
muscular relaxation or paralysis.

For these reasons, I believe that inflammation is not the proxi-
mate cause of tetanus.

In death from cerebral disease, the suspended function of the
sensorium — coma — extends to the medulla oblongata, and death by
apncea takes place. But in many forms of cerebral disease, de-
pressed action of the heart is also very evident, and a tendency to
death by syncope is thereby created.

In fatal cases of tetanus, death takes place partly by apnoea, not
caused by paralysis of the muscles of respiration, as in cerebral
disease, but by their excessive contraction. I have said partly by
apnoea, because in tetanus a depressed action of the heart, with
tendency to death by syncope, is also a prominent symptom, and
one which it is most important to regard in treatment.

The syncope may be due to paralysis of the muscular fibre of the
heart, but in all probability is most generally caused by spasm. On
this question my data are limited ; but I have before mo the notes of

X X 3 ^

678 TETANUS.

three cases observed by me subsequent to my return to India, in which
the heart was firmly contracted — in a state of the so-called concentric
hypertrophy. In all these cases there was general rigidity of the
muscles, and a flexed condition of the fingers at the time of exami-
nation, made, in one three hours after death, in another twelve,
and in the third nineteen.

There is still an observation to make relative to the pathology
of tetanus. It would seem that the reflex actions of the spinal
cord, which affect muscular fibres concerned in organic functions,
and little controlled by volition, are usually exempt from derange-
ment in tetanus. In this respect the contrast with hydrophobia is
very striking ; for in this latter disease the nervous circle of the
eighth pair is remarkably involved. Or this feature in tetanus
may be described by saying, that the muscular structures on
which the excess of action of the spinal cord is expended, are, in
the normal state of the system, also subject to contraction from
volition.

Section III. — Etiology. — Diathesis^ Gold, Entozoa ? — External

Injuries.

The etiology of tetanus is beset with difficulty and obscurity.

1. It is most probable that there are diatheses influential in
the production of both idiopathic and traumatic tetanus. But the
nature of the agencies which induce these diatheses, whether akin
to malaria, or other climatic conditions, or related to habits and
regimen, has yet to be determined.

Though the disease shows itself most frequently in the native
classes who seek relief in civil hospitals, yet it has not been ob-
served by me to be particularly related to asthenic and cachectic
states, for many of the affected have been in good condition. Again,
when we reflect on the possible relation of tetanus to toxaemia, we
naturally turn to the pathology of hydrophobia, a kindred affection
of a limited section of the spinal cord ; and also to the fact, that
tetanus is never recovered from by a sudden cessation of the symp-
toms, but always by gradual and slow restoration.

2. Is cold a common exciting cause of idiopathic tetanus ? My
general impression is, that in a considerable proportion of the cases
the attack has been attributed to such causes as sleeping on the
damp ground or exposure to the night air. But when we inquire
into the seasons of admission and death from tetanus generally,
the influence of cold is not very evident.

inlL m

CAUSES.

679

The following is a statement of the monthly deaths from tetanus
of all kinds recorded by Dr. Leith : —

January
February
March .
April .
May .
June
July .
August .
September .
October
November
December. .

Total

1848.

34
27
29
18
24
25
27
17
16
17
27
22

283

1849. 1850

17
28
24
31
28
24
27
24
24
27
35

313

31
25
45
52
44
50
37
30
27
35
34
37

447

1851.

18
28
26
26
28
21
27
29
31
30
29
39

332

21
32
35
36
22
34
21
24
28
24
35
29

341

128
129
163
156
149
158
136
127
126
130
152
162

1716

From this we find that the deaths from December to May
amounted to 887, and those from June to November to 829, giving
an excess of 58 in favour of the first half-year, which includes the
cold months.

Of the 289 admissions into the Jamsetjee Jejeebhoy Hospital, in
nine years — 164 took place from December to May, and 125 from
June to November, which gives an excess of 39 in favour of the
half year which includes the cold months. Though it may be rea-
sonable to attribute part of the excess of tetanus in both these
instances to the influence of season, yet it must be borne in mind,
that the period referred to is that during which the fluctuating
population of Bombay is at its maximum, and during which there
is consequently the greatest absolute amount of sickness and death.

We saw reason to relate excess of action of the nervous matter
of the brain to elevated temperature as an exciting cause, and the
question naturally arises, may not tetanus — excess of action of the
spinal cord — be related to the same exciting cause ? There is no
good reason for entertaining this opinion ; for it must be remem-
bered that heat as an exciting cause of cerebral disease was most
frequently exhibited in the European constitution ; but tetanus is
far more common in the native.

3. Entozoa in the intestinal canal have been suggested as an
occasional exciting cause of tetanus. The lumbricus teres is very

X X 4

680 TETANUS.

common in natives of Bombay, and doubtless may be found fre-
quently present in patients affected with tetanus. But to infer
from this fact that there has been relation of cause and effect, would
be illogical, just as it would be to regard entozoa as the cause of
pneumonia, cholera, or the many other diseases with which in the
same classes they co-exist with equal frequency.

4. In traumatic tetanus* what part does the wound or injury
play in the causation of the disease ? I have already (p. 676) stated
my belief, that in the pathology of the two forms there is pro-
bably little difference. In all likelihood, the degi'ee of a wound's
influence as a determining cause varies in different circumstances —
considerable when the wound is severe, trifling, if existing at all,
when the injury is slight. Indeed, it is sufficiently common to find
that the history of cases of tetanus with slight external injury,
points as distinctly to cold as an exciting cause, as that of many in
which injury does not co-exist. In a word, when the wound is
trifling, its influence in the causation of tetanus is, I apprehend,
very problematical. If this opinion be correct, then the inference
may be drawn, that of the cases registered by Dr. Leith, or admit-
ted into the Jamsetjee Jejeebhoy Hospital, the proportion of cases
truly traumatic was very limited. f

5. Tetanus, excited by strychnia or other poisons, if such there
be, is related to toxicology, and does not come within the scope of
this work. I have witnessed one case of the effect of an over-dose
of strychnia taken by mistake by a medical apprentice, and reco-
vered from.

Section IV. — Symptoms. — Muscular Rigidity and Spasms. —
Respiration. — Pulse. — Febrile Disturbance, &c.

Here, as in respect to most of the diseases which have been
treated of in this work, it will be taken for granted that the
clinical student is acquainted with the descriptions of systematic
writers,

* I make no special reference to the term ^puerperal, which has been applied to
tetanus occurring in puerperal women. It is sufficient to be aware of the fact that
the adverse conditions in which puerperal women, natives of India, are placed, are
predisponent of tetanus. I would class the disease arising under these circumstances
with idiopathic not traumatic tetanus. A similar remark may be applied to trismus
nascentium, as the history of the Dublin Lying-in Hospital amply proves.

t The train of reasoning which I have followed in this section, will explain why I
have not dwelt upon an inference drawn by Dr. Peet, from an analysis of a portion of his
cases ; viz. that idiopathic tetanus was most common in October, November, December,
and traumatic in April, May, and June.

SYMPTOMS. 681

I shall, therefore, merely notice those symptoms which seem to
me the most important. Tetanus commences with excess of
muscular tension, which leads to that permanent rigidity which
is one of the characters of the disease. This state comes on more
or less quickly in different cases, and involves more or less of the
muscular structures. The muscles of the neck, the jaws, and
abdomen are those which are earliest and most universally aifected.
This excess of tension is accompanied with sense of stififness and
pain, and leads to more or less permanent closure of the mouth,
and rigidity of the anterior abdominal walls.*

Dr. Peet has called attention to a peculiarity in the expression
of the countenance which he correctly thinks is often the earliest
indication of tetanus. He says : —

" But, even before pain is complained of, there is often something very peculiar in
the expression of the face : it is not easy, perhaps, to describe exactly in what this
change consists, — it has seemed to me to depend upon an apparent increase in
breadth, the angles of the mouth being, in some degree, drawn outwards, the lips com-
pressed, and the eyelids slightly corrugated. This expression is very different from
that present at a later period, in which the skin is wrinkled, the furrows of the face
highly developed, the angles of the mouth depressed, and the whole appearance that
which has been so well designated by the term ^risus sardonicus.^ The length of time
over which the change in the expression of face first noticed may extend I am unable
to state : I have witnessed and pointed it out ten hours before any other symptom of
tetanus was present." f

The greater or less permanent rigidity is followed, sooner or
later, and sometimes very speedily, by spasmodic contractions,
which vary in force, frequency, duration, extent, and preference for
particular muscles. In these variations consists the difference in
severity in different cases. The extent and force of the permanent
rigidity are always in proportion to the force, frequency, duration,
and extent of the spasms. The spasms may recur at intervals,
ranging from two or three minutes to half an hour or more, and
may endure from a second or two to half a minute or a minute.
The preference given to one set of muscles over another occasions
the varieties which have been previously alluded to (p. 674).

The spasms may recur without any appreciable excito-motor im-
pression, but they are generally very readily excited by trifling

* The fact that the permanent muscular rigidity — the excess of tension, and the
subsequent spasmodic contractions — excess of reflex actions — are distinct, seems to
me to complete the proof, that normal muscular tension is maintained by nervous in-
fluence generated in the spinal cord. This is a point on which physiologists have not
always agreed.

t " Transactions, Medical and Physical Society at Bombay," 2nd Series, No. 1,
p. 13.

682 TETANUS.

causes, as the sound of the voice, the motion of the observer's han(
the sliglitest touch, &c.

I concur with Dr. Peet in believing that it is not always possible
to say from the symptoms at the commencement whether the course
of the disease will be rapid and fatal, or prolonged and recovered
from. I have seen cases that gave every promise of being mild,
become suddenly and unexpectedly aggravated, and others which
threatened to be severe become unexpectedly moderated.

The statement usually made that the fatal result from tetanus
occurs for the most part within nine days from the commencement
of the attack, is on the whole correct. Yet exceptional cases are
by no means uncommon. I have seen several in which death took
place as late as the twentieth day, under recurrence of an aggrava-
tion of the symptoms, or in consequence of increasing asthenia.
And. I entertain the opinion that more frequent recoveries, and a
more protracted course in fatal cases would result, if depressing
remedies and full narcotism were abandoned, and moderate ano-
dynes, with tonics, stimulants, and support, substituted.

The abnormal muscular contraction and spasm interfere with
the right performance of the function of respiration : hurried re-
spiration is always an unfavourable symptom. The marked de-
pressed action of the heart is practically a very important featiire
of the disease, and one which becomes apparent at a very early
period in severe cases ; the pulse becomes small and very compres-
sible. Dr. Peet dissents from Dr. Parry's remark that, "if the
pulse by the fourth or fifth day does not reach 100 or 110 beats in
the minute, the patient almost always recovers." It is true that
fatal cases, with a pulse considerably below 100, for a longer
period than five days, and recovered cases, with a pulse of 100
from the commencement, may be observed. Such cases I have
witnessed, but still the general clinical fact remains that a frequent
pulse is a bad symptom in tetanus, and that when the pulse be-
comes small it is generally also rapid.

On the co-existence of febjile symptoms with tetanus, Dr. Peet
remarks ; —

*' The mode of commencement of the disease has presented a good deal of variety.
In a certain number of cases the manifestation of muscular derangement has been pre-
ceded by distinct febrile symptoms, not attributable to the state of the wound. These
have reached over a period varying from a few hours to two days. I was at one time
under the impression that such cases were invariably acute ; but further experience
has thrown a doubt upon the accuracy of this opinion. Within the last two years I
have witnessed at least three cases of recovery where the premonitory febrile dis-
turbance was distinctly marked.

TREATMENT. 683

"Febrile symptoms at or previous to the accession of the tetanic symptoms have,
however, been by no means general. In the larger number of cases they were alto-
gether absent."

In these opinions I concur ; and from having witnessed one
case of cured remittent fever succeeded by fatal tetanus, and one
case of improved tetanus followed by fatal fever, it has seemed
to me not improbable that the co -existence of febrile symptoms
with tetanus may be sometimes best explained on the supposi-
tion of a co-existing malarious influence acting on the affected
individual.

The bowels are usually constipated. The condition of the ex-
pellent abdominal muscles, and the small quantity of food taken,
are sufficient to explain this symptom. I am not acquainted with
any fact which countenances the idea that the muscular fibre of
the intestinal canal is in a state of spasm : indeed, it is very doubt-
ful whether there is much abnormal contraction of the sphincter
ani. Eetention of urine very rarely takes place in tetanus, from
which it may be inferred that undue contraction of the sphincter of
the bladder is not common. It has been already remarked that the
phenomena of the disease point chiefly to implication of muscular
fibres normally under the control of volition as well as excito-motor
impression.

Section V. — Treatment of Tetanus,

The most important clinical facts relative to the treatment of
tetanus are : — 1. The evident failing action of the heart. 2. That
recovery never takes place except through a protracted course and
a gradual subsidence of the deranged actions.

From the first fact it may be inferred that remedies sedative, as
blood-letting, tobacco, digitalis, tartar emetic, purgatives, mer-
cury, are contra-indicated. This inference is sustained by clinical
experience. Such meaus have been freely and often used, and, it
may be added, are now universally condemned.

From the second fact, two inferences may be drawn: — 1. That
as recovery is always gradual and slow, it cannot be a safe system
of treatment to use remedies which, while they make a decided
impression on the tetanic symptoms, tend to derange and materially
injure other actions important to life. Such remedies are narcotics
given to the degree of frequently inducing or maintaining a state of
marked narcotism. With this view opium, extract of hemp, bella-
donna, inhalation of ether and chloroform, have been used. The
tendency of this treatment is, while it relieves the spasm, to cause

684 TETANUS.

death by coma. Nay, more, associated with narcotism, there if
always a failing action of the heart ; therefore, under narcotics used
to this degree, the tendency to death by syncope, already distinct
in tetanus, becomes seriously increased. Further, if in cases thus
treated, the narcotics be intermitted, it will be found that the
spasms will recur with greater frequency and severity than before
the exhibition of these remedies had commenced. The explana-
tion is this : the general powers of resistance of the system will
have been lowered, and the influence, whatever it may be,
which causes the tetanus will, being less resisted, be more free
to act.

These statements are not grounded on the observation of the
bad effects of the excessive use of opium or hemp, for I have
always felt that the injurious action of the first especially had
already been proved ; but they rest on my own experience of the
inhalation of sulphuric ether or of chloroform to the extent of
frequently inducing or maintaining a full narcotic influence. The
effect of the inhalation of chloroform in relaxing the spasms and
relieving the suffering of tetanus is most striking, and the tempta-
tion to use it freely is consequently gTeat. But it is treacherous
and unsafe. The influence passes off in two or three minutes, and
the spasms recur. If the chloroform be frequently repeated,
increasing failure of the pulse becomes very evident ; if the remedy
be intermitted, it will be found that the frequency of the spasms
has been augmented by its use ; if it be continued to the close, it
will be found that death is preceded by some degree of muttering
delirium and coma, which are not symptoms of the termination of
tetanus when unmodified by narcotics.

A system which leads to results such as these cannot with pro-
priety be" designated the curative treatment of tetanus. It is
euthanasia through chloroform, and if tetanus w^ere an invariably
fatal disease, the question of its adoption might perhaps be enter-
tained. Such, however, is not the character of this disease, and
this would become still more evident if the second inference were
more generally acknowledged, and practically applied, viz., that as
recovery is always gradual and slow, the indication is to sustain the
strength. This we effect by such moderate use of narcotics as shall
somewhat relieve pain and lessen spasm, and thus ward off part of
that exhaustion which follows the continuance of great suffering; and
by tonic remedies, nourishment, and stimulants. A combination of
quinine with extract of hemp may be used : the former in doses of
from three to six grains, the latter from one to two grains, given at

TREATMENT. 685

intervals of from two to six hours, with animal broths, and other
nourishment in small quantities frequently repeated, and from ten
to twenty ounces of wine in the twenty-four hours. By this system
of treatment not only are the protraction of the disease and the
chances of recovery increased, but the suffering is alleviated —
a fact which the protraction of the disease necessarily implies. I
have also used chloroform, on the principle of merely allaying
the pain and lessening the spasm, every third or fourth hour. For
this purpose the inhalation of thirty or forty minims will generally
be sufficient. The practical objection to chloroform is the risk of
over dose and the temptation to push it beyond the limits of safety.
But the relief of pain is not the only practical advantage gained
by the moderate and safe use of narcotic remedies as now re-
commended: the relaxation of spasm is useful by materially
facilitating the ingestion of food, wine, and medicines. Re-
covery in one case, in which the trismus was complete, seemed
to me to be due to the use of thirty minims of chloroform inhaled
before each time of administering food : this was sufficient to
unlock the jaws to the necessary extent without causing injurious
narcotism.

In February 1853 I had the opportunity of witnessing several
cases of tetanus in the native hospital at Calcutta through the
kindness of Dr. J. Jackson ; and it was satisfactory to me to
hnd that observation in that institution had led to conclusions
on the principles of treating tetanus very similar to those which
have just been detailed, and which had for some time been enter-
tained by me. Dr. Jackson has since published the results of his
experience in the first number of the " Indian Annals of Medical
Science." There is, I apprehend, very little difference in the prin-
ciples of treatment respectively advocated by us. Dr. Jackson,
perhaps, attaches more value to chloroform than I am disposed to
accord to it.

Blisters, cold affusion, &c. — have been used : of these I have
not any experience ; but when we consider the readiness with which
the spinal cord responds to the most trifling peripheral impressions,
it seems to me unreasonable to expect any result but harm from
remedies of this class.

To remove constipation, occasional recourse may be had to com-
binations of castor oil and turpentine, sometimes with addition of
croton oilj or the latter alone given with mucilage. Dr. Jackson
has used aloes in small doses from time to time, with the hemp
and quinine.

G86 TETANUS.

The five following cases will serve to illustrate some of my state-
ments. The first three show the good effect of the treatment
recommended ; the fourth proves the striking influence of chloro-
form in relaxing the spasms, but as the urgency of the symptoms
was great, and the course rapid, the injurious effects of the agent
are not apparent; the short continuance of the relief from the
chloroform is, however, shown. The last case is an instance of the
difficulty which not unfrequently arises in determining the idio-
pathic or traumatic character of the disease.

261. Tetanus. — Treated with quinine, extract of hemp, wine, and nourishment. —
Becovered. — Mahomed Azim Khan, a Beloochee horse-dealer, of stout frame, wa« ad-
mitted into hospital on the 26th April, 1853. He had been the subject of guinea-
worm for fifteen days. Symptoms of tetanus had come on the day before admission,
subsequent to sleeping, exposed to the open air, on the ground. The spasms were
frequent, the trismus incomplete, the breathing hurried, and the pulse, not above 100,
tended to become weak. He was treated freely with quinine and extract of hemp,
and twenty -four ounces of wine were given daily. After this treatment was commenced,
the improvement was striking. The spasms lessened, the pulse improved in strength,
and the breathing became calm. He was removed on the 7th May by his friends,
who wished to take him to Kurrachee. When discharged, there was still some stiff-
ness and pain of the legs, with occasional spasms ; but he was other\yise well, and the
pulse good. This case was treated by Dr. Forbes Wat-on.

262. Idiopathic tetanus. — Treated with quinine, hemp, wine, and nourishment. —
Becovery. — Runnee Ram, a Marwaree labourer, of twenty-six years of age, was ad-
mitted into the Jamsetjee Jejeehoy Hospital on the 29th March, 1853. He had
suffered from tetanic symptoms for ten days unpreceded by injury. Four days before
admission the actual cautery had been applied to the spine and calves of the legs.
There was opisthotonos, incomplete trismus, frequent spasms, much sweating, and the
surface of the body was covered with sudamina. He remained in hospital till the 7th
May, slowly improving ; but on his discharge he was considerably reduced in flesh,
and there was still a good deal of rigidity of the muscles of the legs and abdomen.
He was treated with quinine, forty grains in the twenty-four hours, given with extract
of hemp ; wine sixteen ounces daily, and soup frequently. While under treatment,
the pulse was never above 100, and he took the wine and nourishment well.

263. Tetanus in a child. — Though fatal, the good effects of treatment with quinine,
hemp, and attention to nourishment were very apparent. — Chund Bux, a Mussulman
boy, three years of age, residing with his parents at the Lighthouse, Colaba, in a cold
exposed situation, was admitted into the Jamsetjee Jejeebhoy Hospital on the 5th
December, 1851, on the fifth day of iUness-, with tetanus. He had a superficial, small,
suppurating, but healthy-looking wound on the forehead, caused by a fall ten days
before admission. The spasms were frequent, the trismus complete, the pulse feeble,
and the child was constantly moaning. Ten minims of the tincture of hemp were
given every second hour, and soup, wine, and milk, in small quantities frequently.
The spasms were lessened in severity, and then two grains of quinine were added to
the dose of hemp, and the medicine continued every third hour with the same atten-
tion to nourishment. The child seemed to be slowly impro-sang. The spasms were
not so frequent, and the permanent rigidity of the abdomen was less. The trismus,
however, continued. Nourishment was taken frequently in small quantities, and the
pulse improved in strength. This was the state of the patient on the 14th and the
morning of the 15th. But on the evening of the latter day there was again increase

ILLUSTRATIVE CASES. 687

of the spasms, and he died in the course of the night. The treatment had been un-
changed till the evening of the 14th, when the intervals were lengthened to four
hours ; but three hours were reverted to on the evening of the 15th.

264. Tetanus treated with chloroform. — Fatal. — Suttoo, a Hindoo labourer, was
admitted into the Jamsetjee Jejeebhoy Hospital on the 3rd November, at4|-p.M.,
after three days' illness with tetanus. There was opisthotonos, with constant short
spasms of the abdominal and other muscles, causing general agitation of the body.
The pulse was barely perceptible. There was a superficial abraded wound at the
lower part of the calf of the left leg, caused by a box falling on it. A drachm of
chloroform was inhaled with relaxation of the spasms and development of the pulse,
which continued for about three minutes. The spasms and rigidity then recurred.
The chloroform was then repeated with similar effect ; it was again used at 5\ p.m.,
at 6| and at 8 p.m. : in all five times. In each instance the spasms ceased, continued
absent about four minutes, then recurred. The pulse lost strength. He refused sago
and wine, and died at 9^ p.m.

Bemarh. — The utmost that can be said in favour of the chloroform is, that twenty
minutes' relief from suffering resulted from its use. But whether the fatal result was
postponed or hastened, or not influenced by it, is an open question.

265. Tetanus fatal on the twenty-first day. — Whether traumatic or idiopathic,
doubtful. — Treated with quinine, hemp, nourishment, and stimulants. — Fatal. — Spinal
veins congested. — Deen Mahomed, aged thirteen, a Mussulman buggy driver, was admit-
ted into the clinical ward on the 25th November, 1853. There was tetanic expression
of countenance. The mouth could be opened only to the extent of a quarter of an
inch, and the tongue protruded about half an inch. The corners of the mouth were
drawn outwards. There was rigidity of the muscles of the back, abdomen, and neck.
There were also general tetanic spasms, which lasted about half a minute, and re-
turned after an interval of about three minutes. The skin of natural temperature.
The pTilse, small and compressible, was about 80 during the intervals, and rose to a
100 during the spasms. There was a small wound covered with a scab on the inner
side of the left heel, and a pustule on the anterior surface of the lower third of the
right leg. He had been received into the hospital with trismus four days previously,
but had deserted, and was now brought back by his friends. His statement was, that
the wound on the heel was caused by a stroke from a horse-shoe twelve days before,
but of the pustule he could give no account. The night before his first admission he
slept in the open air in his buggy. "Was temperate in his habits. From the 27th
November to 4th December the spasms were not quite so severe, the intervals were
somewhat longer, the mouth was not quite so closed, and the pulse had improved in
volume. The bowels were generally slow, and the urine passed freely. He became,
however, notably thinner, and increased heat of skin was at times observed. Thus he
continued, still losing flesh, but with the pulse of pretty good volume, till the
morning of the 13th, when he was found bathed in perspiration, with the pulse just
perceptible. There had been increase of spasms during the night, and he had been
unable to swallow the medicine regularly. He died during the visit at which this re-
port was taken. The wound on the heel was nearly well on the 8th. The treatment
consisted of quinine four grains, extract of hemp one grain, or one grain and a half,
every third hour, chicken soup two ounces every fourth hour, sago two ounces, and
arrack half an ounce every fourth hour ; and after the 5th forty minims of chloroform
were inhaled every sixth hour, and the bowels were opened by an occasional dose of
castor oil and turpentine oil. The wound was poulticed. There was no drowsiness
from the hemp. The effect of the chloroform continued for about twenty minutes.

Inspection three hours and a half after death. — The body was much emaciated
and rigid. On examining the wound on the left heel nothing abnormal was detected
in the neighbouring blood-vessels and nerves. Head. — On removing the calvarium,

688

TETANUS.

the vessels of the membranes of the brain were seen congested. About three ounc
of clear serum were found at the base of the skull, but none in the ventricles. The
substance of the brain was in a healthy condition. Spinal Cord. — Spinal veins were
turgid. The structure of the cord was healthy. Chest. — On opening the chest, the
lungs were found collapsed. The structure was healthy, with exception of emphy-
sematous patches here and there, chiefly on the anterior thin edges of both lungs.
The cavities of the right side of the heart were filled with dark fluid blood. The
left ventricle was contracted and contained no blood. Abdomen. — The liver was normal.
The spleen was about three inches long, and an inch and a quarter in breadth, and
was somewhat firmer than usual ; but the structure was healthy. The kidneys were
normal, the distinction between cortical and medullar portions being well marked.

Section VI. — Statistics of Tetanus.

Table XLII. — Admissions and Deaths, with Fer-centage, from Tetanus,
in the Jamsetjee Jejeehhoy Hospital at Bombay, for the Six Years from
1848 to 1853.

1848 to 1853.

Monthly Average.

Admissions.

Deaths.

Deaths on
Admissions.

Admissions

on total
Admissions.

Deaths on
total Deaths.

January

Februar

March

April

May

June

July

August

Septeml

October

Novemb

Decemb

)er

er
er

12
17
25
21
23
15
13
8
12
17
18
23

75-0
52-9
56-0
66-6
60-9
80-0
38-5
75-0
91-7
52-9
55-6
60-9

1-6
0-9
1-2
0-9
11
0-7
0-8
0-4
0-6
0-8
0-8
1-0

2-0
2-8
3-7
4-1
4-8
3-9
1-6
1-8
3-5
2-6
3-0
3-5

Tol

.al

204

127

62-3

0-8

3-9

689

CHAP. XXX.

ON HYDROPHOBIA.

Section I. — Short allusion to Symptoms and Pathology. —
Illustrative Cases detailed,

I HAVE witnessed ten cases of this fearful disease, — one in a little
girl of the Byculla Schools, and the other nine in the Jamsetjee
Jejeebhoy Hospital.

I have not any notes of the first case, but the child was bitten so
severely in the palm of the hand that the excision of the parts was
impracticable : nitrate of silver was freely applied. Symptoms of
hydrophobia came on in about six weeks, and proved rapidly fatal.
Of the other nine cases four occurred from September, 1848, to
September 1849, one in 1850, and three in 1851. Of one the
year is not given. Among the European officers in the Bombay
Presidency I recollect the occurrence of three cases in twenty-
five years. There is so little in common in the symptoms of
tetanus and hydrophobia that an error in the diagnosis ought
to be very rare. In the latter disease there is none of the
permanent muscular rigidity, increased by paroxysms of tonic
spasm, so characteristic of the former. The deranged muscular
action in hydrophobia is confined chiefly to the neck, pharynx, and
larynx, and is more clonic in character. An accumulation of viscid
mucus about the pharynx, larynx, and mouth, and a consequent
hawking and spitting, would seem to be invariably present. I
have observed these phenomena only once in tetanus, in slight
degree, but with the other symptoms of the disease so well marked
as to leave no room for doubt. The sensorial derangement and
the agitated actions consequent on excitement and alarm are
always, more or less, present in hydrophobia. Symptoms of this
kind do not occur in tetanus.

On the pathology of hydrophobia it is sufficient to remark
that the morbid poison, the cause of the disease, chiefly expends

Y Y

GOO HYDiionroBiA.

its force on the nervous circle of the eighth pair, and extends its
influence to the sensorium.

I shall best describe the phenomena of hydrophobia by narrating
the four* cases treated by me in the Jamsetjee Jejeebhoy Hospital.

266. Hydrophobia: three months after the bite. — Camillo Pereira, a native Chris-
tian, from Goa, following the occupation of cook, of fourteen years of ago, was ad-
mitted into the clinical ward on the 24th December, 1850. It was said that he had
been bitten by a strange dog at Karlee on the 26th September. At about the middle
of the outer side of the right leg, there were three cicatrices resembling those caused
by a bite. He stated that on the night of the 21st December he awoke feeling chilly
and uncomfortable, but he fell asleep again, and was able next day to attend to his
avocations. On the following night he was again restless, and alarmed with dreams ;
and at noon of the 23rd, he was found by a friend in a state of agitation and excite-
ment, increased by the sight of water. He passed the night in an excited state, and
was with difficulty controlled by his friends. On admission into hospital the following
day, he was agitated, and constantly talking to himself. He made no complaint of pain,
but when approached or touched he shrieked as if from fear. There was no marked
spasm of muscles observed. The tongue was protruded with effort and with a jerk.
He did not seem to be affected by currents of air, but when water was brrught, he
became more excited, and was unwilling to drink or even to touch it. Noises dis-
tressed him, and he seemed anxious to be left alone. The skin was of natural tem-
perature, the pulse frequent, small, and easily compressed. The bowels had not been
opened for two days. He died at half-past 10 p.m., about six hours after admission.
The excitement and alarm had continued ; the latter was chiefly indicated by an out-
stretching of the hands, as if to protect himself. The mouth became filled with ad-
hesive saliva, which excited coughing, and was constantly trickling down from the
right angle of the mouth. The lower extremities became cold, the pulse scarcely per-
ceptible, and the breathing laborious. Pills of extract of hemp and miiriate of mor-
phia were prescribed, but he had been able to take only two.

267. Hydrophobia, treated with chloroform. — Mussoojee Go-sdnda, a Maratha, aged
fifty, was admitted into the Jamsetjee Jejeebhoy Hospital on the 28th August, 1849,
at 5 A.M. He had been bitten on the calf of the left leg, two months before, by a
dog believed to be rabid. The wound healed, and he remained well till two days
before admission, when he suffered from fever ; and the day before admission, at noon,
he became excited and anxious. On admission, there was constant hawking and spit-
ting of frothy mucus, with a frequent ringing scream ; and these symptoms were
increased in paroxysms from time to time. He seemed anxious and distressed,
somewhat delirious, and maintained a sitting posture, grasping the tapes of the cot.
The pulse was very feeble. One drachm of chloroform was placed on a sponge, and
slowly brought near to the face : it was inhaled with apparently partial relief. It was
repeated every half hour, and in all ten drachms were used. He died at 2 p.m.,
nine hours after admission.

268. Hydrophobia. — Chloroform used, but obliged to be discontinued. — Succaram
Bappoo, aged twenty-eight, a Bundari, was admitted into the Jamsetjee Jejeebhoy
Hospital on the 2nd September, 1849, at half-past 4 p.m. Two months before, he
had been bitten on the right leg by a dog supposed to be rabid. Some native reme-
dies had been used. The wound had not completely cicatrised, but it was granulating

* The other five cases, though seen by me, were treated by Dr. Peet, and have
been fully reported by him in the ninth and tenth numbers of the " Transactions of
the Medical and Physical Society of Bombay."

ILLUSTRATIVE CASES. 691

and Lealtliy. The occurrence took place at Girgaum, and tlie dog was the property of
a Parsee. The patient had continued at his occupation as a day labourer till four
days before admission. He was brought to the hospital exposed to the rain, and all
his sufferings had become aggravated. He was agitated and alarmed, and constantly
talking incoherently, and in a supplicating manner. He lay on the abdomen, hawk-
ing, and at times making a barking sound ; but there was no great spitting of frothy
mucus. The attempt to swallow fluid, or a current of cold air from opening the win-
dow, or the approach of the sponge with chloroform to the face, all excited violent
general spasms, of short duration, but which seemed to cause much distress. The
attempts to give the chloroform were discontinued. The pulse was very feeble on ad-
mission, and by degrees became more so ; and shortly before his death, at eight p.m.,
four hours after admission, was imperceptible.

269. Hydrophobia in a Parsee boy. — Gorabjee Dhunjebhoy, a Parsee boy, of nine
years of age, was admitted into the Jamsetjee Jejeebhoy Hospital about midnight of
the 4th.* About a month before he had been bitten on the calf of the right leg by a
dog on the road. The bite bled freely : it was dressed with plaster, aud got well in
three or four days. He continued well till four days before admission into hospital,
when he became affected with febrile symptoms, but without spasms. On the after-
noon of the 4th, he first showed signs of alarm when water was brought to him, and
since then he has continued in an agitated state, talking much and incoherently, and
in a supplicating manner. He complained of thirst, but when water was offered to
him he became violently agitated, and said that he was unable to swallow. He
pointed to the throat, the head, and the thigh, and the bitten limb as the seat of pain,
but there was no pain experienced in the cicatrix. There was sense of chilliness and
annoyance from the presence of people around him. The pulse was thready and
barely perceptible. An attempt was made to give him some of a native remedy in the
form of a pulp, which had been sent from Kutnagherry by Captain Haselwood ; but
he was able to swallow only a small part of it, and that with great effort. He shortly
afterwards began to hawk and spit, and to make attempts to retch, and some of the
medicine was vomited. He continued with increasing anxiety till 11 a.m. of the 5th,
when he was removed by his friends and died half an hour afterwards.

* The month and year are not mentioned in my note, but it must have been in
:L 1849 or 1850.

Y Y 2

692 BLOOD DISEASES.

CHAP. XXXI.

ON BLOOD DISEASES.

Section I. — Object of the Chapter explained.

An altered state of the blood has been regarded as forming part of
the pathology of several of the diseases which have already been
considered. To discuss the important subject of the pathology of
the blood, is not my present object. The title prefixed to this
chapter, has been adopted simply as a convenient one for enabling
me briefly to notice several blood diseases, which the time, space,
or data at my command, do not admit of my treating in a manner
commensurate with their importance. They are : — 1. Pyaemia.
2. Leprosy. 3. Elephantiasis. 4. Scurvy. 5. Greneral Dropsy,
including Beriberi. 6. Eheumatism. 7. Snake Bite.

- Section II. — Pymmia, — Short notice of Symptoms and
Pathology. — Illustrative Cases.

I use the term Pycemia, to signify the concurrence of several
collections of pus in the subcutaneous and intermuscular areolar
tissue, frequently associated with puriform cysts in the substance
of internal viscera, and generally attended with more or less febrile
disturbance always adynamic and often remittent in type. The
term, however, is objectionable, for it implies a relation between
the development of the abscesses and the pre-existence and cir-
culation of pus in the blood. The previous presence of pus in the
blood is however hypothetical.

Ten cases of this affection are before me: for eight of them I am
indebted to Mr. S. Carvalho, who, at my request, directed his
attention to this subject, during the period that he ofiiciated as one
of the medical officers of the Jamsetjee Jejeebhoy Hospital. Mr.

PYEMIA. 693

Carvallio submitted his notes to Grrant College Medical Society,
and subsequently kindly placed them at my disposal.

Five cases proved fatal, and five recovered. Of the former, an
examination after death was made in four. Small puriform cysts
were found in the lungs in three, associated in two with similar
collections in the kidneys. In none were abscesses found in
the liver. In the fourth case no pus was discovered in any of
the internal viscera. In none were there traces of phlebitis.
In all, the small abscesses had evideatly formed consecutive on
inflammation.

In each of the five recovered cases, there were several large sub-
cutaneous collections of pus, in such situations as the thigh, the
chest, over the scapula, the leg, the neck, &c. In all, two or three
abscesses were opened ; but in some there was, in addition, the
formation of swelling and hardness, which threatened to pass on to
suppuration, but which nevertheless subsided : this latter event,
however, only took place towards the close of the disease, after the
general health had manifestly begun to improve. These abscesses
were all preceded by the ordinary signs of inflammation — some
degi'ee of pain, heat, swelling, and hardness.

The cause of the affection was not apparent in any of the cases.
A suppurating wound was noticed in only one instance: it was
situated on the heel, and after death the veins leading from it were
carefully examined, but showed no trace of inflammation. In
all the cases there was some degree of febrile disturbance. In
the worst, the type was adynamic, with brown dry tongue, failing
pulse, and delirium ; and remissions and exacerbations were gene-
rally well marked. Irregularity in the period of remission, and
the early access of adynamic phenomena, served to raise the sus-
picion that the febrile symptoms were not those of malarious
remittent fever, and to direct attention to the early detection of
suppuration.

The character of the fever, and the nature of the local phe-
nomena, are sufficient to indicate that the disease is one of the
blood. In the milder instances, important internal viscera escape,
in the severer they are involved. The existence of pus corpus-
cles in the blood, entangled in and obstructing capillaries, is un-
proved. But even if these bodies had been detected in the blood
there is surely so little in common between the constitution of a
pus corpuscle and a globule of mercury, as to destroy the force of
the asserted analogy between pyaemia and Cruveilhier's frequently
quoted experiments.

Y Y 3

694 BLOOD DISEASES.

I shall conclude these brief and desultory remarks with a short
summary statement of five of Mr. Carvalho's cases : viz. four fatal,
and one recovered.

270. Fever. — Several abscesses. — Small puriform cysts in lungs. — ^0 trace of
phlebitis. — A Hindoo, of forty years of age, after eight days' illness, was admitted
into hospital with febrile symptoms, enlarged glands of the left side of the neck, and
an abscess in the left dorsal region, succeeded by dyspnoea, with subcrepitoiis rhonchus.
He died five days after admission. There was purulent infiltration about the pectoral
muscles and neck of the left side. The lungs were of dark-red colour and cedematous,
and contained numerous puriform cysts, from the size of a hemp-seed to a small bean,
and many of them immediately beneath the pleura. No puriform cysts in the liver ;
no trace of phlebitis in the axillary and brachial veins of either side.

271. Adynamic fever. — Several abscesses. — Puriform cysts in the lungs. — One in
the kidney. — Small suppurating wound of heel. — JVo trace of phlebitis. — A Hindoo
labourer, of twenty-five years of age, was admitted into hospital with a small wound
in the sole of the left heel discharging pus, caused by a thorn twelve days before. An
abscess formed above the left knee, and further purulent collections took place, pre-
ceded by pain, in both axillae, and about the pectoral muscles, accompanied with
adynamic febrile symptoms, and hurried breathing. He died five days after admission.
There was no trace of phlebitis in the left saphenous and femoral veins, or in the
axillary and brachial veins of the right side. There was purulent infiltration in the
anterior and lateral parts of the chest, and extending up the neck, situated in the sub-
cutaneous and intermuscular areolar tissue. There had been recent pleuritis on both
sides. There were numerous hepatised nodules in both lungs, from the size of a pin's
head to that of a pea, chiefly situated immediately under the pleura, with a small
deposit of pus in the centre of each. No trace of purulent deposit in the liver or spleen ;
but a small one immediately under the capsule of the right kidney.

272. — Adynamic remittent fever, — Small abscess on the forehead. — Carbuncle on
the back. — Nu7nerous puriform cysts in the lungs and kidneys. — A Brahmin, of
twenty-three years of age, was admitted into hospital, after fifteen days' illness with
fever. The type, as observed after admission, was distinctly remittent, and of adynamic
character. On the twelfth day after admission, a small abscess was noted on the
forehead ; and two days afterwards a carbuncle on the back. He died the following
day with hurried breathing. There was recent pleuritis of both sides. The posterior
parts of both lungs were in a state of red engorgement, with many collections of pus,
each aboxit the size of a small pea, and situated immediately under the pleura. No
deposits in the liver. After removing the capsule of the kidneys, dark-red spots were
observed, which, when incised, showed pus deposit in the centre ; there were also two
or three similar collections of pus deep in the cortical substance.

273. Many abscesses. — Fever. — Death by exhaustion. — No puriform deposits in
the internal viscera. — A Hindoo sepoy, of thirty years of age, was admitted into hos-
pital with a small abscess over the left olecranon, which was attributed to a fall sus-
tained eight days before. Other abscesses formed : one over the left trochantei*,
another at the posterior fold of the right axilla, a third in the left lumbar region, and
a fourth on the left natis. The febrile disturbance, slight at the commencement, in-
creased with the progress of the affection. Diarrhoea came on and he died, exhausted,
seventy days after admission. No deposits of pus found in the internal viscera.

274. Adynamic fever. — Several abscesses. — Recovery. — A horsekeeper, of thirty
years of age, was admitted into the Jamsetjee Jejeebhoy Hospital with febrile sjmiptoras
of adynamic type attended with delirium. On the sixth day an abscess over the left
pectoral muscle was detected, which he attributed to a kick from a horse. Sub-
sequently, three other abscesses formed : one in the left lumbar region, a second in

LEPBOSY. 695

the left thigh, and the third in the posterior part of the left leg. The abscesses were
all opened, and discharged red-tinged pus. There was at one time some hurry of
breathing and bronchitic rales. He also became affected with cholera; yet he re-
covered, and was discharged twenty days after residence in hospital.

Section III. — Leprosy — Tubercular and Ancesthetic. — Short
Account of the Symptoms and Pathology.

The disease, which forms the subject of the present section, is
the Elephantiasis Grrsecorum, the Lepra Arabum — but the term
Leprosy is preferred by me, as sufficient and not likely to mislead.
Elephantiasis I shall restrict to Bucnemia — the Barbadoes or
Cochin leg, the Elephantiasis Arabum — as an appellation more
appropriate to this affection than to leprosy. This application of
the words leprosy and elephantiasis to these two diseases is in
accordance with usage in India. It is unnecessary to add that
leprosy is altogether distinct from the genus Lepra, of the order
Squamae of cutaneous diseases.

On the historical interest of leprosy in Europe throughout a
series of centuries, I shall not enlarge. It still prevails in Norway ;
and the Report of a Eoyal Commission appointed some years since
by the Norwegian Grovernment, and drawn up by Drs. Danielssen
and Boek, is, I believe, the best practical account of the disease
as yet published. *

Leprosy is common in India* The numbers received into the
Leper establishment at Calcutta are unknown to me, but I visited
this institution in 1853, and found the accommodation and arrange-
ments altogether inadequate for the comfort and well-being of those
afflicted with this sad disease. Through the kindness of Dr. A.
Hunter, the reports of the Madras Leper Hospital for the years
1851 and 1852 are before me. The admissions in these years
amounted to 212, and the deaths to thirty- two* The system fol-
lowed in this institution, at the time of my visit, when under the
judicious management of Dr. Hunter, formed a pleasing contrast to
that of Calcutta. The patients were classified according to their
previous habits and position in life. Books were provided for the
educated ; and gardening and other light occupations conducive to
health and cheerfulness were encouraged. The arrangements for

*• I have not had the opportunity of consulting the original work of the Norwegian
Physicians, " Traite de la Spedalskhed, ou Elephantiasis des Grecs," &c. It is fully
referred to by Mr. Erasmus Wilson in a series of interesting papers in the " Lancet,"
April 1856, and was noticed some years since in the "British and Foreign Medico-
Chirurgical Keview."

YY4 •

^^JQ ULOOD DISEASES.

lepers in Bombay, inferior to those of Madras, are superior to those
of Calcutta. There is accommodation allotted for them in the
Jamsetjee Jejeebhoy Dhurmsala, and under exacerbations of the
disease they are received into a ward of the Jamsetjee Jejeebhoy
Hospital appropriated for the purpose. *

During the six years from 1848 to 1853, 391 cases of leprosy
were admitted into the hospital, and of these ninety-nine died.
Under the system which obtains of transferring the patients from
the dhurmsala to the hospital on exacerbations of the symptoms,
and retransferring them to the dhurmsala on remissions, there must
necessarily be a considerable number of re-admissions included in
the 391 cases above adverted to.

Though visiting the leprous patients in the hospital almost
daily, the various other subjects which pressed upon my attention
prevented me from entering upon the careful clinical study of this
disease. I, however, requested Mr. Lisboa, an intelligent graduate
of Grrant Medical College, during the period of his service in the
hospital, to investigate the subject, and supply my deficiencies.
His researches formed the subject of an interesting communication
to Grant College Medical Society.f

Leprosy in Bombay occurs both in the tubercular and ansesthetic
form, and occasional cases are observed in which the characters of
both varieties are combined ; but in this brief and imperfect notice I
must confine my remarks to a summary statement of the charac-
teristic symptoms of the two forms, and to a passing allusion to the
pathology and treatment. I trust, however, that at no remote
period, the clinical history and pathology of leprosy may be inves-
tigated in a manner commensurate with the opportunities enjoyed
by many practitioners in India, and worthy of comparison with the
careful inquiry of the Norwegian Commission.

Tubercular Leprosy. — The characteristic phenomena of this form
of leprosy \re sometimes preceded by a sense of languor and de-
pression, and occasionally by distinct febrile accessions. More
generally, however, the symptoms come on gradually and slowly,
without premonitory indications. Irregularly disseminated patches
of the skin become discoloured, and present a dark reddish or livid

* Before leaving India in September 1859, I placed the reports of the Madras
Leper Hospital in the hands of Dr. Bhao Dhajee, and proposed to him as an object
worthy of his well-known zeal and philantrophy the establishment and endowment,
with the aid of his fellow-countrymen, of an institution in the proximity of Bombay,
arranged in such manner as to minister to the comfort and the cheerfulness of this un-
fortunate class of sufferers.

t Extracts have been published in the " Transactions of the Medical and Physical
Society of Bombay," No. 2, New Series, p. 290.

lose ^1

LEPiiosy. 697

appearance, with a surface shining as if oil had been applied to it.
The skin in these situations has, for the most part, its sensibility
blunted ; but this state is sometimes preceded by a stage of tender-
ness and pain. Then the vivid colour fades, the skin is left brown
and tawny, and becomes thickened and tubercular. The morbid
deposit is in some cases confined to the cutis, in others it extends
to the subjacent areolar tissue. The cutaneous tubercles thus
formed are small, soft, reddish or livid, and vary in size from a
pea to an olive. They appear on every part of the face, but par-
ticularly on the nose and ears, and on the legs. In some rare
instances they are confined to the legs. The disease may remain
stationary in this state for some time ; then the tubercles become
affected with inflammation, and either suppurate or pass into states
of foul ulceration, and those about the toes and fingers may lead to
sphacelus and sloughing of the phalanges. The mucous mem-
brane of the mouth, the fauces, the uvula, the tonsils, the pharynx
and the nasal fossae, become also studded with tubercular eleva-
tions, and these may degenerate and ulcerate, and give rise to sero-
puriform and sanious discharges. The disease may now extend to
the cartilages, and bones of the nose, and affect internal organs, as
the lungs.

Ancesthetic Leprosy. — Large bullae are often the first sign of
this form of the disease. They lead to the formation of spots or
patches of lighter shade than the surrounding skin in the darker
races, and of a tawny brown colour in the white races. They
appear first on the feet, hands, legs, and arms, seldom on the face
and trunk till an advanced period. They are sometimes slightly
prominent, and the hair on affected parts falls off. These patches
are insensible, and extend slowly over the legs and arms to the
trunk, and are unattended with swelling. As the disease advances
the toes and fingers become shining and slightly swollen and stiff.
The soles of the feet and palms of the hands present deep ragged
furrows ; ulcers form on the metacarpal and metatarsal articulations
in the lines of flexion, enlarge by sphacelation, and the fingers and
toes drop off, and the parts that are left cicatrise. At this stage
the lobes of the ears and alse of the nose become thickened and
enlarged, and ultimately ulcerate. The voice now becomes hoarse,
ulceration attacks the throat ; and after a period of years, more or
less prolonged, during which these morbid processes have been going
on, diarrhoea or dysentery supervenes, and hastens the fatal result.

General Pathology of both fonns. — Leprosy is a striking in-
stance of a cachexia causing structural change of organs, by exuda-

698 BLOOD DISEASES.

tion-deposit from the blood, witli sub,se(|Lieut degeneration of the
deposit, and more or less of the adjacent structures. Drs. Daniels-
sen and Boek have stated, that in the ansBsthetic form, much of the
deposit takes place about the spinal cord, as between the arachnoid
and pia mater, and that the cord becomes hard, tough, and reduced
in size.

The morbid anatomy of leprosy has been altogether neglected
in India. Mr. Lesboa reports only one case in which an examina-
tion after death was made, and in this, though of the anaesthetic
form, the appearances described by the Norwegian physicians were
not present.

On the nature of the altered condition of the blood, and of the
causes which induce it, I am unable to offer any useful practical
suggestion; and the same remark may be made on the treat-
ment. I am not acquainted with any medicines capable of
controlling this disease, beyond what obtains in all cachectic
diseases from a well-adjusted tonic regimen and suitable tonic
remedies.

Section IV. — Mephantiasis. — Symptoms. — Pathology. —

Causes. — Treatment.

As explained in the last section, I apply the term Elephantiasis
to that disease which has been described under the names Elephan-
tiasis Arabum, Bucnemia, Barbadoes leg. Cochin leg, Egyptian
Sarcocele. It is not uncommon in Bombay, but occurs still more
frequently in other parts of India, as in Bengal and on the coast
of Malabar.

Symptoms. — The parts of the body most generally attacked are
the extremities — the lower more frequently than the upper — the
scrotum, the labia pudendi, and the mammae. The affection is very
often ushered in with rigors, nausea, headache, and febrile excite-
ment ; then the part which is to suffer becomes red, swollen, with
a sense of smarting heat, and sometimes tenderness and hardness
in the course of the lymphatics leading to the nearest glands:
similar phenomena also occasionally occur in the course of the
veins. These general and local symptoms, with exception of a cer-
tain degree of tumefaction of the part, disappear in a few days.
Then, after irregular intervals, the same train of symptoms recurs
from time to time ; and after each attack, the affected part is left
more tumefied and indurated, till finally it attains that great in-
crease of bulk, to which it owes the designation elephantiasis.
The cutaneous surface is left of a pale yellowish or livid colour ; it

ELEPHANTIASIS. 699

is often scal}^, rough or fissured, and covered with soft vegetations
or horny excrescences, and more rarely is ulcerated. In other cases
the surface is traversed by enlarged veins. In the advanced stages,
deep-seated suppuration, with offensive discharge and sphacelus,
may take place in different parts of the diseased mass, or in the
enlarged lymphatic glands in its proximity : sometimes a milky-like
fluid oozes in considerable quantity from the hypertrophied papillae
of the skin, and generally coagulates spontaneously into a gelatinous
mass.

Pathology. — From the circumstance of the local affection being
preceded by febrile excitement*, being liable to frequent recurrences,

* Since these remarks appeared in the first edition of this work, a report on
" Elephantiasis as it exists in Travaneore," has been published in the ninth number
of the " Indian Annals of Medicine," by Mr. "Waring, in which the primary character
of the fever and the secondary character of the deposits is advocated. Dr. Ballingall,
in the fourth number of the new series of the "Transactions of the Medical and Phy-
sical Society of Bombay," dissents from Mr. Waring' s views, and regards the local
affection as the primary morbid state, and the fever as symptomatic, and he thinks that
the solution of this question has an important bearing on the surgical treatment of
elephantiasis. Dr. Ballingall justly does not attach much importance to conclusions
drawn from the mere statement of native patients, and he states that his own
experience, which he admits to have been limited, does not support the view of
periodicity of the attacks of fever and deposit. The fact that fever has ceased to
appear in his cases of elephantiasis of the scrotum, after removal of the tumour, seems
to him also a valid reason for concluding that the affection is local.

I still retain the opinion indicated in the text, that the disease is endemic, the fever
primary, and the deposit secondary — just as the albuminous deposits in the liver and
spleen are secondary on recurring intermittent fever. Further, that by preventing
the fever in its early stages by suitable treatment and change of air, the deposits
may be prevented in a great many cases. The argument in favour of a local origin
from the circumstance of fever not returning after removal of the tumour, must, it
seems to me, be received with much reservation. First, there should be a complete
history as to the dm'ation of the local affection, the locality of its origin and progress,
as bearing on the likelihood of the return of fever at the locality, of operation.
Second. The existence of a large scrotal tumour is sufficient in a malaria-tainted
constitution to determine recurrences of fever, with a frequency that may admit of
being materially lessened by removal of the tumour, irrespective of considerations
relating to changes in the locality of origin, progress, and surgical operation.

Mr. Waring also, it seems to me, attaches too much importance to the likelihood of
return as an argument against surgical interference ; for thou^gh the treatment of the
constitutional state cannot receive too much attention after the operation, still it
must be remembered that, in the instance of the scrotum, the deposit has probably
selected that part in consequence of the favouring influence of anatomical conditions of
structure and position, and that, when the tumour is removed, the conditions which
favoured its origin have also ceased to exist, and therefore the return of the tumoiu'
becomes improbable. Why elephantiasis of the leg is common in some places, and that of
the scrotum in others, I do not know. But the fact is so, and is practically important
in forming an estimate of the chances of return of elephantiasis in other parts after the
removal of a scrotal tumoxtr.

There is still room for further accurate clinical research in this disease.

700 BLOOD DISEASES.

consisting of inflammatory action in particular tissues, and leading
to peculiar results, elephantiasis may be regarded as a blood disease.
An exudation of liquor sanguinis takes place into the interstices of
the afifected structure, and the lymph becomes formed into fibrous
tissue of low organisation. On examining the diseased parts after
death, the epidermis and the cutis are found thickened, sometimes
to the extent of half an inch and more. The subcutaneous areolar
tissue is either hypertrophied in a less degree than the cutis, or it
has a semi-liquid gelatinous matter deposited in its areolae. The
microscopic appearances of this abnormal fibrous and elastic tissue
are described and figured in an interesting account of this disease
published by Professor Allan Webb.* The muscles are in general
pale, thin, or softened.

By some pathologists, as Dr. T. A. Wise f, elephantiasis is sup-
posed to originate in inflammation of the veins, preventing the free
return of blood from the affected part ; but this opinion is not
generally concurred in. The more probable view is, that the
thickening of the coats of the veins, the state sometimes of dilata-
tion, at others of contraction of these vessels, are due to the influ-
ence of the lymph exudation and organisation, and the varying
necessity, hence arising, for freer channels for the return of an
abnormal quantity of blood. A marked difference between the
pathology of Leprosy and Elephantiasis is, that in the former
there is a more general and extensive exudation deposit, and a
greater deviation in it from the blood plasma, as is shown by its
readiness to undergo softening, ulceration, and gangrene.

Causes. — Elephantiasis would seem to be related to particular
localities ; to be most common in damp, low situations, near to the
sea, in warm climates. It has also been supposed that the use of
fermented ■ toddy is favourable to its production, just as wine and
beer are to that of gout.

Treatment. — It is of great consequence to note the earliest
indications of this disease ; to treat the febrile symptoms on ordi-
nary principles with emetics, purgatives, diaphoretics, and rest,
and the local inflammation by evaporating lotions and position.
After the febrile attack and the coincident local phenomena have
been removed, then the indication of cure is to elevate the general
health, to prevent recurrences of fever by the use of quinine, and,

* " Indian Annals of Medical Science," No. 4.

t The veiy instructive observations on Elephantiasis by Dr. Wise, will be found at
p. 156, of the seventh volume of the " Transactions of the Medical and Physical
Society of Calcutta."

SCURVY. 701

wlien practicable, to have recourse to change of locality. It is
very important to follow this course of treatment, for when con-
siderable hypertrophy of these fibrous tissues has taken place, their
restoration to a normal state is beyond the resources of medical
art. By compression with bandages, friction, and iodine applica-
tions, the bulk of the affected part may become diminished to
some extent; but this result is consequent on the absorption of
the liquid inter-areolar effusions, not the removal of any part of
the abnormal fibrous tissue.

The question of the removal by surgical operation of parts
affected with elephantiasis, is the only remaining practical con-
sideration. Elephantiasis of the scrotum has of late years been
very frequently the subject of surgical operation, and much suc-
cess has attended the proceeding. It is to Brett, Esdaile, Allan
Webb, Shircore, and Baboo Permanand Sett, that we are chiefly
indebted for the elucidation of this department of surgery in
Bengal *, and to Dr. Ballingall in Bombay.

Section V. — Scurvy, — Prevalence in India, — Short practical

Remarks,

The admissions from scurvy into the European Greneral Hospital
at Bombay, during the fifteen years from 1838 to 1853, amounted
to 618, and the deaths to nine. Those of the first five years of
this term, the period of my service in the hospital, were 182 in
number, being 2*4 of the total hospital admissions: of these, none
proved fatal. These cases were almost exclusively of seamen from
merchant ships, generally small class vessels, badly found, having
made long voyages, and belonging to English or Scotch provincial
ports. But, in all probability, it will be found that of all ships
which trade to our Indian ports, scurvy appears most frequently in
coal ships — of these many arrive yearly at Bombay as well as
Aden — and this result might have been anticipated, for their
voyages are generally long, and cleanliness is out of the question.

* It was in tlie removal of these scrotal tumours that mesmerism was practically
applied by Dr. Esdaile, and afterwards by Professor Allan "Webb, and a small hos-
pital was established for the purpose in Calcutta. The Mesmeric Hospital still
existed at the time of my visit in 1853, but chloroform as an anaesthetic had displaced
mesmerism ; and, though endeavours were made, with much courtesy and kindness,
to show me the mesmeric effects, they proved unsuccessful. I witnessed the dexterous
removal of these tumours by Mr. Shircore and Baboo Permanand Sett, and several suc-
cessful cases in various stages, after the operation. For details relative to the
operation, I would refer to Mr. Webb's and Dr. Ballingall' s papers already ad-
verted to.

702 RLOOD DISEASES.

in the report of the European General Hospital for the year
1851 *, Dr. Stovell makes somewhat similar observations on the
cases of scurvy for that year.

During the six years from 1848 to 1853, 364 admissions of
scurvy took place into the Jamsetjee Jejeebhoy Hospital: of these,
sixty-four died. A considerable proportion of this class of patients
had been labourers on the public works at Aden ; and among these
many deaths occurred from extensive scorbutic, sloughy ulceration,
chiefly of the lower extremities. Consequent on improvement in
the regimen of these public servants at Aden, there was, during
the last three years of the term, a considerable diminution in this
great but remediable evil.

In the years 1853 and 1854 admissions of scurvy began to take
place from a quarter altogether different.

In consequence of the desertion of European crews from ships
at Melbourne, for the Australian gold diggings, Lascars were
shipped in numbers from Calcutta to supply the deficiency.
Arriving at Melbourne, after a voyage of two or three months,
they were transferred to the deserted ships, and again soon
sent to sea. Ships with these Lascar crews, in a very scorbutic
state, have arrived at Bombay, and doubtless at other ports also.
I am not aware whether these events continue to occur, but if so,
it is clearly the province of the magistrate to enforce the regula-
tions relative to the shipment of Indian Lascars to other countries,
or, should these be insufficient, to bring about their revision and
change.

The general historical details of scurvy are of great interest,
but they need not be repeated here ; nor is it necessary to detail
the symptoms.

In regard to the ^pathology, I would only observe, that scurvy
escaped the solidism of Cullen, and has always been regarded
as a blood disease. The particular nature of the changes in
the blood are now very little better understood than in the days
of Huxham and Lind. The water and fibrine are in excess, the
red corpuscles defective, and the other constituents within the
normal range. These, I apprehend, are all the positive facts which
chemists, at the present time, can advance in respect to the blood
in scurvy.

I shall conclude my notice of this disease with the following
practical observations : —

* "Transactions Medical and Physical Society of Bombay," November 10.

SCURVY. 703

1. Scurvy is caused by defects in diet, which involve deficiency
in the quantity and variety of the alimentary principles, essential
to the healthy constitution of the blood.

2. The defect is by some attributed to absence of organic vege-
table acids ; by others, to insufficient proportion of sulphur, phos-
phorus, potash, or vegetable albumen.

3. Whatever the explanation may be, the practical fact remains,
that a diet with a just proportion of azotised nutritive principles
and succulent vegetables, is that which prevents scurvy, and effects
its cure. The curative effect of a suitable diet is increased by the
use of acid fruits or vegetable acids, of which the citric is the best.
The bad effects of an unsuitable diet are lessened by the use of
vegetable acids or fruits.

4. Dr. Christison attributed the occurrence of scurvy in the jails
of Scotland, in 1845 and 1846, to a reduction in the proportion of
milk in the dietaries. That milk is a necessary part of an anti-
scorbutic diet for the adult, is sufficiently disproved by the fact,
that it does not form a part of the dietary of the British navy. On
the other hand, that milk is an efficient anti-scorbutic under certain
circumstances, is evident : were it otherwise, scurvy would be very
common in children under two years of age.

5. A review of all these facts seems to justify the practical state-
ment, but nothing more, that a diet adequate to prevent and to cure
scurvy, should consist of a suitable and varied combination of the
albuminous, saccharine and oleaginous principles, with the salts
usually associated with them. Milk, as was first observed by Prout,
is a typical combination of these principles appropriate for the
early periods of life ; therefore it is not improbable that Christison 's
statement is correct, that the reduction of the proportion of
milk in a particular dietary is likely to affect its anti-scorbutic
properties.

6. The phenomena of scurvy are well marked, but it is reason-
able to infer that the changes in the blood take place gradually,
and that they are present in some degree, before they attain to
that which occasions the well-known scorbutic symptoms. This
consideration is practically important, from the wide range
which it justifies us in giving to a scorbutic taint as a condition
predisposing to various forms of disease.

7. I have frequently adverted to certain debilitating influences
as predisposing causes of disease generally. The influences alluded
to are exposure to cold or wet, elevated temperature, malaria,
vitiated atmosphere, inattention to cleanliness, over fatigue of body,

704 BLOOD DISEASES.

anxiety and depression of mind, previous diseases, &c. These are
also predisposing causes of scurvy, and as such are often influential
in favouring the development of the disease ; but it will not occur
under their influence without the exciting cause of unsuitable diet.

8. If the conditions just enumerated predispose the system to
attacks of scurvy, it may readily be understood that the opposite
conditions — viz. absence of cold, wet, heat, malaria, and defective
ventilation, with attention to cleanliness, cheerful occupation of
mind, and avoidance of bodily fatigue, must fortify the system
against the influence of the exciting cause when operative, must
tend to keep off the disease for a time, and to lessen its severity
and hasten its cure.*

9. It is very useful, with reference to a right understanding of
the etiology and prevention of scurvy, to appreciate justly this
distinction between predisposing conditions and the exciting cause
of scurvy, and to estimate truly their relative importance.

Section VI. — General Dropsy. — Beriberi. — Symptoms. —
Pathology. — Treatment. — Illustrative Gases.

The occurrence of general dropsy in connection with renal and
cardiac disease, has been already considered, but the affection is
not confined to these circumstances. Cases of dropsy related to a
very asthenic state, as that proceeding from frequently-recurring
malarious fever, are not unfrequent in India. But my principal
object, in this section, is to describe a train of dropsical symptoms
to which writers on tropical disease have for a long time applied
the term *' Beriberi."

Beriberi. — The unnecessary introduction of this word into
Indian nosology has served to retard and obscure our know-
ledge of the pathology and treatment of general dropsy, as it
presents itself to our notice in the natives of India. In the
month of February 1851 I called the attention of the Medical
and Physical Society of Bombay to this subject, and explained
the opinions on beriberi which I had been in the habit of stat-
ing to the students of Grrant Medical College. In June 1853
several cases of beriberi were admitted into the Jamsetjee Jejeebhoy
Hospital, and were carefully observed by me. They confirmed

* A large proportion of the men of the German Legion, sent from the Cape of Good
Hope to India, were on arrival at Poona in N'ovember and December 1858, tainted with
scurvy, from unsuitable food at the Cape. Some of them improved during the voyage,
^nd all did so very rapidly at Poona, under the influences adverted to in the text.

BERIBERI. 705

the opinions which I had previously expressed on the pathology
of this affection.*

I shall first describe the symptoms of beriberi, then explain the
views on its pathology which I have long entertained, and finally
narrate the circumstances connected with the hospital cases above
adverted to.

The symptoms sometimes advance gradually, but at other
times suddenly appear. When they have been gradual in their
approach, the individual experiences for several days a sense of
weakness, and inability, or unwillingness to exert himself, and
shortly afterwards pain, numbness, stiffness, with more or less
oedema of the lower extremities. There is also some degree of
dyspnoea present, with a sense of oppression and weight at the
epigastrium. The oedema is not confined to the extremities, but
extends to the trunk and face, and occasions a puffed and bloated
appearance. The weakness of the limbs and the dyspnoea are
particularly complained of on motion. As the disease advances,
the difficulty of breathing increases, the face becomes more swollen,
and the lips livid. The limbs become almost paralytic, the oppres-
sion at the epigastrium is aggravated, frequent vomiting takes
place, and the ejected matters are sometimes mixed with blood.
The urine is scanty and high-coloured, sometimes almost sup-
pressed, the thirst is great ; the pulse, at first quick and small,
or unaffected, becomes irregular, intermittent, and fluttering.
Palpitations are experienced, attended with a sense of suffocation,
a sinking pulse, and death. These symptoms may run their course
in from two to three weeks ; or the progress may be much more
rapid, and when so, the numbness, the stiffness, and oedema of the
lower extremities become quickly followed by the dyspnoea, the
palpitation, and the sinking pulse.

These are merely the usual phenomena which attend on serous
effusion into the connecting areolar tissue of the extremities, the
cavity of the abdomen, the pleura, the pericardium, or into the air
cells of the lungs, and their connecting areolar tissue — in other
words, the symptoms of general dropsy more or less extensive, more
or less qiTickly forming. Dr. Watson, in his excellent lectures,
thus writes of dropsy : — " Now from whatever cause this watery
condition of the whole body may arise, the effects resulting from

* In August 1853, "Kemarks on the Pathology and Treatment of Beriberi," were
presented by me to the Medical and Physical Society, and published in the 2nd Number
of the "Transactions," New Series.

Z Z

706

BLOOD DISEASES.

the presence of the ivater are the same : and of what do patients in
this state usually complain ? Why, of shortness of breath and pal-
pitation of the heart ; of a sense of impending suffocation if they
attempt to lie down or actively to bestir themselves ; of tightness
and distress across the epigastrium, relieved somewhat by eructa-
tion, augmented by food and drink ; of weight and stiffness of the
limbs, and sometimes of drowsiness."

The morbid appearances found after death in fatal cases of
beriberi are anasarca, oedema of the lungs, hydrothorax, hydro-
pericardium, ascites, and cranial effusion. In some cases, traces
of old or recent inflammation of internal viscera exist ; but these
constitute no essential part of the disease. It was the opinion
of Dr. Malcolmson, entertained chiefly on account of the supposed
paralytic symptoms, that the chief part of the disease was in the
spinal cord or its membranes. This idea, however, cannot be sus-
tained. Beriberi is a general dropsy ; and in order to understand
its pathology, let us call to mind the circumstances in which
general dropsy usually occurs.

There is one form to which the name active has been given : it
arises when the surface of the skin, after free exhalation, has
become suddenly exposed to cold. The excretion of water by the
skin is checked, the blood is driven inwards, and the kidneys from
some cause or other do not take on their compensating action —
they become congested, and general dropsy with scanty urine is the
result. Active dropsy, under these circumstances, implies a certain
amount of fulness of the vessels. There are several varieties of
passive general dropsy, depending on different deranged conditions

— on congestion of blood, local or general, on disease of the heart
or of the lungs, or perhaps merely on feeble action of the heart,
and also on disease of the kidneys. Passive dropsy, more parti-
cularly when related to diseased kidney, more surely occurs when
cold or wet is applied to the surface of the body, and the excretion
of water by the skin thereby impeded. Again, dropsy may arise,
not from disease of the heart or lungs or kidney favouring conges-
tion, but from blood deteriorated and abounding in watery consti-
tuent ; and here, too, the onset of the dropsy will be favoured by
the action of external cold upon the cutaneous surface. If diseased
heart, or lungs, or kidneys, or blood too dilute, or vessels too full
of blood, in their separate influences, lead to dropsical effusion,

— how much more surely will this result take place if two,
three, or more of these conditions are associated together — if,
for example, we have disease of the kidney and of the heart com-

BERIBERI. 707

biued ; or if we have the vessels tolerably full of blood, with excess
of watery constituent, circulated by a feeble heart, and the
sufferer in both instances be exposed to the influence of external
cold.

Beriberi is, in my opinion, a general dropsy of this complicated
character. A state of the system in which the blood is sufficient in
quantity, and its water in undue proportion, is the predisposing
condition ; and cold or wet is the exciting cause : no doubt in some
instances the effusion is further favoured by co-existing heart, lung,
or kidney disease. But how does this state of the blood arise ? It
is present in the scorbutic diathesis, and this constitutional con-
dition may exist to some extent before the phenomena characteristic
of scurvy appear. Let it further be remembered, that impaired
irritability of muscular fibre, that of the heart included, is among
the early derangements of the scorbutic state. We have thus as
predisposing conditions of dropsy, not only watery blood, sufficient
in quantity, but also propelled by a feebly acting heart. Let us
suppose an individual in this state to have the surface of the body
exposed to an atmosphere cold and damp, or to the chilling influence
of piercing winds, and we have a combination of circumstances
surely adequate to predispose to and excite general dropsy — the
more certainly if the skin has been previously actively perspiring,
and the kidneys, from congestion or structural defect, do not
readily assume a compensating action.

The circumstances in which beriberi has usually appeared justify
this view of its pathology. The disease always attacks many of a
community, and has been chiefly observed in Ceylon, on the Malabar
Coast, in the Circars, and among Lascars in ships on the adjacent
seas. There has been much written on it by army surgeons in
Ceylon, and by medical officers of the Indian army — Dr. Malcolm-
son and others, and more lately Mr. Carter ; — but, on the whole,
there is a want of fulness in the descriptions on the points on which
accuracy is chiefly desirable. There is too much dwelling on
symptoms, not difficult to understand, and too little of precise
statement on important etiological conditions. I would except,
however, Mr. Carter's excellent paper*, which contains much
useful information. Notwithstanding these general defects there
is still sufficient in the narratives to countenance the opinion
that beriberi, more particularly in its acute form, occurs usually
in persons favourably circumstanced for the development of a

* " Transactions, Medical and Physical Society of Bombay," No. 8.
Z z 2

708 BLOOD DISEASES.

scorbutic taint, and subsequently exposed to cold dry or moist
winds, or to lying on the ground wet with rain or dew, while
the body has been inadequately protected with clothing. The
practical view to take of each separate case of beriberi is to
regard it as a general dropsy, and to investigate it in the method
observed in other cases of general dropsy. We should inquire into
the state of the heart, the lungs, the kidneys, the condition of the
blood ; and carefully review the circumstances in which the indi-
vidual has been placed, with the object of ascertaining whether he
has been exposed to predisposing and exciting causes of dropsy. It
is by keeping distinctly in view the general pathological principles
involved in this inquiry that we may hope to reconcile the seeming
contradictions of the confused details of which the accounts of this
disease are for the most part composed. To me then it seems that
beriberi is a general dropsy, and that in regard to each instance, the
question ought to be, what is the pathology of this case of general
dropsy ? Grenerally it will be found that a scorbutic diathesis and
external cold or wet are the determining conditions.

The symptoms, the pathology, the causes of beriberi have been
discussed. The treatment need not detain us long. It resolves
itself into prevention and cure. If it be true that a scorbutic
diathesis is the predisposing condition, then attention to the means
which are preventive of scurvy will also prove preventive of beri-
beri; and if external cold be the ordinary exciting cause, then
attention to clothing and avoidance of exposure are most important
sanitary measures.

The treatment of the disease when fairly formed should accord
with the principles observed in general dropsy. In the acute
forms of dropsy in a sthenic habit, with excited vascular action,
there may be scope for general blood-letting, but it can be only
under such conditions of the general system and of the circulation
that this measure can be admissible, and these will not, I appre-
hend, be often found present in beriberi. In other cases of dropsy
in which vascular action is not depressed, in which there is no irri-
tation of the gastro-intestinal mucous lining, we may endeavour to
reduce the effusions — by active purgatives, as elaterium, or other
members of this class. Then there are other instances in which
cathartics are unsafe, and diuretics are the chief remedies to be
trusted to. Cases also occur in which the action of the heart is
depressed, and in these stimulants must be given at the same
time with diuretics. Nor may we forget that the skin is some-
times an appropriate channel by which to lessen the water of

BERIBERI. 709

the blood, and favour the absorption of dropsical effusions. The
vapour bath, or the hot air bath may be used with this view. In
the treatment of beriberi general blood-letting, purgatives, diuretics,
and stimulants have been recommended. But if the pathology and
therapeutics of dropsy have been rightly explained, then there is
no special method of treating beriberi. The means which are the
best in one case may be the worst in another.

Beriberi as observed in the Jamsetjee Jejeebhoy Hospital in
June 1853. — In the month of June 1853, four cases of beriberi
w^ere received into the Jamsetjee Jejeebhoy Hospital. The suf-
ferers were Lascars, belonging to a ship which had just arrived
from sea. Many others of the crew had also suffered. One indi-
vidual died on his way from the ship to the hospital, and an
inquest was held on the body. The expediency of eliciting
information relative to the length of the voyage, and the manage-
ment of the crew, was suggested by me to the coroner. I shall
first quote the deposition of the captain of the ship; then state the
important facts of the cases admitted into hospital ; and finally
inquire whether they confirm or not the view which has already
been taken by me of the pathology of the disease : —

William Eames, on being duly sworn, says : — I am master of the ship Faize
Allum, of the port of Bombay, and have been constantly commanding, or been
chief officer of vessels trading out of Bombay, with a Lascar crew, since the year
1838. I last left Bombay on the 3rd day of June, 1852, with a Lascar crew of
sixty-five men and boys ; and the deceased, Bhana Moorar, aged about forty years,
and deceased Jadow Dewa, aged about twenty-five years^ both Hindoos, formed
part of the crew. We proceeded from Bombay to Singapore, and from thence to
Siam, and returned from thence to Singapore, and so back again to Siam ; and from
thence to Singapore, which place I quitted for Bombay on the 3rd March this year,
expecting to make the voyage in seven weeks, the average passage being about two
months. I had on board curry-stuff, rice-water, dall, ghee, salt, &c., as pi'escribed by
the regulations, with a good supply of water ; and during such time as the ship was in
harboiir always supplied the crew with greens, fresh fish, and fresh provisions. The
crew all remained healthy tUl about the 21st day of May last, in latitude 10° N.,
longitude 64° W. We had then been two months and eighteen days at sea. On the
15th day of April I was within about seventy miles or thereabouts of the island of
Ceylon ; but being unable to stand the strong current and west winds then blowing,
after consulting with my Serang and chief officer and passengers, I determined on re-
linquishing the attempt to get round Ceylon, and bore away for the line, to come up to
Bombay by the southern passage, round the Laccadives and Chagos, and ran to the
south of the Hne as far as 8° 49', and then to the westward as far as 63° W., and
crossed the line again, running north, about the 6th or 7th May, and during most of
the time had rain and squalls. Most of the water having been consumed, we fiUed
up the water casks with rain water, collected on the surface of a clean awning. After
making the line on the 6th of May, we had light weather, with occasional squalls and
constant rain, and came on with the S.W. moonson up to 16° N. latitude on or about
the 2nd June, and arrived in the harbour of Bombay on the 6th June, I consider that
I first fell in wiih the S.W. monsoon about three degrees north of the line. The crew

Z Z 3

710 BLOOD DISEASES.

were all healthy up to the 21st of May. When in latitude 10"^ N., longitude 64° W.,
symptoms of disease first showed themselves. The deceased Jadow Dewa complained
of pains in his feet, and loss of strength down the legs, and pain in the chest, with
difficidty of breathing, and constipated bowels. I gave him jalap and cream of tartar,
and to rub on the chest hartshorn, laudanum, and sweet oil. The crew since the 15th
of April had been on reduced allowance of about ten pounds in ninety pounds of rice,
fish and water full allowance, the latter being rain water. Between the 21st day of
May and 6th June, eight other men were seized in the same manner, and aU died ; the
average suiFering about four or five days ; a Portuguese sepoy died in three days. The
deceased Jadow Dewa appeared to be recovering fast, and left the ship on the evening
of the 6th of June. Bhana Moorar also appeared convalescent, and left the ship in
my dingy. AU the survivors of the crew are landed, the voyage being completed.
The passengers, twelve in number, natives, and myself and officer, and the majority
of the crew, are M^ell. We drank the rain water very freely, and I believe the deceased
died of a disease caUed the beriberi of Ceylon. I had a good medicine chest on board,
and treated those taken ill according to the instructions laid down in Dr. Thomas'
book of medicine. We had no liquor on board the ship. I offered the crew pickles
and vinegar, and also sugxir, but they refused to eat it. The passengers and myself
used pickles, sugar, and vinegar freely, but the crew declined till latterly. The whole
number who were attacked were about thirty-five, of whom ten have died. We were
in the latitude of Cochin when the disease first appeared, and were about 10° to the
westward of the coast of India, with light N.W. and N.E. winds. The crew were pro-
tected from wet as far as possible. The disease attacked persons of all ages, but
principally the old and more infirm of the crew. Further I know not. The cargo
consisted principally of sugar in bags, of Mailing ivory, teak wood, plant and sapan
wood, and raw silk. The hatches were kept constantly open when the weather would
permit, the forecastle well cleansed and fumigated with powder burnt and benjamin."
The jury returned the following verdict : — "Deceased died of beriberi."

275. Beriberi. — Eecovery. — Purshotum Zeena, a Hindoo kalasee, of the ship Faize
Allum, twenty-five years of age, a man of stout frame, was admitted into the Jamsetjee
Jejeebhoy Hospital on the 7th of June, 1853. He had been ill sixteen days. The
feet, legs, and thighs were oedematous, and, in consequence of the stiffness of the thighs
and groins from the swelling, he walked with a waddling gait. The pulse was easily
compressed. There was no abnormal dulness of the prsecordial region, and the sounds
of the heart were normal. The bowels were rather confined, and the urine scanty.
He complained of uneasiness at the epigastrium and the hypogastrium. There was no
vomiting ; the tongue was not coaled, but was rather florid. There was no sponginess
or discoloration of the gums. He continued in hospital till the 27th Jun,e, when he
was discharged well. For some days after admission he complained of uneasiness and
sense of weight at the epigastrium, and there was abnormal dulness on percussion, to
within two inches of the umbilicus. The urine showed no trace of albumen. He was
treated with occasional doses of compound powder of jalap, the anti-scorbutic mixture
of the hospital, a diet with fresh vegetables, and lemonade, and a small allowance of
arrack. Under this treatment the dropsical symptoms and the fulness at the epigas-
trium disappeared, and he left the hospital quite well.

276. Beriberi. — Slight discoloration of the ff urns. — Eecovery. — Bhowan Rama, a Hindoo
kalasee, of the ship Faize Allum, thirty-five years of age, and of stout frame ; iU for
fifteen days. The legs, thighs, and feet were very anasarcous, and his gait waddling
from the stiffness of the legs and groins. The pulse was very feeble, and the urine
scanty. He had uneasiness at the epigastrium, but no dyspnoea, except after walking.
The sounds of the heart were normal, and there was no dulness of the prsecordial or
other regions of the chest, and the respiratory murmur was distinct ; the tongue moist
and without fur ; the gums discoloured, but not swollen ; the teeth felt tender on

BEKIBERI. 711

eating ; urine not albuminous. The treatment followed was the same as in the first
case, with the addition of the occasional use of the warm bath. He was discharged
well on the 27th June.

277. Beriberi. — Anasarca. — Death. — No kidney disease. — Liver congested. — Cavities
of the heart full of thin blood,— Y\s,v&m. Narrayen, a Hindoo kalasee, of the ship
Faize Allum, twenty years of age, ill fourteen days, was admitted into the Jamsetjee
Jejeebhoy Hospital on the 7th June, 1853. There was general anasarca. The pulse
was feeble. There was no abnormal prsecordial dulness ; the sounds of the heart were
normal ; there was slight fulness of the abdomen ; no swelling of the gums. On the
8th and 9th the pulse became feebler, and the breathing oppressed ; the urine was
very scanty, but showed no trace of albumen. He died on the afternoon of the 9th.
He was treated with stimulants — ammonia and arrack. The body was examined two
hours after death, and Mr. Lisboa has favoured me with the account of the appearances.

Head. — On opening the cranium, about five ounces of serous fluid oozed out. The
structure of the brain, cerebellum, pons Varolii, and medulla oblongata was healthy.
The ventricles of the cerebrum contained the normal quantity of fluid. Chest. —
The cavity of the chest contained only two ounces of thin transparent fluid. Both
lungs collapsed freely, and their structure was healthy ; they showed no appearance
of cedema. The heart appeared slightly enlarged. On opening both the right and
left cavities, they were found to contain a thin red fluid and a few soft red coagula of
blood ; the fluid in the right ventricle was frothy. Abdomen. — The abdominal cavity
did not contain more than two ounces of thin transparent serous fluid. The peritoneal
siu'face of the intestines was of reddish colour from congestion ; all the abdominal
viscera were more or less congested, but their structure was healthy. The liver pre-
sented appearances of congestion more than any other organ ; from its incised surface
fluid blood flowed freely.

278. Beriberi. — Anasarca. — Gums discoloured, — Hydrothorax. — Fatal. — Cavities of
the heart full of fluid blood. — Jadow t)ewa, a Hindoo kalasee, of the ship Faize
Allum, twenty-five years of age, ill sixteen days, was admitted into the Jamsetjee
Jejeebhoy Hospital on the 7th June, 1853. There was general anasarca, the abdomen
was rather full, and distinctly fluctuating ; the breathing was oppressed ; there was no
abnormal prsecordial dulness ; the sounds and action of the heart were irregular. He
complained of pain at the epigastrium ; the pulse was very small, and the skin
coldish ; the gums were discoloured, but not swollen. He died on the morning of the
8th. The body was examined five hours after death; and I am indebted to Mr.
Lisboa for the account of the appearances.

Head. — On removing the calvarium, about five ounces of thin serous fluid oozed
out. The structure of the brain, and of the other contents of the cranium, was
healthy. The ventricles of the cerebrum contained a little more than the normal
quantity of thin transparent serum, with a few bubbles of air. Chest. — Both cavities
contained about twelve ounces of serous fluid. The right costal pleura adhered to
the visceral, by means of old bands of areolar tissue, which was also infiltrated with
serous fluid, except at the lower part of the chest, where there was a sort of sac,
holding about four ounces of serum. The left lung collapsed freely. The structui-e
of both was healthy, except that it appeared to be slightly compressed. On pressing
the incised surface, a small quantity of frothy serous fluid oozed out. The heart was
apparently enlarged (dilated) ; both auricles and both ventricles were distended with
fluid blood, and some few soft red coagula. The fluid in the right ventricle contained
a few bubbles of air. The structure of the heart was healthy. All the abdominal
viscera were more or less congested, but otherwise they were healthy. The peritoneal
lining of the abdominal cavity, and that covering the intestines, presented a reddish
appearance. The blood, examined under the microscope, showed a normal state
of the corpuscles,

Z Z 4

712 BLOOD DISEASES.

The circumstances in which beriberi made its appe^-rance in
the ship Faize Allum were certainly confirmatory of the view
which I had taken of the pathology of this disease. The ship had
been two months and eighteen days at sea. The crew were for the
last month on somewhat diminished rations, and at no period did
anti-scorbutics form part of the dietary. The weather was bad, and
there was exposure to fatigue. The disease appeared on the 21st
May. The weather during the fifteen days preceding had been
wet and squally. Of a crew of sixty-five, thirty-five were attacked,
and ten died. The officers and passengers of the ship did not
suffer from the disease : they used antiscorbutics freely, and we
may assume, at least as regards the passengers, that they were not
exposed to the inclemencies of the weather ; and as regards the
officers, that they were by clothing better protected than the
Lascars.

It is true that in the four cases which came under my observa-
tion in hospital, the external phenomena of scurvy were not
present : in two the gums were discoloured, but not swollen and
spongy. But in order to explain the pathology of the disease the
actual presence of scorbutic phenomena is not necessary. The
diathesis is doubtless of gradual formation, and requires, in all
probability, the influence, for a considerable time, of the conditions
which induce it, before the characteristic symptoms of scurvy
appear. Nor can it be questioned that the changes which the
blood is slowly undergoing in the gradual development of the
scorbutic state must predispose to derangements of various kinds,
— must, for example, be favourable, on the surface of the body
becoming chilled, to the occurrence of internal congestions with
dropsy and occasional haemorrhage. It is, indeed, only when
the diathesis is partially formed, that we are likely to meet with
beriberi, for it is not probable that sailors really scorbutic will be
fit for duty, and exposed to wet and squally weather.

Though the acknowledged characters of scurvy were absent in
these cases, still there were facts which showed that the diathesis
existed in some degree. In both the fatal cases the blood was
found more or less fluid after death. In all the cases the feeble
action of the heart was very remarkable : in three— the two suc-
cessful cases, and one fatal — this could not be attributed to thoracic
dropsical effusions, for in none of them was there oedema of
the lungs, or effusion into the pleui*a or pericardium. Again, in
the two fatal cases, all the cavities of the heart were dilated and
filled with blood, showing that the circulation had ceased from

BEIIIBERI. 713

failure of irritability of the muscular fibre — that death had been
by syncope. This defective irritability of the heart points to
something in the pathology of the disease, in addition to the drop-
sical effusions ; and, perhaps, there is no condition of the system
more generally characterised by impaired irritability of muscular
fibre than the scorbutic. There is no fact more familiar in the
history of disease than occasional sudden death by syncope in
patients affected with scurvy.

There are other considerations of interest in these cases. A sense
of weight and uneasiness at the epigastrium is a common symptom
of beriberi: in one of the successful cases enlargement of the
liver was evident on percussion, and in both the fatal cases a
congested state of this organ was well marked. This symptom, then,
is probably due to congestion of the liver. This congestion, with
the altered state of the blood, also explains the occasional occurrence
of haematemesis in beriberi. In these cases there was no disease
of the heart or kidney. •

The principles of prevention and treatment are sufficiently
clear. By suitable dietaries, to prevent the formation of the
scorbutic diathesis ; by suitable clothing, as far as practicable,
to protect the crew from inclement weather. In regard to treat-
ment : (a.) the use of antiscorbutic regimen and remedies ;
(6.) to regard the feeble pulse as a condition independent of the
dropsical effusions, and to give stimulants more or less freely ; (c.) to
remove the dropsy by purgatives or diuretics, being guided
to the use of the one or the other by the state of the pulse;
(d,) to increase the cutaneous capillary circulation by friction and
warm clothing. The hot air bath or warm water bath requires
caution, in consequence of the increased depression of the heart's
action which follows transient excitement from these means.
They had better not be regarded as part of the regular treatment
of the disease. I attach great importance to the fact, which
these cases clearly establish, that the feeble pulse is not con-
sequent on the functions of the heart or lungs being interfered
with by serous effusions, but is dependent on impaired irri-
tability of the fibre ^ — one of the phenomena of the scorbutic
diathesis. We shall therefore be disappointed if we expect the
power of the heart to improve by the mere removal of the
dropsy by purgatives or diuretics. The use of stimulants must
go hand in hand with that of these evacuants ; indeed must
in many cases, in advanced stages, be the only safe measure.
While we keep up the action of the heart, and remove the effu-

714 BLOOD DISEASES.

sions, it is, if these pathological doctrines be correct, also a very
important indication to improve the diathesis by antiscorbutic
means.

In the statistical report of the health of the royal navy for the
year 1856, ordered to be printed by the House of Commons, on the
26th July, 1858, mention is made of an epidemic dropsy which
prevailed in the ship Juno in the Australian seas, and the cause of
which appeared to be wrapped in mystery. There is no clinical
description of the dropsical symptoms — but from the terms " epi-
demic ascites" and " peritoneal dropsy" being used — it may be in-
ferred that the effusions were chiefly abdominal. The only account
of symptoms is the following : —

" In general the patients, amongst whom were a large proportion of the strongest men
in the ship, exhibited little or no constitutional disturbance, and, with the exception
of a sallow complexion or paleness of the whole surface, they presented no unusual
appearance. They, however, complained of mental depression, a feeling of uneasiness,
and a troublesome barking cough, which generally existed for some days or even weeks
previously to the attack."

The prominent facts were these : — The ship's company had been
victualled for a considerable time on salt provisions during the last
quarter of 1855. The ship returned to Sydney about the begin-
ning of January 1856, from a lengthened cruise amongst the
islands in the Pacific ; left Sydney on the 8th of March, reached
Hobart Town on the 13th ; sailed again for Sydney on the 28th,
and arrived on the 6th April.

During the stay of the Juno at Sydney, from January to 8th

March, three cases occurred. From the 16th to the 28th March,

at Hobart Town, eighteen cases. From the 6th April to 2nd June,

at Sydney, eight cases. There is a slight discrepancy between the

total of these figures, extracted from the report, and the following

summary : —

" The total number of cases of this singular malady put on the sick list between the
3rd January and the 2nd June, amounted to thirty : of these eleven were invalided
and nineteen returned to duty. Though no case terminated in death, they were all
exceedingly protracted, and the recovery in most instances imperfect."

The holds were free from offensive effluvia, and to the eye ap-
peared to be thoroughly clean ; but in cleansing the lower deck, the
wooden shot-racks, placed close to the sail lockers, were found
to be in a rotten state, and a quantity of dark, slimy matter was
discovered beneath. Notwithstanding the occurrence of cases,
long after the removal of these offensive matters, the surgeon con-
tinued of opinion that the disease originated from " a malarious
poison arising from the putrefaction of the vegeto-animal accumu-

RHEUMATISM. 715

lation on the lower deck, which had been imperfectly going on, and
injuriously affecting the health of the ship's company." The re-
porter objects to this view, that the persons most constantly en-
gaged in cleaning the holds were not attacked in greater number
than the rest of the ship's company; and that offensive effluvia,
or malaria, arising from similar collections of matter, have existed in
innumerable instances, both in houses and in ships, without pro-
ducing any disease of the same nature.

The two following further extracts from the report are, it seems
to me, conclusive as to the etiology and pathology of this disease : —

'* The assistant surgeon, in a well written report, observes, ' That although the bad
effluvia arising from the dirt and moisture under the shot racks might have had a
predisposing influence, he considered that the disease depended on causes producing a
morbid state of the fluids, which most resembled their condition in scorbutus.' "

The surgeon remarks : —

" A certain reduction of temperature appeared to be necessary for the development
of the disease ; for while the men in warm weather continued in the enjoyment of
tolerable health, on getting into cooler weather at Sydney and Hobart Town, the dis-
ease broke out in consequence of the cold rendering the poison more active, or the
people more susceptible, or probably from both causes."

The disease was clearly dropsy, excited by external cold in a
scorbutic diathesis — in other words Beriberi,

Section VII. — Rheumatism,— Prevalence in India,

The admissions under this head into the European General
Hospital at Bombay, during fifteen years, from 1838 to 1853,
amounted to 1457, and the deaths to six.

Of these 528, with four deaths, took place during the five years
of my service in this hospital, being 6*8 per cent, of the total
hospital admissions. The admissions were pretty equally divided
throughout the year : the greatest proportion, in the month of
February, 12*1 per cent., and the least, in the month of October,
3-6. By far the largest number were of chronic rheumatism,
traceable, in many cases, to a scorbutic taint or previous venereal
affection. In the treatment of rheumatism in India, as well as in
temperate climates, it is necessary to recollect the great tendency
to pericarditis and endocarditis.

Metastasis to the testicle was observed in several cases of chronic
rheumatism, — swelling and hardness of the organ coming on, fol-
lowed by cessation of the pain and swelling of the joints, which,
however, recurred on the alleviation of the orchitis.

716

BLOOD DISEASES.

In my remarks on pericarditis and affections of the heart, it
was explained, that though acute rheumatism is not of such
frequent occurrence in India as in European countries, yet
that it is sufficiently so to command our careful attention, more
especially as its relation to cardiac disease is quite as important in
the one country as in the other ; chronic rheumatism, however,
is much more common in India, particularly in natives. The
term is applied to pain in the muscles and joints, often without
much or any swelling of the latter, frequently attended with
irregular febricular disturbance, and very generally related to
scorbutic, malarious, syphilitic, or mercurial cachexia.

The admissions from rheumatism into the Jamsetjee Jejeebhoy
Hospital for four years, from 1848 to 1852, amounted to 1384 ; of
these 574 were registered as acute, and 810 as chronic. The
following tabular statement shows the prevalence in different years
and castes : —

Admissions and Deaths, from Rheumatism, in the Jamsetjee Jejeebhoy
Hospital at BombaTj, from 1848 to 1852, arranged according to Caste
and Sex.

Hindoos.

Mussulmans.

Christians.

Parsees.

Females.

Total. .

S
<

•o

•o
<

1848-49
1849-50
1850-51
1851-52

120

114

4
1
2
1

95
112
151
129

3
3

58
53
64
71

13
17
43
35

39
32
57
26

1
1

288
286
435
375

6
5
6
2

Total

389

487

246

108

154

1384

Section VIII. — On Snake- Bite,

My experience in snake-bite is exclusively confined to one
species, and to one period of my service in India. The observa-
tions which follow were published nearly in their present form,
in the year 1850.*

* " Transactions, Medical and Physical Society of Bombay," No. 10.

SNAKE-BITE. 717

In the years 1834 and 1835, while in medical charge of the
Convalescent Station on the Mahabuleshwur Hills, I made some
observations on the effects resulting from the bite of the phoorsa, a
small snake common on the hills, and known to the natives by that
name. The phoorsa snake is about a foot in length, the tail tapers
suddenly from about an inch from the end; the colour is olive
brown, of different shades, variegated with white : on the back and
sides there are olive brown lozenge^shaped patches ; the belly is
white, with brown spots, and the transverse plates under the belly
and tail are single ; a small isolated fang is distinct in the upper
jaw.

279. A small dog bitten by the phoorsa snake : fatal. — About the montli of January
1834, a small puppy dog was brought to me, said to have been bitten on the upper lip
by a phoorsa snake, — but, as the animal seemed lively and well, I thought that there
might be some mistake : the snake, however, was shown to me, and the dog had been
found playing with it. In a short time the lip swelled slightly, and was painful on
being touched ; it was rubbed with ammonia, and some was also given internally.
During the course of the day the animal appeared sufficiently lively, took food and
ran about ; but the swelling continued to increase, and caused much pain. On the
following day the face and neck were very much swollen, especially under the lower
jaw. The dog died in the course of the day, about thirty hours from the time it had
been bitten.

On dissection, the swollen face and neck were found much infiltrated with bloody
serum ; and in some places, especially in the neighbourhood of the bitten part, there
was extravasation of blood. The larynx, trachea, and lungs were healthy; no con-
gestion of the mucous lining. The other organs seemed healthy.

280. A horsekeejper bitten by the phoorsa snake: fatal. — At 11 a.m., on the 20th
March, 1834, a horsekeeper, in the service of Colonel Lodwick, was brought to me.
On the middle finger of his left hand there was a small ptmctured wound, caused by
the bite of a snake. The occurrence took place about half an hour before I saw him.
He made no complaint of pain ; there was no swelling around the wound ; the pulse
was natural : the bitten part was excised, caustic applied, and a ligature tied round
the wrist. At 3 p.m., appearance unchanged ; no complaint but of pain in the hand,
which was somewhat swollen. This I attributed chiefly to the ligature, and removed
it. On the morning of the 21st, he was reported to have slept well. The hand was
considerably swollen — the swelling was tense, painful, and extended above the wrist ;
the tongue natural. He made no complaint but of the hand. Cold lotion was
directed to be applied. At 1 p.m. it was observed, that over the right tibia, here and
there, on the right foot, and also between the fingers of the right hand, the skin had
cracked, or rather had assumed an abraded appearance ; and from these points fluid and
florid blood oozed and trickled slowly. One of these points had existed on the pre-
vious day, but the others had only been noticed within an hour or two. The skin was
natural in temperature ; the hand was more swollen ; pulse 64, full and firm ; and he
had a sense of weight in the forehead. The saliva was tinged slightly with blood, the
tongue expanded, but not furred ; breathing slow. About ten ounces of blood were
abstracted from a vein in the right arm, by which the uneasy sensation in the head
was relieved and the pulse reduced ; the blood did not flow vei^'^ freely, the orifice in
the vein being small. At 4 p.m. I found that there was haemorrhage from the arm in
which he had been bled ; it had been necessary to renew the compress twice, and three
or four ounces of blood had been lost. About the right elbow joint, principally ante-

718 IJLOOD DISEASES.

riorly, extending down the fore-arm and up the arm, there was tense, elastic, painful
swelling, very similar to that of the bitten hand ; the blood, dark and thin, trickled
down the ai'm from the orifice made in the vein. It was impossible, from the swelling
and haemorrhagic tendency, to stop the bleeding in the ordinary way ; it was in part
eflFected by pressure with the finger, afterwards by means of a cork compress and ad-
hesive plaster. The pulse had become smaD, the skin cold ; he was restless and dis-
tressed looking, but answered questions freely when spoken to. The tongue was ex-
panded, and its edges deeply marked with indentations from the teeth. The blood
taken from the. arm had not coagulated in the slightest degree ; it was a dark red-
brown liquid. Stimulants of brandy. and ammonia were given in full doses, and
frequently ; he continued restless and drowsy, but was always roused when spoken to.
The pulse continued barely perceptible ; he complained chiefiy of the pain of the swel-
ling of the arm in which he had been bled. At 1 0 p.m. the swelling of the bitten hand
had become much reduced, and softer ; that of the opposite arm, in which he had
been bled, had increased. He continued pulseless, restless, and drowsy, but answering
questions when roused, till 5 a.m. of the 22nd, when the breathing became difficult,
and he died at 7 a.m. There was nothing peculiar in the appearance of the body ;
the bitten hand was much less swollen than it had been. No examination of the body
permitted after death.

281. Parsee woman bitten hy a jphoorsa snake. — Recovery. — On the 20th April, 1835,
at 10 A.M., a Parsee woman, resident in the bazaar at Malcolm Peth, was bitten by a
phoorsa on the dorsum of the last phalanx of the ring finger of the right hand. I saw
her half an hour afterwards ; a ligature had been applied to the finger ; I excised the
bitten part, and applied caustic, and continued the ligature till the afternoon, when it
was removed, in consequence of the pain which it occasioned. She complained once or
twice of her head, and took some doses of eau de luce. There was swelling of the fin-
ger, and the hand, but to no great extent. There was constant oozing of blood from
the excised part, which on the 22nd increased to a constant dropping of blood, and
continued so during the night. On the 24th the bleeding continued, and the pulse
was feeble ; the actual cautery was used, and stopped the bleeding, which was absent
on the 25th, but recurred on the 26th, and was stopped by pressure. On the 1st of
May she was quite well. Ammonia was the only internal remedy used.

282. Bog bitten by a phoorsa snake. — Fatal. — Post mortem examination. — A full sized
dog, on the morning of the 24th May, 1834, at 10 a.m., was bitten over the right false
ribs by a large phoorsa snake. He continued well all day, took food and water freely.
In the evening sKght diffused swelling about the bitten part, but the animal did not
cry on pressure of the part. On the morning of the 25th the dog seemed dull, and did
not take his food, the swelling was slight and diffuse, and did not seem to cause pain
on pressure. At 2 p.m. the sluggishness was found to have increased, and near to the
animal there was some dark foetid pitch-looking fluid, which must have been either
vomited or passed by stool. About eleven o'clock at night he was heard to howl, and
probably died at midnignt ; he was found dead early in the morning of the 26th
having lived about forty hours ; and more of the dark pitchy fluid was found on the
ground, and as it covered the legs and tail of the animal, it seemed to have been passed
by stool. The body was not at all swollen.

Inspection. — The body was carefully examined after death. Around the bitten
part there was infiltration of the subcutaneous cellular tissue, for an extent of eighteen
inches in a longitunal direction, and six in a vertical. The fibres of the tissue seemed
thickened and condensed, so that the fiuid did not run freely nor in quantity from the
cut surfaces. Where the infiltration was greatest the thickness was about a quarter of
an inch, and formed a dark red fleshy-looking substance. Towards the periphery
of the infiltrated portion the colouring matter of the fiuid was much less in quantity.
In no situation did the infiltration pass the mesial line to the left side of the thorax.

SNAKE-BITE* 719

It was not an ordinary infiltrated cellular tissue, such as is seen in anasarca ; the
organisation of the tissue seemed to have undergone a change, so that a portion
macerated in water lost its dark red colour, but retained the other physical properties
— its thickness and firmness. Thorax. — The heart was empty and pale. The ar-
terial system empty and contracted. The jugular veins contained some thin fluid
blood. The lungs were much collapsed, and perfectly pale, with the exception of a
few superficial red patches ; when incised they were perfectly dry. I never saw lungs
so devoid of anything like congestion of blood, or so absolutely without serous infiltra-
tion, or the natural secretion of the mucous lining. The mucous membrane of the
trachea and bronchial tubes was perfectly pale. Head. — The brain firm, healthy,
pale, ex-sanguine. Abdomen. — The liver healthy, but with some red serous conges-
tion. The stomach and intestines were externally natural ; there was no discoloration
nor vascular congestion ; they were laid open from the pharynx to the rectum. The
oesophagus was natiu'al ; the stomach contained yellow fluid, mixed with food ; its
coats were natural. About two feet of the upper part of the small intestine contained
mucus, deeply tinged with bile ; descending the bowels the mucus became tinged
with blood, like red currant jelly. Descending still further, this state of the secretion
increased in quantity, and deepened in colour ; in the large intestine, extending to
the anus, there was a thick coating of it, very foetid, and in colour and consistency
resembling pitch. Wherever this secretion was scraped from the lining tunic the
appearance of the latter was natural, no discoloration, no vascularity, no alteration
of condition; in every point it was a pale healthy mucous tissue. The bowels
were not distended, and, take away their contents, they could not have been more
healthy or natural, in colour, structure, and relations. The kidneys were healthy.
The bladder was filled with healthy urine ; its lining membrane presented one faint
discoloured patch.

720 DRACUNCULUS.

CHAP. XXXII.

ON DRACU NCUL US.

Section I. — Prevalence of, in Bombay Presiden/yy. — Relation
to Season. — • Allusion to Theories respecting its mode of ori-
gin. — Short notice of Symptoms and Treatment.

Dracunculus, or guinea- worm, from its great prevalence in many-
parts of the Bombay Presidency, has, during the last thirty years,
engaged the attention of several medical officers* of that establish-
ment.

The inquirers have generally assumed that there probably exists
some connection between guinea-worm and an external existing
species. Therefore a leading object of their research has been to
determine whether any relation subsists between the prevalence of
this affection, and particular seasons, soils, and sources of water
supply ; and to discover whether the soil or water of affected
localities constitutes the habitat of any species of worm zoologically
allied to this entozoon. These investigations, as well as those
relating to the manner of entrance into the human body of the ova
of the assumed external related species, have not led to positive
or satisfactory results. In fact, the obscurity in the natural history
of entozoa generally, is well illustrated in the instance of dracun-

* 1. Dracunculus, as prevailing in the Artillery while stationed at Matoongha in
tlie Island of Bombay, has been described by Mr. Smyttau and Dr. Bird, in the early
volumes of the " Transactions of the Medical and Physical Society of Calcutta,"

2. There are two papers by myself in the 6th and 8th volumes of the " Calcutta
Transactions," on Dracunculus in the 4th Light Dragoons, at Kirkee, published in
1833 and 1835.

3. A communication by Mr. Duncan, on Dracunculus at Bhewndy, in the 7th
volume of the " Calcutta Transactions," in 1834.

4. A Eeport by Mr. D. Forbes, on Dracunculus at Dharwar, in 1836 and 1837, in
the 1st Number of the "Transactions of the Medical and Physical Society of
Bombay."

5. Note on Dracunculus in the Island of Bombay, by Mr. H. J. Carter, in the 2nd
Number of the 2nd Series of the "Transactions of the Medical and Physical Society
of Bombay," in 1853.

PREVALENCE. — LOCALITIES.

721

cuius. , I shall briefly notice some of the statements which have
been recorded, and allude to the principal inferences which have
been drawn from them.

Annexed to this chapter are tabular returns of dracunculus, as
observed by me in Her Majesty's 4th Light Dragoons, in the
Jamsetjee Jejeebhoy Hospital, and as prevailing generally in the
Bombay army in 1832 and 1833. The total number recorded in
these tables amounts to 2926. The ratio of admissions from
dracunculus to the total strength of the Bombay army was, for
these two years, 3*055 per cent.* During the six years from 1848
to 1853 the ratio to total admissions into the Jamsetjee Jejeebhoy
Hospital was 2*2 per cent. In considering these tables with the
view of determining whether this affection is more prevalent in
some months than in others, I have arranged the months in three
groups of four each, with the following result : —

May
June
July

August

ADMISSIONS IN-

448
480
428
337

693

March .
April .
September
October

165
273
246
224

908

November
December
January .
February

123
93
46
64

326

It was in the hospital of the 4th Light Dragoons at Kirkee, in
1832, that I first had an opportunity of studying this disease.
The secondary trap formation of the part of the Deccan in which
Kirkee is situated, suggested to me the idea of following out the
opinion formed by Chisholm, from observation in Grrenada, that
there was a relation between dracunculus and the use of water
taken from wells sunk in rocks of igneous origin. This inquiry
forms the' subject of my communication in the eighth volume of
the Calcutta Transactions.

Through the courtesy of the Zillah collectors I obtained a series
of official reports, made by the village or district native function-
aries, relative to the absence or presence of Gruinea-worm in the
villages of the Northern and Southern Concan, and the sub-
collectorate of Bagulcotta. The results have been published in
the paper just adverted to, but they lead to no satisfactory con-
clusion, and need not be reproduced. The following extract of the
general summary will suffice : —

^ In 1857, there were admitted into the Hospitals of the several Police Corps in
the Deccan, viz., at Poona, Sattara, and Ahinudnuggur, 1260 cases of Guinea- worm,
being a ratio to the strength of 3*4 per cent. Poona was the highest, — 5-7 per cent.

3 A

722 DRACTJNC0LUS.

" 1. In four talookas ^ Guinea-worm does not occur, and in all the upper crust is of
laterite rock. The water used is not specified, but, from the physical features of tho
districts, it must be chiefly that of wells.

" 2, There' are reports from 494 villages in which Guinea-worm does not occur. Of
these 364 are in a district the upper crust of which is of laterite rock : the nature of
the water is not mentioned ; but, from the physical features of the district, it must be
chiefly that of wells. Of the remaining villages, in 109 the water of rivers of con-
siderable size is used (of these 102 being situated in districts where primitive rocks,
chiefly marble and clay-slate, constitute the geological features, and seven in secon-
dary trap districts), and twenty-one villages use the water of nullahs, wells, and tanks.

"3. Of 991 villages in which Guinea- worm prevails, 309 are in districts of secon-
dary trap formation; 451 in districts in which there is a probable alternation of
geological structure, but in which the secondary trap formation prevails to a consider-
able extent; 215 are in districts in which primitive rocks prevail: in 120 limestone
and clay-slate are the principal members of the series.

"4. Of the 991 villages in which Guinea-worm occurs, in 479 the nature of tho
water is not stated ; but, from the physical features of the districts, it must be chiefly
of wells. Of the remaining villages, 276 use the water of weUs ; 131 the water of
nullahs or tanks, and 58 the water of rivers; but in a great proportion of these
villages, in which nullah water or river water is used, the disease is stated to occur
every second, third, or fourth year, and not annually."

The anatomy of dracunculus has been adverted to by Mr. Dun-
can and Mr. Forbes, but only minutely and carefully investigated
and described by Mr. Carter. Mr. Duncan first called attention to
the fact that the greater part of the interior of the mature Guinea-
worm is occupied by an ovisac filled with myriads of minute vermi-
form young. This observation has been confirmed by Mr. Forbes
and Mr. Carter, and all three observers describe minutely the
appearance of the young Guinea-worm and the nature of its active
movements.

When the period for the extrusion of the Guinea-worm from the
human body has arrived, the young are emitted in large numbers
from the orifice of the protruding end of the worm. Both
Duncan and Forbes found that the young died in about six
days when placed in water ; but the latter observer noticed that
when placed in moist red clay they survived for about twenty dajs,
but did not increase in size. Mr. Duncan states, that the soil and
pools about Bhewndy abound, in the rainy season, with a worm
smaller and more slender, but otherwise exceedingly like the
Guinea-worm : it does not, however, appear whether this resem-
blance refers to the mature or young dracunculus. Mr. Forbes
found that in the months of August and September the tanks in
the neighbourhood of Dharwar were abundantly supplied with
animalcules, some of which very much resembled the young
Guinea- worm, and others were eight times the size : they inhabited

* A talooka is a subdivision of a district.

SYMPTOMS. 723

the half-dry beds of the tanks, and appeared to live longest when
partially covered with water.

Mr. Carter discovered that minute worms, having a great resem-
blance to the young dracunculus existed in great abundance in
confervae of some tanks in Bombay. He describes the size of the
young Gruinea-worm to be, length 3^-3 inch, breadth -^^ ; that of the
tank-worm to be length -^^ inch, breadth ygVo"- He believes iif the
identity of these animalcules, notwithstanding the fact, that the
specimens taken from the ovisac were double the size of those
which were born and leading an independent existence ; and the
additional fact, recorded by Duncan and Forbes, that the young of
the Gruinea-worm invariably die in the course of five or six days
when placed in water. The further opinions of this able micro-
scopic inquirer are also very improbable, viz., that Gruinea-worm is
produced by the small tank-worm working its way into the human
body through the tubules of the sudoriferous glands, and that the
spread of the affection may be best obviated by preventing those
affected with it from bathing in tanks and contaminating the water
with the young issuing from the protruding end of the parent en-
tozoon ; — an idea conceived in forgetfulness of the fact, that the
young of the Guinea-worm die in water.

Dr. Helenus Scott remarks, '' It is well known that the men who
in India are employed in camps or elsewhere to carry water in
leathern bags on their backs, are infested by this animal over all
that part of the skin that has often been wetted. " * And this state-
ment has generally been used as an argument for the entrance of
the ovum through the skin. I am ignorant of the nature of the
facts on which this observation, with which I have long been fami-
liar, is grounded ; but I can affirm, after ample opportunity, and on
little attention bestowed on the study of dracunculus, that I am unable
to bring to my recollection a single instance of a water-carrier affected
with it at that part on which the water-bag rests, nor have I any
reason for supposing that they suffer more than other classes.

The manner of propagation of the Gruinea-worm, its mode of
entrance into the human body, and the question of its relation to
an external species, are at the present moment, I believe, no more
positively determined than the same propositions in respect to
other entozoa. They are all, with one exception —taenia — involved
in equal obscurity.';

Symptoms, — The presence of Gruinea-worm is often discovered
by a corded substance being felt beneath the skin before any indi-

* Johnson and Martin, on Tropical Climates, 1841, p. 370.
3 A 2

724 DRACUNCULUS.

cation from sense of itching, swelling, or the formation of a bulla
has been given.

The extraction of the worm is sometimes attended with much
inflammation and suppuration ; at others it gives rise to little dis-
turbance. The first result is influenced by the state of constitution
of the individual aff'ected, the situation of the worm — whether en-
twined round tendons or not — and the care with which the pro-
ceeding is conducted.

Both Duncan and Forbes are of opinion that the diffusion
of the young of the Guinea-worm, consequent on rupture of
the parent, among the human tissues, is the cause of the inflamma-
tion. It is true that this result is often consecutive on the worm
being broken; but whether the explanation just adverted to is
correct or not, I am unable to decide.

The presence of dracunculus, however, does not necessarily en-
tail its extrusion : the worm may shrivel, become cretifiod and
enveloped in areolar tissue. It is not very uncommon to find them
thus changed in the dissecting-room of Grrant College ; and I have al-
ready detailed a case (2 1 5) in which a cretified Gruinea-worm was found
between the pericardium and the inner aspect of the right lung.

Treatment. — There has been a good deal written on the treat-
ment of this affection. It has been a favourite subject for nostrums
and special applications. It is best managed on simple surgical
principles. The question of extraction when the worm is qui-
escent and felt only under the skin first arises. This practice I saw
followed extensively in the 4th Dragoons. The worm was cut
down upon with a lancet, and a probe passed underneath, and
extraction cautiously made. The method followed by native
barbers, of digging a small hole down to the worm with a needle
and razor, I have also frequently witnessed. By these means ex-
traction is often successfully and speedily effected. At other times
it is followed by all the evils of inflammation and suppuration. If
the worm be over a fleshy part, the operation will generally succeed.
If, on the other hand, the worm be situated near tendons — as in
the foot, near the ankle, or the popliteal space — the risk of injury
from inflammation will be great. On the whole, as a rule of
practice, I incline to non-interference.

When, after the formation of the usual bulla, the end of the
worm protrudes, the extraction should be very gently and gradually
effected, care being taken, by means of rest of the part and ordinary
simple surgical appliances, to prevent or moderate inflammatory
action. The only caution necessary in respect to water applica-

STATISTICS.

725

tions, is not to allow them to come in contact with the worm, lest,
by softening its structures, they lead to its rupture. Should,
unfortunately, much inflammation with suppuration take place,
then the only safe course is to be guided by sound principles of
surgery, and not to be led away by an unwise credulity in the
asserted efficacy of special plasters and cataplasms, many of which
are irritating and injurious.

Section II. — Statistics of Guinea-Woimi,

Table XLIII. — Admissions of Guinea-Worm in the Ath Light Dragoons

at Kirkee.

1827.

1828.

1829.

1830.

1831.

1832.

1833.

1834.

Total.

January;

Februar

March

April

May

June

July

August

Septeml

October

Novemb

Decemb

3er

—

3
3

2
3

5
5
2
1
3
1

2
1

5
7
57
64
48
26
3

1
3

2
3

7
3
1
3
1
1
3

2
5

101

Totti

—

215

104

390

Table XLIV. — Guinea-Worm in Jamsetjee Jejeehhoy Hospital.

1848 to 1853.

Monthly Average.

Admissions.

Deaths.

Deaths oa
Admissions.

Admissions

on total
Admissions.

Deaths on
total Deatlis.

January

5-5

0-9

0-2

February

—

0-7

—

March .

—

1-02

—

April

—

2-3

—

May

—

3-2

—

June

1-5

3-1

0-3

July

—

4-06

August

—

3-5

—

September

2-3

0-3

October

—

2-01

—

November

2-6

1-8

0-3

December

3-2

1-3

0-3

Tot

552

0-9

2-2

1-2

3 A 3

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3 A 4

728 HILL SANATARIA OF THE DECCAN.

CHAP. XXXIII.

It will save unnecessary repetition and the risk of misapprehension
if the sense in which certain terms are used is first explained : —

1. By " Deccan Hill climate or station " is meant an altitude

of from 4000 to 4500 feet on the Western Grhaut range
or its easterly projecting spurs, between about 20"" and
15° N. latitude.

2. The term " Deccan table land " is restricted to that por-

tion of it between 20° and 15° N. latitude which is
within about sixty miles of the eastern side of the
Western Grhauts, and has a general elevation of from
2300 to 1700 feet. It is necessary to be thus precise
in indicating the sense in which the term Deccan is used
in this report, because at localities more remote from the
Grhauts the extremes and the range of temperature are
greater at all seasons, and the atmosphere during the
rainy season is drier.

3. The " cold season " is imderstood to extend from the

middle of November to the end of February.

4. The '^hot season^'' from the beginning of March to the

middle of June.

5. The " rainy season " from the middle of June to the end

of September.

6. October, which has been excluded from this division of.

the seasons, presents much of the character of the hot
season months.
There are two recognised Sanitaria in the Deccan, Malcolm Pait
on the Mahabuleshwur Hills, established in 1828, and the Hill
Fort of Poorundhur in 1852.

Mahabuleshwur Hills, — On the medical topography and

* Written early in 1859, and communicated to the Bombay Goyernment.

HILL SANITARIA OF THE DECCAN.

729

meteorology of these hills there are full and excellent reports*
by Mr. Murray, published in the first, second, and seventh num-
bers of the Transactions of the Medical and Physical Society of
Bombay, from which the following summary statement of some of
the leading qualities of the climate has been compiled : —

Malcolm Pjiit.

Mean
Temperature.

Mean Range.

Mean
depression of

Wet Bulb
Thermometer

Rain- fall,
Inches.

Direction of
the Wind.

Cold Season •
Hot Season .
Eainy Season
Month of October .
t Annual Means .

64-5
72-8
64-4
66-6
66-6

13-

13-6
3-6
9-8
9-7

10-2

13-5

2-2

6-4

7-8

0-11
1-09

243-28
4-58

254-05

Easterly.
NE., NNW.
WSW.
Variable.

The station Malcolm Pait is situated on the western slope of the
table-land in 17° 56'' N. latitude and 73° 30^' E. longitude, and
has a general elevation of about 4,500 feet. The accommodation

* Mr. Murray is unquestionably still the best authority on the hill climates of
India, though it is now sixteen years since he last wrote on the subject ; and he will
undoubtedly continue to be so, so long as the present rule of changing the medica
officers in charge of hill stations every two years continues in force.

Mr. Murray was resident at Mahabuleshwur about twelve years, and thus ample
opportunities were afforded for the exercise of his intelligent and enquiring mind, and
for arriving at useful and safe results.

The biennial tour of duty came into operation when Mr. Murray left Mahabuleshwur
in 1844, and since then at least six different medical officers have been in charge
of the station, but without contributing the most fragmentary addition to our know-
ledge. Indeed, it is impossible to conceive a system better calculated to cramp and
check inquiry than that now in force, not only at Mahabuleshwur, but, I believe, in
all the hiU stations in India, and this, too, with reference to sanitary questions iU
understood and of great moment to the State.

On this point I write with confidence and from experience. About twenty -five years
ago I was for two years in medical charge of Mahabuleshwur during Mr. Murray's
absence at the Cape of Grood Hope, and I left the station just as I had acquired that
preliminary knowledge which further experience of the hill climate might have enabled
me to mature and usefully apply. Such, I apprehend, is the process through which
every medical officer in charge of a hill station on the biennial system must pass, and
such the reason for the backward state of our knowledge of the meteorology and the
action on the human body of the hill climates of India.

Officers should be selected with reference to their qualifications and tastes for the
kind of investigation required, and should be left in charge so long as their efficiency
and zeal remain unimpaired. The principle, that it is just to extend the benefit of
the hill climates to a number of officers, and to effect this by biennial removal, is
very considerate ; but it is not one by which scientific objects are likely to be advanced,
and this is the paramount end which should be kept in view in medical appointments at
hill stations in India.

t As the month of November has been excluded from the summary, the annual
means here given, taken from the original tables, will be found to differ slightly from
the means calculated from the sums of the columns of the summary.

730 HILL SANITARIA OF THE DECCAN.

at present consists of Grovernment quarters for sixteen sick officers,
and seventy-seven private bungalows. In the year 1829 a party
of invalid soldiers was sent to this Sanitarium, bat the selection of
cases and of the season was unsuitable. The result was unfavour-
able, and the experiment has not been repeated. Since that period,
however, the annual resort of an average of about 300 visitors —
civilians, military officers, and others, with their families — has affi)rded
ample opportunity of determining the qualities of thi^ hill climate
and its influence on the European constitution in health and disease.
Poorundhur, — The hill on which the Fort of Poorundhur is
placed is an offshoot from the easterly side of the Western Ghaut
range. It is situated in 18° 22'' N. latitude and 73° 54'' E. longitude,
and is distant nineteen miles from Poona. It is a saddle-backed
mountain. The altitude of the highest part of the ridge is 4570
feet, but that of the lower fort, in which the Sanitarium is located,
is 4200 feet. The lower fort occupies a narrow table about a
mile in length, projecting from the northern slope of the mountain.
There are two barrack rooms, which afford accommodation for one
hundred men, and a very good hospital, adapted for forty sick.
There are ten private bungalows, generally occupied in the hot
season by officers and their families. A patchery for ten fami-
lies and a small female hospital are in course of erection. The
Sanitarium may, therefore, at present, be considered sufficient
for 130 soldiers and ten families. A good foot-road has been
carried round the hill on the level of the Sanitarium, as well
as round Wuzurghur, an adjoining hill connected at the same
level by a narrow ridge to Poorundhur. This foot-road is about
seven miles in extent, and in consequence of its circular character,
its position 230 feet below the highest ridge, and the general form
and direction of the mountain, there is space for exercise shaded
from the sun till nine or ten in the morning. The climate of
Poorundhur compared with that of Malcolm Pait has a temperature
about three degrees higher, and, in consequence of its more inland
position, there is greater atmospheric dryness in the months of
March, April, and May. The great difference, however, is in the
rainy season : at Poorundhur the rain-fall is seventy-two inches ;
at Malcolm Pait it is 254. The rain and fog are so incessant at
Malcolm Pait that the station is uninhabitable during the rainy
season. The Hill of Poorundhur is also frequently enveloped in
mist, and though the convalescents remaining there at this season
have in general benefited, yet the climate is gloomy, and out-door
exercise is often prevented by rain and dense fog. About 650 sick

niLL SANITARIA OF THE DECCAN. 731

and convalescents have been received into the Poorundhur Sani-
tarium since its establishment. The greater number have belonged
to regiments stationed in the Deccan. A proportion, however, has
been sent from Bombay, Guzerat, and Scind. The selection of
cases and of season has been sometimes suitable, at other times the
reverse. It is this mixed experience, both at Poorundhur and
Mahabuleshwur, not again we may hope likely to occur, which has
created data from which the medical inquirer is enabled to ascertain
with confidence the right sanitary use of these hill climates.

Pancligunnee, — Malcolm Pait is rendered uninhabitable from
the middle of June to the end of September by incessant rain and
fog, consequent on its position on the western side of the mountain ;
but it is to this position also that are due a greater coolness and
softness of the climate in March, April, and May. There are
localities on the eastern side of Mahabuleshwur which possess a
climate nearly resembling that of Poorundhur, in which the tem-
perature is about three degrees higher than that of Malcolm Pait,
the fog less constant during the rainy season, and the rain-fall
about fifty inches. Panchgunnee, distant ten miles from Malcolm
Pait, overlooking the valley of Wye, at an elevation of 4000 feet,
is the locality on the eastern side of which the character of the
climate is best known. Notes on the monsoon climate of Panch-
gunnee were published by me in the year 1840.*

Singhur, (&c. — The Hill Fort of Singh ur, distant fourteen miles
from Poona, is placed on a table about 4200 feet above the sea.
It has an irregular surface, with a circuit of about a mile and a
quarter. There are fifteen private bungalows, usually rented
during the hot season by officers and their families from the Poona
and Kirkee Brigade. The climate of Singhur cannot differ much
from that of Poorundhur.

Between the river Taptee on the north and the fifteenth degree
of north latitude on the south, there are probably many situations
more or less spacious on the easterly side of the Western Grhaut
range, or on the spurs projecting inland from it, with an elevation
from 4000 to 4500 feet, which present the same characteristics of
climate in the dry and rainy seasons as Panchgunnee, Poorundhur,
and Singhur. But it must be borne in mind, for reasons which
will presently appear, that the hot-season climates of such localities
are two or three degrees warmer and are drier than Malcolm Pait
and other similar positions on the western or seaward side of the
Ghauts.

* " Transactions, Medical and Physical Society of Bombay," No. 3.

732 HILL SANITARIA OF THE DECCA.N.

The conclusion to which those several statements lead is, that
the soldier in this Presidency has not as yet derived much benefit
from the Deccan Hill climates ; and the practical question which
has now to be determined is, by what system this benefit, if real
and important, may be extended.

The practice hitherto has been to select from, among the sick
and convalescents in Hospital those men who are not regaining
health, or are progressing slowly to recovery. Kut the climate of
these Hills is by no means suited at any season for all cases which
come under this description, and at some seasons is unsuitable for
them all. It is therefore of the utmost importance that medical
officers on arrival in India should early familiarise themselves with
the principles relative to the sanitary application of the Deccan
Hill climates which past experience has enabled us to advance with
tolerable certainty. With the view of facilitating this necessary
preliminary object, a memorandum * was prepared by me in May,
1858, when Superintending Surgeon of the Poena Division, relative
to the Poorundhur Sanitarium, and the doctrines inculcated in it
may be regarded as equally applicable to other Hill stations of
similar altitude and climate. It will be sufficient to state here as
the general result of past experience, that the debilitated soldier,
who in the plains of the Deccan, the Concan, Bombay, and Grujerat
regains his strength and efficiency slowly, will after the removal of
positive disease be much benefited by a Deccan Hill climate in
the month of October and in the hot season ; and at those Hill
stations (as Poorundhur) in which the rain-fall is not more than
seventy inches, and the mists, though frequent, by no means con-
tinuous, there will be still further advantage to many of this class
of convalescents by — after a hot-season residence — their stay being
prolonged throughout the rainy season and the month of October.
The benefit which may be looked for is this : — The soldier will have
become fitted for duty, he w411 be less liable to fresh attacks of
disease, and when attacked the disease will be of milder t3rpe.
Whereas had he continued exposed to the exhausting hot season
of the Deccan or of the coast, he would have remained inefficient,
and have become very predisposed to attacks of the severer forms
of tropical disease — those forms which swell the mortality and in-
validing rates of European troops in India. The ultimate effect of
these Hill Sanitaria applied as now explained must be, in propor-
tion to the degree in which they are used, to reduce mortality and
invaliding.

* See Appendix.

HILL SANITAEIA OF THE DECCAN. 733

But a large proportion of the class of convalescents just adverted
to, if sent to the Hills in the cold or rainy seasons, would run the
risk of being injured by the return of their former diseases or by
the access of others of similar character. It is therefore necessary
that caution and judgment should be exercised, not only in the
selection of the cases, but also in determining the season. There
are cases of imperfect recovery from some forms of organic disease
which, if the opportunity of a sea voyage and change to colder
latitudes is not available, may be sent to the hills in the hot season,
if the facilities of carriage are good, with temporary advantage
from avoiding the heat of the plains. But for all cases of imperfect
recovery from all forms of organic visceral disease the cold and
rainy seasons of the Hills are altogether unsuited, and are generally
positively and markedly injurious. The evils which result from
the neglect of this now well-ascertained truth were apparent at
Mahabuleshwur in the experiment of 1829. They have occurred
also from time to time at Poorundhur, and have been very fre-
quently observed at the Neilgherry and Himalayan Hill Sanitaria.

The superiority of the Deccan Hill climate is in the month of
October, and from March to early in June.

The Deccan table-land has, during the cold season, a mean tem-
perature of 70°, and a range of 25°. Its climate at this season
exercises no injurious influence on the European constitution, and
is less likely to be prejudicial in the conditions described above
than the climate of the Hills at the same period of the year.

The Deccan table-land has, in the rainy season, a mean tempera-
ture of 73*70°, a range of 14-6*^, and a rain-fall from about 30 to 20
inches. The climate is genial and refreshing. Though the lower
temperature of Poorundhur (67*3^) at the same season is an ad-
vantage to some convalescents, still in others it is counterbalanced
by the gloom and confinement to quarters consequent on the fre-
quent fog and rain. It may therefore, under existing data, be con-
cluded that the Hill climate in the rainy season has no advantage
over that of the table-land in the neighbourhood of the Grhaut range.

In the hot season the mean temperature of the Deccan table-
land is about 80°, the range 25*^, the dryness 22*5°, and a hot wind
blows throughout a considerable part of the day. At this season the
European constitution is apt to suffer from the influence of elevated
temperature, and to become more or less debilitated ; and con-
valescence from all forms of disease is tardy and unsatisfactory.

In the 9th Number of the Transactions of the Medical and Phy-
sical Society of Bombay there is a paper by Mr. Murray on the

734 HILL SANITARIA OF THE DECCAN.

climate and diseases of Sattara. It contains much valuable infor-
mation on the meteorology and general dliaracters of the different
seasons in the Deccan, and may be consulted with much advantage
with reference to the subject under consideration.

In Bombay the mean temperature of the hot season is 82*^, and
the range 11^. The mean temperature of the rainy season is 80-8^,
and the range 6*2° ; the rain-fall is 75 inches ; and the atmosphere
from the middle of June to the end of September is humid, and
often not far from the point of saturation. The hot and the rainy
seasons in Bombay are exhausting to the European, and a similar
remark may be applied to the same seasons on the Western Coast
generally, and the low southern portion of the province of Gruzerat.

It appears, then, that the hot season of the Deccan table-land and
the hot and rainy seasons of Bombay, the Coast, and Gruzerat are
inimical to Europeans, the degree being in proportion to the pre-
vious state of debility of those who are exposed to their influence.

The value of the Deccan Hill Sanitaria is restricted to the hot
season. The weakly soldier of the Deccan stations with the cold
and rainy season on the table-land, and the month of October and the
hot season at a Hill station, has every advantage which the climate
of this part of India is capable of affording. The weakly soldier of
the Coast and Gruzerat stations with the cold season of his own
locality and the rainy season of the Deccan table-land and the
month of October and the hot season at a Hill station, has also
every benefit from climate which his circumstances admit of.

Hitherto the improvement to health which results from a judi-
cious use of the climates at our command has, in the instance of
the soldier, been confined to the small number of hospital cases for
which a change to Poorundhur has been considered suitable. In
order to extend the advantage, a modification of system would seem
to be all that is necessary. In addition to the hospital cases a per-
centage of the men in barracks and of their families, say of the
former from 10 to 25 per cent, (varying according to the necessities
of service), should be selected at Deccan, Coast, and Guzerat
stations. The selection should be made by the medical officer with
reference to constitution, medical history, and service in India.
The men thus selected should leave their stations towards the end
of February, so as to reach the Hills at the beginning of March.
The Deccan soldiers should return to their stations in the first week
of June, if within the salubrious limit, but if belonging to more
inland stations, they with those of the Coast and Gruzerat should
be sent to a well-selected Deccan table-land Sanitarium ; and

HILL SxVNITARIA OF THE DECCAN. 735

all should return to the Hills in the first week of October, remain
there till the middle of November, and then proceed, to rejoin their
respective stations for duty, so as to reach them early in December.

In this view the Hill stations are regarded merely as hot season
Sanitaria, and the establishments and arrangements should be
organised with reference to this limited object. For the Sanitarium
of the rainy season a suitable locality on the Deccan table-land
would require to be selected.

By this system the Deccan soldier, whether in 'hospital or at duty,
would have the advantage every fourth or fifth year of a hot season
on the Hills ; and the Coast and Guzerat soldier of a hot season on
the Hills and a rainy season on the table-land. It may be confidently
anticipated that a sanitary measure of this scope and nature, in
connection with a never-failing attention, under all circumstances,
to barrack accommodation and the various other matters of detail
which relate to the health and welfare of the soldier, would in a
few years have a marked effect in reducing the proportion of sick,
of mortality, and of invaliding. It cannot be too often repeated
that, by maintaining the general health of troops at as high a stan-
dard as the conditions of service in a tropical climate permit, not
only is present efficiency increased, but the predisposition to dis-
ease, and particularly to disease of bad t3rpe, may be so diminished
as most materially to reduce mortality and invaliding. To what
degree this advantage may ultimately be found to reach, future
experience must determine ; but there can be no doubt that the
principles are true, and that a sanitary system founded on their
strict observance, and faithfully and judiciously followed for a series
of years, must prove of very great advantage to the European
soldier in India, and consequently to the State.

The method now proposed of applying the Hill and Deccan
climates for the preservation and improvement of the health of
the soldier rests on no new or untried doctrines. The proposition
merely aims at extending to the soldier, and to the families of
soldiers, a system which has for the last thirty years been success-
fully followed by civilians and officers and their families ; and which
by them has been found to include all the benefit which these cli-
mates are capable of conferring.

It now remains to state briefly the means by which these viev/s
may be, under existing circumstances, most readily reduced to
practice. The Sanitarium at Poorundhur should be continued on
its present scale and plan for the reception of convalescents on sick
certificate from regiments in the Deccan. It should be continued

736 HILL SANITAKIA OF THE DECCAN.

as now during the rainy season, so as to admit of further observa-
tion of the effects of this season, and of careful comparison of the
results with those of the hospital cases from the Coast and Gruzerat,
whom, as will presently appear, it is proposed to locate on the
Deccan table-land during the rains. Though there can be little
doubt that the monsoon climate of the Deccan table-land is on the
whole preferable to that of Poorundhur, still it is very expedient to
take advantage of the already organised establishment at this Sanita-
rium for prosecuting the enquiry further, and finally settling the
question to the satisfaction of those who may still entertain doubts
on the subject. Poorundhur does not admit of extension as a
Sanitarium for all seasons, but a hot season site may be found on
Fitzclarence Point. Considering, however, the limited space on the
mountain, even this extension is inexpedient as a permanent
arrangement.

For the men selected from barracks from all stations, whether in
the Deccan or elsewhere, and for the hospital cases from Bombay,
the Coast, Gruzerat, and Scinde, a hot season Sanitarium should be
established on the Mahabuleshwur Hills in the proximity of Mal-
colm Pait. The Deccan soldiers should return to their stations at
the beginning of June, and those from elsewhere should be moved
to Sattara for the rains, return to Mahabuleshwur in October, and
thence proceed to their respective stations in the latter half of
November.

Sliould it on further experience at Poorundhur, and on com-
parison with the results at Sattara, appear that there is greater
advantage from the monsoon residence on the Hills than existing
data seem to suggest, then instead of moving the Coast and Gruzerat
and Scinde soldiers to Sattara for the rains, let monsoon barracks
and a suitable hospital be built at Panchgunnee, which would thus
become the rainy season position of the military Sanitarium on the
Mahabuleshwur Hills. There would in this arrangement be merely
the cost of original erection. The establishment of the hot season
would be available for the rains, whether passed at Sattara or at
Panchgunnee. As the barracks at Panchgunnee would not be
required for men belonging to Deccan stations, they would neces-
sarily be on a smaller scale than those at Malcolm Pait. Consider-
ing the proximity of Bombay, Poena, and Sattara to Malcolm Pait
the many advantages possessed by the western side of the mountain,
and the fact that a well-proved Sanitarium has long existed there,
and assuming that the views expressed in this report on the true
use of these Hill stations are accepted as just, then there need be

HILL SANITAKIA OF THE DECCAN. 737

no delay in erecting barracks at Malcolm Pait. For should it
afterwards be proved that there are advantages in a residence during
the rains at such positions as Panchgunnee, which it is desirable to
secure, no unnecessary outlay will have been incm-red in erecting
barracks at Malcolm Pait, for it must be always remembered that
the western side of the mountain has advantages in the hot season
over the eastern side, which it would be unwise to throw away ;
and as respects the cost incurred at Sattara in carrying out the
measures suggested for immediate adoption, it cannot under any
circumstances be lost, for there is little risk of barrack accommo-
dation proving excessive at a station healthy like Sattara, and
otherwise not unimportant.

Should, however, the distance to Mahabuleshwur be found incon-
venient to regiments in the southern Mahratta country or in
Kandeish, or, after the railway lines are completed, to those in
Central India, then other Hill stations may be sought for, north
and south of Mahabuleshwur, in the Grhaut range itself, or on the
spurs that project inland from its easterly side; it being borne
in mind that if the Sanitarium is for the hot season alone, a
westerly position is very important, but that if the rainy season
is to be included, then a station on the eastern side of the
Grhauts, or more inland on the projecting spurs, must be selected,
and the full advantages of the Deccan Hills in the hot season be in
some measure sacrificed.

Though the sanitary advantages to be derived from the Deccan
Hill climates, and the means by which they may be effected, have
now been considered, there yet remains an important question to
discuss with reference to the full benefit attainable from change of
climate within the limits of the Bombay Presidency.

It has been argued in this report that the chief use of these Hill
Sanitaria is confined to the hot season, and to the acceleration of
convalescence from disease that has been removed, or of recovery
from disease which is merely functional ; but that for individuals
affected with chronic organic disease benefit from the hot season
at a Hill station is only occasional, and at other seasons in
such cases the climate is generally positively injurious. It is from
organic visceral disease, primary, or complicating or consecutive
on the various types of fever, that the greater part of ordinary
mortality in India results. It is from these same forms of disease,
after they have passed into a chronic state, and also from chronic
rheumatic affections, that the great proportion of invaliding in
India proceeds. The climate of the Hills in the cold and rainy

738 HILL SANITAEIA OF THE DECCAN.

seasons is injurious in all these forms of disease, and the climate
of the Deccan table-land in the cold season is also often unsuit-
able. It is therefore important to inquire whether in such cases,
stationary or retrograding in the cold season in the Deccan, there
is any prospect of advantage from change of climate, short of a
voyage to sea and return to colder latitudes. It may be with con-
fidence replied that the climate of the coast, about the latitude of
Bombay, from the middle of November to the end of February,
with a temperature of 74*8°, and range of 14°, and without the
atmospheric dryness of the inland upland stations, affords this
advantage.

A cold season Sanitarium suitably placed on the coast, and
accessible with little fatigue, would be frequently of much utility
in the management of cases of organic disease which are retrograd-
ing or stationary or slowly convalescing in Deccan hospitals in the
cold season. They would recover more rapidly, and become more
surely fitted for transference to a Hill station in the hot season,
and, in some cases, life might be saved, and invaliding prevented.
A sea-coast Sanitarium, then, on a small scale, may be regarded as
an important part of the sanitary system of this Presidency. But
in order to the safe application of the principle on which its utility
rests, it will be very necessary that medical officers, on arrival in
India, should early become well acquainted with the state and
stages of disease for which it is appropriate, and that the locality
be selected with reference to accessibility, facility, and comfort
of transport.

On the subject of a coast Sanitarium it may be useful to remark
that, under the improved state of general health which will accrue
to the soldier in India from an improved sanitary system, including
the avoidance in the hot season of the heat of the plains by resort
to Hill stations, the proportion and severity of visceral organic
disease and of rheumatic affections will, after a time, become so
diminished that gradually the necessity for change to the sea-coast
will be lessened. This result may be expected for the same reasons
that it is anticipated that mortality and invaliding will, by these
same means, become very materially reduced.

Though this report has reference to the Deccan, and to troops
for which the Deccan Hill Sanitaria are available, still it may not
be altogether inappropriate briefly to allude to other Hill climates
and troops in other parts of India.*

* For information on the Hill stations of the sub-Himalayan range, the reader is
referred to the first, second, and fourth yolnmes of the " Indian Annals of Medical

HILL SANITAMA OF THE DECCAN. ^39

The general principles which have been advanced are applicable
to all localities and to all European troops in India, for they tend
to one leading practical object, viz. the maintenance of the greatest
degree of health and efficiency for the ordinary contingencies of
service in a tropical country. This end is to be attained by avoid-
ing, as much as possible, unhealthy localities and seasons, such as
localities with malarious characteristics, the hot season all over
India, and the rainy season in many parts of it.

The advantages which are, in some measure, peculiar to the
Bombay Presidency are : —

1. Hill stations which, from elevation (4000 to 4700 feet),

proximity to the sea, and safe approach at all seasons,
afford a cool retreat from the heat of the plains in the
hot season, without the risk of injury from cold and wet.

2. A considerable extent of country on the Deccan table-land

possessing in the rainy season a climate salubrious and
refreshing.

3. Facilities for the establishment of Sanitaria on the sea-

coast in suitable latitudes.
WTiereas the sub-Himalayan Hill stations, with elevations from
4200 to 7400 feet, are of unsafe approach at some seasons, and
present, in greater degree than Mahabuleshwur and Poorundhur,
the disadvantages of the cold and rainy seasons ; while during the
hot season, owing to distance from the sea and other causes, their
climates are not so temperate, equable, and dry. Thus the un-
favourable hot and rainy seasons of the adjoining plains are ill
provided against by these Sanitaria. There is no healthy monsoon
climate, and no facility of access to a suitable sea-coast.

The approach to the Neilgherries is, at some seasons, unsafe, but
there are stations at different elevations and on different sides of
the mountain, which, with the Mysore table-land and a sea-coast,
though of low latitude, give to the Madras Presidency in consider-
able degree the advantages stated to appertain chiefly to that of
Bombay.

The problem which has been kept in view in preparing these
observations has been, how to fit the European soldier for the

Science," also to the eleventh number of the same work, in which the subject is treated
fully in Mr. Chever's elaborate paper, " On the means of preserving the health of the
European soldier in India."

Mr. M'Clelland's " Medical Topography of Bengal " contains very useful information
on Hill climates and allied subjects.

The climate of Mount Aboo on the AravaUi range is described in the third number,
new series, " Transactions, Medical Society of Bombay," by Dr. Lownds.

3 B 2

740 HILL SANITARIA OF THE DECCAN.

maximum of efficient service in India with the minimum sacrifice
of health and of life. The attempt has not been made to inquire
by what means he may attain to the full physical constitutional
vigour of his native land and of the other countries of the colder
latitudes of the globe — simply because this condition is incompatible
with the circumstances in which he is placed. The question has
at different times been proposed, whether a regiment fresh from
Europe located at an elevation of 7300 feet, and in a climate such
as that of Ootacamund on the Neilgherry Hills, would not retain
much of its European vigour. Doubtless it would, a deduction,
however, being made on account of the rarefied atmosphere. But
this regiment would not be efficient for the contingencies of service
in India. If suddenly called to the plains for service in the hot
season, it would soon show a heavy sick list, and a rapid loss of
vigour and stamina would ensue. Let us suppose the service to be
concluded, and the regiment, exhausted by heat and fatigue and
sickness, moved back to Ootacamund, and the result would be
much mortality and invaliding from congestive, inflammatory, and
organic visceral disease. The proof that this is no fancied picture
will be readily found in what takes place under the ordinary cir-
cumstances of troops fresh from Europe arriving at the commence-
ment of the hot season ; and in what has taken place between the
years 1840 and 1850 on the transference to the Himalayan Hill
stations of several European regiments weakened by service, cli-
mate, and disease.

There is no antagonism between the Hill climates of India and
a voyage to sea, followed by a residence in the higher latitudes.
The states of disease for which the latter is required are usually
unsuited for the former. The Hill climates can never be regarded
as a substitute for a voyage to Europe or to Tasmania, but their
judicious use will render the greater change less frequently neces-
sary, will improve the general health, minister to the comfort and
happiness, and increase the efficiency of the European soldier in
India.

741

APPENDIX,

Notes and Tables on the Meteorology of Bombay.

(Prepared by T. M. I.ownds, Esq., M.D., Assistant Surgeon, Bombay Establishment.)

These tables* of the meteorology of Bombay, for the six years from 1847
to 1852, have been compiled from the Colaba Observatory Reports, from
the published reports for four years ; and for 1851-52, I am indebted to
Dr. Leith, to whom the daily observations are ftirnished from Colaba.

Temperature. — The monthly mean is calculated from the daily obser-
vations taken each hour in the twenty-four. A very cursory examination
will show how slight are the differences in one year from the mean of six
as recorded. The greatest diiferences from the mean of six years are only
as follows, the greatest difference in any of six months being taken : —

Thus, of six months

of January, greatest
„ February
„ March

diflference fro

m mean is + 2-1°
- 1-4
+ 0-7

n )>

, April
5 5 May
, June

55
)5
55

+ 07
+ 1-5
+ 1-6

5, July
, August
, September
, October

+ 11

+ 0-8
- 1-3
^ 1-2

M J> >

, November

„

+ 3-3

55 55 5

nciwr i« t"hp ori\c

, December

psf-. mnnth of tViP.

vp.a,r. Tif^.cx

+ 0-9

almost the same, as also November and March ; October forms a mean
between March and April. April and May are the hottest months. The
monsoon months vary little in mean temperature, and, as might be expected,
the range in them is very small. The great difference between hot and
cold months is not so much in greater temperature during day, but in cool
nights, and hence the range forms a distinguishing character between the

^ These tables and memorandum, kindly prepared, at my request, with much care,
are published in the form in which they were communicated by their zealous and able
author.

3 B 3

742 METEOROLOGY OF BOMBAY.

hot and cold season ; of course the range being much gi'eater during the
cold than in the hot months. A considerable degree of correspondence
will be foimd relatively between the mean daily and monthly range, and
the range of the Wet-bulb Thermometer. The extremes caU for no
remark.

The daily temperature is at its minimum at sunrise, almost without
exception. It then rises rapidly for the first two or three hours, until
9 A.M., when it rises slowly, and attains its maximum at noon ; occasionally
at 11, or even 10 a.m., but this is rare; still more rarely it is delayed till
1, or even 2 p.m., declines slowly till 5 p.m., or sunset, when it again takes
a stride or two rapidly downwards tiU about 7 p.m., when it continues
slowly declining till sunrise. The mean daily monthly variation is well
represented in the table. The daily variation is sometimes very great,
as much as from 20° to 23°, but this is comparatively rare, and only
occurs in cold months. In the monsoon, on the contrary, the range is
very slight.

Wet-bulb Thermometer. — I have preferred giving the temperature of
wet-bulb, to the calculated dew-point, as some diiFerence of opinion exists
about the proper calculation. It will be seen that the temperature of wet-
bulb does not dijffer much from year to year, and that the range in each
month corresponds pretty closely. The mean temperature of humidity
represents the point of saturation. Full saturation is supposed to be unity.
This enables us to compare the atmospheric moisture pretty exactly. It
does not vary much.

Barometer. — Of the barometer I have only given the mean height for
each month, and this may be said to be almost without variation in the
series of years. It descends with great regularity from its highest in
January to its lowest in June, and the height varies little during the monsoon.
The average range of the barometer during the whole year is very slight,
0*110 inch, or 0*112 inch, representing it. The extreme range is highest
in the cold months, occasionally the daily variation is as much as 0*2 inch,
or a little more. The variation is least in the monsoon months.

Eain Fall. — The rain table is given so fully, that it seems unnecessary
to add anything to it.

The evaporation in Bombay is excessive, and by the accounts pub-
lished, almost equals the average fall of rain. (Yide tables for 1849 = 72
inches.

Direction and Force of Winds. — The wind usually sweeps round the
horizon every day, blowing, as the tables quoted show, chiefly from the sea,
and with a force usually of about half a pound, for an hour or two daily,
generally less. In the monsoon, the force is greatly increased, and reaches
as high as 8 or 10 lbs. The account of the wind must only be taken as
approximative, as often there is not wind enough to move a feather.

I have not said anything of particular variations, as I conceive the pur-
pose of the table to be, to give a correct idea of the general climate of
Bombay, and such as may easily be referred to for practical purposes. For
minute investigation, the Observatory Reports are most admirable.

METEOROLOaY OF BOMBAY.

743

1^
s

p
<

8AI j[ _}0 83Ka9AV

cb4t<<N6a)>0'^-^<X)oo3wo

i-Hi— (,— tr-H ,-(,_(,_|,_,

a
n

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-^ooc^cpooocp-^iriooo

•mntuixBi^

0000a>OiOiO5000000OiO5OS

•uunuiiuij5

«>»pOC9kOOl0kO00Ort<O

•uinuiixBj\[

OiOS050sa>050500QOQOOiOO

•ranrain}j\[

-* O ip (M ^ O

to «0 CO t^ CO CD

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OOOiOOS Oi Oi <J> Oi

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looi^-THoOTtHioocoipioeo
oot-a><Ncb'*cbibib'^«5oo i

iOCDCOt^t^t~-t^l>.t^t^l>.CO

•uinuiixBjtt

(MCOOOOOOOUSOVOO
COO5CI5O5OSO5QOQ00OO5O5O>

•amiuiuiptt

000«) cpOOCO(NQpb-
CO^COCD t^t^t^t^t^coco

•mnuiiXBH

vO.-lOt^ipr-llpOOcpb-C<JiO
GOCT>O5O5CiO5O500C»00O»OS

•ranuiiaijtt

OC9>pcpJ~»ip kp05l>-W3
COkOt^»>-l>-t— l>.t^COCO

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ipipo<rqcpo ipcp(N
(b a> CO -it* ^ Oi 1 1 iMJ^T^ i

O5CJ0OSO5OiQ0 050005

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.^»bo(^:)cbec<f^oo(^^Olbo

l>-lr^O0O0QO00000C0000aOt--CX>

cqiooocpt~-ipT-io5'*ip»poip
cqib65cb4^icqbo50.^65^65 '

t-~l^t^O0Q0O0O0t~-QOQOt^t^l>.

'*f-lcoo-^oo^-o^-ocoooo5

C<>«365C<I-^o:)i^T^bo365io65
l^t^t^COOOOOOOOOOOOOt^t^t^

COQOC^T^cr^OOi^TylQOC^COipcO

M«:)650^^T-cbboorl^4-icb65

t^t-t-COCO0000001--0000l^t^

«3<-<t^f;-lcp«5i7((N005COCpOO

ibkb«5<«'^»-<'--'bt^b65cb65
t^t^t-oooooocooooooot^t-t^

C<lt-'*.-l05OTf<0005.-ig5l^O

ibcb65<rqo?i^bo5oo<fq«3th)65
t^t^t^oocooooot^t^oot^t--t-

llllitllllll

3 B 4

744

METEOROLOGY OF BOMBAY.

Average

Six

Years.

<»Q0OSOSO5OiOiO5O5O>OS00OS
6600660060600

•UBan

^050i.-lOi(5«5«0<£>-*<000i^
QOOOQ0050iO>0505050SOOOOOi

6666666666666

•UBaitt

t^Of-l(M(M<X>COt^'*rt<fHQO(N
00OSO5OSO>O>CT.O5a>CT>O500O»

6666666666666

•UTjan

OOOOt-l,-ieO<X>»:^<D«5'*<050(M

6666666666666

•UBaH

00O5OSOSO5O5OSO5O5O5O500Oi

6666666666666

•uBaH

005F-(eoeoot^co«5ir>T-ii— leo

Oi00O^OSO5OiO5OSO5O5O5OSOS

6666666666666

•uBajv[

oo50eoTt<t^t^t^«ow5(Moeo

O50OOiO>O5OSOiO>O5OiO5OSOS

6666666666666

P
g

Mean

of
Four
Years.

05U5CCQO?0000(Mr-IOO<r»TJ<

66»beoeb««)ebM-^-*tb4t<

oipiptpa>Qpw5t-ipo5-*-<*H<r)

cprt<<Ncoioeocpw30o-^ix>00

Average

Five

Years.

(rq»poco<NOi?^cp>pvpopOTH

i^oo<^36oo66i^6t^c<i64H

OO.^'^OJOOOiOSOOQOOOSlOOO

ibb-o^ib oo6a)i>-6oOf^64j<

OOOSOOlr^OOOTtlcpoOipMCp

66(f^«3oo6oob»66iboo4H

(r5cpcpTt<Vp-*.7lO-0005»pQp

6c»<^^l>.ooaooo^~^»oo(^^6-^

c501^m6<Xi(X)1^1^6|^66'*

January .
February
March .
April
May .
June
July

August .
September
October .
November
December
Annual .

METEOROLOaY OF BOMBAY.

745

s, ^

^ s

■rt<

,_4

t—

1—1

rt<

^'S^

CJS

CSI

■>*'

to"

c<t

t~-

»>•

CJS

o«

C<J

1-4

b«.

»»

«3

-!*<

!>.

(>»

i-l

<->

r-iii

•o

t>.

c:s

(><

t>.

T-l

■*

IfJ

,_(

!>.

»>.

c»

C3S

1—1

f-(

C<l

I— 1

?■

<3S

(>»

f-H

.-t

»^

b»

«3

■<^

t>.

t-»

!>.

cri

•

<>4

1-5

1
1

§3

1=1
a

746

JIETEOROLOar OF BOMBAY.

■sjnoH 'puBi moiji

b-»OW3(Ni-«Tt< 1 "C^I^O^S

g g

•»4noH -BBS wiojj

f-<i-(i-l(N(MC<JC^CO<Nr-li-l^

•sanoH 'puBi uiojj

OSM5iM(MCO(NrH^(M-^00Oi

•sjnoH -Bag uiojj

Comparison of
Average of
Six Years of
Mean Tempera-
ture,
with Wet Bulb.

•?3M

(MlOOCO(MOC^OO»pkf5000TH

•^ua

t^l>.t:^O0O00O0O00Q0O0t^t^l>.

& s

•syfBQ ^utisji JO jaqiunK

102

•saqDui

78-61

■s^2(i ituiBa JO jaquin^

(M (N <M <M 05

•saqoai

0-01

0-30
21-76
2217
1115
12-69

0-17

1-01
69-26

•Sj^bq ^utBa JO jaquin^

(M (M (M r-( Oi

•saqDui

•siBQ ifarea JO jaquinK

ec o (M o oo -H • -*
1 I 1 1 1 (N eo <M (M o

1— 1

•soqoui

(M (M T-H CO Oi (M Oi

cq 6> 4*1 4j< 4t< o 'lb

.-H r-t ^

•s.iBa: ifuiBH JO jaquinjsi

(Ml I 1 it^iX>f-HOC0(Mi^
(M (M iM (N O

1—1

•saqauj

Oi 1 i i0300(Mtl-00''^

<M -* 1— 1 <N I— 1

■s.tBa ^uiBH JO jaquin^

' ■ ■ "^^S^SS^^^ ■ ^

•saqDui

QO 1— «0 r-l t^ O 05 OS 1>.

1-1

-s/Cbq ^uibh JO Jaqiun^

,_I,-H ,,-IC00i05O05r-l»0 |C<1
(M (M CO i-H F-H

•saqoui

<M<M t--COC<IOiC5rH05rt lO
C^O ,C<JrHiC)05Cq(MC^t^ iCO

6o o-^iiibooibovb o5
CO .-f t^

January .
February
March .
April .
May .
June
July

August .
September
October .
November
December
Annual .

SANITARIUM AT POORUNDHUU.

747

Memorandum on the Sanitarium at Poorundhur, 19 Miles

DISTANT from PoONA, LATITUDE N. 18*12, LONGITUDE E. 73*54,

Altitude 4200 Feet. — Established in 1852.

1. Table showing the Atmospheric Pressure^ the Temperature, the Dryness^
the Rain-fall, and the Direction of the Winds at Poorundhur.

Barometer.

Thermometer.

Direction of Winds.

OS
S.

isS

lla

•3

«|^

Inches.

January

26-022

66-8

71-0

61-8

17-3

0-5

SE. NW. W. NE.

February . .

26-023

73-3

76-6

66-6

24-4

0-30

Variable.

March . . .

25-940

76-7

81-0

69-6

26-4

0-20

NW.

April . . .

25-958

78-1

83-0

70-6

28-3

0-50

NW.

May . . .

25-883

72-9

78-4

68-0

12-1

5-70

NW.

June

25-795

69-8

80-0

65-4

3-2

10-18

NW.

July . . .

25-806

66-9

70-8

65-2

22-98

SW. and NW.

August , . .

25-837

65-4

68-2

64-4

0-7

16-34

SW. and NW.

September

25-844

67-4

72-6

65-4

2-1

7-39

NW.

October . .

25-946

71-2

74-2

67-0

10-6

6-54

SE.

November . .

26-041

69-3

73-2

65-2

18-8

0-67

SE.

December . .

26-011

64-1

69-8

59-2

13-2

1-36

E. and SE.

Mean

25-925

70-1

74-9

65-7

13-2

72-21

Total inches.

The Pressure, Temperature and Dryness are taken from the Eeport for the years
1852-53, and are therefore to be regarded merely as an approximation. The Eain-
faU is the average of six years' observation : the greatest was in 1854, viz. 97*24
inches; the least in 1856, viz. 44-76 inches. The hill is more or less covered with
fog in June, July, August, and September ; in greatest degree in July and August.

2. The object of this Sanitarium is to promote the restoration to health
and strength of soldiers who have become debilitated from the effects of
climate, or from recurrences, or from long duration of various forms of dis-
ease, and thus to increase their efficiency, lessen their liability to suffer
from severe types of disease, and add to the probabilities of lengthened
service.

748 SANITARIUM AT POORUNDHUR.

3. These beneficial results occur with greater certainty in convalescents,
in whom there exists no internal organic disease, or marked tendency to
it. It will, therefore, be found that the young soldier derives more benefit
from the climate of Poorundhur than the soldier of ten years' service and
upwards in India.

4. From the commencement of the month of March to the middle of
November is the season during which these advantages will be gained.
The period of residence required for complete restoration of strength will
vary in different cases, and its determination should be left to the discre-
tion of the Medical Officer in charge of the Sanitarium.

5. Though in the class of invalids adverted to in the 3rd paragraph,
the hill climate from the middle of November to the end of February
might not prove injurious, still it possesses no advantages over that of
Poona, and the season is suitable for return to this latter station and to
duty.

6. The class of convalescents hitherto referred to as likely to be bene-
fited by this climate, are : 1st. — Those who have become reduced in
strength from recurrences of intermittent or remittent fever at Poona, or
other adjacent stations, in June, July, August, and September, may, with
advantage, reside at Poorundhur from the beginning of September to the
middle of November. After this period, however, such cases had better
be returned to Poona ; for, from the middle of November to that of Feb-
ruary, there will be a greater liability to re-attacks of fever in the hill
climate than at Poona. 2nd. — Those who have suffered from recurrences
of malarious (intermittent or remittent) fever in October, November,
December, January, and February, may be sent to the hill with every pros-
pect of benefit, in the month 'of March ; the duration of residence in each
instance being prolonged or not according to necessity. 3rd. — Young
recruits debilitated from attacks of common continued fever (febricula) in
March, April, and May, will, after convalescence has fairly commenced, be
benefited by the climate of Poorundhur. 4th. — Those whose health and
strength have become enfeebled from the general effects of a tropical cli-
mate or from strumous or allied diathesis, and in whom chronic lymphatic
glandular swellings, or indolent external ulcerations are present, are likely
to derive advantage from a residence, more or less prolonged, between the
beginning of March and middle of November.

7. The months in which invalids may resort to Poorundhur are : 1st. —
From the commencement of September to the middle of November, —
regard being had to the character of the monsoon weather, in different
years, in the first named month. From the middle of November till to-
wards the end of February, convalescents of all kinds are probably better
in Poona than at Poorundhur ; and, as already stated, it will generally be
expedient to return to the former station invalids who have been sent to
the hill in the September and October immediately preceding. 2nd. —
Though invalids already at Poorundhur, and who have been resident there
for some time previously, are generally improved by the climate of July
and August, it is, nevertheless, unadvisable to send them there in these

SANITARIUM AT POORUNDHUE. 749

months. 3rd. — March, April, and May are the months most suitable for
the transfer of convalescents to Poorundhur. A greater variety of cases
may be sent at this period, and they can haVe the advantage, if necessary,
of a continued beneficial residence of eight months and a half, viz. to the
middle of November. In many cases more or less of the climate of March,
April, and May is necessary to fit the constitution for deriving benefit
from the monsoon months.

8. The more precise application of the climate of Poorundhur will be
best explained by reference to some of the chief forms of disease.

I. Fevers. The convalescent, from all forms of uncomplicated fever,
will be benefited from March to the middle of November. Individuals
who have suffered fi-om frequent attacks of malarious fever are liable to
have the disease re-excited — chiefly in the tertian form — by external
cold in the months of December and January ; this liability (the degree of
predisposition in both instances being assumed equal) is greater at Poo-
rundhur than at Poona ; therefore the former locality should, under these
circumstances, be avoided in these months. Such individuals are also
liable to re-attacks in July, August, September, and October ; this liability
would seem to be greater at Poona than at Poorundhur, probably in con-
sequence of the great equability of temperature of the latter not favouring
cold as a determining cause, and the more continuous moisture preventing
the generation of malaria. Therefore, the predisposed to intermittent fever
may pass the rains with advantage at Poorundhur, provided he has resided
there a month or six weeks of the hot season just preceding. Convalescents
from malarious fever, in whom some degree of splenic enlargement is present,
may resort to Poorundhur at the suitable seasons without risk of injury,
and with every prospect of advantage, provided appropriate care and man-
agement be at the same time adopted. A similar remark may be applied
to those in whom, with the febrile recurrences, there has been tendency to
hepatic congestion, provided the disease has not been of long duration, nor
the subject of it long resident in India. For it is reasonable to infer that
where congestion of the spleen or of the liver is coincident with, and in a
measure consequent on, the febrile recurrence, and diminishes or ceases
with its intermission, the tendency of a climate which prevents the return
of the febrile paroxysm must be gradually to remove the dependent con-
gestions and their consequences, if appropriate medical treatment and
management be at the same time had recourse to. It follows, then, from
these observations, that benefit from the climate of Poorundhur to con-
valescents from fever will be contingent on accuracy of diagnosis as respects
absence, nature, and degree of organic complications.

II. Dysentery and Diarrhcea. The convalescent from uncomplicated
dysentery or diarrhoea may with propriety be sent to Poorundhur in
March, April, and May, and his stay there prolonged or not according to
circumstances.

III. Hepatitis. Individuals who have recently suffered from attacks
of acute hepatitis, and who are consequently predisposed to recurrence,
should, as a general rule, avoid this climate at all seasons, though probably

750 SANITARIUM AT POORUNDHUR.

there is still room for experiment as to whether the monsoon season at
Poorundhur may not, under these circumstances, be useful in young, pre-
viously sound, and at the time thoroughly convalescent constitutions.

IV. Cirrhosis. The hill climate is unsuitable for the soldier in whom
this condition of the liver is suspected to be present.

V. Dyspepsia. When the symptoms to which this term is applied are
related to debilitated states of constitution, or to chronic irritation of the
mucous membrane of the stomach, the climate of Poorundhur, with due
attention to diet and medical treatment, is in general very useftd. When,
however, they are dependent on cirrhosed liver, or other allied visceral
change, benefit is not to be looked for : such cases, indeed, have been
erroneously classed.

VI. Pulmonary Affections. In the incipient and early stages of
phthisis, good will probably result negatively in March, April, and May
from avoidance of the debilitating influence of the heat of the plains. The
soldier, generally of some length of service in India, suffering from chronic
bronchitis or asthma, is not likely to be improved by a residence at
Poorundhur ; on the contrary, these affections are liable to be increased.

VII. Affections of the Heart. Organic disease of the walls or
valves of the heart will, it need hardly be observed, derive no benefit.
The symptoms consequent on the embarrassed action of the organ will
generally become aggravated. Yet there are cases of disease, occasionally
erroneously named Carditis, characterised chiefly by palpitation, often
distinctly traceable to frequent exposure to the sun, or to alcoholic or
other intemperance, which may be improved by avoidance of the hot
season of the plains. In selecting such cases, however, carefiil attention
to diagnosis is essential.

VIII. Cerebral Congestive, Inflammatory, or Structural Disease
is liable to be aggravated by the climate of Poorundhur.

IX. Kheumatism. — Cases of pain, with or without slight swelling of the
jojints, occurring in cachectic constitutions, provided the cachexia is not
decidedly syphilitic, often derive benefit if sent to the hill after the begin-
ning of March ; and if the improvement has been considerable in the
months of April and May, it will probably be increased and perfected by a
residence continued during the monsoon months.

X. Secondary Syphilis. — There is no quality of the climate of
Poorundhur calculated to aid in the eradication of the syphilitic virus.
Still, in cases in which treatment has been inefficacious in the plains, and
in which the cachexia is rapidly advancing, it may be reasonable enough
to expect greater benefit from treatment conducted at Poorundhur in
March, April, and May. In some instances syphilitic eruptions have im-
proved during the monsoon months. This climate will also be usefiil to
the debilitated convalescent from syphilis, just as it is in similar conditions
of constitution consecutive on other forms of disease.

9. It may be inferred from the general tenor of these observations,
that complete restoration to health and strength fi'om a residence at
Poorundhur wiU be chiefly found to occur in the soldier of a few years'

SANITARIUM AT POORUNDHUR. 751

service in India, in whom a proclivity to attacks of malarious fever has
not become firmly established, and organic disease is as yet slight and
remediable in character. If such as respects previous disease be also the
conditions of the soldier of ten years' service and upwards, then to him
also the climate of Poorundhur will prove beneficial. The tendency
of the advantage thus gained, Avill be to maintain and increase the vigour of
the constitution, to render it less predisposed to the severer forms of disease,
and thus prolong the period of the soldier's efficient service in India.
But when the soldier has served in India ten years and upwards, and
during that period has frequently suffered from disease, and the question
of invaliding has arisen, then, though it may be of advantage to him to
pass at Poorundhur the period that it may be necessary for him to remain
in India ; still it is not to be expected that residence there will be in any
respect, under these circumstances, a substitute for invaliding, or will
lessen the number of unfits of this class.

10. The transfer of sick in states and stages of serious disease at the
time requiring care and medical treatment, in the hope that these may be
conducted with more advantage at Poorundhur, was not in contemplation
when the Sanitarium was established ; and there has been nothing in ex-
perience there since to justify this proceeding, but much to dissuade fi-om
it. It is, doubtless, disheartening and unsatisfactory to watch disease
progressing, notwithstanding our best eflfbrts to remove it ; but this evil
is not to be prevented by the heedless transfer of sick from station to station.
It is to be lessened: 1st. — By such sanitary measures in regard to barracks,
hospitals, dress, rations, duties, amusements, and judicious use of hill and
other Sanitaria, as shall maintain the health and vigour of the soldier at as
high a point as practicable, and, therefore, less prone to the severer types
of disease. 2nd. — By such careful study of the pathology and rational
principles of treatment of disease in India as shall teach us to distinguish,
at the earliest periods, all serious forms, and to conduct the cure with
watchful care and steady judgment.

1 1 . There are diseases, as recurring malarious fevers with or without
splenic and hepatic complication, idiopathic affections of the liver and
bowels, pulmonary, cardiac, nephritic, and rheumatic affections, for which
the climate of Poona fi'om the middle of November to the end of February
is not favourable, and for which that of Poorundhur at the same season is
still more adverse. For these a Sanitarium on some well-selected site on
the sea-coast would be a great boon to the suffering soldier, and, conse-
quently, a great advantage to the Government. It would, further, be useful
in those forms of hepatic disease for which both Poona and Poorundhur
are unsuited also in the hot months of the year.

^^* This Memorandum was prepared by me, when Superintending Surgeon of the
Poona Division, after full consideration of the Eeports of the several Medical Officers,
and careful personal inspection of the Sanitarium and of the Invalids at the time
(May 1858) resident there, in the hope that it might be useful to Medical Officers in
charge of European troops, more especially those who had recently arrived in the
Poona Division, It makes no pretension to having exhausted or fiilly developed the
subject, and was intended to be suggestive, not dogmatic.

LIST OF CASES

The Numetml at the end of the Title of each Case is that of the Case in the
First Edition, and is now added to facilitate lieference from one Edition to the
other. Those without a second number are published for the first time in this
edition.

CHAPTEE III.

INTERMITTENT FEVER,

1. Abnormal prsecordial cMness from en-
larged spleen, 8. . . . Page 36

2. Abnormal prsecordial dnlness from en-
larged spleen associated with systolic
murmxir, 9. . . . . .37

3. Abnormal prsecordial dulness from
splenic enlargement. Systolic murmur
present, 10. . . . . .37

4. Abnormal prsecordial dulness from en-

• largement of the spleen. Systolic mur-
mur present, 11. , . . .37

6. Extended prsecordial dulness, with
systolic and venous murmurs, without
splenic enlargement from anaemia
alone, 12 38

6. Intermittent fever complicated with
hepatitis. Death from cholera. Liver
in a state of vascular turgescence, 17. 44

• 7. Intermittent fever with enlargement

of the liver, 18 44

8. Intermittent fever with gastric irri-
tation treated with quinine, 19. .49

9. Intermittent fever, 20. . . .50

10. Intermittent fever, with chronic me-
ningitis. Symptoms chiefly during ac-
cession. Death from unexpected col-
lapse, 21. . , . . ,51

11. Intermittent fever: some of the par-
oxysms complicated with convulsive
fits, one of which terminated fatally.
Thickening and opacity of the arachnoid
membrane, 22. . . . .51

12. Intermittent fever complicated with
pericarditis and pneumonia, Ee-
covery, 23 54

13. Intermittent fever complicated with
asthma, 24 55

CHAPTEE V.

REMITTENT FEVER.

3 c

14. Eemittent fever fatal from unexpected
collapse, 25 Page 68

15. Great collapse in the course of re-
mittent fever. Eeeovery by stimu-
lants, 26 69

16. Exhaustion taking the place of exacer-
bation in remittent fever, 27. . . 70

17. Eemittent fever. Death by coma.
Bright's disease of both kidneys, 28. . 77

18. Eemittent fever, with adynamic sym-
ptoms. Serum underneath the arach-
noid and at the base of the cranium. No
coma. The liver much enlarged. Dark
rosy tint of the mucous coat of the
stomach, 29 78

19. Eemittent fever with irregular sym-
ptoms in an intemperate man of very-
corpulent habit, and in whose head,
heart, liver, and kidneys there was ex-
tensive old organic disease, 30, . 78

20. Eemittent fever in a person of very
intemperate habits, with symptoms in
some respects resembling delirium tre-
mens. Death by coma. Three ounces
of serum at the base of the skull ; liver
much enlarged. Commencing degenera-
tion of the kidney. Mucous coat of the
colon softened, with here and there
red patches, with a mucous follicle in
the centre of each discoloration. Sof-
tening of the mucous coat of the sto-
mach, 31. 79

21. Eemittent fever with adynamic sym-
ptoms. Obscure pneumonia. Death
without coma. Bright's disease of both
kidneys, 32 80

22. Eemittent fever. Death by convulsion
and coma. Vascular congestion of the

754

LIST OF CASES.

vessels of the pia mater. Rosy tint of
the substance of the brain. One ounce
of serum ut the base of the skull. The
heart dilated and its tissue pale and
liabby. Partial redness, thinning, and
softening of the mucous coat of the sto-
mach. Peyer's glands enlarged. The
spleen enlarged and softened, and the
kidneys congested, 39 . . Page 82

23. Remittent fever in a man of intempe-
rate habits. Fatal with convulsion,
coma, and tumultuous action of the
heart. Considerable eflfusion of serum
in the head. Streaked redness and sof-
tening of the mucous membrane of the
stomach. Deep red tint of the endo-
cardium and muscular tissue of the
heart, 33 .83

24. Remittent fever in a man of intem-
perate habits. Death by coma. Increased
vascularity of the membranes of the
brain and considerable efftision of serum.
Softening and vascularity of the mucous
coat of the stomach and large intestine.
Commencing degeneration of the kid-
neys, 34 83

25. Remittent fever. Simulating delirium
tremens. Pia mater very vascular, with
bullse of air between the arachnoid and
pia mater and in the vessels, 35. .84

26. Remittent fever proving fatal by col-
lapse and coma at the close of an exacer-
bation. No serous efiusion in the head.
Dotted redness and softening of the
mucous membrane of the stomach. En-
largement of the mucous follicles of the
colon and of Peyer's glands. Lumbrici
in the small intestine, 36. . . 85

27. Remittent fever. Drowsiness and
coma. Considerable quantity of serum
effused in the head. Vascularity and
thickening of the mucous membrane of
the stomach, 37 86

28. Remittent fever. Coma from exhaus-
tion, 38. 86

29. Remittent fever. Meningitis. Effu-
sion of serum in the cavity of the arach-
noid and sub-arachnoid space. Opacity
and thickening of the arachnoid mem-
brane, 40. . "... 87

30. Remittent fever admitted after a week's
illness. Head symptoms chiefly marked
by unsteadiness of manner, and latterly
drowsiness. Arachnoid membrane opaque
and thickened. Increased serous effu-
sion, 41. 87

31. Remittent fever admitted in an ad-
vanced stage. Death by coma. Exten-
sive lymph and serous effusion in the
sub-arachnoid space. Hepatisation of
both lungs, 42. . . . .88

32. Remittent fever with adynamic sym-
ptoms. Slight vascularity of the mem-

branes of the brain with air in the
vessels and beneath the arachnoid, Tur-
gesccnce and ulceration of Peyer's glands
at the end of the ileum, 43. . Page 89

33. Remittent fever. Symptoms adynamic
and badly-developed. Serous effusion
and slight vascular congestion in the
head, also air in the vessels. The colon
distended and in part displaced, 44, 89

34. Remittent fever, with head and gastro-
enteritic syinptoms ; two or three ounces
of serum in the cranium. Firm granular
exudation on the mucous surface of the
colon. Dark redness of the end of the
ileum. The subject of a large hydro-
cele, 45. 95

35. Remittent fever. Peyer's glands en-
larged and ulcerated. Head symptoms
with moderate turgescence of the ves-
sels, 46 95

36. Remittent fever with jaundice. Drow-
siness. Biliary congestion of the liver.
Enlarged lymphatic glands in the course
of the common duct. Slight dilatation
of the hepatic duct, Gastro-duodenitis,
Granular exudation on the mucous sur-
face of the ileum and colon. Nodules of
pulmonary apoplexy; one softened into
a cavity, 47 98

37. Remittent fever with jaundice. Tender-
ness at margin of right ribs. Coma.
Gastro-duodenitis. Enlarged lymphatic
glands in the course of the common duct.
Biliary congestion of the liver, 48. 99

38. Fever with jaundice. Tenderness at
the margin of the right ribs. Drowsiness.
Bniary congestion of the liver. Ob-
struction of the hepatic duct by a lum-
bricus, of which there were many in the
duodenum and stomach. No gastro-duo-
denitis. Enlargement of the lymphatic
glands in the course of the common duct.
Hepatic cells distinct, 49 . . .99

39. Remittent fever with jaundice. Ten-
derness at the margin of the right ribs.
Drowsiness, Enlarged lymphatic glands.
Enlarged head of the pancreas. No
duodenitis. Biliary congestion of the
liver, 50 100

40. Remittent fever with jaundice. Ten-
derness at the margin of the right ribs.
Death from exhaustion. Enlargement
and biliary congestion of the liver,
Gastro-duodenitis. Hepatic cells dis-
tinct, 51, , .... 101

41. Remittent fever with jaundice in an
opium-eater. Tenderness at the epigas-
trium. No coma. Death from exhaus-
tion. Enlargement and bUiary con-
gestion of the liver. No duodenitis.
No enlargement of. the lymphatic
glands, 52, , . . . . 101

42. Remittent fever with jaundice. Ten-

LIST OF CASES.

755

deniess at the margin of the right ribs.
Death from exhaustion. Cirrhosis. Gall
bladder distended. Enlarged lymphatic
glands around the common duct. Duo-
denitis. Granular exudation on the
mucous membrane of the ileum and large
intestine, 53 Page 102

43. Fever with jaundice. Died exhausted.
Biliary congestion of the liver. No en-
largement of the lymphatic glands. Con-
traction of the cystic duct. Distention
of the gall-bladder, mucous membrane of
gall-bladder and ducts normal, with ex-
ception of slight vascularity of common
duct at point of entrance into duodenum.
Hepatic cells distinct, 54. . .103

44. Eemittent fever with jaundice. Drow-
siness. Enlarged lymphatic glands in
course of common duct. Constricted cys-
tic duct. GaU-bladder full, 55. . 104

45. Eemittent fever with jaundice. No
tenderness at margin of ribs. Drowsi-
ness. No enlargement of lymphatic
glands. Dark-redness of mucous mem-
brane of duodenum, 56. . . 104

CHAPTER XIV.

DYSENTERY.

46. Under treatment nine months. Dy-
sentery alternating with rheumatism,
probably syphilitic ; terminating in gen-
eral cachexia with febrile symptoms.
The lungs, liver, mucous coat of stomach
and intestines presented morbid appear-
ances of various characters, 131. . 239

47. Chronic dysentery, discoloration with
thickening of parts of the mucous mem-
brane of the large intestines. Com-
mencing degeneration of kidneys, 133.

239

48. Melanosis of the colon. No ulceration.
Tubercles in the liver, 134. . , 240

49. Membranous mucous exudation on the
inner surface of the large intestine, 240.

60. Chronic dysentery in an opium-eater.
The mucous coat of the colon lined with
a firm granular layer. The lungs tuber-
cular. Cartilaginous contraction of the
pyloric orifice of the stomach, 135. 241

51. Diarrhoea tedious. Granular yellow
exudation on the mucous surface of the
large intestine with thickening of the
tunic, 136 .242

52. Dysentery with adynamic febrile sym-
ptoms. Granular exudation on the mu-
cous coat at the end of the ileum. Sloughy
ulceration of the large intestine, 141. 246

53. Granular exudation on mucous surface
of ileum and colon, with irregular ulcera-
tion of the latter. No disease of the liver.
Displacement of the colon, 162, . 247

54. Dysentery alternating with febrile ac-

cessions. Bands of granular deposit at
the end of the ileum. Sloughy idceration
of the colon, 143, . . _. Page 247

55. Dysentery. Sloughy ulceration of large
intestine, Granidar deposit in transverse
bands in the ileum. Peritonitis and
matting of the omentum. An opium-
eater, 144 248

56. Probable scorbutic taint. Dark, irre-
gular, ragged, internal surface of the
colon, with thickening. Granular de-
posit on mucous membrane of ileum, with
thickening, 145 249

57. Thickening and sloughy ulceration of
large intestine, with here and there a
small encysted abscess in the thickened
tissue. Granular deposit on inner sur-
face of ileum. Peritonitis. Old peri-
carditis and heart disease, 146. . 249

58. Dysentery. Sloughy ulceration in
transverse bands, and the follicles of the
colon in different stages of disease. In-
sensibility for an hour before death. Two
ounces of serum at the base of the skull,
147 250

59. Dysentery neglected for thirteen days,
attended with abscess in the liver.
Sloughy ulceration of the mucous coat
of the colon, with fringe of granular
exudation, 148 250

60. Acute dysentery. The large intestine
ulcerated in transverse ridges. The
mucous follicles enlarged. Considerable
effiision of serum in the head without
symptoms, 149 251

61. Acute dysentery. The ulceration in
transverse ridges. Considerable effusion
of serum in the head, without symptoms,
150 251

62. Dysentery in an advanced state ob-
scured by secondary peritonitis. Gra-
nular deposit on the mucous surface of
the large intestine, 151. , . 252

63. Several attacks. Colon thickened.
Sloughy ulceration, with granular deposit
on other parts of the mucous surface of
the colon. Slight peritonitis, 152. 252

64. Dysentery admitted in the last stage.
Peritonitic inflammation. Sloughy ul-
ceration of the mucous coat of the
colon, 153 253

65. Patches of submucous puriform in-
filtration in colon, 161. . . . 255

66. Sloughy patches of mucous mem-
brane of colon, with submucous
oedema, 162. . . . .255

67. Numerous small follicular \ilcerations
of the colon, 163 256

68. Chronic dysentery in a person ol
broken constitution. Numerous lolli-
cular ulcers in the large intestine, many
of them cicatrising. Serous effusion in
the head without symptoms, 164. 256

C 2

156

LIST OF CASES'.

G9. Dark-grey discoloration, with some
degree of thickening of mucous mem-
brane of colon, with numerous circular
ulcers, 165. . . . Page 267

70. Circular and transverse ulcers of the
large intestine. Matting of the omen-
tum over the colon, with displacement.
Liver healthy. Distention of the urinary-
bladder, 167 257

71. Dysentery. Death in early stage by
cholera. Gangrenous patches of mucous
membrane of large intestine, but no
separation . . . . . 258

72. Dysentery. Sloughs of the mucous coat
passed before death. Much displace-
ment of the colon to the left side. Ab-
scess in the liver, 169. . . . 258

73. Acute dysentery. Extensive sloughy
ulceration of the inner surface of the
large intestine. Dark-red grumous dis-
charges, 170. . . . , 259

74. Dysentery. General peritonitis be-
fore the fatal termination. Serous eflPu-
sion in the head; no head symptoms.
The mucous coat- of the colon in pro-
cess of separation from the other
tunics, 171 260

75. Sloughy state of mucous membrane
of the colon. Submucous puriform in-
filtration, forming little cavities. Ge-
neral peritonitis. Matting of omentum.
Eetention of urine, 172. . . 260

76. Mucous membrane of colon sloughy
and separating in shreds. General
peritonitis and matting of the omen-
tum, 174 261

77. Dysentery attended by general peri-
, tonitis. The ulcers in different stages

of progress,- some cicatrised, one per-
forating, but patched up, 176 . . 263

78. Chronic dysentery. Enlarged me-
senteric glands. Mucous coat of the
colon firm and thickened. The cica-
trices of ulcers, 177. . . .264

79. Pleuritis cured, succeeded by hydro-
cele radically cured ; followed by rheu-
matism, succeeded by dysentery, ca-
chexia, and recurrence of dysentery.
Colon xdcerated, 178. . . . 264

80. Sloughy ulceration of eolon. Ge-
neral peritonitis and matting of the
omentum, 181 266

81 Sloughy ulceration of large intestines
without thickening. Commencing ab-
scesses in the liver. Peritonitis, 182. 266

82. Sloughy ulceration and thickening of
large intestine. Matting of omentum.
Dysuria, Peritonitisof bladder, 183. 267

83. Much sloughy destruction of the
colon. Peritonitis and matting of the
omentum. Former attack of hepatitis.
Puckered fibrous bands in liver, 184. 267

84. Thickening of the colon. Numerous

deep ulcers. Matting of the omen-
tum. Liver with fibrous puckered
bands, 185. . . . Page 267

85. Thickening and sloughy ulceration of
large intestine. Matting of omentum.
Congestion of the liver, 186. . .268

86. Habitual constipation. Colon con-
tracted in parts and strictured by a band
of the omentum. Tubercular infiltration
of the limgs. Ulceration of the ileum
and ccecum, probably from softening of
tubercles, 187 268

87. Chronic dysentery. A palpable tu-
mour of the ccecum. The lungs studded
with tubercles not suspected during
life. Considerable effusion of serum in
the head, 188 269

88. Dysentery. Perforation of the cce-
cum, with consequent formation of a
circumscribed sac, with gangrene of the
muscles and integuments, 189. . 270

89. Circular ulcers with sloughs in mu-
cous membrane of colon and stomach.
No thickening, 190. . . .271

90. Grey - softening, with a few ulcers of
the mucous lining of the stomach and
colon. Cicatrices of ulcers in the
former, 191. . . . .272

91. Dysentery. The use of purgatives
too much abstained from. The lower
end of the ileum distended from thin
feculence, 192 301

92. Good effects of opium, in the treat-
ment of some states of dysentery, illus-
trated, 199 303

93. Acute dysentery in a child. Treated
with ipecacuanha and blue pill, 194. 315

CHAPTER XV.

HEPATITIS.

94. Abscess in the brain not suspected
during life. Abscess in the liver, with
pneumonia of the lowest lobe of the right
lung, revealed by symptoms. Vascular
turgescence of liver, 195. . . 330

95. Hepatitis. Several abscesses in the
right lobe. Nodules in the left lobe.
The mucous coat of the colon ulcerated.
Serous effusion in the head without
symptoms, 196. . . . .331

96. Dysentery complicated with delirium
tremens. Milkiness of the arachnoid.
Matting cf the omentum over the colon.
Numerous sloughy ulcerations of the
mucous coat of the ccecum. Many ab-
scesses in liver, 179 331

97. Illustrates formation of abscesses from
breaking down of lymph deposit. Pus
tinged with bile. The corpuscles gra-
nular and broken down. Surrounding
tm'gescence, 198 . . . .331

LIST OF CASES.

757

08. Hepatitis. Abscesses, in one, break-
ing down of the parenchyma ; in the
other the deposit in the interstitial tissue
had not yet broken doAvn into pus.
Mucous coat of the colon dark-red, and
covered with firm granular exuda-
tion, 199. . . . Page 332

99. Hepatitis. An abscess lined by firm
membrane in the right lobe. Several
nodules in different places of the liver ;
in some suppiu'ation commencing at the
centre. Traces of ulceration in the
colon. Granular exudation on the mu-
cous coat of the rectum, 200. . 332

100. Hepatitis. Two large abscesses from
degeneration of lymph and tissue. The
liver mottled buff. The mucous coat of
the colon dark-grey with red patches,
and several ulcers. The kidneys mal-
formed, 201. . . . . .333

101. Abscess in the liver. Sac smooth
without flocculi. Large intestine, with
sloughy ulceration of the mucous coat.
Complicated with intermittent fever,
which, at the commencement, was the
prominent feature. Several lymph
nodules, 202. . . . .333

102. Large hepatic abscess, with shreddy floc-
culent walls and surroundin g vascular tur-
gescence. No intestinal ulceration, 204. 334

103. Abscess in liver discharged by the
lung, followed by convalescence. Pro-
ceeded to England, and died shortly after
arrival. No account of the post mortem
appearances, 205 336

104. Hepatic abscess attributed to blows.
Opening into the lung. Improvement.
Eecordastothe issue incomplete, 206. 336

105. Hepatic abscess opening through the
lung. Result of the case not recorded,
207 336

106. Hepatic abscess communicating with
the hmg (?). ^ Result not known, 208. 337

107. Dysentery. Secondary hepatic ab-
scess forming obscurely. Opening into
the lung. No ulceration of the intes-
tine, 209 .337

108. Large hepatic abscess with brick-red
pus. Smaller one opening into lung.
Brick-red sputa. No diarrhoea till just
before death. Intestines not examined.
A spirit-drinker, 210. . . .338

109. Hepatic abscess opening through the
lung. Causing pleuritis and effusion.
Also presenting externally, but not
opened, 211 339

110. Hepatitis, ending in abscess discharged
through the lung. An abscess in the
third lobe of the right lung, communi-
cating freely through the diaphragm with
the abscess of the liver. Mucous coat of
the large intestine ulcerated. Many of
the ulcers cicatrised, 214. . . 340

111. Two hepatic abscesses. One opening
into the lung, with expectoration of deep
bile-tinged puriform sputa, Page 215. 340

112. Abscess in the liver opening througli
the diaphragm into the sac of the pleura,
and causing purulent effusion there, 217.

341

113. Abscess in the left lobe of the liver
opening into the stomach. No vomiting.
No detection of pus in the intestinal dis-
charges. No intestinal ulceration, 221.

343

114. An abscess of the liver communi-
cating with the colon. Others in process
of repair by absorption, 228. . , 344

115. Hepatic abscess, recovered from, by
probable opening into the colon, 222. 344

116. Hepatic abscess opening into the
colon (?). Recovery. . . . 345

117. Hepatic abscess opening into the colon
and stomach (?). Recovery. . . 345

118. Two hepatic abscesses in process of
absorption. Death from cholera. Pain-
ful decubitus on right side explained by
the situation of one of the abscesses. Ul-
ceration of colon, 224. . . . 346

119. Four hepatic abscesses. General pe-
ritonitis, but no evidence of abscess rup-
ture. Two of the abscesses in process
of cure by absorption, 225. . . 347

120. Hepatic abscess in process of cure by
absorption .348

121. Hepatic abscess. Absorption (?). Re-
covery. 348

122. Purulent sac between the liver and the
diaphragm, communicating with the left
lung. No hepatic abscess. . .349

123. Amputation of the right hand, fol-
lowed by general bad health and chronic
hepatitis. A purulent sac between the
liver and the ribs filled with foetid pus.
Hepatisation of the lower part of the
right lung, 226 349

124. Abscess in the liver. Also one ex-
ternal and circumscribed communicating
with former. Dark-red colour of mucous
surface of large intestine, which con-
tained much clotted blood, 227. . 350

125. Hepatitis. Abscess bounded beyond
by a firm sac. A circumscribed abscess
in the peritoneal cavity over the edge of
the liver. Substance of the liver mottled
red and white, 228. . . . 350

126. Abscess in the liver communicating
with purulent deposit in the right iliac
region. Habitual constipation. The
sigmoid flexure of the colon much con-
tracted, 230 351

127. A circumscribed sac between the liver
and the ribs. An abscess in the sub-
stance of the right lobe. The mucous
coat of the colon studded with circular
ulcers, 231 351

3 c 3

75B

LIST OF CASES.

128. Abscess in the liver. Empyema of
the right pleura. Symptoms not well
marked. Dejection of a pint of clotted
blood before death. Mucous coat of the
colon dark-red, with ulceration, 232.

Page 353

129. Abscess in the liver. Effiision of
four pints of serum, with lymph in the
right pleura. Ulcerated colon. No
coma. Serum between the pia mater
and arachnoid, and two or three ounces
at the base of the skull, 233. . . 353

131. Hepatitis. Abscess in the liver.
Five pints of pus in the sac of the right
pleura. A layer of lymph on the sur-
face of the heart and inner surface of the
pericardium. General peritonitis, vdth
effusion of lymph and sero-purulent
fluid, 236 354

132. Pericarditis. The inner surface of
the pericardium and the outer side of the
heart covered with a thick layer of ir-
regular lymph. Also efiusion of serum
and displacement of the liver, partly
caused by the distended pericardium.
Abscess of the liver, 237. . . 355

133. General peritonitis. Abscess of the
liver following head symptoms. Serous
effusion in the head with thickening of the
arachnoid membrane. The kidneys had
undergone yellow degeneration, 239. 356

134. General peritonitis. Matting of the
omentum over the coecum. Round ulcers
in the colon, and an abscess in the liver,
240. 357

135. General peritonitis, with sero-purulent
effusion and abscess in the liver, 241. 357

li36. Probably small superficial abscess of
under surface of lobulus Spigelii, leading
to puriform sac in gastro-hepatic omen-
tum, and this by laipture to general
peritonitis. Jaundice, 245, . . 358

137. Large abscess in right lobe, flocculent
walls, communicating with branch of he-
patic vein. Lumbricus in the abscess.
Pus orange-coloured. No ulceration of
large intestine. Jaundice, 249. . 364

138. A large abscess in the liA'er. No
dysenteric symptoms. No ulceration.
No projection of liver below the ribs,
260 366

139. Hepatitis, Abscess in the right lobe.
Mucous coat of the large intestine dark
red without ulceration, 261. . 366

140. Chronic pneumonia of upper part of
left lung. Secondary hepatitis and ab-
scess, with flocculent walls, and perito-

nitic inflammation. No intestinal ulce-
ration, 265 Pago 367

141. Three abscesses in different stages of
progress. Pus bile tinged. General
peritonitis without rupture. No ulcera-
tion of the intestine, 269 . . . 367

142. Hepatic abscess. No ulceration of the
intestine 368

143. Hepatic abscess. No ulceration of the
intestine 368

144. Slight dysenteric symptoms of somo
days' duration, followed by febrile sym-
ptoms. Those of hepatic inflammation
coming on obscurely, and ending in ab-
scess, 281 379

145. Diagnosis doubtful: whether right
pleuritic eflfusion, or large hepatic ab-
scess, or both conjoined, 282, . .381

146. Hepatic abscess. Mistaken for pleu-
ritic effusion 382

147. Asthenic pneumonia mistaken for
communicating hepatic abscess, 283. 384

148. Whether asthenic pneumonia or
communicating hepatic abscess. Doubt-
ful, 284. . . . . .384

149. Hepatic abscess pointing at the epi-
gastrium and successfully punctured.
Trocar used, 285 393

150. Hepatic abscess pointing at the epigas-
trium, punctured successfully, 286, 394

151. Hepatic abscess pointing between the
eighth right rib and umbilicus, success-
fuUy punctured, 287. . • .394

152. Hepatic abscess, punctured. Re-
covery, 288. . . . . .394

153. Hepatic abscess, punctured at the
point of the right ninth rib. Recovery,
289. ...... 394

154. Hepatic abscess pointing between the
right ninth rib and umbilicus, punctured.
Case not followed to the close, but in all
probability successful, 290 . . 395

155. Hepatic abscess pointing at the epi-
gastrium, punctured. Result not known ;
probably successful, 291. . . 395

156. Chronic hepatic abscesses. One was
pinictured and healed, but there was no
adhesion to the abdominal wall at site
of puncture found after death. Ulcera-
tion of colon; but dysentery clearly
secondaiy. Second abscess and death,
292 396

157. Abscess in the liver pointing be-
tween the right seventh and eighth ribs.
Opened into the lung and also exter-
nally. Gangrene of the integuments
around the orifice, also of the inter-
costal muscles, and necrosis of a rib,
293 397

158. Hepatic abscess punctured over the
last right false rib. Gangrene and
sloughing around the wound. Death.
No inspection, 294. . . . 398

LIST OF CASES.

759

159. Large hepatic abscess punctiu'ed.
Death from exhaustion, with sloughing of
the wound. No examination after death,
295. . . . . Page 398

160. Superficial abscess of right extremity
of the liver leading to circumscribed
sac between the organ and lateral abdo-
minal walls. Piuictured between the
tenth and eleventh rib. Sloughy state of
wound. Necrosis of rib, and death from
hectic fever, 296 398

161. Abscess in the liver punctured. Carious
ribs projecting into the abscess. At
first superficial and leading to circum-
scribed sac between liver and diaphragm.
Also empyema of right pleural sac with-
out communication, 297. . . 399

162. Two large hepatic abscesses. One
deep, the other a sac between the sur-
face of the liver and abdominal walls,
originating probably in rupture of a
small superficial abscess, there being
lymph nodules in the part of the liver
adjoining. This abscess punctured.
Sloughing. No ulceration of intestine,
298 400

163. Hepatic abscess punctured at the
epigastrium. Gangrene and sphacela-
tion around the orifice. Death. No
inspection, 299 401

164. Hepatic abscess pointing at the epi-
gastrium, punctured. Extensive sphacelus
around the opening. Death, 300; . 401

165. A single abscess at the thin edge of
the left lobe of liver existing for five
months, punctured. Gangrene of the
orifice. Dysenteric symptoms latterly.
Ulceration of mucous membrane of the
colon, 301 402

166. Two hepatic abscesses. One punc-
tured with increase of febrile symptoms.
Attributed to fist blows. Habits tem-
perate. Diarrhoea, with redness of
mucous membrane of colon. No ulcera-
tion. Commencing gangrene at the
opening in the abscess, 302. . . 402

167. Hepatic abscess pointing at the epi-
gastrium, punctured. Sloughing around
the wound. Death, 303. . . 403

168. Cirrhosis of liver. Abscess in thin
edge of liver punctured. Purulent sac
between liver and diaphragm. Ulcera-
tion of large intestine. Death, 304. 403

169. Hepatic abscess in epigastric region,
punctured; very little discharge. Dysen-
teric symptoms, secondary. Died. No
examination, 305 404

170. Abscess partly of right and left
lobe, punctured. Death from dysentery
clearly secondar}^ Ulceration of large
intestine. EflSision in both pleural
sacs, 306 405

171. Pleuritic effusion. Abscess in the

liver punctured. Attributed to a blow.
Death the day after the abscess was
opened. No examination after death,
307 ... . Page 406

172. Large abscess of right lobe of liver
punctured with trocar. Several abscesses
in left lobe in different stages. Also
lymph nodules, 308. . . 406

173. Large abscess in the right lobe. The
liver free of abnormal adhesions. The
cicatrices of former ulcers in the colon.
Jaundice. Enlarged glands in the course
of the ducts, 309 413

174. Aneurism of the abdominal aorta.
Acute pain of right hypochondrium and
shoulder. The edge of the liver dis-
tinct. Treated four times for disease of
the liver, 310 416

175. A tumour, situated between the edge
of the liver and the transverse colon,
311 416

CHAPTER XVI.

CIllRHOSIS, ETC.

176. Cirrhosis, with enlargement. Ascites.
No kidney or heart disease. Jaun-
dice, 312 422

177. Ascites. Liver small and indurated.
Cirrhosis. Considerable effusion of
serum in the head, 313. . . . 423

178. Abscess in the liver. Cirrhosis.
Sloughy perforations, patched, of large
intestine, but no thickening of its coats
noted, 314. . _ . . . .424

179. Abscess in liver with cirrhosis, not-
withstanding ptyalism. Displacement of
colon. Adhesion of it to the left side of
diaphragm. Sloughy ulceration of large
intestine, without thickening, 315. 425

180. Abscess in liver, notwithstanding
ptyalism. Cirrhosis. Ccecum and as-
cending colon thickened and ulcerated,
316 .425

181. Dysentery complicated with delirium
tremens. Abscess and cirrhosis of the
liver, 318 426

182. Remittent fever. (Edema of the
liver . 428

183. Treated for supposed dyspeptic sym-
ptoms. Numerous cancerous tubera dis-
seminated throughout the liver. One
had opened into the stomach, 320. 429

184. Phthisis pulmonalis. Lungs tuber-
culated, hydatid sac in the abdomen, also
in the liver. Peritoneum studded with
miliary transparent tubercles, 321. 430

185. Hepatitis. Abscess. Inflammation
of the external and internal surface of
the gall-bladder. Sudden collapse, con-
tinuing with varying symptoms for
several days, 322 431

3 c 4

760

LIST OF CASES.

186. Fever with jaundice. Gall-bladder
distended, seemingly, from inflammation
of the common duct. Little improye-
ment from treatment, 323 .Page 432

187. The gall-bladder, distended, reached
to the umbilicus. Gastritis. Colon con-
tracted, 324 432

CHAPTER XVII.

PERITONITIS, ELEUS AND COLIC.

188. General peritonitis from a penetrating
wound of the liver and eiFusion of blood
into the abdomen. Considerable eifu-
sion of serum in the head without sym-
ptoms, 325. ... . . .444

189. Fracture of both thigh bones. Ab-
domen bruised by a fall. Death in
fifty-four hours, under symptoms of
peritonitis. General redness and effu-
sion of lymph on the peritoneal sur-
faces. A pint of turbid serum in the

. cavity, 326 444

190. Wound of the abdomen with protru-
sion of intestine. Tascularity of, and
lymph- exudation on, the peritoneum, and
the protruded intestine, 327. . . 445

.191. Peritonitis. Purulent effusion into the
cavity of the abdomen. Lymph general
on the peritoneal surfaces, 328. . 446

.192. Peritonitis after parturition, but pro-
bably caused by blows, 329. . . 446

193. Partial peritonitis leading to forma-
tion of a large circumscribed purident
sac, 330 446

194. General peritonitis. The lungs
studded with crude tubercles. The
mesenteric glands tuberculated. The
end of the ileum, the ccecum, and colon
xilcerated. Considerable effusion in the
head, 331 448

195. Extensive ulcer on the groin. Mili-
ary tubercles in the lungs and under-
neath the peritoneum throughout its
whole extent. Follicular ulceration of
the large intestine. Three ounces of
serum in the cavity of the cranium, No
head symptoms, 332, . , . 449

196. Chronic peritonitis. Tubercular,
Much effusion and complete dulness on
percussion, 333 450

197. Effusion in chest and abdomen. Ac-
cess of cholera. Disappearance of the
effusion. Bright's disease of the kidney
and tubercular peritonitis, 99. . 451

198. Ileus, vdth granular effusion on the
inner surftice of the ileum. Biliary
calculi, 334 454

199. Ileus. Strangulation of part of the
intestine by old peritonitic adhesions,
335 .454

200. Colica-pictonum, The colon was much
distended and disf)laced. Death with
head symptoms. Only slight serous effii-
sion at the base of the skull, 336. Page 456

CHAPTER XVIII.

AFFECTIONS OF THE STOMACH.

201. Poisoning by arsenic, admitted in the
stage of collapse, after the active sym-
ptoms of gastritis were passed, 337 .458

202. Poisoning from arsenic in which sym-
ptoms of narcotism were prominent at the
commencement, 338. . . .459

CHAPTER XIX.

BEIGHT's disease OF THE KIDNEY.

203. A diver by occupation. Anasarca
ascites. Urine of low density and albu-
minous. Dilatation of the right ventricle
of the heart. Hypertrophy, and dilatation
of the left. Kidneys enlarged, lobulated,
in a state of yellow granular d*^ genera-
tion, 340 468

204. Dropsical symptoms. Urine of low
density and albuminous. Bronchitis,
diarrrhoea, periostitis, erysipelas, as se-
condary affections. Kidneys large, and
in a state of yellow granular and fatty
degeneration. An opium eater, 341. 469

205. Gastro-enteritis, anasarca, and ascites.
Urine of low density and albuminous.
Paracentesis. Death from peritonitis.
Kidneys small, in a state of yellow gra-
nular degeneration, 342. . . 470

206. Anasarca and ascites. Urine of low
density and albuminous. Was eight
times tapped. Kidneys in a state of
yellow gi'anular degeneration, 343. 471

207. Anasarca and ascites. Urine of low
density and very albuminous. Sunk
under diarrhea. The kidneys in a
state of yellow granular degeneration.
The mucous coat of the colon and ileum
with dotted red patches and granular de-
posit. A spirit drinker. Cirrhosis, 344. 472

208. Anasarca with ascites. Urine of low
density and generally albuminous. Died
comatose. Kidneys small, with cysts
and excess of cortical portion. Cirrhosis.
Thrice admitted, 345. . . .472

209. Febrile symptoms, followed by ana-
sarca, ascites, and dysenteric symptoms.
Urine of low density and albuminous.
Death by coma. The kidneys in a
state of yellow granular degeneration.
The mucous membrane of the large
intestine ulcerated, and with granxilar
exudation, 346 474

210. Vesicular emphysema of both hmgs.
Displacement of the heart. Dilatation
and hypertrophy of the ventricles. Athe-

LIST OF CASES.

761

romatous doposit, with ulceration, in the
aorta. Granular degeneration of the
kidneys. Urine once noted, albuminous.
Dropsy, 348, . . Page 474

211. Admitted in an advanced state of
disease. Hepatisation of both lungs.
Circumscribed pleuritic effusion of the
righf side. Kidneys enlarged, and in a
state of yellow granular degeneration.
Urine not tested, 349. . . .4 75

212. The subject of intermittent fever,
followed by bronchitis, and slight ana-
sarca. Urine of low density, and very
albuminous, 351 476

213. Febrile symptoms and dropsy after
exposure to cold and wet. Traces of
albumen in the urine, slight throughout,
finally disappeared. Addicted to the
occasional use of spirits and opium.
Finally sunk under increasing asthenia.
Granular degeneration of the kid-
neys, 352 476

214. Dropsical symptoms with diarrhoea,
following exposure to cold and wet.
Urine very albuminous. Drowsiness
coexisting with sinking pulse, removed
by stimulants, did not recur. Death
by exhaustion. Kidneys large and
granular. Spirit-drinking not ad-
mitted, 353. . . . .477

2 15. Syphilis, primary and secondary.
Merciu'ial influence. Slight dropsy.
Albuminous urine, pain of loins, dysen-
tery. Fatal. Bright's disease. Ulcera-
tion and granular exudation on intes-
tinal mucous membr,ane. Cirrhosis.
A cretified guinea-worm encysted be-
tween the right lung and the peri-
cardium, 354. . . . ._ 478

216. Dysentery. Dropsy. Albuminous
urine, with fat globules, in an old
spirit-drinker and opium-eater. Fatal.
Ulcerated intestines. Kidneys enlarged.
Fatty degeneration, 355. . . 479

217. Dropsy. Albuminous urine. Death
from dysenteric symptoms. Kidneys en-
larged with fatty degeneration. Kedness
in patches of the intestinal mucous
lining. Habits not known, 356. . 480

CHAPTER XX.

ABNORMAL STATES OF THE UEINE.

218. Urine thick, white, opaque, coagulat-
ing with heat and nitric acid. No im-
provement under the use of varied
remedies. Recovery by attention to
the general health, chiefly by change of
air, 398. . ._ . . .500

219. Urine thick, white, opaque, coagulat-
ing with heat and nitric acid. No im-
provement from medical treatment. Re-
covery from change of air, 399. . 501

220. Urine opaque and white, occasionally
coagulating spontaneously. Recovery
from change of air, 400. Page 501

221. Urine milky, coagulating by heat and
nitric acid, becoming clear by addition
of sulphuric ether. No improvement
from treatment. Change of air recom-
mended. Result not known, 401. 501

222. Chylo-serous urine, removed by change
of air 502

223. Chylo-serous urine, removed twice by
change of air. .... 502

224. Diabetes. Symptoms improved some-
what under the use of creosote and mu-
riate of morphia, 402. . . . 503

225. Diabetes. No improvement from pre-
parations of iron, permanganate of po-
tass, and opium, 403. . . . 504

226. Diabetes. Not improved by treat-
ment, 404 504

227. Diabetes. No improvement from
permanganate of potass, or from creosote
alone, but marked benefit from addition
of opium, 405. . . . '. 504

CHAPTER XXI.

PNEUMONIA.

228. Pneumonia extensive of right lung.
Grey induration with cavities formed
in upper lobe by molecular gan-
grene, 413 524

229. Grey, almost cartilaginous, induration
of the lower part of the right lung, with
several excavations by process of gan-
grenous molecular softening. The seve-
ral stages of the process well shown.
Bright's disease of the kidney, 414. 525

230. Grey and red induration of the upper
lobe of the right lung with gangrenous
excavation, 415 525

CHAPTER XXIV.

PERICARDITIS AND ENDOCARDITIS.

231. Pericarditis. Friction murmur dis-
tinct, and then altogether disappearing.
He was cured. Eight months afterwards
death from cholera. Opaque patches on
the surface of the heart. No pericardial
adhesions, 448 573

232. Phthisis pulmonalis. Secondary pe-
ricarditis. Friction murmur, distinct
for twenty days. Death eighteen months
afterwards. Firm pericardial adhesions.
Bright's disease of the kidney, 450. 574

233. Asthenic pneumonia, leading to red
induration of the upper lobes. In its
course, pericarditis and endocarditis of
the left ventricle and auricle, causing
structui'al disease of the mitral valve.
Not traced to rheumatism. Dilatation of
all the cavities of the heart, 461. 576

762

LIST OF CASES.

234. Empyema of the right Bide of chest.
Secondary pericarditis. Friction mur-
mur. Lymph effusions found after death,
462. . . . . . Page 577

235. Acute arachnitis and pericarditis
leading to considerable effusions, coagu-
lating into a jelly-like mass when re-
moved from the body. Friction mur-
mur. In a pregnant female, 463. . 577

CHAPTER XXV.

ORGANIC DISEASE OF THE HEART.

236. Contraction of the orifice of the pul-
monary artery, probably congenital.
Much hypertrophy, without dilatation of
the right ventricle of the heart. No
disease of the left side, 236. . . 582

237. Dilatation of both ventricles. Hy-
pertrophy of the left. Disease of aortic
valves, and the well-marked results of
pericarditis and endocarditis, consecutive
on rheumatism, related to syphilis, 464.

583

238. Aneurism of the left ventricle of the
heart, consequent on endocarditis and
pericarditis, 467 583

239. Rheumatism, followed by pericarditis
and endocarditis. Disease of the mitral
valve. Dilatation of the right side of
the heart. Dilatation and hypertrophy,
with circumscribed aneurism of the left
ventricle. Death expedited by acute
general peritonitis, 468. . . 584

240. The former subject of rheumatism.
Dilatation of the left ventricle. Disease
of the mitral valve. Much thickening
of the endocardium. An aneurismal
sac at the apex. Also the marks of
former pericarditis, 471. . .586

241. Rupture of the heart from fatty de-
generation, 479 587

242. Great dilatation of the ascending aorta
and the arch. An aneurismal tumour at
the commencement of the descending
aorta. There was no external swelling,
but the other signs of the disease were
very well marked, 494. . . . 588

243. Aneurism of the abdominal aorta.
Death by rupture, 493. . . 589

244. Acute rheumatism. Pericarditis and
endocarditis. Dilatation of the right
side of the heart. Dilatation and hyper-
trophy of the left ventricle. Ossific
state of the mitral valve. Hepatic con-
gestion, 465. . . . .596

245. Aortic and mitral valvular disease.
Hypertrophy, with dilatation of the left
ventricle. Greneral dropsy. Rapid relief
from elaterium. Discharged, 489. . 599

CHAPTER XXVII.

ON DELIRIUM TREMENS.

246. Meningitis. Effiision of lymph and

serum in the sub-arachnoid space. Sym-
ptoms of delirium tremens, 564. Page 645

CHAPTER XXVIII.

ON CEREBRAI/ DISEASE AND PARALYSIS.

247. Acute hydrocephalus, 506. . 653

248. Amaurosis of both eyes, headaxshe,
fatuity, convulsions, tumour in the brain,
with much softening of the cerebral
substance, 507 654

249. Hemiplegia of the right side. Soften-
ing of the left corpus striatum, 508. 66 1

250. Apoplexy. Hemiplegia of the right
side. Death. GTeneral congestion of
the membranes of the brain. Red
softening of the left corpus stria-
tum, 509 661

251. Hemiplegia of the right side. Soften-
ing of the left corpus striatum. Disease
of the mitral valve, 510. . .661

252. Symptoms of inflammation of the
brain, followed by hemiplegia of the
right side, and death by coma. Red
softening of the left corpus, striatum
found after death. 511. . . .662

253. Hemiplegia of the right side. Me-
ningitis and softening of the anterior
and middle lobes of the left cerebral
hemisphere. The premonitory symptoms
well marked, -512. . . . . 662

254. Incomplete paralysis of the left side.
Improvement. Disease of heart and
valves. Death hastened by diarrhoea.
Purifoi'm softening of part of anterior lobe
of right cerebral hemisphere, 513. . 662

255. Hemiplegia of the left side. White
softening in the right cerebral hemi-
sphere, 514. ..... 663

256. Abscess in the left hemisphere of the
brain ; for some time general febrile
symptoms. Hemiplegia of the right side
some days before death, 515. . . 664

257. Apoplexy, followed by hemiplegia of
the right side. Gangrene of the left
foot and leg, apparently from obstruc-
tion of the femoral artery, 516. . 664

258. Hemiplegia of left side, persistent.
Facial palsy of the right side, con-
secutive and transient, 517. . . 665

259. Division of the left half of the spinal
cord by a wound. Paralysis and anaesthesia
of the left lower extremity, 519. 669

260. Paralysis from arsenical poisoning.
Pneumonia also present, 520. .670

CHAPTER XXIX.

ON TETANUS.

261. Tetanus. Treated with quinine, ex-
tract of hemp, wine, and nourishment.
Recovered, 521 686

262. Idiopathic tetanus. Treated with
quinine, hemp, wine, and nourishment.
Recovery, 522 686

LIST OF CASES.

763

263. Tetanus in a child. Though fatal,
the good effects of treatment with
quinine, hemp, and attention to nourish-
ment were very apparent, 523. Page 686

264. Tetanus treated with chloroform.
Fatal, 524 687

265. Tetanus fatal on the 21st day. Whe
ther traumatic or idiopathic doubtful*
Treated with quinine, hemp, nourish-
ment, and stimulants. Fatal. Spinal
veins congested, 525. . . . 687

CHAPTEK XXX. '

ON HYDROPHOBIA.

266. Hydrophobia. Three months after
the bite, 526 690

267. Hydrophobia, treated with chloro-
form, 527 690

268. Hydrophobia. Chloroform used, but
obliged to be discontinued, 528. . 690

269. Hydrophobia in a Parsee boy, 529. 691

CHAPTER XXXI.

ON BLOOD DISEASES.

270. Fever. Several abscesses. Small
puriform cysts in lungs. No trace of
phlebitis, 535 694

271. Adynamic fever. Several abscesses.
Puriform cysts in the lungs. One in the
kidney. Small suppurating wound of heel.
No trace of phlebitis, 536. Page 662. 694

272. Adynamic remittent fever. Small
abscess on the forehead. Carbuncle on
thS back. Numerous puriform cysts in
the lungs and kidneys, 537. . .694

273. Many abscesses. Fever. Death by
exhaustion. No puriform deposits in
the internal viscera, 538. . . 694

274. Adynamic fever. Several abscesses.
Recovery, 539 694

275. Beriberi. Recovery, 549. . .710

276. Beriberi. Slight discoloration of the
gums. Recovery, 550. . . .710

277. Beriberi. Anasarca. Death. No kidney
disease. Liver congested. Cavities of
the heart full of thin blood, 551. .711

278. Beriberi. Anasarca. Gums disco-
loured. Hydrothorax. Fatal. Cavities
of the heart fuU of fluid blood, 552. . 711

279. A small dog bitten by the Phoorsa
snake. Fatal, 553. . . .717

280. A horse-keeper bitten by the Phoorsa
snake. Fatal, 554. . . .717

281. Parsee woman bitten by Phoorsa
snake. Recovery, 555. . . .718

282. Dog bitten by Phoorsa snake. Fatal.
Post mortem examination, 556. . 718

STATISTICAL AND METEOEOLOGICAL TABLES.

Table I. — Admissions and Deaths, with
Per-centage, from all Diseases, in the
European General Hospital at Bombay
for the Five Years from July, 1838, to
July, 1843 . . . . Page 13

Table II. — Admissions and Deaths, with
Per-centage, from all Diseases, in the
European General Hospital at Bombay
for the Five Years from 1844 to 1848 14

Table III. — Admissions and Deaths, with
Per-centage, from all Diseases, in the
European General Hospital at Bombay
for the Five Years from 1849 to 1853 14

Table IV. — Admissions and Deaths, with
Per-centage, from all Diseases, in the
Jamsetjee Jejeebhoy Hospital at Bom-
bay, for the Six Years from 1848 to
1853 15

Table V.— Admissions and Deaths, with
Per-centage, from Fever of all kinds, in
the European General Hospital at Bom-
bay, for the Six Years from July 1838 to
July 1843 171

Table VI. — Admissions and Deaths, with
Per-centage, from Fever of aU kinds, in
the European General Hospital at Bom-
bay, for the Five Years from 1844 to
1848 171

Table VII. — Admissions and Deaths, with
Per-centage, from ' Fever of aU kinds, in
the European General Hospital at Bom-
bay, for the Five Years from 1849 to
1853 172

Table VIII. — Admissions and Deaths,
with Per-centage, from Intermittent
Fever, in the European General Hospital
at Bombay, for the Five Years from July,
1838, to July, 1843 . . .173

Table IX.— Admissions and Deaths, with
Per-centage, from Intermittent Fever, in
the European General Hospital at Bom-
bay, for the Five Years from 1844 to
1848 173

Table X, — Admissions and Deaths, with
Per-centage, from Intermittent Fever, in
the European General Hospital at Bom-

bay, for the Five Years from 1849 to
1853 .... Page 174

Table XI. — Admissions and Deaths, with
Per-centage, from Ephemeral Fever, in
the European General Hospital at Bom-
bay, for the Five Years from July, 1838,
to June, 1843 . . . .174

Table XII. — Admissions and Deaths, wich
Per-centage, from Remittent and Inter-
mittent. Feve;', in the Jamsetjee Jejee-
bhoy Hospital at Bombay, for the Six
Years from 1848 to 1853 . . 176

Table XIII. — Admissions and Deaths, with
Per-centage, from Intermittent Fever, in
the Jamsetjee Jejeebhoy Hospital at
Bombay, for the Six Years from 1848 to
1853 177

Table XIV. — Admissions and Deaths, with
Per-centage, from Remittent Fever, in
the European General Hospital at Bom-
bay, for the Five Years from July, 1838,
to June, 1843 . . . .178

Table XV. — Admissions and Deaths, with
Per-centage, from Remittent Fever, in
the European General Hospital at Bom-
bay, for the Five Years from 1844 to
1848 178

Table XVI. — ^Admissions and Deaths, with
Per-centage, from Remittent Fever, in
the European General Hospital at Bom-
bay, for the Five Years from 1849 to
1853 179

Table XVII. — Admission and Deaths, with
Per-centage, from Remittent Fever, in
the Jamsetjee Jejeebhoy Hospital, at
Bombay, for the Six Years from 1848 to
1853 180

Table XVIII. — Admission and Deaths,
from Intermittent and Remittent Fever,
in the Byculla Schools, for the Seventeen
Y'ears from 1837 to 1853 . . 181

Table XIX. — Admissions and Deaths, with
Per-centage, from Epidemic Cholera, in
the European General Hospital at Bom-
bay, for the Six Years from 1838 to
1843 233

766

LIST OF STATISTICAL TABLES.

Table XX. — Admissions and Deaths, with
Per-centage, from Epidemic Cholera, in
the European General Hospital at Bom-
bay, for the Five Years from 1844 to
1848 . . . . Page 234

Table XXI, — Admissions and Deaths, with
Per-centage, from Epidemic Cholera, in
the European G-eneral Hospital at Bombay,
for the Five Years from 1849 to 1853 234
Table XXII. — Admissions and Deaths?
with Per-centage, from Epidemic Cholera,
in the Jamsetjee Jejeebhoy Hospital at
Bombay, for the Six Years, from 1848 to

1853 235

Table XXIII. — Admissions and Deaths,
with Per-centage, from Epidemic Cholera
in the Byculla Schools, at Bombay, for
the Seventeen Years from 1837 to

1853 235

Table XXIV. — Admissions and Deaths,
with Per-centage, from Dysentery, in
the European Greneral Hospital at Bom-
bay, for the Five Years from July, 1838,
to June, 1853 . . . ,318

Table XXV. — Admissions and Deaths,
with Per-centage, from Dysentery, in the
European General Hospital at Bombay,
for the Five Years from 1844 to

1848 318

Table XXVI. — Admissions and Deaths*
with Per-centage, from Dysentery, in the
European General Hospital at Bombay,
for the Five Years from 1849 to

1853 319

Table XXVII. — Admissions and Deaths,
with Per-centage, from Dysentery, in the
Jamsetjee Jejeebhoy Hospital at Bom-
bay, for the Six Years from 1848 to

1853 319

Table XXVIII. — Admissions and Deaths*
with Per-centage, from Diarrhoea, in the
Jamsetjee Jejeebhoy Hospital, at Bom-
bay, for the Six Years from 1848 to

1853 320

Table XXIX. — Admissions and Deaths,
with Per-centage, from Diarrhaea and
Dysentery, in the BycuUa Schools, for the
Seventeen Years from 1837 to 1853 320
Table XXX. — Admissions and Deaths, with
Per-centage, from Hepatitis, Acute and
Chronic, in the European General Hos-
pital at Bombay, for the Five Years from
1838 to 1843 . . . .418

Table XXXI. — Admissions and Deaths,
with Per-centage, from Hepatitis, Acute
and Chronic, in the European General
Hospital at Bombay, for the Five Years
from 1844 to 1848 . . . .418
Table XXXII. — Admissions and Deaths,
with Per-centage, from Hepatitis, Acute

and Chronic, in the European General
Hospital at Bombay, for the Five Years
from 1849 to 1853 . . Pago 419

Table XXXIII. — Admissions and Deaths,
with Per-centage, from Acute Hepatic
Affections, in the Jamsetjee Jejeebhoy
Hospital at Bombay, for the Six Years
from 1848 to 1853 . . . .419

Table XXXIV. — Admissions and Deaths,
with Per-centage, from Chronic Hepatic
Affections, in the Jamsetjee Jejeebhoy
Hospital at Bombay, for the Six Years
from 1848 to 1853 . . . .420

Table XXXV. — Admissions and Deaths,
with Per-centage, from Pneumonia, in
the Jamsetjee Jejeebhoy Hospital at
Bombay, for the Six Years from 1848 to
1853 647

Table XXXVI. — Admissions and Deaths*
with Per-centage, from Bronchitis, in the
Jamsetjee Jejeebhoy Hospital at Bom-
bay, for the Six Years from 1848 to
1853 553

Table XXXVII. — Admissions and Deaths,
with Per-centage, from Phthisis Pulmon-
alis, in the Jamsetjee Jejeebhoy Hospital
at Bombay, for the Six Years from 1848
to 1853 560

Table XXXVIII. — Admissions and Deaths,
with Per-centage, from Delirium Tre-
mens, in the European General Hospital
at Bombay, for the Five Years from July
1838 to June 1843 . . . .646

Table XXXIX. — Admissions and Deaths,
with Per-centage, from Delirium Tremens,
in the European General Hospital at
Bombay, for the Five Years from 1844
to 1848 . 646

Table XL. — Admissions and Deaths, with
Per-centage, from Delirium Tremens, in
the European General Hospital at Bom-
bay, for the Five Years from 1849 to
1853 647

Table XLI. — Admissions and Deaths, with
Per-centage, from Paralysis, in the Jam-
setjee Jejeebhoy Hospital at Bombay, for
the Six Years from 1848 to 1853

Table XLII. — Admissions and Deaths,
with Per-centage, from Tetanus, in the
Jamsetjee Jejeebhoy Hospital at Bom-
bay, for the Six Years from 1848 to
1853 688

Table XLIII. — Admissions of Guinea-
worm into the Hospital of Her Majesty's
4th Light Dragoons at Kirkee, during
Eight Years from 1827 to 1834 . 72o

Table XLIV. — Admissions and Deaths
with Per-centage, from Dracuneulus, in
the Jamsetjee Jejeebhoy Hospital at

LIST OF METEOROLOGICAL TABLES.

767

Bombay, for the Six Years from 1848 to
1853 .... Page 725

Table XLV. — Admissions from Draeun-
culus, in the Bombay Army, in the Year
1832 726

Table XL VI. — Admissions from Dracun-
eulus, in the Bombay Army, for the Year
1833 727

Table I. — Obserrations on the Temperature
at Bombay ..... 743

Table II, — ObserA-ations with the Wet
Bulb Thermometer, at Bombay. Page 744

Table III, — Barometric Observations at
Bombay 745

Table IV. — Observations on the Rainfall
and the Direction and Force of the
Winds at Bombay . . . .746

Table showing the Atmospheric Pressure,
the Temperature, the Dryness, the Rain-
fall, and the Direction of the Winds at
Poorundhur 747

INDEX.

Abscess, Hepatic. — Pathology ; formation
of, 328; opening into lung or pleural
sac, 335 ; into stomach and intestine,
342 ; into pericardium, 345 ; into hepatic
duct, 345 ; into peritoneal sac, 345 ; fatal
without rupture, 329, 380; recovery by
absorption, 345 ; character of contents,
359. — Causes ; pysemic theory discussed,
365. — SymptoTns of, 370, 384; pointing
towards diaphragm, 380 ; opening into
lung, brick-red sputa, 382. 384. — Treat-
Tnent of, 384 ; question of puncture fiiUy
considered, 393 ; hepatic abscess not un-
common with cirrhosis, 424,

Antimony — ipotassio-tartrate, use of, in
intermittent fever, 28, 53; remittent
fever, 110. 118; ardent continued fever,
166 ; pneumonia, 537 ; delirium tremens
with opiates, 631 ; cerebral disease, 649.

AoKT A— aneurism o^ 587.

Apoplexy — cerebral, 650.

Arsenic — acute gastritis from, 458 ; liquor
in intermittent fever, 32 ; paralysis from,
670.

Asthma — relation to malaria, 65 ; to em-
physema, 553,

Astringents — in cholera, 223 ; in chronic
dysentery, 304. 308, For particulars
see these.

Auscultation — importance of, in fevers in
India, 532, note ; in rheumatism, 562.

Barkers — alluded to, 669.

Beebeerine — use in intermittent fever, 34.

Beriberi — name objected to, 155, note, —

Symptoms, 705 ; author's views of its

Pathology explained, 706. Treatment,

708. 713.
Bile — defect of so-called torpor of the

liver, 441.
Biliary Calculi, 433; ducts, inflamma-

tion of, 98. 431 ; compression of by
enlarged lymphatic glands as cause of
jaundice, 97, 435.

Blisters — use of, in remittent fever, 119 ;
121. 140; dysentery, 308; hepatitis, 391;
pneumonia, 541 ; pericarditis, 578,

Blood-letting — general and local, in in-
termittent fever, 28; cold stage of, 124;
remittent fever, 110. 112. 114. 115, 118.
122 ; continued fever, 166 ; cholera epi-
demic, 225. 229 ; dysentery, 293 ; hepa-
titis, 385, 386 ; pneumonia, 534, 636 ;
pericarditis, 578 ; cerebral disease, 649,

Brain — aifections of, 648 ; congestion of,
and determination to, in remittent fever,
70, 81. 118; serous effusion on, 90.

Bright' s disease. See Kidneys.

Bronchitis — complicating, intermittent,
fever, 52; idiopathic, 552 ; tabular state-
ments of, in the Jamsetjee Jejeebhoy
Hospital, 553.

Calculus — urinary, 505.

Calomel — cholagogue action in remittent
fever, 110; epidemic cholera, 228; in
dysentery, 296 ; hepatitis, 386 ; abuse
in intermittent and remittent fever, 34.
125 ; Annesley's supposed sedative ac-
tion of large doses of calomel dissented
from, 136,

Cancer — of liver, 429,

Causes — of disease, predisposing and ex-
citing, general notice of, 1. 9 ; of par-
ticular diseases, will be found under
name of.

Change of Air and of Climate, in inter-
mittent and remittent fever, 42. 150;
dysentery, 312 ; hepatitis, 414.

Chicken Pox, 200.

Children — fevers in, 168; dysentery, 314;
hepatitis, 415.

Cholera — bilious — not common in numer-
ous classes in India, 214, 440.

3 D

770

INDEX.

Cholera, Epidemic — prevalence of, in
Eombay, 202 ; causes of, 204 ; s3Tnptoins
of, 208 ; different degrees of severity,
209 ; rate of mortality from, 215 ; rela-
tion of mortality to age, 216 ; to period
of epidemic, 217 ; to duration on ad-
mission, 217. — Pathology of, 218. — Treat-
.ment of preliminary diarrhoea, 221; stage
of collapse, 224 ; of secondary affections,
226 ; by general blood-letting, 229 ; hot
hath, 229 ; emetics, 230 ; hot saline ene-
mata, liniments, injection into veins,
inhalation of vapours, 230 ; galvanism,
cold effusion, wet sheet envelope, 231 ;
recapitulation, 232. Statistics of, in
European General Hospital and Jamset-
jee Jojeebhoy Hospital, Bombay, 233.

Cirrhosis. See Liver.

■CoiJCA. Pictorium, 456; coliqufi v6g6tale,
455.

Datura poisoning, in Bombay, 641, note.

Delirium Tremens — prevalence of, and
mortality from, in European General
-Hospital, Bombay, 624. 8i/mpiom,s and
Treatment, division into two species, 625 ;
first species, 627 ; second species, first
stage, 628 ; second stage, 629 ; cold affu-
sion, 630 ; tartar emetic and opium, 631 ;
stimulants, 632; importance of food, 633;
objections to treatment with free opiates
and to expectant method stated, 633.
.639; third stage, 635. Eemarks on blood-

. letting, 637 ; purgatives and emetics,
fiS8.; general management, 638. Patho-
logy— with remarks on principles of treat-
ment, and diagnosis, 641 ; complicated
with meningitis, 645 ; in natives of
India, 645 ; statistics of, in European
General Hospital at Bombay, 646.

Diabetes — saccharine, 502.

Dlafhoretics — in fever, 28. 110; dysen-
tery, 302.

Diarrhoea, 316.

Diathesis — general notice of importance of,
2 ; great prominence given to it in the
etiology of all the diseases treated of.

Diet in remittent fever, 149 ; dysentery,
311.

Diuresis, 505.

Duodenitis — in remittent fever in relation
to jaundice, 98.

Dracunculus —prevalence of, in Bombay
Presidency, 720 ; obsciirity of origin, 722;
ananagement, 724 ; statistics, 725.

Dropsy, in Bright's disease, 481 ; cardiac
disease, 593 ; in scorbutic diathesis Be-
xiberi, 704 ; in ascites from cirrhosis of
liver, 421.

Dysentery — prevalence of, 236. — Pathology
— general remarks, 237 ; morbid appear-

ances, change of colour of mucous mem-
brane of large intestine, 239 ; exudations
on free surface and into tissue, 240 ; im-
plication of follicles and solitary glands,
242 ; different forms of ulcer, transverse,
245 ; circular, 253 ; puriform infiltration,
253 ; oedema and sloughing erysipelatous,
258; tubular sloughs of mucous membrane,
258 ; intussuscepted gut, 262 ; cicatrisa-
tion of ulcers, 263 ; complication of in-
flammation of mucous membrane of largo
intestine with peritonitis, 265 ; adhesions
of omentum, 265 ; tumefaction of region
of cceeum or sigmoid flexure, 269 ; dis-
placement of the colon, 270 ; complicated
with lesions of small intestine and stomach ,
271; with enlargement of mesenteric
glands, 272; part of intestine chiefly
affected, 272 ; microscopic morbid ana-
tomy of dysentery, 272. — Etiology of —
preliminary theoretic remarks, 273 ; im-
portance of noting both predisposing and
exciting causes, 273; exciting causes,
cold, 273 ; much importance attached to
predisposing causes, 275 ; common be-
lief that malaria is an exciting cause,
dissented from, 276. — Symptoms, 280. —
Treatment — general principles, 288 ; de-
tails of treatment, 291 ; blood-letting,
general and local, 293 ; cholagogue action
of calomel, principle explained, 296 ;
mercurial influence, induction of, con-
demned, 297 ; use of ipecacuanha, 298 ;
purgatives, 300; diaphoretics, 302; opium,
principles of use explained, 302 ; chloro-
form, 304 ; astringents and tonics, 304 ;
bael fruit, 306; acetate of lead, 306;
trisnitrate of bismuth, quinine, siilphate
of copper, nitrate of silver, 307 ; prepara-
tions of iron, 307 ; vegetable astringents,
307; fomentations, blisters, 308; largo
warm water enemata, principles con-
sidered and dissented from, 308; diet, 311;
change of air and climate, 312; dysentery
in children, 314. Statistical tables, 318.
Dyspepsia-— functional notice of, brief, and
chiefly inculcating, in reference to etiology
and treatment, its character as symptom-
atic of diathetic states, 462.

Elephantl^sis— arabum, 698.

Emetics, use in intermittent and remit?tent

fever, 28. 110. 140; in cholera, 230.
Emphysema of the lungs, 553.
Encephalitis, 604, note.
Endocarditis, See Pericarditis.
Erysipelas, 200.
Etiology — considered in reference to each

disease, which heads see.

INDEX,:

771

FEnnicuLA — 162.

Feveu, prevalence of, iii India, 16; Ardent^
continued, 164. — Symptoms, 165. — Path-
ology and Treatment, 166.

Fever — intermittent types of, 17. — Simple
Sympto)ns of, 20. — Pathology, 24 ; mor-
tality, 24. — Treatment va. different stages,
nse of quinine, arsenic, bebeerine, mui-iate
of nareotine, mercury condemned, from
28 to 35. — Complicated, with splenic
enlargement; Symptoms of, 36'; abnormal
precordial diilness and cardiac murmur,
36. — Pathology oi, 38; laceration- of spleen,
427, note. — Treatment of, 40; liability to
dysentery and cautions therefrom, 41 ; use
of bromine, iodine, 41 ; injurious effects of
mercury, 41 ; with hepatic affection —
Pathology, 44; Treatment, ^ib; with jaun-
dice and affection of stomach and bowels,
47; with cerebral affection, 49; with
bronchitis, pneumonia, rheumatism, scor-
butus, pericarditis, asthma, 52 ; relation
of asthma to malaria, bb ; intermittent
fever in children, 168; statistics of, in
European Greneral Hospital and Jamsetjee
Jejeebhoy Hospital, 174, 176.

Fever, Remittent ; causes of, same as of in-
termittent fever, bQ ; diagnosis of, from
intermittent and ardent continued, 56. —
Symptoms of Ordinary remittent, 58 ;
inflammatory, 60; adynamic, 62; con-
gestive, 64 ; badly developed, 66 ; unex-
pected collapse, 67 ; occasional pecu-
liar symptoms, 69 ; of Complicated, cere-
bral, 70; irritability of stomach,72; gas-
tric and bilious remittent, 73 ; pneumonia
and bronchitis, 73 ; diagnosis from hectic
and symptomatic fever, 74. Pathology —
mortality from, 75 ; importance of dia-
thesis or pre-existing structural disease,
76 ; complicated with cerebral determina-
tion, 81 ; cerebral inflammation, 86 ; cere-
bral adynamic, 88; import of cranial serous
effusion analysed, 90 ; gastric irritability,
93 ; bilious remittent, 93 ; complicated with
affection of bowels, 94; hepatic and splenic
affection, 96 ; jaundice, 97 ; parotitis, 105 ;
Treatment — contrast of principles with
those of zymotic continued fever, 105 ; of
ordinary form, 109; inflammat-ory, 113;
congestive, 115 ; continued and adynamic,
116 ; badly developed symptoms, 117 ; of
complicated, with cerebral affection, with
question of mercurial treatment in, 118,
120; gastric irritability, 121 ; jaundice,
121 ; hepatitis, dysentery, 122 ; remarks
on blood-letting, 122 ; mercurial treat-
ment, author's opinion of, 125; opinion
of other writers on, 128 ; origin and history
of, 130 ; on cold affusion, 137 i wet sheet

packing, 137; purgatives, 138; emetics,
140 ; blisters, 140 ; opiates, use of, dan-
gers from, 140; quinine, 143; question of
large doses examined, 146 ; Warburg's
drops, 148, note; diet, 149; change of air,
use and injudicious application of, 150 ;
question of hmar influence, 154, note.
Infect ioics .Adynamic Remittent — Pali
disease, 155 ; statistics of remittent fever
in European General Hospital and Jam-
setjee Jejeebhoy Hospital, Bombay, 177,
180 ; Byculla schools, 181.

Fever — European relapsing, typhus, un-
known as yet in India, 16i

Fever — typhoid, of occasional occur-
rence, further research necessary, 160.

Females — hepatitis in, caution in respect
to, 415.

Gall-Bladder — inflammation and disten-
tion of, 431.

Gangrene of limg, 523, 7iote.

GA'Stritis — acute, 458; chronic, 460.

Gastro — enteritis, 316.

Glossitis — efficacy of application o£- ai-
t-rate of silver in, 461.

Headache — paroxysmal, functional, and
organic, diagnosis of, 654.

Heart — organic disease of, in natives in
the Jamsetjee Jejeebhoy Hospital, 581 ;
dilatation of both ventricles, 581 ; dila-
tation and hypertropliy of left ventricle,
581 ; hypertrophy of right ventricle, 582 ;
aneurism of left ventricle, 583 ; valvular
disease of, 586 ; previous pericarditis and
endocarditis, 586 ; rupture from fatty
degeneration, 587 ; aortic- disease, 587 ;
pulmonary complication, congestion, oede-
ma, hepatisation, emphysema, 589 ; re-
lation of, to sex, caste, age, occupation,
habits of life, season, 590, 591, 592 ; to
pericarditis, endocarditis, Bright's disease,-
592 ; leading symptoms and signs, dys-
pnoea, 593 ; dropsy, 593 ; praecordial
pain, 593 ; pain below margin <rf right
ribs, 593 ; scapidar pain, 594 ; character,
of puise, 594 ; prsecordial fulness, 595 j-
increased impulse, 595; prsecordial dul-
ness, 595 ; dulness below right costal
margin, 5S5 ; character of cardiac muiv*
murs, 595; prsecordial thrill, 599. Treat-
ment, 599 ; illustrative cases, 599 ; heart
disease in Europeans in India, 600.

Hemiplegia. — in natives, 658 ; relation
to age and caste, 658, 659. — Pathology of,
660 ; illustrative cases, 660; symptoms.

772

INDEX.

HErATrris — anatomictil position and rela-
tion, important, 321 ; terms hepatitis and
cirrhosis preferred to suppurative and
adhesive inflammation, 324. Pathology

. — question of which capillaries affected,
considered, 325 ; inflammation of capside
and substance, 327 ; turgescence, 327 ;
lymph exudation, 327; formation of
abscess, see "Abscess; " secondary peri-
tonitis, puriform sacs, 348; secondary
pleuritis, general and circumscribed em-
pyema, 352 ; secondary pericarditis, 352 ;
general secondary peritonitis, 355 ; re-
lation of secondary serous inflammation
with suppuration to cachectic states,
359. Causes. — not uncommon in na-
tives of India, 323 ; exciting, cold and
heat, 361 ; special influence of, 363 ; in-
temperance not proved, 363 ; predisposing
causes, cachectic states, but not evidence
to relate to particular cachexia, 363 ; re-
lation of hepatic abscess to dysentery
considered, 365 ; primary hepatitis, se-
condary dysentery, 369 ; hepatic abscess
without intestinal ulceration, cases of,
365; dysentery preceding abscess, 369.
— Symptoms of acute hepatitis, pain
of side, 370 ; of right shoulder, 371 ;
import of enlargement of liver, 372 ;
tension of right rectus muscle, 373 ;
altered states of biliary secretion, 373 ;
jaundice of no value as a symptom,
373; fever, 374; occasional obscurity, 375;
of formation of abscess, see "Abscess."
— Treatment of early stages, 384 ; general
blood-letting, 385 ; local blood-letting,
mercurial and other purgatives, ipeca-
cuanha, 386 ; caution in regard to relapse,
386 ; treatment of exudation stage, 388 ;
mercurial influence, principles of, 389 ;
blisters, '391 ; after abscess formed, see
" Abscess ; " hepatitis iu females and
children, 415 ; occasional difficulties in
diagnosis, 416; statistics of, in European
General Hospital and Jamsetjee Jejeebhoy
Hospital at Bombay, 417, 420.

Hepatic phlelbitis, 361.

Hill Sanitaria in Deccan — Mahubulesh-
wur, Pannehgunnee, Porrundhur, Sing-
hiir. Principles applicable to all Hill
Sanitaria in India, 728—740. 747.

Hooping Cough — 201.

HvDxiTiDS — in liver, not common in India,
430.

Hydrocephalus — acute, 652 ; chronic, 654.

Hydrophobia — as observed in Bombay,
illustrative cases, 689.

Ileus — 453.

^pecacuajjha— use of, in dysentery, 298.

Iron — preparations of, in splenic enlarge-

ment, 40 ; dysentery, 307 ; cachexia of
Bright's disease, 494.

Jaundice — complicating remitting fever,
73, 97, 121 ; idiopathic Pathology, 433.
— Causes, 436. — Treatment, 438; of no
value as a symptom of hepatitis, 373.

Kidneys — Bright's disease, prevalence of,
in some classes of the native community,
465 ; want of data in respect to Eu-
ropeans, 466 ; summary statement of
morbid anatomy of, 467; illustrative cases,
468 ; dropsical symptoms, 481 ; secondary
head symptoms, believed not to be so
common in India, 481 ; the same state-
ment of secondary cardiac affection,
482 ; the ursemic theor}' of the secondary
affections discussed, 483; alteref! relation
of albumen in the blood and urine con-
sidered, 485 ; remarks on the proximate
cause of albumen in the urine, 486. —
Causes — Eelation to cachectic states,
487 ; external cold, 490. — Symptoms
— Relative to the kidney, 491 ; con-
dition of the urine, 492. — Treatment — of
the kidney disease, 492 ; of the secondary
affections, dropsical, 493; inflammatory,
495 ; reference to diagnostic value of
epithelial debris, tube casts and oil glo-
bules in urine, 492.

Laryngeal affections in phthisis pulmo-
nalis, 558.

Leeches — sizes of, used in Bombay, note,
294.

Leprosy — tubercular and anaesthetic; ar-
rangements for care of lepers in Calcutta,
Madras, and Bombay, 695. — Symptoms,
Q^Q.— Pathology, 697.

Liver — cirrhosis of; Pathology, ^21. — Symp-
toms, 422. — Treatment, 422 ; illustrative
cases, 422 ; congestion of the liver, 426 ;
cancer and hydatid formations of, 429.
430 ; fatty degeneration of, 428 ; lardace-
ous, 427 ; so called torpor of, 441 ; inflam-
mation of. (See Hepatitis.)

Malaria — applied in this work exclusively
to the miasmatic cause of intermittent
and remittent fever : summary statement
of existing knowledge, 4 ; iii relation

INDEX,:

773

to intermittent fever, 18. 19, note; toremit-
. tent fever, 60, note; a predisposing cause
of dysentery, but .not an exciting one,
276, 279; the cause of many obscure de-
rangements, 153 ; modifying influences
on inflammatory symptomatic fever, 278,
374, 327, 576, 542.

Measles — account of in Byculla Schools
and elsewhere, 194; mortality rate, 198.

Meningitis— complicating remittent fever,
86 ; idiopathic,. 652.

Meecury — constitutional effect of, injurious
in splenic enlargement, 41 ; use of, in re-
mittent fever fully discussed and con-
demned, 125 to 136; in dysentery also
disapproved, 297 ; use of, in hepatitis ex-
plained, 386, 389 ; also in pneumonia and
in pericarditis, 538, 579.

Meteoeology of Bombay, 741 j of Deccan
HiU Sanitaria, 729, 747.

Mumps, 198.

Myelitis, 667.

Officees, Eueopean — diseases of: remit-
- tent fever, 75 ; small-pox, 190 ; measles,

197; dysentery, 237, table; peritonitis,

443 ; Bright's disease, 466 ; pneumonia,

608; phthisis pulmonalis, 554; cerebral

affections, 650; tetanus, 673.
Opium — use of: in remittent fever, 110,

140 ; cholera, 222, 225 ; dysentery, 302 ;

delirium tremens, free and routine use

cautioned against, 633.

Paealysis — from arsenic, 670; facial, 671.
(See Hemiplegia and Paraplegia.)

Paeaplegla., 668 ; case of wound of spinal
cord, 669.

Pebicaeditis and Endocaeditis — analysis
of 25 cases : proportion of pericarditis
and endocarditis, 561 ; result, 563 ; re-
lation to sex, caste, age, occupation,
habits, season, 564 to 567 ; relation to
rheumatism, cachexia, pulmonary in-
flammation, 567. — Spnptoms and signs
— ^Pain at margin of left ribs and prse-
cordial region, 568 ; increased impulse,
568 ; character of pulse, 569 ; febrile
symptoms, remittent character of, 569,
570 ; dyspnoea, 570 ; anxiety of coun-
tenance, 570 ; delirium, 570 ; increased
prsecordial dulness, 571 ; purring tre-
mor, prsecordial fulness, friction mur-
mur, 571; duration and causes of friction
murmur, 571 ; jogging movement of
heart, 578. — Treatment — General and
local blood-letting, 578; blisters, 578;

mercurial influenpe, 579 ; illustrative
cases, 573.

Peeitonitis. — Pathology — Karity of idio-
pathic sthenic form, 443 ; traumatic, 443 ;
sero-puriform, 445 ; chronic tubercular,
447 ; chronic form with effusion observed
at Aden, 452.

Phthisis Pulmonalis — not unfrequent
either in Europea,ns or natives, 554. —
Causes — influence of rainy season, question
of malarious influence, 554. — Symptoms,
5oQ. — Pathology — Question of rapidity
of course in India, 55Q; stage in which,
hospital patients i;idmitted, 557 ; which
side most affected, 557 ; co-existing pleu-
ritis, 558 ; pneumonia, 558 ; laryngeal
complication, 558 ; intestinal ulceration,
558 ; frequency of diarrhoea, 558 ; tuber-
cular peritoneum, fatty Kver, 559. Trcat-
Tuent, 559 ; statistics of the Jamsetjee
Jejeebhoy Hospital, 560.

Pleueitis, 548. — Symptoms, 548. — Games,
54cd.— Pathology, 54:9.— Treatment, 551.
Question oi Paracentesis of Chest, 551.

Pneumonia — rare in Europeans, 508 ; com-
mon in asthenic natives, 508 ; division
into primary and complicating remittent
fever, considered together, analysis of
103 cKnical cases, 509. Etiology — ^rela-
tion to sex, age, caste, habits, constitu-
tion, season, 509 — 512. Pathology —
Preliminary remarks on question, which
capillaries affected, 512 ; rate of mor-
tality, 515 ; duration of illness before
admission, 517 ; stage of disease, 518 ;
which lung affected, 518 ; residence in
hospital, 520 ; morlaid anatomy, sum-
mary of, 521 ; illustrative cases, 524.
Symptoms. — Fever, remittent character
of, 527 ; pain of side, 529 ; pain below
margin of right ribs, 529 ; dyspnoea, 531 ;
cough, 532 ; delirium, 5S3 ; character of
the sputa, 533 ; physical signs, 554. —
Treatment — Blood-letting, general prin-
ciples explained, those of some previous
writers dissented from, 534 ; local blood-
letting, 536 ; tartar emetic, 537 ; mer-
curial influence, 538 ; blisters, 541 ; qui-
nine, utility and principles explained,
542 ; liquor potassse, 543 ; stimulants,
543 ; concluding remarks on general
principles of treatment relative to the
use of antiphlogistics and tonics in pneu-
monia and inflammatory disease gene-
rally, 544 ; statistics of, in Jamsetjee
Jejeebhoy Hospital, 547.

PuEGATiVES — use in remittent fever, 138 ;
dysentery, 300 ; hepatitis, 386 ; pro-
bable injurious effects from, in hepatitis,
366.

Pyemia, 692, 693 ; illustrative cases,
question of relation to hepatic abscess,
365.

774

INDEX.

Quinine — disulphato, use in intermittent
and remittent fever, 29, 114, 143 ;
propliy lactic use, 149 ; in pneiiraonia,
both febrile and idiopathic, 642.

Rheumatism, 661. 662, note, 592, 716.

Scarlatina — very rare if not unknown in
India, 199.

Scurvy — not uncommon in India, 701.

Ska-coast — Sanitaria, 738. 751.

Saiall-Pox — as observed in Jamsetjee
Jejeebhoy Hospital, 182 ; prevalence of,
in Bombay, 187; prevention of, 189.

Snake-bite — Phoorsa snake, on Mahubule-
sliurr Hills, 716.

Spinal Cobd — disease of, 668 ; wound of,
669.

Spleen — inflammation of, rare, 36, note; en-
largement of, 36 ; — Tathology, 38 ; Treat-
ment, 37 ; abnormal prsecordial dulness
from heart, displacement by enlarged
spleen, 37 ; laceration of, by injury, 427,
note.

Statistics — see list of tables ; injury to
medical science from use of imperfect
statistical data, 12, iiote; 311, note;
516, note.

SuNSTBOKB, 603. — S^i/mptoms, GOG. Patho-
logy, 611. — Etiology ^ dli.^-' Prevention
and Treatment, 619,

Tetanus — prevalence of, 672. Pathology,
673. Causes, 678. Symptoms, 680.
Treatment, 683 ; illustrative cases, 686 ;
statistics of, in Jamsetjee Jejeebhoy Hos-
pital, 688.

Tonics — regimen, 10; remedies in dysen-
tery, 304 ; remarks on general prin-
ciples j 644,

Urine — imperfect acquaintance with nor-
mal standard of, in India, 497 ; chylo-
serous, 498 ; saccharine, 502 ; with excess
of urates, oxalates, phosphates, 605.

Vaccination; 189, imperfect in Native
Army, 190.

Warburg's Fever drops, 148, note.
Wet Sheet packing, in fever, 137.

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CLASSIFIED INDEX

Agriculture and Rural
I Affairs.

I Bavldon on Valuing Rents, ftc. - 4

■ " Road Legislation - i

Caird's Prairie Farming - - 6

Cecil's Stud Farm - - " °

Hoskyns'B Talpa - - - - 1»

Loudon's Agriculture - - - ia

Low'? Elements of A anculture - 1-

Morion on Landed Property - lt>

Arts, Manufactures, and
Architecture.

Bourne's Catechism of the Steam

Engine - - 7 . ' f

Brande's Dictionary of Science, Sec. 4

« Organic Chemistry- - 4

Cresy's Civil Enscineering - ' ^

Fairbairn's Infofma. for Engineers '

Gwilt'sEncyclo. of Architecture - 8

' Harford's Plates from M. Angelo - 8

Humphreys's Prtrn6Ze« Illuminated 11

Jameson's Saints and Martyrs - H

" Monastic Orders - ' ,

'< Legends of Madonna - U

" Commonplace-Bdok - 11

Konig's Pictorial Life of Luther - 8

Loudon's Rural Architecture - 13

MacDougall's Campaigns of Han- .

nibal - - - ,^ - - ]\

MacDougall's Theory of War - 11

Moseley's Engineering - - - 1^

Piesse's Art of Perfumery - - is

Richardson's Art of Horsemanship 18

Scoflern on Projectiles, &c. - - 10

Steam-Engine, by the Artisan Club 4

j Ure's Dictionary of Arts, &'c. - 2d

I Biography.

Arago's Lives of Scientific Men - :^

Baillie's Memoir of Bate
Brialmont's Wellington - - *
Bunsen's Hippolytus - - - 5
Bunting's (Dr.) Life - - - 5
Crosse's (Andrew) Memorials - b
Green's Princesses of England - 8
Harford's Life of Michael Angelo- 8
Lardner's Cabinet Cyclopaedia - 1-
Marshman'8 Life of Carey, Marsh-
man, and Ward ■ " " it
Maunder's Biographical Treasury- 15
Morris's Life of Becket - - 16
Mountain's (Col.) Memoirs - - 16
Parry's (Admiral) Memoirs - - 17
Russell's Memoirs of Mooie - - 16
" (Dr.) Mezzofanti - - 19
SchimmelPenninck's (Mis.) Life - 19
Southey's Life of Wesley - - 21
Stephen's Ecclesiastical Biography 21
Strickland's Queens of England - 21
Sydney Smith's Memoirs - - 20
Symond's (Admiral) Memoirs - 21
Taylor's Loyola - - " " 21
" Wesley - - - - 21
Uwins's Memoirs - - - - 23
Waterton's Autobiography & Essays 24

Books of General Utility.

Acton's Bread-Book ... 3
" Cookery - - - - 3
Black'sTreatise on Brewing- - 4
Cabinet Gazetteer - - - - 5
" Lawyer - - - - 5
Cust's Invalid's Own Book - - 7
Hints on Etiquette - - - 9
Hudson's Executor's Guide - - 10
" on Making Wills - - 10
Kesteven's Domestic Medicine - 12
Lardner's Cabinet Cyclopaedia - 12
Loudon's Lady's Country Compa-
nion ------ 13

Maunder's Treasury of Knowledge
' ' Biographical Treasury
" Geographical Treasury
" Scientific Treasury
" , Treasury of History
" Natural History -

Piesse's Art of Perfumery
Pitt's How to Brew Good Beer
Pocket and the Stud - - -
Pvcroft's Englisli Reading -
Rich's Comp. to Latin Dictionary
Richardson's Art of Horsemanship
Riddle's Latin Dictionaries -
Roget's English Thesauius -
Rowton's Debater - - - -

Short Whist

Simpson's Handbook of Dining -
Thomson's Interest Tables -
Webster's Domestic Economy
Willich's Popular Tables
Wilmot's Blackstone - - -

Botany and Gardening.

Ilassair^ British Freshwater Algoe 9

Hooker's British Flora - - - 9

" Guide to Kew Gardens-- 9

Lindley's Introduction to Botany 13

" Synopsis of the British

Flora - - - - 13

" Theory of Horticulture - 13

Loudon's Hortus Britannicus ' - 13

'• Amateur Gardener - 13

■' Trees and Shrubs - - 13

" Gardening - - - 13

" Plants - - - - 13

Pereira's Materia Medica - - 17

Rivers's Rose-Amateur"? Guide - 19

Watson's Cybele Britannica - 24

Wilson's British Mosses - - 24

Chronology.

Brewer's Historical Atlas - - 4

Bunsen's Ancient Egypt - - 5

Haydn's Beatson's Index - - 9

J aquemet's Chronology - - 11

" Abridged Chronology - 11

Nicolas's Chronology of History - 12

Commerce and Mercantile
Affairs •

Gilbart's Logic of Banking - - 8

'■' Treatise on Banking - 8

Lorimer's Young Master Mariner - 13
M'Culloch's Commerce* Navigation 14

Thomson's Interest Tables - - 23

Tooke's History of Piices - - 23

Criticism, History, and
Memoirs.

Brewer's Historical Atlas - - -
Bunsen's Ancient Egypt

" Hippolytus - - -
Chapman's Gustavus Adolphus -
Conybeare and Howson's St. Paul
Connolly's Sappers and Miners -
Crowe's History of France -
Frazer's Letters during the Penin-
sular and Waterloo Campaigns
Gleig's Essays . - - -
Gurney's Historical Sketches
Hayward's Essays - - - -
Herschel's Essays and Addresses -
Jeffrey's (Lord) Essays
Kemble's Anglo-Saxons
Lardner's Cabinet Cyclopaedia -
Macaulay's Crit. and Hist. Essays
" History of England -
" Speeches - - -

Mackintosh's Miscellaneous Works 14

" History of England - 14

M'CuUoch'sGeographicalDictionary 14

Maunder's Treasury of History - 15

Merivale's History of Rome - - 15

" Roman Republic - - 15

Milner's Church History - - 15

Moore's (Thomas) Memoirs, &c. - 16

Mure's Greek Literature - - 16

Normanby's Year ol Revolution - 17

Perry's Franks - . - - 17

Porter's Knights of Malta - - 18

Raikes's Journal - - - - 18

Riddle's Latin Lexicon - - 18
Rogers's Essays from Edinb. Reviewl9

" (Sam.) Recollections - 19

Roget's English Thesaurus - - 19
SchimmelPenninct's Memoirs of

Port Royal ... 19
SchimmelPenninck's Principles of

Beauty, &c. - - - 19

Schmilz's History of Greece - 19

Southey's Doctor - - - - 21

Stephen's Ecclesiastical Biography 21

" Lectures on French History 21

Sydney Smith's Works - - - 20

" Lectures -• - 21

" Memoirs - - 20

Taylor's Loyola - - - - 21

•Wesley - - - - 21

Thirlwall'sHistoryof Greece - 23

Turner's Anglo-Saxons - - 23

Uwins's Memoirs - - -23

Vehsc's Austrian Court - - - 23

Wade's England's Greatness - 23

Y'oung's Christ of History - - 24

Geography and Atlases.

Brewer's Historical Atlas - - 4

Butler's Geography and Atlases - 5

Cabinet Gazetteer - - - - 5

Johnston's General Gazetteer - 11
M'Culloch's GeographicalDictionary 14

Maunder's Treasury of Geography 15

Murray's Encyclo. of Geography - 16

Sharp's British Gazetteer - - 20

Juvenile Books •

Amy Herbert - - - - 20

Cleve Hall - - - _ . 20

Earl's Daughter (The) - - - 20

Experience of Life - - - 20

Gertrude ----- 2O

Ho Witt's Boy's Country Book - 10

" (Mary) Children's Year - 10

Ivors ----.. 20
Katharine Ashton - - - -«20

LanetonPaisonage - •• - 20

Margaret Percival - - - - 20
Piesse's flivinical, Natural, and

Physical Magic - - - - 18

Pycroft's Collegian's Guide - - 18

Medicine, Surgery, See

Brodie's Psychological Inquiries - 5

Bull's Hints to Mothers - - - .5

" Management of Children - .5

" . on Blindness - . . 5

Copland's Dictionary of Medicine - fi

Cust's Invalid's Own Book - . 7

Holland's Mental Physiology - 9

" Medical Notes snd Reflect. 9

Kesteven's Domestic Medicine - 12

Pereira's Materia Medica - - 17

Richardson's Cold-Water Cure - 18

' Spencer's Psychology - - - 21

Todd's Cyclopaedia of Anatomy

and Physiology - - - - 2?

Miscellaneous and General
Ijiteratnre.

nacon's (lonl) Works -
Dtff nee of Eclipnf of faith -
l)e Fon Manque ou Army Adminia

tration - . - .. --
Eclipse of Faith - - " ."
Fisclu r's Bacon and Uealistic Pki-

losophv . - . - -
Grciithett's Letters from Delhi
Greyson's Select Correspondence -
Gurney'8 Evening Recreations -
HasBiiH'sAdulterationsDetectcdj&c.
Havdn'8 Book of Dignities -
Holland's Mental Physiology
Hooker's Kew Guide - - -
Howitt'B Rural Life of England

Visitsto RemarkablePlaceg 10

Jameson's ('Ommonplace-Book - 11

Last of the Old Squires - - 17

Letters of a Betrothed - - - 13

Macaulay's Speeches - - - 13

Mackintosh'sMiscellaneous WorhS U

Martineau's Miscellanies - - 14

Pvcroft's English Reading - - 18

Rich's Comp. to Latin Dictionary 18

Riddle's Latin Dictionaries - - 18

Rowton's Debater - - - 19

Sir Roger De Coverley ■ - - 20

Southey's Doctor, &C. - - - 21

Spencer's Essays - - - ' ^\

Stow's Training System - - 21

Thomson's Laws of Thought - 23
Trevelvan on the Native Languages

of India 23

WiUich's Popular Tables - - 24

Yonge's Enslish-Greek Lexicon - 24

" . Latin Gradus - - 24

Zumpt'8 Latin Grammar - - 24

Natural History In general.

Agasfiz on Classification - - 3

Catlowa Popular Conchology - 6

Ephemera's Bonk of the Salmon - 7

Garratt's Marvels of Instinct - 8
Gosse's Natural History of Jamaica 8

Kirby and Spence's Entomology - 12

Lee's Elements of Natural History 12

Maunder's Natural History - - 15
Morris's Anecdotes in Natural

History - - - . - - 16

Quatrefages' Naturalist's Rambles 18

Stonehenee on the Dog - - 21

Turton's Shells ofthpBritishlslands 23

Van der Hoeven's Zoology - - 23

Waterton'sEssavson Natural Hist. 24

Ynuatt'g Work on the Dog - - 24

Youatt's Work on the Horse - 24

1 -Volume Encyclopsedias
and Dictionaries.

Blaine's Rural Sports - - - 4

Brande's Science, Literature, and Art 4

Copland's Dictionary of Medicine - G

Cresy's Civil Engineering - - S

Johnst(m's Geographical Dictionary 11

Loudon's Agriculture - - - 13

" Rural Architecture - 13

" Gardening - - - 13

" Plants . - - - 13

" Trees and Shrubs - - 13

M'CuUoch's Geographical Dictionary 14

" Dictionary of Commerce 14

Murray's Encyclo. of Geography - 16

Sharp's British Gazetteer - - 20

Ure's Dictionary of Arts, &c.- - 23

Webster's Domestic Economy - 24

Religious & Moral Works.

3
20
4
5
6
6

Afternoon of Life - - - -
Amy Herbert - - - -

Bloomfield's Greek Testament
Bunvan's Pilgrim's Progress
Calvert's Wife's Manual .
Catz and Farlie's Moral Emblems

CleveHall

Conybeare and Howson's St. Paul
Cotton's Instructions in Christianity
Dale's Domestic Liturgy
Defence of Erlipsp of Faith -
Earl's Daughter (The) - - -
Eclipse of Faith - - .
Englishman's Greek Concordance
" Heb.&Chald. Concord.

Experience (The) of Life
Gertrude - - - - -

Harrison's Light of the Forge
Home's Introduction to Scriptures

" Abridgment of ditto
Hue's Christianity in China -
Humphreys's Parables Illuminated

Ivors ; or, the Two Cousins - 20
JameHun'sSucrtd Legends - - 11
" Monastic Legends - - 11
*' Legends of the Madonna 11
" Lectures on Female Em-
ployment . - ... 11
Jeremy Taylor's Works - - - 11
Katharine Ashton - - - 20
Kftnig's Pictorial Life of Luther - 8
Laneton Parsonage - - 20
Letters to my Unknown Friends 13
LyraGermanica - - . _ 5
Maguire's Rome - - - - 14
Margaret Percival - . - - - 20
Marshman's Serampore Mission - 14
Martineau's Christian Life - - 14
" Hymns - - - 14
* Studies of Christianity 14
Merlrale's Christian Records - 15
Milner'8 Church of Christ - - 15
Moore on the Use of the Body - 16
" " Soul and Body - 16
" '8 Man and his Motives - 16
Morning Clouds - - - - 16
Neale's Closing Scene - - - 16
Pattlson's Earth and Word - - 17
Powell's Christianity without Ju-
daism - - - - 18
" Order of Nature - - 18
Readings for Lent . - - 20
" Confirmation - - 20
Robinson's Lexicon to the Greek

Testament - - - - - 19

Self-Examination for Confirmation 20
Sewell's History of the Early

Church - - - - 20

Sinclair's Journey of Life - - 20

Smith's (Sydney) Moral Philosophy 21

" (G.") Wesleyan Methodism 20

" (J.)St. Paul's Shipwreck - 20

Southey's Life of Wesley - - 21

Stephen's Ecclesiastical Biography 21

Taylor's Loyola - _ - - 21

" Wesley - - - - 21

Theologia Germanica - - - 5

Thumb Bible (The) - - 23

Ursula - 20

Young'sChrist of History - - 24

" Mystery - - - - 24

Poetry and the Drama.

Aikin's (Dr.) British Poets - - 3

Arnold's Merope - - - - 3

" Poems - - - - 3

Baillie's (Joanna) Poetical Works 3

Goldsmith's Poems, illustrated - 8

L. E. L.'s Poetical Works - 13

Jjinwood's Anthologia Oxoniensis - 13

Lyra Germanica - - - - 5

Macaulay's Lavs of Ancient Rome 14

Mac Donald's Within and Without 14

" Poems - - - 14

Montgomery's Poetical Works - 15

Moore's Poetical Works - - 16

•' Selections (illustrated) - 16

" Lalla Rookh - - - 16

" Irish Melodies - - - 16

" National Melodies - - 18

" SacTed SoTi^s {tcith Music) 16

" Songs and Ballads - - 16

Shakspeare, by Bowdler - - 19

Southey's Poetical Works - - 21

Thomson's Seasons, illustrated - 23

The Sciences in general
and Mathematics.

Arago's Meteorological Essays - 3

" Popular Astronomy - - 3
Bourne's Catechism of Steam-

Engme . _ - . . 4

Boyd's Naval Cadet's Manual - 4

Brande's Dictionary of Science, &c. 4

" Lectures on Organic Chemistry 4

Conington's Chemical Analysis - 6

Cresy's Civil Engineering - - 6

De la Rive's Electricity - - 7

Grove's Correla. of Physical Forces 8

Herschel's Outlines of Astronomy 9

Holland's Mental Physiology - 9

Humboldt's Aspects of Nature - 10

" Cosmos - - - 10

Hunt on Light - - - - 11

Lardner's Cabinet Cyclopaedia - 12

Marcet's (Mrs.) Conversations - 14

Morell's V:iements of Psychology - 16
Moaeley'sEngineering& Architecture 16

Ogilvie-s Master- Builder's Plan - 17

Owen's Lectureson Comp. Anatomy 17

Pereira on Polarised Light - - 17

Peschel's Elements of Physics - 17
Phillips's Mineralogy - - . 17
" Guide to (ieology - - 17
Powell's Unity of Worlds . . 18
Bmee's Electro-Metallurgy - - 20
Rteam Engine (The) - - - 4
Webb's Celestial Objects for Com-
mon Telescopes - - - 24

Rural Sports.

Baker's Rifle and Hound in Ceylon 3

Blaine's Dictionary of Sports - 4

Cecil's Stable Practice - - - 6

" Stud Farm - - . _ 6

Davy'sFishing Excurflion3,2 Series 7

Ephemera on Angling - - . 7

" 's Book of the Salmon - 7

Freeman and Salvin '8 Falconry - 8

Hawker's Young Sportsman - - 9

The Hunting-Field - - - 9

Idle's Hints on Shooting - - 11

Pocket and the Stud ... 9
Practical Horsemanship - -9

Pycroft's Cricket Field - - - 18

Richardson's Horsemanship - - 18

Ronalds' Fly-Fisher's Entomology 19

Stable Talk and Table Talk - - 9

Stoiiehenge on the Dog - - - 21 '

" on the Greyhound 21

The Stud, for Practical Purposes - 9

Veterinary Medicine, &c.

Cecil's Stable Practicr

" Stud Farm
Hunt's Horse and his Master
Hunting-Field (The) -
Miles's Horse-Shoeing -

" on the Horse's Foot -
Pocket and the Stud
Practical Horsemanship
Richardson's Horsemanship
Stable Talk and Table Talk -
Stonehenge on the Dog -
Stud (The) - -

Youatt's Work on the Dog -
Youatt's Work on the Horse

6
6
11 &

9
15
15

9
18

9
21

9
24
24

Voyages and Travels.

Baker's Wanderings in Ceylon

Earth's African Travels

Burton's East Africa ...

" Medina and Mecca .
Domenech's Texas ...
" Deserts of North America
FirstlmpressionsoftheNewWorid
Forester's Sardinia and Corsica -
HinchhfTs Travels in the Alps -
Howitt's Art-Student in Munich -

(W.) Victoria - -
Hue's Chinese Empire ...
Hudson and Kennedy's Mont

Blanc - - - . -

Humboldt's Aspects of Nature
Hutchinson's AVestern Africa
Kane's Wanderings of an Artist -
Lady's Tour round Monte Rosa -
M'Clure's North- West Passage
MacDougairsVovageofthei&so?«<t
Mintura's New York to Delhi
MoUhausen's Journey to the Shores

of the Pacific - - - .
Osborn's Quedah ....
Peaks, Passes, and Glaciers
Scherzer's Central America -
Senior's Journal in Turkey and

Greece . . . . -

Snow's Tierra del Fuego
Tennent's Ceylon - . - -
Von Tempsky's Mexico
Wanderings in Land of Ham
Weld's Vacations in Ireland -

Works of Fiction.

Connolly's Romance of the Ranks 6
Cruikshank's Fals'aff - - - 7
Hewitt's Tallangetta - - - 10
Mildred Norman .... 15
Moore 8 Epicurean - - .16
Sewell's Ursula - ... 20
Sir Roger De Coverley - - - 20
Sketches (The), Three Tales - 20
Southey's The Doctor &c. - - 21
TroUope's Barehester Towers - 23
" Warden - - - 23

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