f>A-l ■. ■ -1. \*f CLINICAL LECTURES CERTAIN ACUTE DISEASES. z-^V 35ca u Multurn egerunt, qui ante uos fuerunt, sed non peregerunt; multum adhuc restat operis, multumque restabit, nee uUi nato post mille saecula pnecluditur occasio aliquid adhuc adjiciendi."—Seneca. C. SHERMAN & SON, PRINTERS, Corner Seventh and Cherry Streets, Philadelphia. TO THE FORMER AND PRESENT HOUSE-PHYSICIANS AND CLINICAL CLERKS OF KING'S COLLEGE HOSPITAL, WHO HAVE FOR NEARLY TWENTY YEARS KINDLY AND ABLY ASSISTED THE AUTHOR IN HIS CLINICAL OBSERVATIONS, ®fnw f ap m gftottb, WITH EVERY FEELING OF AFFECTION AND THANKFULNESS, BY THEIR SINCERE FRIEND, THE AUTHOR. December 2S, 1859. PREFACE. The design of the lectures published in the present volume, is to describe and illustrate by examples the clinical history and treatment of the more important acute diseases. There will (the author believes) be found in the following pages evidence enough to show that the ordinary so-called anti- phlogistic treatment is unnecessary (to say the least) for the cure of acute internal inflammations ; and that the supposed neces- sity for such treatment rested upon an untenable hypothesis respecting the nature of inflammation and of fevers, and cannot be regarded as a legitimate induction from accurately observed clinical facts. The conclusions, which the clinical observations detailed in the lectures tend more or less to establish, may be summed up in the following propositions :— 1. That the notion so long prevalent in the schools, that acute disease can be prevented or cured by means which depress and reduce vital and nervous power, is altogether fallacious. 2. That acute disease is not curable by the direct influence of any form of drug or any known remedial agent, excepting when it is capable of acting as an antidote, or of neutralizing a poison, on the presence of which in the system the disease may depend (materies morbi). 3. That disease is cured by natural processes, to promote which, in their full vigor, vital power must be upheld. Reme- dies, whether in the shape of drugs, which exercise a special physiological influence on the system, or in whatever form, are useful only so far as they may excite, assist, or promote these natural curative processes. viii PREFACE. 4. That it should be the aim of the physician (after he has sedulously studied the clinical history of disease, and made him- self master of its diagnosis), to inquire minutely into the inti- mate nature of these curative processes—their physiology, so to speak; to discover the best means of assisting them, to search for antidotes to morbid poisons, and to ascertain the best and most convenient methods of upholding vital power. If one may venture a suggestion respecting the future of pathology, and of practice founded on it, it would be that a time is not far distant when all men who practise medicine in a scientific spirit, and divested of the trammels of routine, will discard the distinction of acute inflammations and acute disease in general, into asthenic and sthenic—that all these maladies will be regarded as more or less asthenic, and as promoting more or less an undue waste of tissue, and that, in treatment, an object of primary importance will be the early adoption of means to uphold-vital power, and the watchful and continued use of them throughout the duration of the case. It will not be affirmed by any one that the doctrines of a science so abstruse and so difficult as pathology, should not be reviewed and reconsidered from time to time. There never was a period when a candid and ample reconsideration of general pathology promised more fruitful results than the present. Our vastly ex- tended acquaintance with anatomy and physiology, the greatly enlarged security of the basis on wThich our knowledge of func- tion rests, the much increased accumulation of facts of clinical history, all afford most important data for new inductions. And I would remark that such inductions ought to be made from the deranged functions of the living rather from the facts of morbid anatomy, which properly should rank with the facts of clinical history, and which, in reality, are inferior in value to most of the phenomena of disease during life, being no more than marks of the ravages of disease, and affording comparatively little insight into its intimate nature. The real basis of all pathological in- quiry must be clinical research, made with the fullest apprecia- tion of the facts of anatomy and physiology; mere morbid ana- tomy leads necessarily to erroneous views of pathology and prac- tice. Such a review of pathological doctrine, as I have alluded to will assign its true value to the influence of the quantity of blood PREFACE. ix in the production of disease; will determine what is the real point of departure of morbid change, whether it is due to a superabun- dant or a deficient blood supply; or whether the condition of the blood supply is the consequence of a primary morbid change, such as a disturbed innervation, or a contamination, or waste of the ele- mentary tissue. The following problem lies at the root of the pathology of acute disease, and it has never yet received an adequate explanation, and is uniformly ignored by the zealous advocates of the so-called antiphlogistic method:— A man has a patch of pneumonia in the base of his left lung, brought on (he conjectures) by some exposure to cold. Why is it in his left lung ? why at the base rather than the apex ? how is it limited to a certain patch ? In other words, what is the proxi- mate cause of this localized derangement of nutrition ? If so much has yet to be determined as regards the very al- phabet of pathology, it cannot surely be thought presumptuous to question the soundness of the practice founded on such crude doctrines. And more especially are we justified in such a course, when it is considered that much of the practice of former days rests upon the insecure foundation of a partial and imperfect diagnosis of the primary disease, and a very inadequate interpretation of the subsequent phenomena of the case. Thus, in many instances the practitioner found himself treating a disease of the clinical history of which he had but a very imperfect knowledge, and on these occasions, he would be led to attribute changes in the symptoms (whether for better or for worse), which were essen- tially part of the ordinary course of the malady, to the influence of certain remedies. The temptation to draw hasty conclusions as to cause and effect, and to adopt the post hoc ergo propter hoc, so common among all classes, unlearned or learned, often like- wise stood in the way of sound reasoning upon these subjects. Did space permit, it would be easy to adduce many instances to show that a more exact diagnosis must necessarily lead to al- tered views of practice. A few may be briefly referred to. The precise discrimination of the different forms of continued fever has arisen out of the clinical investigations of the last fif- teen or twenty years. And it is now ascertained that continued fever may be caused by any one of three separate poisons, each of X PREFACE. which developes its characteristic phenomena, namely, those of typhus, typhoid, or pythogenic and relapsing fevers. Neverthe- less, there is good reason for believing that any two of these poi- sons may coexist in the same individual and produce their special phenomena. Dr. Murchison's researches render it highly pro- bable that the great epidemics which formerly ravaged Ireland, and some of the large towns of Scotland, were chiefly the fever which is called relapsing, and that it was by this form of fever that the practice of bleeding and low diet was best borne. However this may be, it is clear that even just to the present day physicians were not in a position to discriminate whether certain changes in the phenomena of the disease were due to the influence of their remedies, or were simply part and parcel of the ordinary train of the clinical phenomena of the disease. The whole class of the so-called apoplectic diseases must now be viewed, as regards their pathology and treatment, in a totally different light from that in which they were regarded formerly, even so lately as the celebrated work of Abercrombie. Both the pathology and practice of that able physician must now be, with but little exception, entirely discarded. And to what is this owing ? Undoubtedly to a more extended knowledge of clinical history, and to the consequent more pre- cise discrimination of the different forms of brain disturbance, which lead to comatose and paralytic phenomena. For example, the author has shown long since that many cases of hemiplegia are the result, not of a clot in, or of a rupture of fibres of the brain, but simply of the influence of an epileptic fit. The history of these cases is, that the patients suddenly fall into epileptic coma, with or without convulsion, and that they emerge from it writh more or less perfect hemiplegia. This paralysis often gets well with remarkable rapidity after a few hours, very often after a few days, and sometimes after some weeks. A case of this kind falling into the hands of a practitioner accustomed to use the lancet freely in diseases tending to coma, (the so-called congestion of the brain), would not suffer any dis- advantage from a moderate bleeding and from purging; the patient would speedily recover, and'the case would be quoted as a glaring instance of the excellent effect of the treatment, whereas an exact diagnosis might have saved unnecessary prac- tice, and a familiar knowledge of clinical history would have PREFACE. xi enabled the practitioner to have foreseen and foretold the course which the disease would be likely to take. The much vaunted powers of mercury as a remedy, not only to promQte the resolution of acute inflammation, but also to cause the absorption of its product, lymph, rests first upon a false analogy; and, secondly, upon imperfect knowledge of clinical history. It was found that iritis, the result of the influence of syphilis^ was cured under the use of mercury with a rapidity and certainty which did not belong to any other-kind of treatment. Lymph effused in more or less quantity upon the surface of the iris, and even recent adhesions gluing the margin of the pupil to the capsule of the lens, quickly melted away under the peculiar change which mercury was capable of inducing. Primd facie, there was no more reasonable suggestion than that mercury would exercise a similar influence on inflamma- tions of like tissues to the membrane of the anterior chamber, and promote the removal of any lymph that might be effused upon them, preventing adhesions or dissolving them if formed. But although it was a perfectly reasonable suggestion to give full trial to the use of mercury in inflammations of serous mem- branes, the analogy did not justify the expectation of such deci- sive results as were obtained in syphilitic iritis, although suffi- cient to call for experiments. In fact, the analogy was inexact: there was no further resemblance between syphilitic iritis and rheumatic pericarditis or pleurisy, than in the tendency of both inflammations to develope lymph, and to cause adhesion of opposed surfaces. Nor in any of their other effects was there any such marked similarity between the syphilitic and the rheu- matic poisons as would fully justify the expectation that the experimental trial of mercury for the cure of such inflammations would prove successful. And what has been the result of the long-tried use of mercury in both affections, syphilitic as well as rheumatic ? Why, that whilst, in the former, mercurial treatment has never ceased to find favor with practical men,# in the latter, such has not been the case. No one would now venture to assert that mercurial influence, however quickly induced, ever checked pericarditis or pleurisy; nor would it be easy to adduce an instance in which, Xll PREFACE. with any reasonable degree of certainty, it could be stated that mercury broke down adhesions, or prevented their occurrence. Examples were no doubt of frequent occurrence in which such effects appeared to follow the use of mercury. But a more inti- mate acquaintance with clinical history has taught physicians that changes are apt to occur which simulate the absorption of a lymph-deposit. It is very common to find a marked pericar- dial friction sound disappear for a time, and the hopeful prac- titioner is led to regard this as the result of his remedies, some- times of a few leeches or a cupping, sometimes of a blister, but more especially of the use of mercury. In a day or two, the friction sound returns, and the practitioner is forced to cdnclude that his remedies have not produced the desired result. And there are the best reasons for inferring that the early temporary suspension of the friction sound is due in a large number of cases to a slight liquid effusion, which separates the opposed rough surfaces, and so destroys the friction sound, which, how- ever, returns on the reabsorption of the liquid. Moreover, it is now proved by a multitude of examples (and some will be found recorded in the following pages), that pericarditis will do per- fectly well without mercury, nay, better than with it; and that in general the real benefit which the patient derives is to be re- ferred to the opium with which the questionable mercury is com- bined. How often and often has the author most anxiously watched a mitral bellows-murmur, caused by recent endocarditis in patients under mercurial treatment, hoping to discover that it had disap- peared under the mercurial influence! Yet in his whole expe- rience he is unable to discover a single case in which such a murmur had been even modified by any influence save that of good nourishment, as tending to maintain a normal state of blood, and of time, as furnishing opportunity for the mecha- nical wearing down (by attrition) of the deposited lymph. A curious instance may be mentioned in illustration of the way in which an erroneous opinion may be readily formed with respect to the effects of remedies. The author attended, along with a medical friend, a tradesman of middle age, who became quickly, although not suddenly, comatose, with hemiplegia of the right side, and marked rigidity of the muscles of the arm and leg. It was difficult to determine whether the symptoms PREFACE. xiii indicated a superficial apoplectic clot, or were due to a patch of inflamed brain in the left hemisphere. It was resolved to act on the latter view, and mercury was given freely with the inten- tion of producing salivation. About the second or third day of this treatment the patient recovered his consciousness, although retaining a certain degree of somnolency; the paralyzed limbs regained a greater degree of power and the muscles became less rigid. During#this and the succeeding day everything favored the conclusion that the mercury was telling upon the inflamma- tory process, and that it was undergoing resolution. The gums became affected just at this time. But, in another day, the hopes of the patient's friends and attendants were seriously checked by the rapid recurrence of the comatose and paralytic symptoms, in a more severe form, leading to a profound coma, under which the patient succumbed. The inspection after death showed a considerable apoplectic clot on the surface of the left hemisphere, causing a deep inden- tation on the convolutions, which did not disappear when the clot was removed, such was the degree of pressure on the cere- bral surface. On cutting through the clot, it was found to con- sist very distinctly of two portions, one brownish in color, and looking old; the other consisting of dark, currant-jelly-like coagulum, which had been only quite recently effused. It was plain, then, in this case, that the original cause of the symptoms was a meningeal effusion of blood compressing the brain to a very great extent. After a few days, the watery part of the coagulum was absorbed, and the shock which the brain had received,at the first effusion of blood had subsided. It was then that the restoration of consciousness and the improvement in the other symptoms, which were attributed to the influence of mercury, took place. This improvement, however, soon gave way before a fresh hemorrhage, which led quickly to a fatal result. Had an exact diagnosis been possible with certainty in this case, the patient would have been spared the mercurial course to which he was subjected, and the physicians would have had nothing else to do but to support the powers of life, with the hope, that by the brain adapting itself to the pressure, and the gradual absorption or contraction of the clot, the life of the patient might be considerably prolonged. And, indeed, this xiv PREFACE. would most probably have been the case in this patient, had it not been for the second hemorrhage. Enough has been said, the author hopes, by way of apology, for his venturing to dissent from current views of pathology and practice, sanctioned as they are by great names, both dead and living—for which the author will yield to no one in admiration and respect; but • Amicus Plato, amicus Socrates, magis arnica Veritas. The author has not referred to the hypothesis suggested by some who admit the necessity of a considerable modification of practice in the treatment of acute diseases ; namely, that the type of disease has undergone material change of late years, and has assumed a much lower grade as regards vital power, owing either to some change in the human constitution, or to some atmospheric modification which has taken place in recent times. It is supposed that this modification dates from the period of the first introduction of cholera into these countries. Upon this point, the author can say that he has been a not careless observer of disease for several years antecedent to the first cholera epidemic. At no time was the antiphlogistic treat- ment (so called) more rife than some years prior to the cholera epidemic, and many excellent observers were then beginning to see that it was carried too far, and was inadequate for its object in either cutting short or curing disease. Certainly opportu- nities of studying the morbid anatomy of acute diseases, pneu- monia, pericarditis, endocarditis, pleurisy, were then,- and for many years afterwards, much more common than now, when such inspections are among the least frequent in our hospital theatres. The author has notes of many cases treated in this way, which he is confident would have recovered, had vital power been not only spared but upheld. The author would venture to doubt the proposition that disease is of a lower type now than it was twenty or thirty years ago. Certainly we have long been spared those ravaging epidemics of fevers, dysenteries, exanthemata, all of which exhibited innume- rable examples of the lowest type of disease. Their comparative disappearance now is due in part, no doubt, to the improved PREFACE. XV condition of the .people, better food, better clothing, cleaner and better ventilated dwellings, and to many wise preventive sanitary measures. But, on the other hand, population is vastly increased, overcrowding exists to a large extent, and were disease of a very low type, it would spread freely, and epidemics would be com- mon. It is well known that such is not the case, and that the fevers which were formerly the scourge of the poor, occur now on a very limited scale. In concluding these remarks, which have extended further than the author intended, it only remains for him to return his most cordial thanks to his highly intelligent friend and former pupil, Dr. Liveing, for his invaluable aid in carrying these pages through the press, and to his friends, Dr. Hyde Salter, Professor Beale, and Dr. Conway Evans, by whom several of the lectures were first reported. 26 Brook Street, Grosvexor Square, December 28, 1859. CONTENTS. LECTURE I. General remarks on the clinical history and pathology of rheumatic fever—Case in illustration—Importance of observing narrowly and studying carefully a few well-marked cases—A special fever the essence of the malady, not merely symptomatic of the articular affection—The articular affection the chief source of suffering—Order in which the joints are affected—Hyper- semic condition of the synovial membranes with excessive secretion—Erratic character of the local inflammations—Objections to the notion of metastases —The profuse acid perspirations an important medium for eliminating nox- ious matters—Scanty and loaded character of the urine—A thickly furred tongue characteristic of the disease, and a guide to the progress of the case —Proneness of the heart to become affected—Sudamina incidental to many diseases where free sweating occurs—Association of rheumatic fever with the puerperal state—Pathology of " puerperal acute rheumatism"—Case— Occurrence of severe carditis and pleurisy during salivation—Free employ- ment of opium—Three cases, examples of the average course of the disease under eliminating treatment—The pathology of acute rheumatism considered, with a View to promote the natural cure by treatment, . • . pp. 17-29 LECTURE II. General remarks on the treatment of rheumatic fever—Points to be aimed at in the treatment of acute diseases generally—Caution against the permanently injurious effects of heroic remedies—Of so-called rapid cures—Various methods of treatment—Free venesection—Danger of producing a lasting anasmia and prolonging convalescence, or hastening a fatal termination by exhaustion—Case illustrating the inefficacy of bleeding either to promote the cure or prevent the recurrence of rheumatism—A similar case—Danger of being misled by the favorable progress of some cases after venesection— Example—Moderate bleeding with diaphoretics—Objections—Treatment by lA XV111 CONTENTS. mercury—Permanent ill effects of mercury—Its inefficacy against severe internal inflammations—Case treated on this plan—Colchicum and guaia- cum—Treatment by opium—The great value of this drug—Remarkable tole- rance of opium in rheumatic fever—Case in illustration—Bark and quina— Treatment by elimination—Promotion of excretions—Alkalies and opium —Local remedies—Objections to leeches—Use of cotton wool and s,mall blisters—Indications for stimulants—Case in illustration, . . pp. 30-48 LECTURE III. Treatment of rheumatic fever resumed—Precautions necessary to insure the successful employment of opium—Blisters—Small blisters preferable to large ones—The best method of applying them—Caution against the exhausting effects of excessive excretion—Importance of paying close attention to the heart—Signs of commencing heart affection—Irregularity of pulse—Endo- carditis—Mitral and aortic bellows sounds—Distinction between endocardial and anaemic murmurs—Diagnosis of mitral disease, with and without valvu- lar imperfection—Local treatment of the heart-affection by blisters—Of the contents of blisters, their plastic nature—Effects of blistering compared with those of bloodletting—Points to be aimed at in the treatment of internal rheumatic inflammations—Of the pathology of valvular concretions—Will bleeding oppose their formation ?—General inefficacy of bleeding in local rheu- matic inflammations—A relative increase in the plastic rUatter of the blood the result of bleeding—Tendency of bleeding to promote liquid effusions— Value of opium in internal inflammations—Rheumatic delirium, its clinical history and pathology—It is the result of perverted nutrition by a poisoned nutrient fluid, and not of true inflammation of the brain or its membranes —Coma—Case illustrating the inefficacy of mercury and similar remedies in these cerebral complications—Delirium essentially independent of, although often associated with, rheumatic carditis—Favored by exhausting causes- Treatment of delirium and coma—Support, opium, blisters—Cases illustra- ting the preceding remarks—Pale urine an indication for more generous treatment'—Concluding remarks, ...... pP< 49-71 LECTURE IV. Observations on a case of continued fever—Importance of the retrospective consideration of fatal cases—The kind and degree of benefit which may be expected from treatment in fever cases—A fever cannot be cut short —The value of good nursing—Case of Gavin—Early history—Usual pro- gress of a case of fever after about the fifth day—Case continued__The pulse as an index of debility—Danger of moving fever patients—Termi- % nation of the case in fatal exhaustion hastened by hemorrhage from the bowels—Summary of treatment—Retrospective consideration of the case— CONTENTS. xix Extreme prostration the result of intestinal ulceration—The exhaustion out of proportion to the impairment of the function of the bowels from the destruction of mucous membrane—A perforating tendency necessary to this effect—Affection of the mesenteric glands—Production of a state analogous to pyaemia by absorption of matter from the ulcerating surface—Evidence from cases of puerperal fever, erysipelas, and direct purulent infection— Termination by perforation — Symptoms — Case—Termination by colli- quative diarrhoea—Objections to the use of alcohol on the score of its increasing the intestinal irritation unfounded—Cases of severe fever success- fully treated on a supporting, plan—Hemorrhagic tendency—Cases in illustration—A discrimination of cases, methodical administration, and due regard to digestion necessary to the successful employment of stimulants— Treatment of ulceration by opium and astringents, . . . pp. 72-93 LECTURE V. Further remarks on continued fever—On the nature offever—Fever produced by the inoculation of the blood with a variety of specific poisons, and by their eliminations—The exanthematous and paludal poisons and pus— Varieties of continued fever—Relapsing fever—Typhoid, marked by enteric disease and scattered rose eruption—Typhus, its characteristic rubeoloid eruption—Cases of typhoid and typhus—Exceptional cases—Rubeoloid erup- • tion with enteric symptoms—Rose spots without enteric symptoms—Case of extensive ulceration of the ileum without diarrhoea—Case of an intermediate character—Petechias—Sudamina—Complications of fever—General path- ology of local congestions—Pulmonary congestion—Symptoms—Its purely passive character—Example—A special treatment not required—Local treat- ment—Congestion of the brain—Symptoms few and uncertain—Influence of the mode of death on the condition of the brain—Post-mortem appearances —Case—Numerous bloody points, and darkened gray matter—Case—Ven- tricular effusion—Conservative character of sub-arachnoid effusions—Deli- rium, coma, convulsions, not necessarily symptomatic of true cerebral in- flammation—Treatment—Increasing delirium an indication for increased support—Local remedies—Blisters—Cold affusion—Three examples—Other incidental complications—Meteorism, its pathology—Not confined to enteric forms of fever—Occurrence under various circumstances of defective nervous influence—Treatment—Paralysis of the bladder—Albuminuria—Crises and critical days—Critical evacuations—Cases of favorable critical purging— Case of unfavorable crisis by sweating—Case of crisis with temporary ex- acerbation—Critical days—Researches of Traube—Termination by lysis —Aphorisms on the management of fever cases, . . . pp. 94-122 LECTURE VI. Clinical history of erysipelas—Case of erysipelas of the head and face—Favor- able termination without secondary affection under supporting treatment— XX CONTENTS. Frequent commencement with vomiting and rigors—Sore throat—Duration —Natural divisiou of the phenomena into primary and secondary—Tendency of the subcutaneous areolar tissue to become involved—Unfavorable case of erysipelas of the leg in a half-starved lad—Development of the secondary phenomena—Evidence afforded by this case against a directly antiphlogistic treatment—The pulse as a guide to the progress of a case—Clinical history of erysipelas of the head and face—Erratic nature of the tegumentary affec- tion—Frequent commencement in the throat—Subsequent course to the skin, or respiratory raucous membrane—Erysipelatous bronchitis—Mode of death in—Case commencing with severe throat affection—Case illustrating the erratic character of erysipelas—Rapid and fatal termination of a case of traumatic erysipelas by bronchitis and pulmonary oedema—Intractable nature of capillary bronchitis—CEdema glottidis—Its depressing and fatal nature—Great promptitude and decision required in the treatment—Com- plete failure of all antiphlogistic measures—Case successfully treated on an opposite plan—Case illustrating the depressing nature of the disease, and danger of slackness in the treatment—Another successful case—High per- centage of deaths after tracheotomy—Erysipelas inducing paralysis of the fauces—Erysipelatous character of puerperal peritonitis—Termination by exhaustion—By capillary bronchitis—With coma and delirium—Mode of dying as affecting the condition of the brain—Classification of cases with a view to ascertain the benefit of treatment—Cases which get well of them- selves—Cases which, from their malignant character, defy all treatment— Severe cases, but which yield to treatment in the first stage—Cases in which the secondary phenomena are developed—Cases which terminate by purulent infection—Management of cases by supporting treatment—Signs of over- stimulation—Case—Case showing the danger of delay in the use of stimu- lants—Alcohol the best antidote to the poison of erysipelas—Sesquichloride of iron—Seven cases illustrating the good effects of the treatment advo- cated, ........... pp.123-150 LECTURE VII. On a rare and hitherto undescribed affection of the fauces, probably erysipela- tous—The shortness and severity of the malady—Characteristic features__ Paralysis of the pharynx the distinguishing mark—Dusky red color of the mucous membrane—Efforts at deglutition—Termination mainly influenced by the treatment adopted—Aim of the treatment to prevent death by ex- haustion—Feeding by the rectum—Local application of nitrate of silver__ Case—Diagnosis—How distinguished from stricture of the oesophagus__ From spasm of the oesophagus—From disease of the medulla oblongata__ From the dysphagia of aneurism—From inflammation of the epiglottis__ From cynanche tonsillaris—Fatal case treated antiphlogistically—Two cases successfully treated on a supporting plan—Case treated antiphlogistically and terminating in fatal exhaustion—First case resumed—Favorable pro- gress under supporting and stimulating treatment—Complication with tris- CONTENTS. XXI mus—How explained—Favorable termination of the case—Reasons for considering the case erysipelatous—How distinguished from the sore throat of influenza—Of diptheritis—Of scarlet fever—From aphthous sore throat— Another case complicated with some affection of the laryngeal membrane and haematuria—Successful treatment—Fatal case—Post-mortem examina- tion, ...........pp. 151-165 LECTURE VIII. Observations on the treatment of acute internal inflammations generally, founded on a case of rheumatic pericarditis with endocarditis and pneu- monia—History of the case—Treatment directed to support the vital powers of the patient while the natural cure is effected—Clinical history of the natu- ral cure of pneumonia—Structural, physiological, and chemical changes— Association of acute internal inflammations with particular diatheses—Natu- ral cure by elimination—Depression of vital power the direct result of the inflammatory process—A supporting treatment suggested by the foregoing considerations—Objections to the use of alcohol founded on an imperfect view of the inflammatory process—On the nature of inflammation—Inflam- mation considered as a vital process involving waste and demanding supply, or producing exhaustion—Case resumed—Favorable progress under active stimulating treatment—Alcohol a preventive of and antidote to delirium— Diarrhoea a natural antiphlogistic, followed by no good effect—The pulse a guide to the progress of the case—A rapid convalescence—On the import- ance of managing the supplies of alcohol and other food with a due regard to the digestive process—Objections to the use of stimulants arising from their slovenly use or abuse,........pp. 166-176 LECTURE IX. Observations on a case of pyaemia—History of the case—Source of infection in a closed chronic abscess in the perineum—Case mistaken for rheumatic fever—Developmentofpleuro-pneumonia—Formation of secondary abscesses —Free purulent expectoration—Further abscesses—Rationale of such cases —"Varieties in the contaminating material—Course of the more and less severe cases—The amount and nature of the poisonous matter, and the con- dition of the patient as affecting the result—Experiments of Cruveilhier— Sources of purulent infection—Phlebitis—Essay by Mr. Arnott—Experi- ments by Mr. Lee—Nature's opposition to diffuse purulent infection— Danger from injuries to bones—From confined collections of pus—From the puerperal state—From erysipelas—From typhoid fever—Direct infection by dissecting wounds—Ou secondary pus-formations—Localization in paren- chymatous organs—On serous surfaces—In muscles and areolar tissue— Pathology—Anatomical considerations—Emboli—Insufficiency of purely mechanical considerations to account for all the phenomena—Gordon's case XX11 CONTENTS. resumed—Peculiarity of the pulmonary affection—Practical division of cases —First class : cases rapidly and certainly fatal without secondary deposits- Experiments of Gaspard—Case in illustration—Puerperal cases of this class —Two examples—Another rapidly fatal case without any obvious source of pUS_References to cases of direct purulent infection—Case of traumatic erysipelas terminating fatally in pyaemia with, profuse purulent expectora- tion and secondary pus formations—Error in treatment—Unfavorable termi- nation of other surgical cases with symptoms of pyaemia—Second class : more slowly fatal cases—The so-called puerperal acute rheumatism—Case in illustration—Third class : much less fatal cases—Case of Gordon con- cluded—Case successfully treated with a large amount of alcohol—A tedious case improperly treated—Support the sum of the treatment—Hint for the management of puerperal cases—Of severe injuries—Doubtful prognosis in erysipelas, ..."....•■•• PP- 177-198 LECTURE X. Observations on some cases of pneumonia with a view to solve the problem of treatment—General scope of the treatment pursued : eliminating and sup- porting not directly antiphlogistic—Sthenic and asthenic cases—Distinction more apparent than real—Remedies distinguished as directly and indirectly antiphlogistic—Case—The peculiar characters of pneumonic sputa—How explained—Constitutional symptoms—Physical signs—Dulness from pleu- ritic effusion distinguished from that of pneumonia—Phenomena of bron- . chial breathing and bronchophony explained—Due to pulmonary solidifica- tion from a variety of causes — Bronchial breathing of pleurisy and of pneumonia distinguished—iEgophony — Partiality of pneumonia for the posterior and inferior parts of the lungs—Extent and position of the inflam- mation as influencing prognosis—Case resumed—Particulars of the treat- ment and satisfactory progress—Second Case—Importance of noting the frequency of the pulse and respirations — Remarks on the treatment— General aim to promote the natural cure—On digitalis as an antidote to pneumonia—Importance of considering the natural tendencies of the dis- ease, and of a classification of cases in forming a judgment of any particular treatment—The worthless character of most numerical returns.—Treatment, age, and position of the inflammation as affecting the result—Unsatisfactory results of the directly antiphlogistic treatment of pneumonia—Difficulty of assigning limits to bloodletting—The kind and degree of benefit derived from tartar emetic—Third example of the treatment—Chemical observations of Redtenbacher and Beale on the urine and sputa in pneumonia—On pleuro- pneumonia as a complication of rheumatic fever—Case of double rheumatic pleuro-pneumonia and pericarditis successfully treated—Particulars of the treatment—Free use of opium—A similar severe case—Error in the inter- pretation of the physical signs from the presence of a dilated stomach__ Fatal termination and post-mortem—Retrospect of the case—Addendum__• Three cases of pneumonia from the practice of three different physicians illustrating the treatment here recommended, .... pp. 199-232 CONTENTS. xxiii LECTURE XL On the object of clinical lectures, and the duties of clinical clerks—Simple in- flammation of the lung a suitable introduction to the study of pulmonary diseases—Clinical varieties of pneumonia—Simple pneumonia—Rarely un- complicated with pleurisy or some constitutional peculiarity—Pneumonia complicated with acute gout or rheumatism—Strumous pneumonia—Typhoid pneumonia—Traumatic pneumonia—Of the so-called lobular pneumonia— Pathology of pneumonia—Red hepatization—Nature of the preceding sta^e of active congestion—Its relation to hepatization—Uncertainly distinguished by physical signs during life and anatomical characters after death—Other causes of hyperemia, acute bronchitis, passive congestion—Casts of air-cells and tubes—Thej^ne crepitation of Laennec rarely detected—Gray hepatiza- , tion—Purulent infiltration—Resolution—How effected—Case of Everitt— Nature of the sputa in pneumonia—Case continued—Physical signs—Degrees of dulness—From simple hepatization—From hepatization with slight pleu- ritic effusion—With large effusion—Vocal vibrations—Bronchial breathing and bronchophony—Diagnosis—Importance of attending to the general symptoms as well as the physical signs—Confirmation of the diagnosis by subsequent progress of the case—Of crepitation as a sign of resolution and of purulent infiltration,........pp. 233-246 LECTURE XII. Differential diagnosis of pneumonia and various diseases—How distinguished from simple pleurisy—Characters of the percussion—Pleuritic friction sound —Nature of the pain in pleurisy—Difficulty of distinguishing pneumonia from pleurisy with small effusion—With large effusion—Character of the percussion—Vocal vibrations—iEgophony—Effect of old adhesions and a weak voice in obscuring the diagnosis—Aid derived from the history and general symptoms—Differential diagnosis of pneumonia and tubercular infil- tration—History—Part of the lung affected—Nature of the expectoration— Pneumonia distinguished from cancerous disease of the lungs—History— General symptoms—Cancerous cachexia—Pneumonia distinguished from pulmonary apoplexy—Diagnosis of strumous pneumonia—The urine in pneu- monia—Composition of the urine in health—The saline ingredients deficient in pneumonia—Method of testing the urine—Case of Everitt resumed— Observations on the urine—On the presence of chloride of sodium in the sputa of pneumonia, and its deficiency in the blood—Tabulated results of analyses of the urine in the case of Everitt—Treatment before and after admission—Critical evacuations in pneumonia—Reasons for adopting an eliminating plan of treatment, and rejecting the so-called antiphlogistic remedies,...........pp. 247-262 XXIV CONTENTS. LECTURE XIII. Concluding observations on pneumonia—A fatal case—The importance of re- viewing our practice in fatal cases—History and treatment of the case— Indications for stimulants—On the danger of lengthened sleep in acute disease—Observations made on the urine ana! sputa—Complication with in- cipient renal disease—Importance of studying the chemistry of the excre- tions—Tabulated results of the chemical analyses of the sputa and urine— Post-mortem—In estimating the results of treatment the amount of lung involved must be considered—Case—Favorable progress and termination— An cedematous condition of the lung a cause of persistent dulness—Retro- spective consideration of both cases—Modes of termination in pneumonia— Recovery, with critical evacuations—Death—Circumstances which should influence the prognosis—Great fatality of pneumonia in the young and old— French statistics—Extent of lung involved—Epidemic constitution—Treat- ment adopted—Comparison of the results of the reducing and supporting • treatment in seventy-eight cases,......pp."263—278 LECTURE XIV. On the therapeutical action of alcohol—Introductory considerations—History of a fatal case of poisoning by alcohol—Rapid production of coma, with hemiplegia and convulsions—Treatment—Evidence afforded by the post- mortem, chiefly negative—Mottled fatty kidneys—Probable explanation and bearing on the history—Practical information to be obtained from the case —The rapid development of the symptoms—Three cases, by Dr. Christison, illustrating the same point—The digestion of alcohol, a simple process of absorption—Exhalation with the breath, a proof of actual absorption and rapid diffusion—Not observed in disease—The mechanism of the action of alcohol—Its poisonous effects chiefly referable to the nervous system, less to the digestive—Alcohol .in moderation promotes, in excess impairs, the nutri- • tion of nervous matter—Inflammation of internal organs not an effect of alcoholic poisoning—Coma and delirium due to a poisoning of the nervous matter, not to congestion—Depression following the use of alcohol more apparent than real—Alcohol an aliment peculiarly adapted to nourish the nervous system, and feed the calorifacient process—Importance of a well- adjusted supply—Alcohol as a therapeutic agent—The tendency to depres- sion of vital power from acute diseases, a general indication for its employ- ment—The support of the patient during the natural progress of the disease, the principal object in view—The mode of administration, all important— Various cases illustrating the use of alcohol—Two cases of fever—Case of pneumonia—Case of bronchitis—Alcohol in erysipelas—A preventive of delirium in various exhausting diseases and fevers—Case of violent delirium in the course of variola—Another case—Case of delirium tremens—Case of early coma in typhus—Indications that too much alcohol is being given__ Deranged digestion—Delirium and coma—Coma from excess of alcohol dis- tinguished from that due to disease—Retrospect of the case on which the lecture is founded,".........pp. 279-308 LIST OF CASES. CASE PAGE I. Rheumatic fever, with pericarditis, following the puerperal state— * recovery,...........17 II. Rheumatic fever, complicated with severe carditis and pleurisy occur- ring during salivation—recovery, ....... 22 III. Ditto with pericarditis—recovery,.......25 IV. "Ditto without heart affection—ditto,.......27 V. Ditto with endocardial and pericardial affection—ditto, ... 27 VI. Ditto—ditto—tedious and recurrent case—repeated bloodletting, . 33 VII. Ditto with endocarditis—repeated bloodletting, . . 36 VIII. Ditto—repeated bleeding—recovery,......38 IX. Ditto with endocarditis and pericarditis—remarkable tolerance of mercury, ........... 40 X. Ditto—restlessness and delirium—recovery,.....44 XL Ditto ditto ditto .....48 XII. Ditto with pericarditis—delirium with a tendency to coma—death, . 60 XIII. Ditto—severe carditis and delirium—death—post-mortem, . . 63 XIV. Ditto—endocarditis—delirium, coma, and convulsions—death—post- mortem,........... 66 XV. Ditto—carditis—delirium, recovery,......68 XVI. Typhoid fever—extensive ulceration and hemorrhage—death—post mortem,...........74 XVII. Ditto—death by perforation,........84 XVIII. Typhoid fever—recovery,........86 XIX. Ditto ditto .........87 XX. Ditto ditto .........88 XXI. Ditto ditto .........88 XXII. Ditto—death—post-mortem—numerous extravasations of blood, *. 90 XXIII. Ditto—excessive hemorrhage—death,......90 XXIV. Ditto—recovery,..........^ XXV. Typhus fever—delirium, coma, convulsions, and death—post-mortem, 100 XXVI. Continued fever, with enteric symptoms, measly and rose eruptions —recovery, . . . • •.....101 XXVII. Ditto—rose spots, without enteric symptoms—recovery, . . .102 IB XXVI LIST OF CASKS. CASE XXVIII. Ditto—severe enteric disease, with little diarrhoea—death- post-mortem. (Foot-note, 2 cases), XXIX. Typhoid fever—petechias—death,, . XXX. Typhus fever—delirium, stupor, death—post-mortem XXXI. Continued fever, with rubeoloid eruption and diarrhoea—delirium and tremors—death—post-mortem, XXXII. Typhoid fever-paralysis of bladder—delirium—death—post mortem—serous effusion into the ventricles of the brain, XXXIII. Ditto—recovery,........ XXXIV. Ditto—delirium and coma—cold douche—recovery, XXXV. Ditto—delirium ditto ditto .... XXXVI. Typhus (?) fever—critical purging—recovery,. XXXVII. Ditto ditto ditto XXXVIII. Typhoid fever—critical sweating—coma—death, . XXXIX. Typhus fever ditto recovery,.... XL. Erysipelas of the head and face—recovery, XLI. Phlegmonoid erysipelas of the leg in an exceedingly debilitated subject—secondary phenomena, . XLII. Erysipelas of the head and face—severe throat-affection—re covery, ......... XLIII. Ditto—very erratic—recovery,..... XLIV. Traumatic erysipelas—capillary bronchitis—death, . XLV. Erysipelatous oedema of the glottis—tracheotomy—recovery, XLVI. Ditto—death from exhaustion, ..... •XLVII. Ditto—tracheotomy—recovery, ..... XLVIII. Erysipelas of the head and face—over-stimulation—recovery XLIX. Ditto—death from exhaustion, L. Ditto—violent delirium—recovery, . LI. Ditto—recovery, .... LII. Ditto ditto .... LIII. Ditto djjtto .... LIV. Ditto ditto .... LV. Ditto—high delirium—sloughs—recovery, LVI. Ditto—recovery, ........ LVII. Erysipelas of the fauces, with paralysis and trismus—recovery LVIII. Ditto ditto—without trismus—death, LIX. Ditto ditto—recovery, ..... LX. Ditto ditto ditto..... LXI. Ditto ditto—death,..... LXII. Ditto—with some laryngitis and hematuria—recovery LXIII. Ditto—death—post-mortem, ..... LXIV. Severe rheumatic carditis and pneumonia, LXV. Pyaemia—Pleuro-pneumonia—secondary abscesses—recovery LXVI. Ditto—rapidly fatal, ••..... LXVII. Ditto ditto—puerperal, .... LXVIII. Ditto ditto—no obvious source of infection, LIST OF CASES. XXvii CASE PAGE LXIX. Ditto—from traumatic erysipelas—pus formations and purulent expectoration—death, ....... 190 LXX. Ditto—" puerperal acute rheumatism" abscesses in the joints— death,...........193 LXXI. Ditto—thirty-one pints of brandy—recovery, .... 194 LXXII. Ditto—tedious case—recovery,......196 LXXIII. Pleuro-pneumonia—recovery,.......201 LXXIV. Ditto ditto.........207 LXXV. Ditto ditto.........214 LXXVI. Double rheumatic pleuro-pneumonia and pericarditis—recovery, 218 LXXVII. Ditto—death—error in diagnosis,......222 LXXVIII. Pneumonia—recovery,........227 LXXIX. Ditto—delirium—recovery (Dr. Budd),.....229 LXXX. Typhoid fever with pneumonia.—recovery (Dr. G. Johnson), . 231 LXXXI. Pneumonia—analysis of the urine,......240 •LXXXIL Pleuro-pneumonia—analyses of the urine and of the sputa— death,...........264 LXXXIII. Ditto—recovery,.........272 LXXXIV. Poisoning by alcohol—death—post-mortem, .... 280 LXXXV. Typhus—treated with alcohol—recovery,.....294 LXXXVI. Typhoid ditto ditto.....295 LXXXVII. Pneumonia ditto........ .295 LXXXVIII. Bronchitis ditto........ .296 LXXXIX. Variola, complicated by violent delirium—recovery, . . 298 XC. Inflammation of the fauces, pneumonia—delirium—recovery, . 299 XCI. Violent delirium-tremens treated by alcohol and chloroform, • . 301 XCII. Epileptic delirium treated by alcohol,.....303 XCIII. Typhus—early coma—recovery under alcohol treatment,. . 304 9 CLINICAL LECTURES ON VARIOUS ACUTE DISEASES. LECTURE I. On Rheumatic Fever} Gentlemen,—The appropriate treatment of Rheumatic Fever is still, in some degree, a vexata quastio. I propose, therefore, in this and one or two other lectures, to call your attention more especially to this subject; and, by way of introduction, I shall make some remarks on the clinical history and pathology of this interesting form of acute disease. Case I. (Vol. xxiii, p. 184.) The case by reference to which I shall particularly illustrate my observations is that of Elizabeth Stocking, aged 23 years, admitted on the 19th of April, 1848, and still in the hospital,—a case in which the prominent cha- racteristics of the disease are very well marked, and which, there- fore, may be properly selected as a good example of the malady. Let me take this opportunity of recommending you to study with care, by taking full and daily notes of them, a few cases of this disease. It is a disease which, by and by, you will be fre- quently called upon to treat; we are seldom without several examples of the disease in the hospital; and, by taking careful notes of some eight or ten of these cases now, you will so impress upon your minds the history and symptoms of the disease, that 1 This lecture was delivered at King's College Hospital in 1848. 2 18 LECTURE I. you will be well prepared to treat them for yourselves, and each new case will be the more profitable to your practical knowledge. This is the more to be recommended, because rheumatic fever exhibits remarkably little variety of symptoms, or difference of phase. In one case the symptoms may be more severe than in another; but the same essentials which characterize the disease are present in all. Therefore, I say, study a few cases carefully, and you will get a good knowledge of this disease before you are called upon to treat it on' your own responsibility. The case of Elizabeth Stocking affords, as I have said, a good opportunity of studying the characteristic symptoms of rheumatic fever. The two most prominent features are: First, a special fever, of the continued kind, varying in intensity in the different cases, but always maintaining the same essential characters. This fever is the essence of the malady—the nucleus, as it wTere, around which all the other symptoms are grouped. Secondly, a peculiar affection of the joints, involving more or less swelling of them, and also-pain, which is aggravated by motion. The fever may exist without the affection of the joints, and it may be accompanied even by an internal inflammation, such as pleurisy, or pericarditis, or endocarditis, as I have witnessed in several examples. But the articular affection never exists without the fever. You will, therefore, not regard the fever as merely symptomatic of a peculiar morbid state of joints; it is, in truth, a fever sui generis, of which the articular affection and the other phenomena are but clinical features—attendant symptoms, which may or may not occupy a prominent position. But as the arti- cular affection is very commonly present, and must necessarily demand much of your attention, since it gives rise to much of the patient's suffering, I will assign the first place to the few remarks I have to offer respecting it. The articular affection almost always commences in the lower joints, and then travels up to the higher; thus it is first found in the ankles and knees, and then it goes to the elbows and wrists. The hip escapes more frequently than any large joint; the shoulder is much more commonly implicated than the hip. "When the hip is severely attacked the patient suffers much; the other joints have the affection comparatively mildly; and in several instances it has seemed to me as if the whole force of the rheumatic inflammation had spent itself upon one hip joint. ON RHEUMATIC FEVER. 19 The implication of the joints is almost always shown by what may be considered its peculiar characteristic—swelling. Almost invariably there is an increase of the synovial secretion, some- times to a very great extent, so as to prove a source of great annoyance to the patient. The synovial membranes in this con- dition are highly vascular; so much so, that I have sometimes seen them, in cases where I have had an opportunity of examin- ing them, as red as the conjunctiva when in a state of violent inflammation. Another characteristic of the disease is its tendency to shift its position. To-day it will be in the right knee, which will be swollen, hot, and tender; to-morrow all this will have disap- peared, and you will have the same symptoms in.the left. This erratic tendency—this disposition to wander from joint to joint— is a symptom which you should carefully keep in mind; where it exists in a very marked degree it must be considered a bad feature, indicative of a low form of the disease, and a low state of the vital powers; and it is to cases in which this symptom is prominent that depressing treatment is found to be particularly prejudicial, often aggravating the disease generally, and this feature of it in particular. This erratic tendency is present, not only in rheumatic fever, but likewise in the analogous disease of gout. It was this dis- position to shift from one place to another that led the old writers to regard the internal inflammations, which are apt to come on in the course of these diseases, as "metastatic"—an idea which, however it may have some degree of support in gout, is inadmis- sible in rheumatic fever. It by no means follows that an inflam- mation of an internal part should be a metastasis of an external inflammation, even should the latter diminish or cease on the appearance of the former. A strong objection to the doctrine of metastasis is founded on the fact that internal and external inflammations often manifest themselves simultaneously, and very frequently the internal inflammation comes first. More- over, it rarely happens that the external inflammation becomes diminished or exacerbated by the increase or diminution of the internal, and the converse. Another feature of this disease is the profuse sweating by which it is accompanied. This is a special phenomenon of the fever. It is not distinctly of a critical or sanitary nature, as we some- 20 LECTURE I. times see it in other fevers ; for the sweats do not produce any marked immediate good effect, either on the joints which are implicated in the disease, or on the general state of the patient. In Stocking's case the sweating was profuse: you doubtless re- collect how it poured forth from the patient's head and chest, and, indeed, from the surface of her body universally; and from that you may judge how much fluid must have escaped through the channel of the sudatory apparatus. I must say, however, that I do not regard these sweats as otherwise than salutary within certain limits; I think that, in the early days of the fever, they should be encouraged as an important medium for the elimination of noxious matter from the system, and that you ought to be cautious how you stop such sweats, except where they are distinctly debilitating to the patient. Large quantities of free acid are carried off by these swreats: you remember that, on several occasions, we applied litmus to the skin of this pa- tient, and that it always was deeply reddened. In contrast with this extraordinary action of the skin, we remark generally, as it was with our patient Stocking, a deficiency in the quantity of the urine, and an abnormal condition of it; that fluid being loaded with lithates and purpurates, and even oxalates, and sometimes, as in a patient now in the hospital, containing blood: the kidneys are in some degree irritated; less water passes off by them, but apparently a large amount of solid ingredients. Another symptom, which always accompanies this disease more or less, is a peculiar furred condition of the tongue. This is very characteristic, and will be readily recognized by an expe- rienced eye as distinctive of the rheumatic fever. A thick fur covers the tongue like a wet blanket, and it is not until fhe fever gives way that this fur begins to pass off. The state of the tongue is the best index to the true condition of the patient; so long as it continues furred, you cannot say that you have succeeded in thoroughly eradicating the rheumatic state; and I would warn you not to be confident in the result of your treatment, unless you see the tongue become quite clean. Even although the pain in the joints and other external signs may have been sub- dued, yet, if the tongue remain furred, I should greatly fear that the patient may suffer a relapse, or that he may linger on in the rheumatic state for a considerable time. Further, we had in our case an illustration of the way in which ON RHEUMATIC FEVER. 21 rheumatic inflammation affects the heart. On May the 25th, about the thirteenth day of jthe disease, a rubbing sound was heard over the base of that organ, leading to the conclusion that there had been an effusion of lymph on the opposed surfaces of the pericardium. This was evidently not metastatic—in other words, there was no direct transference of the inflammation from the external parts to the heart—because it coexisted with an undiminished, or but slightly diminished, inflammation of the joints. All these symptoms—namely > the articular swellings, the profuse sweats, the high-colored and loaded urine, the furred tongue, the tendency to heart affection—are present in all cases of rheumatic fever; nor can we regard a case as of this nature in which these symptoms do not exist. In too many the heart affection actually takes place; sometimes it ushers in the attack, and takes precedence of the articular affection; in all it is to be apprehended, and, if possible, guarded against. There are, however, two points in the case before us which are peculiar, or, at least, which do not occur constantly in cases of rheumatic fever. First, you will remember that, at several of our visits, I pointed out to you on the skin of this patient a copious eruption of what have been called sudamina or miliary vesicles: they were scattered all over the surface of the thorax, and if you passed your finger over the skin, you found it rough. These sudamina are seen, on close examination, to be minute vesicles, filled with pellucid fluid. They do not especially belong to rheumatic fever, but they are characteristic of a sweating state. If a patient, suffering under typhus fever, pneumonia, phthisis, &c, sweats profusely, these sudamina are apt to appear upon the skin in great numbers. The presence of the vesicles must not be regarded as indicative of any special form of dis- ease, but merely as an accompaniment of a state of very free perspiration. The second peculiarity in the case of this woman is, that the rheumatic fever followed quickly upon the puerperal state. The connection between rheumatic fever and deranged uterine secre- tions is very remarkable. Some of the most severe cases I have ever seen have followed dysmenorrhea. It would seem as if, in these cases, the uterus were but imperfectly evacuated, and its contents becoming decomposed, and getting into the circulation, produced a morbid state of the blood, which gives rise to the 00 LECTURE I. symptoms under which the patient labors, and requires for its cure the elimination of the unhealthy material by the various emunctories—a state similar and analogous to pyaemia. Not unfrequently, after the puerperal state, the patient exhibits all the symptoms of ordinary rheumatic fever: the same profuse sweats, the swollen joints, the fever, the lithic urine. But in some cases the disease runs a more formidable course; the joints, instead of getting better after a time, continue to get* worse, till at last the cartilages ulcerate, pus is secreted in large quantities, and fills the synovial membranes to distention ; the articular extremities of the bones are laid bare, and the rough osseous surfaces grate against each other wdien the limb is moved. I have seen all the large joints in this condition. At the same time deposits of pus form in tjie muscles, and in other parts, even in the eyes. Some of the French writers describe this dis- ease under the name of "puerperal acute rheumatism." It is, in fact, a form of puerperal fever, due to inflammation of some of the uterine veins; this gives rise to the formation of pus, wThich, infecting the blood, excites articular and other inflammations in its passage through the circulation. Such cases throw light on the pathology of rheumatic fever, and show how a morbid mat- ter, generated at one part of the circulation, and carried through- out it, may occasion serious disturbance in the local nutrition of the various parts through which it may be undergoing elimina- tion, and give rise to a train of symptoms, closely resembling, and not to be distinguished (save by the history) from those of rheumatic fever. In our patient Stocking there was some morbid state of the uterus prior to the development of the rheumatic condition. Im- mediately after her confinement she seems to have had symptoms of peritonitis, wdiich appeared to yield to treatment; but she had not long recovered from these symptoms when the rheumatic condition showed itself. I think it will be as well, before proceeding to the treatment, to adduce some other cases for the further illustration of the pre- ceding remarks as well as for after reference. Case II. (Vol. xxxvi, p. 227.) The second case is that of Sarah Green, a girl in her 16th year, who came under my care in the hospital in January, 1853. This case affords an example of the ON RHEUMATIC FEVER. 23 more severe form of cardiac complication, and is also instructive as regards the treatment. Five days before her admission, on the 8th of January, she was taken ill with pain and swelling of both knees; she was therefore placed under medical treatment, and, among other things, took gray-powder until slight ptyalism was produced. While in this condition, with her gums still sore, during the night immediately preceding her admission to the hospital, she suffered from uneasiness about the chest with some cough; there was also a considerable discharge of blood from her throat or nose, to which she-has been subject. On admission, she was suffering from pain in both knees, both shoulders, and ankles; her pulse numbered 110, and respirations 36 in a minute; a slight sound, like a bellows'-sound, accom- panied the systole, and was heard best over the base of the heart. A mustard poultice was applied to the chest, and followed by a blister. She commenced taking one grain of opium every three hours, and large sweating doses (six drachms) of the liquor ammonia? acetatis with camphor mixture. The next da}r, on examining her chest, I detected a loud, harsh, to and fro, pericardial rubbing sound; this was audible all over the region of the heart. On the 10th we have the fol- lowing note: " She complains of much pain in her elbows, knees, and ankles; pulse 106, full and strong; tongue very red where not coated with a whitish-yellow fur; she sweats profusely, sleeps little, and looks pale and anaemic. Her pupils are but slightly affected by the opium." The blister was then dressed with un- guentum sabinse. On the 11th, the pains in the joints, especially in the left knee and right elbow, were aggravated; the sweating had abated, and her skin was hot and dry; the tongue dry and red. The to and fro rubbing sound was very loud and harsh, and heard very distinctly in the course of the left subclavian artery and underneath the left clavicle,—as if the pleura over the pericardium were involved; the rubbing, however, was not synchronous with respiration. A blister was again applied to the chest, where the rubbing sound was heard. I would just remark, with reference to this case, that you find here all the phenomena of rheumatic fever; and, in addition, the remarkable fact that a severe internal inflammation, involving the pericardium, and likewise, probably, the endocardium and 24 LECTURE I. the pleura, supervened whilst the patient was in a state of saliva- tion from the early administration of mercury. On the 12th we found our patient suffering rather less pain; she had also been refreshed with some sound sleep. From that day until the 24th she continued steadily improving: the pain in her joints diminished, and then ceased altogether; the pulse and respirations became less frequent, and the sweating dimi- nished. The pericardial friction sound continued to retain its to and fro character, but shifted towards the apex of the heart, becoming less extensively heard and softening down. A pleu- ritic friction sound was heard for one day only, the 15th, over about the sixth rib on the left side. On the 24th she experienced a return of pain in the left side of the chest, and also in the left shoulder. On the 26th we found her not nearly so well; her tongue was dry and furred; the pulse was feeble, and had risen to 140; she was restless and could not sleep. On examining her chest, we found extensive dulness on percussion in the pericardial region; the heart-sounds were dis- tant and indistinct; the to and fro sound had ceased, and in its place we heard a distant' systolic murmur; a pleuritic rubbing sound was detected also over the lower part of the right lung in front. These changes in the physical signs seemed to point, clearly enough, to a considerable effusion of fluid into the peri- cardium. The quantity of opium taken, which had been reduced on the 18th to half a grain three times a day, was again increased to a grain; a blister was also applied over her heart. With the exception of the extension of the pleuritic rubbing over nearly the whole of the right lung in front, some oppression of breathing, and a change in the joints affected, there was no marked alteration in the condition of our patient or in the phy- sical signs until the 29th : all oppression of breathing then ceased; there was no longer extensive dulness on percussion over the heart; the former to and fro rubbing sound returned, loud and harsh, and was heard pretty extensively over all the front of the chest, but most marked towards the base of the heart and under the clavicles; the pleuritic rubbing was still heard on the right side. From these changes the reabsorption of the effused fluid was at once inferred. By the 3d of February the general condition of our patient had much improved: both the pleuritic and pericardial friction ON RHEUMATIC FEVER. 25 sounds had disappeared, and the systolic bellows sound, which had been masked by the to and fro rubbing, was again distinctly heard. On the 5th there was distinct evidence of a circumscribed patch of pleuritic inflammation on the left side. From this time, however, a rapid and steady improvement took place, and by the 10th the pulse had fallen to 70, and improved in tone and quality; all pain and abnormal sounds had ceased, excepting a mitral systolic murmur, which continued audible at the apex of the heart, and there was now some return of color in her lips and cheeks. This was after about five weeks' residence in the hos- pital. The opium was now discontinued, and a tonic plan of treat- ment commenced, the patient taking a grain of quinine three times in the day, which was subsequently changed for three grains of the ammonio-citrate of iron. A rapid convalescence, after so severe an illness, was hardly to be expected ; our patient accordingly remained in the hospital for some weeks, and, although on the whole improving, had occasional accessions of pain and swelling in some of her joints. I will now give the history of three other cases which I have selected as average examples of the course and duration of this disease under the plan of treatment which I now pursue; and with these I must bring this lecture to a conclusion. Case III.1 (Vol. xlv, p. 103.) Matthew Baldwin, aged 29 years, a laborer, accustomed to liberal potations of beer. His father, he says, suffered much from rheumatic gout, but his own health has been generally good. For about four weeks previous to his admission on September 21st, 1854, he had been generally ailing, with feverishness, head- ache, disordered bowels, and loss of appetite. In the course of the last of those weeks there had been an accession of rheumatic pains in the ankle, knee, and hip of the left side, then of the right, with increasing severity. Finally, the day before admis- sion, he was seized with pain in the right shoulder and prsecor- dial region, with a sense of tightness and difficulty of breathing. The first night after his admission, he slept little and perspired profusely. When examined, the following day, he appeared pale 1 The record of this case was kept by my clinical clerk, Mr. Goodall. 26 LECTURE I. and ill, and distressed by shortness of breath; his tongue was furred, his skin warm and moist; the right wrist was the only painful joint. The urine, which was highly acid, and of specific gravity 1035, contained much lithate of ammonia. The pulse numbered 100, and the respirations 40. A distinct rubbing sound was heard all over the region of the heart. As his bowels were confined, he was ordered some of the hos- pital white mixture, consisting of the sulphate and carbonate of magnesia, and this was followed by frequent doses of the usual alkaline mixture, containing fifteen grains of the bicarbonate and five of the nitrate of potass in each dose. A blister was also applied over the heart. His breathing appeared almost immediately relieved after the application of the blister. On the third night he slept well; and on the following day, September 23d, he had almost lost the pain in his chest; the respirations were much easier, and had fallen to 27 in a minute, his pulse to 98. On the 25th there was an increase in the number of joints affected, the right knee, ankle, and wrist, being very painful; small blisters were therefore applied to them, and the blister to the chest was repeated. He was then sweating freely; his tongue was cleaner, bowels open, and appetite improved; the urine wag clear, and had fallen in specific gravity to 1028 ; the pericardial friction sound still continued. The following day (26th) he was or- dered two drachms of brandy every two hours, or six ounces daily. There was no important alteration for some days. On the 2d of October the decoctum cinchonae was substituted for water in the alkaline mixture, and he was ordered five grains of the pil. saponis comp., with three of calomel, in pill every night. On the 3d, the blister to the chest was repeated. On the 4th, his back was observed to be covered with sudamina. On the 7th, being the seventeenth day from his admission, the following note was taken: " He is now improving daily. Pulse 84, respi- rations 26; sleeps well, and does not sweat; the pain is confined to some of the muscles; a slight friction sound alone remains audible at the apex of the heart; tongue clean, appetite good, bowels open; he still continues the brandy."' After this he remained some weeks in the hospital, gaining strength, and improving much in health; there was a return of slight pain in the joints, especially the shoulders, for which ON RHEUMATIC FEVER. 27 iodine paint was applied. A tonic mixture of quinine and acid was substituted for the alkaline one. Case IV.1 (Vol. xxix, p. 188.) Johannah White, a servant girl, 16 years of age, came under my care in the hospital on the 24th of January, 1850; for some months before her admission she had not had her usual good health. On the night of the 22d she awoke with severe pain in her back; this was soon fol- lowed by pain in her knees and shoulders, gradually increasing in severity! On the 25th, the day after her admission, she was suffering from great pain in the right shoulder, with pain and effusion into both knee-joints; her skin was hot and sweating, the per- spiration acid in reaction and smell; she had no appetite, was thirsty and sleepless; the tongue was thickly coated with a blankety white fur; pulse 120, respirations 36; urine very acid, and loaded with lithates. She at once commenced taking the ordinary mixture of the bicarbonate and nitrate of potass, with five minims of the tincture of opium every four hours. A blister was also applied above the left knee. The next day, January 26th, the joints were much the same, and, in addition, the right wrist had become extremely painful, and much swollen; she had slept badly; her pulse still num- bered 120, and respirations 36; urine the same. On the 27th, the third day of the treatment, her pulse had fallen to 84, and the respirations to 30; she had slept well, her appetite had returned, and she was free from pain. The follow- ing day she had slight pain in the right shoulder, but continued otherwise improving. On the 31st of January, the tenth day of the attack, she was quite free from pain; her tongue was clean; pulse 72; respira- • tions 20. There was no relapse, and she was soon after dis- charged well. Case V. (Vol. liv, p. 140.) Deborah Monssey, a servant girl, 14 years ,}f age; accustomed to much out-of-door work and ex- posure. About six days before her admission she was seized with rheum^ic pains in her ankles; the knees were next af- fected ; and, the following day, all the joints of her limbs. 1 This case was recorded by my clinical clefk, Mr. Monckton. 28 LECTURE I. On admission, January 31st, 1857, her face was flushed; skin hot, but not perspiring much; features constrained; tongue covered with a thin white fur; bowels confined ; pulse 126, and respirations 36. The joints most affected were the shoulders and knees. The urine deposited a dense brick-colored sediment. She complained of uneasiness, or slight pain in the precordial region; on listening, we detected a distinct pericardial rubbing sound. Soon after, a soft systolic bellows sound, heard most distinctly over the base of the heart, was also observed. She was ordered to take two-drachm doses of the liq. ammon. acet. with three minims of tincture of opium every four hours. Six leeches were applied over the region of the heart, an alkaline wrash to the lower limbs, and a blister above the most painful joints. On the third day of the treatment, February 2d, the rubbing sound had almost ceased, the systolic bruit remaining distinct; she had sweated more freely during the night, and the limbs, on the whole, were easier. Her medicine was now changed for the mixture of the bicarbonate and nitrate of potass, and fifteen minims of the liquor morphiae muriatis were ordered to be taken at night. On the fifth day, February 4th, the pain was almost confined to her wrists and hands; the tongue was cleaning in ., the centre; her countenance was natural; pulse 124; respira- tions 36. She continued in the hospital for about a fortnight after this, improving, but suffering more or less from pains in the different joints, shifting about, and varying in intensity; she was also much troubled with nausea and vomiting. Her pulse steadily declined to 65; her tongue became quite clean ; the urine clear • and bright; and the bellows sound softened down. Before I enter upon the description of the treatment of the disease, let me come to some understanding with you as to its nature ; for we cannot adopt a particular plan of treatment without having some theory of the nature of the disease. Now, what is the most reasonable view of the pathology of this dis- ease ? I have not time to enter into the discussion of this ques- tion with you as fully as I could wish; and I must, therefore, be content with simply recounting to you the articles of my own creed upon this subjeet. ON RHEUMATIC FEVER. 29 Rheumatic fever, then, I would say, is a state of high febrile excitement, induced by the accumulation of a peculiar morbid product, or materies morbi, in the circulation; and the other symptoms which accompany it are merely caused by certain local derangements and disturbances produced at those points whence its elimination from the system is taking place. This materies morbi is the result of a vitiated state either of primary or secondary assimilation, or of both, and the parts where it accumulates are just those which, wrhile they are very vascular, and therefore contain a large quantity of the diseased material, present the least obstruction to its escape from the circulation. These are the delicate synovial membranes of the joints, and the almost identical structures, the serous membranes—the pericar- dium, endocardium, and pleura, the air-cells of the lung itself, and even the peritoneum—parts where the bloodvessels are naked, or covered by but a film of membrane. These mem- branes, being largely supplied with rheumatic blood, pour forth into their cavities an enormous amount of their ordinary secre- tion, contaminated with the diseased material. Thus the syno- vial membranes become distended with a morbid synovia, which, instead of being alkaline, as it is in health, has a reaction de- cidedly acid. Thus, likewise, the skin is covered with profuse sweats, which are due to the irritation established in the sweat- glands by the morbid product; and the abundant fluid thus got rid of has, like the synovia, a marked acid reaction. The func- tions of the kidneys are, doubtless, similarly affected, and you get an abundance of lithic acid in the urine. But this morbid matter may escape likewise through the serous membranes, as it does at the synovial, at the lungs, or at the heart; and hence, at any of these places it may excite inflammation, and at all of • them is disposed to do so; and it is evident that the more its elimination is encouraged and favored at the skin, at the kid- neys, at the joints, and at the mucous membrane of the aliment tary canal, the less likely are the other important parts to suffer— the less chance have you of pleurisy, pneumonia, pericarditis, &c. I have thus given you an outline of, and illustrated the prin- cipal features, both essential and accidental, of rheumatic fever, and we have come to an understanding as to the pathology of the disease. I must defer to another lecture some account of the treatment which appears to me the most appropriate. 30 LECTURE II. LECTURE II. On Rheumatic Fever. Having, in my last lecture, described and illustrated the promi- nent points in the clinical history of rheumatic fever, I must now proceed to that upon which I wish to dwell particularly, and which, indeed, is the main object of these lectures, namely, the treatment of that disease. Upon this subject there still exists a good deal of difference among practitioners; and as I have my- self, after much inquiry, come to some decided conclusions as to the line of practice which should be pursued in these cases, and as they are confirmed to me by daily experience, I am anxious to bring the whole subject before you, and explain fully to you the principles which regulate my practice in the treatment of this formidable malady. It is important that we should determine what are the parti- cular objects to be kept in view in the treatment of diseases of an acute kind. They are these:— 1st. To relieve pain. 2d. To strike at the root of the malady. 3d. To cure our patient with as little trial to his constitution 4 as possible, so that afterwards he may not be in a worse condi- tion than he was before. We often hear in society such expres- sions as these: " I was always very well till Dr. So-and-so treated me for rheumatic fever, and he purged and bled me to such a degree, and treated me so violently, that my constitution could not stand it, and I have never been the man I was before." ]STow let us endeavor to conquer this frightful malady, and let it be our boast that, when we have done so, we leave our patient a constitution unimpaired, at least by our remedies. In some cases it is not possible to accomplish this; the lungs may be- come affected, or the pleura, or the pericardium, or the endocar- ON RHEUMATIC FEVER. 31 dium, and so much organic mischief may be done in a short time as to leave important organs permanently damaged; still, notwithstanding these lesions, the general nutritive powers need not be materially injured. 4th. A good plan of treatment should aim at securing for the patient a short convalescence. I do not speak of a speedy cure, because that is, to a certain extent, implied in a short convales- cence. At the same time, I must caution you against the so- called rapid cures said to be effected by the heroic treatment of rheumatic fever. If these cures are rapid, they leave a tedious and painful convalescence; indeed, it may be more properly said in such cases, that the treatment converts an acute into a chronic disease, rather than that it cures the former. Such a cure, if cure it can be called, is not what you should aim at obtaining for your patients; nor is that a bona fide cure of rheumatic fever unless the febrile and constitutional symptoms are subdued, the secretions re-established in their normal quality and quantity, the tongue rendered clean, and the joints relieved of their swelling and pain: if such a cure as this can be effected in a short; time, not entailing a tedious convalescence, your patients will have good reason to be satisfied. Now I must tell you that I do not believe that a bona fide cure and a short convalescence are, in the generality of cases, really obtainable by the heroic modes of treatment; and I would add my conviction that it is not desirable to shorten very much the period of cure in this disease, as it is not likely that a sufficient elimination of morbid matters can be effected in a very short time. These, so-called rapid cures, are also apt to leave the patient very subject to relapse, which you should'endeavor to guard against as much as against a tedious convalescence. The most instructive way, as it seems to me, in which we can discuss the treatment of this disease, will be to enumerate the various methods which have been proposed for this purpose, and to point out the reasons for rejecting some and for adopting others. As many as seven different plans may be specified, of which I shall place last that which I am in the habit of following here, and which I call the treatment by elimination. The first plan is that by venesection. It was formerly the prevailing opinion, and it is still, unfortunately, thought by some that, when called to a case of rheumatic fever, one had only 32 LECTURE II. to open a vein, and if he could succeed in taking away a suf- ficient quantity of blood, which, in many instances, it was laid down should be little short of one or two pints, that, by this large and rapid abstraction of blood, the disease may be cut short, and a malady, which ordinarily lasts some weeks, may be converted into one of a few days' duration. Frequently, not content with one large bleeding, those, who hold these views, will bleed a second, a third, or a fourth time, at short intervals, and in large quantities. The chief advocate of this practice at the present day is Bouil- laud, of Paris. Now, if you look through the record of cases, as given in.his book, you wTill see that his patients, although some of the more urgent symptoms are apparently very quickly overcome, yet linger on in the hospital for a considerable period, suffering much from chronic rheumatism, and exhibiting an extreme anaemia, from which they but slowly, if ever, recover. This plan of treatment has been advocated by some English phy- sicians, and among others by the celebrated Sydenham, who, however, in the latter part of his career, abandoned, or greatly moderated it; and, I am happy to say, the number of its sup- porters at present is very small. It is a practice from the adoption of which I would most earnestly dissuade you, as having the support neither of reason nor of experience, and as being fraught with the most dangerous consequences to your patients. I could tell you of several cases in which a fatal result has been clearly produced by the adoption of this method of treat- ment, which, most probably, would have recovered completely had they been left alone, or treated by a milder method. One case in particular made a deep impression upon me. The sub- ject of the case was a young and strong man, of great promise in his profession; he was seized with rheumatic fever, and one of the knee-joints was severely affected. On a previous occasion a similar attack seemed to yield readily to a very large bleeding, and the patient recovered. His medical attendant, naturally enough, determined on the second attack to adopt the same treatment which had seemed so successful before, and accord- ingly bled him very largely, and applied leeches to the inflamed joint. The result was violent delirium, and death by exhaustion in the course of about eight-and-forty hours. The following case, treated some years ago in the hospital, will ' ON RHEUMATIC FEVER. 33 serve to show what venesection, and the loss of blood by other means, can do, as well as wThat it cannot do:— Case VI. (Vol. i, p. 260.) Charles Davis, a porter, 28 years of age, was admitted into King's College Hospital on the 12th of October, 1840. He stated that, about a week previously, after exposure to cold, he was seized with lumbago; that the pain afterwards left his back, and attacked his arms and legs. On the day of admission (the 12th), the left knee and ankle and the right wrist were painful, and somewhat swollen; his pulse numbered 90. Fourteen ounces of blood were immediately taken from the arm, and a purgative draught administered; the blood drawn was buffed and much cupped, and the clot large. That night he sweated freely, but the severe pain prevented sleep. The following day (13th) the pulse was rather less fre- quent, 80, and a white fur on the tongue, so usual in acute rheu- matism, was noticed. He was ordered to take a quarter of a grain of the muriate of morphia twice in the day. On the third day he was suffering severe pain in the left hip, and along the back of the thigh ; the sweating had continued; his pulse had risen to 100, was thumping, full, and compressible. The mor- phia was discontinued; he was ordered two grains of the sulphate of quina three times a day, and was cupped near the painful hip to twelve ounces. The pain diminished after the cupping. When he had been eight days in the hospital he was nearly free from pain in the joints, but complained of a pain in the prae- cordial region, where an indistinct bellows sound, following on the systole, was detected. He was cupped over the heart to six ounces. On the 12th day he complained of a sense of weight in his chest, for which a blister was applied, apparently with benefit. But the next day there was a pericardial rubbing sound heard in addition to the bellows sound; the pulse had risen to 96, and there was a return of pain in several joints, and a red blush over the left ankle. He was again bled from the arm to eight ounces; the quina was discontinued, and a pill, containing one grain of calomel and a fourth of a grain of opium, was ordered to be taken three times a day. For five or six days afterwards he con- tinued suffering chiefly from wandering pains; the rubbing sound was persistent; the pulse about 96, full, and slightly thrill- ino- He had taken two colchicum draughts with morphia, m °* 3 34 LECTURE II. addition to the medicines above prescribed; but these were all discontinued on the eighteenth day of admission and the quina resumed. The last report of him was made when he had been ill about five weeks, and in the hospital about a month. He was then complaining of slight pain in the chest, and had a throbbing pulse numbering 80, but was otherwise improving. This patient remained another fortnight in the hospital, and was then discharged; but had hardly been away a fortnight when he had a slight fit of shivering, soon followed by pain and stiff- ness of several joints, and considerable swelling of the feet and knees. He waited a fortnight and was then admitted, for the second time, to the hospital, December 23d, 1840, with all the symptoms of rheumatic fever. He was immediately bled from the arm to sixteen ounces, ordered to take a purgative draught at once, and an ounce and a half of guaiacum mixture three times a day. Besides suffering pain in almost all his joints, he complained, for many days, of a constant painful sense of weight and tightness in his chest, for which he was cupped to twelve ounces on the third day of admission. At first the heart sounds were normal, but, on the fourth day, a slight systolic bruit was heard, and there was occasional hiccough. He continued taking the guaiacum mixture for a week without any decided benefit; at the end of that time the left shoulder and wrist were still painful, and the pain in the chest continued. A grain dose of the acetous extract of colchicum every six hours was then sub- stituted for the guaiacum. On the fourteenth day from his second admission, a blister was applied to the chest, as the pain there continued; and on the twenty-first day there was some increased articular affection; the left wrist especially was swollen and red. Six leeches were applied to the wrist, ten grains of Dover's powder were ordered to be taken at night, and the col- chicum to be omitted. On the following, or twenty-second day, there was great pre- cordial pain, preventing him from lying down, with hurried respiration, and a slight pericardial friction sound. He was cup- ped, over the heart, to seven ounces, and a pill, containing three grains of calomel and half a grain of opium, was ordered to be taken every three hours. After the cupping he was in less pain, OF RHEUMATIC FEVER. 35 and able to breathe more comfortably for two days, but his pulse continued up to 100, and the rubbing remained. On the twenty-fifth day, there was a fresh accession of pain in the chest, with dyspnoea; he was therefore bled again to sixteen ounces; the blood was much buffed and cupped; the pain was less after the bleeding. The next day the $ulse was 100, and the respirations 48, with considerable dyspnoea on any exertion; a distinct pericardial rubbing sound was heard near the sternum, "between the third and fourth ribs, and over the anterior surface of the heart; a bellows sound was also distinctly audible at the apex. He was again bled to twelve ounces; the blood was not buffed. During the two or three following days our patient continued suffering much pain in his chest, as well as in some of the joints; the rubbing and bellows sounds continued; there was consider- able sweating, and sudamina made their appearance on the neck and chest. As we might have expected, he was now very pale and feeble, with a quick pulse, sleeping badly, and suffering from palpitation on any exertion. After slight ptyalism, the calomel was discontinued, and some Dover's powder given alone ; three ounces of wine were also added to his diet, but soon changed for a pint of porter. He continued very slowly improving for nearly three weeks, but at the end of that time, seven weeks from his admission, he. had more pain again in his chest, with catching breathing, and a quick, throbbing pulse; a return of pain soon followed in the joints. A blister was applied to the chest, and ten leeches to the left knee and ankle. The pain then shifted to other joints; the right pleura became affected—there was pain in that side increased by deep inspiration, and a rough rubbing could be dis- tinctly felt and heard; pain continued over the heart, and there was hiccough. When the pleuritic symptoms appeared, leeches were applied to the right side, and also to one hand; the next day he was cupped to seven ounces, and a sixth of a grain of the muriate of morphia was ordered every six hours. He remained more than five weeks longer in the hospital, im- proving very slowly: he continued to have pain with a sense of dragging in the right side, the creaking sound also remaining audible. The morphia was soon discontinued, and the quina resumed; occasional blisters were applied to the right side. He LECTURE II. was at length discharged better, but not free from pain, on the 30th of March, having then been ill sixteen weeks, and an inmate of the hospital, the second time, for nearly fourteen. The case, however, does not end here; he was discharged only to be readmitted twro months afterwards, having then been suf- feriner for a month."from a fresh attack of rheumatism. He was admitted on the 26th of May; the left elbow was then painful, and both ankles painful and swollen, with effusion into the sheaths of the neighboring tendons. When he had been in the' hospital a day or two, he had an attack of acute pain in the lower part of the chest, on the right side, with dulness on percussion. Ten leeches were applied, and he lost the pain, but continued to complain of a feeling of oppression, for which a blister was. tried. He again got better, and left the hospital, but the date of his discharge is not recorded. During the two former periods of his residence in the hospital he had been bled altogether five times, and cupped five, so that one hundred and ten ounces of blood had been taken,, besides what was lost by leeches ! I shall con- tent myself with remarking upon this case, simply, that it seems to me one well calculated to show that bleeding, mercury, and colchicum are not all-powerful for good in the treatment of rheumatic fever. This subject is so important, that I shall offer no apology for bringing before you a second case treated on a similar plan. Case VII. (Vol. i, p. 228.) Elizabeth Freethy, a servant, 21 years of age, was admitted to the hospital September 9th, 1840, with rheumatic fever. She had then been ill three weeks, and attributed the commencement of the attack to having caught cold in a damp kitchen. She was first seized with violent pain in her back; her limbs soon became affected, and two days after- wards she had nearly lost the use of them, but she did not take to her bed until about three days before her admission. When admitted (9th) she was ordered to take a dose of the hospital white mixture, and ten grains of Dover's powder at night. On the following day (10th) the aperient mixture was repeated, and she was cupped in the loins, but the amount of blood taken was very small. On September 11th she was bled from the arm to the amount of eight ounces, and the Dover's powder was continued. On the OF RHEUMATIC FEVER. 37 12th, the bleeding was repeated, and twelve ounces more of blood were taken; she was then ordered two grains of the sulphate of quina three times a day. On the 19th, twelve ounces of blood were again taken from the arm, and on the following day the quina and Dover's powder were omitted, and*a small dose of the muriate of morphia substituted. On the 25th she complained of pain in the region of the heart, and a slight bellows sound was heard. There was some effusion into both knee-joints; the pulse numbered 122; the tongue con- tinued white and furred. Twelve leeches were applied to the chest over the heart. The next day she was perspiring profusely. On the 27th, when she had been ill rather more than five weeks, and under treatment in the hospital nearly three, the fol- lowing note was made: " She chiefly complains of her knees, which are very painful, and full of fluid, the left one especially, the skin of which is slightly red on the inner side, and very pain- ful, even when lightly touched; pulse 112; no sleep." Six leeches were applied to each knee. On the 28th there was no material change; a systolic bellows sound continued audible; her pulse numbered 120; she still perspired profusely, and had not slept. Ten-grain doses of bicarbonate of potass, three times a day, in soda-water, were then ordered. On the following day there was some general amendment, and less pain, and by the 1st of October all feverish symptoms had subsided; her appetite was returning, and she could sleep better. The knees and ankles, however, continued painful, and somewhat swollen. After this she made little progress; and on October 6th, when the last report was made before her discharge, the knees, though not swollen, were still painful, and her pulse continued as high as 98. She had then been ill very nearly seven weeks, and had been rather less than a month in the hospital. In this case, again, you have a striking example in which the disease was of long duration, despite of free and repeated bleeding. I think it but right to state, in justice to those who have adopted this practice, that patients so treated sometimes do very well; and the next case that I shall quote will furnish an ex- ample of this. At the same time I must caution you against allowing such a case to lead you to adopt a similar plan of treat- ment. That it might justly so influence you, it would be neces- 38 LECTURE II. sary to show that such favorable cases arc not only as common, but more common, under an antiphlogistic plan of treatment, than when less violent remedies are used; and not only so, but that, among unfavorable cases also, those are most disastrous in which the abstraction of blood has been abstained from. Judg- ing from no inconsiderable number of cases, treated on both plans, I am convinced tha't the opposite conditions obtain. I would go so far as to say that, even were we certain that vene- section would produce the desired effect on the leading symp- toms of the disease, we should yet hesitate ere we make use of a remedy which, in the general effect it may have, is often un- certain, and most perilous. In one case you may relieve your patient, in another you may send him to a premature grave ; or in the same individual, in a first attack, you may obtain complete relief by this method, and in a second attack you may place his life in jeopardy, or subject him to a tedious convalescence. Case VIII. (Vol. i, p. 210.) Francis Barrett, a carpenter, 26 years of age, was admitted an in-patient of King's College Hos- pital, wTith rheumatic fever, on September 11,1840. The attack began the day before with pain, redness, and swelling of the left foot and ankle, accompanied by feverish symptoms, great thirst, and heat of skin. The pain soon extended to the muscles of the calf. When admitted he was bled to twelve ounces and purged. He gradually became worse, and by the 12th all his joints were affected and the pain severe. On the 14th he was still suffering severe pain in every joint, and also complained of some uneasi- ness about the heart; his pulse was observed to be intermittent, and occasionally there was a sort of double systole of the ven- tricle. He was then cupped, and sixteen ounces of blood taken; a mixture was prescribed, consisting of sulphate of quina with one-eighth of a grain of muriate of morphia in each dose. At night he perspired freely, and on the morning of the 15th he was in less pain. During that day, however, and the two following, there was no great improvement: the redness and swelling of the w^rists remained; his tongue was coated with a white fur; there was profuse perspiration, and a high pulse of about 100. On the 18th he wras again bled from the arm to sixteen ounces, and the clot formed was much cupped and buffed. On the 19th, OF RHEUMATIC FEVER. "39 the joints of the right upper extremity were still acutely painful, but his pulse had fallen to 88. On the 20th there was decided improvement, and on the 21st he was much easier: the swelling had disappeared from the right wrist, he had slept better, was sweating less, and his tongue was cleaning; pulse 68. The quina was repeated without the morphia. He continued improving; and on the 24th, being the fifteenth day of tfye disease, he was free from pain, but weak; his pulse was 60, his appetite improving, and tongue clean. A chop and a pint of porter were now added to his diet, and we have no his- tory of a relapse. 2. The second plan of treatment is that by moderate bleeding and diaphoretics. This may be called an " expectant" treat- ment ; but it is more than that as regards the venesection; while in other respects it sufficiently merits the name. The advocate of such a plan will say—"When I am called in to a case of rheumatic fever, I think it advisable to commence the treatment by abstracting about ten or twelve ounces of blood, and then to give sudorifics and purgatives." Now, the objection which I entertain to such treatment is this: that the routine abstraction of blood can scarcely be called neces- sary in any case, and that in many it is injurious. The tendency of rheumatic fever is to impoverish the blood, especially as re- gards that highly important portion of it, its coloring matter. All that bleeding really effects is to relieve pain (which, however, may quickly return) for a few hours, while it undoubtedly aids the bleaching power of the rheumatic matter, and, as I have observed in several cases, it increases much the tendency to a chronic rheumatic state, and consequently prolongs the con- valescence. That bleeding in rheumatic fever is unnecessary, and that its omission diminishes rather than increases the ten- dency to certain internal inflammations, I am so convinced, that for several years I have not abstracted blood, in any way, in a single case of the disease. The treatment of rheumatic fever by the abstraction of blood, even in moderate quantity, but more especially in large quantity, appears to me to increase the danger of internal effusions into the pericardium and the pleura, and also into the synovial sacs of the joints (vide Case VII). Under this treatment we also meet with the most violent and trouble- 40 LECTURE II. some cases of delirium, which, under other methods, either does not occur, or is developed in a form sufficiently easily controlled. I am very much disposed to believe that this treatment predis- poses to pericarditis and endocarditis; and that, if these affec- tions occur in a case in which venesection has been freely prac- tised, they are much less tractable than when you have to deal with them in a patient who has not suffered from loss of blood. 3. A third plan is that by mercury. Some recommend that calomel and opium should be freely administered until salivation is produced. The great objection to this treatment is, that it is an attempt to cure one fever by setting up another, and, in some respects, a worse: even supposing the original disease succumbs, your patient comes out of his rheumatic fever with loose teeth, ulcerated gums, and all the painful and offensive concomitants of ptyalism. Now, I say, that, under such circumstances, the remedy is nearly as bad as the disease; and, moreover, it does not in the least guard the patient against what may be termed the accidents of his malady—those severe internal inflamma- tions—pericarditis, endocarditis, pneumonia, pleuritis, perito- nitis. I have more than once seen pericardial inflammation supervene while the patient was in a state of salivation, of which the Case (II) of Sarah Green, detailed in the first lecture, is a good example. When we consider how differently various per- sons are affected by a mercurial course, and how much some suffer from it, even if given in small quantity, it would seem highly inexpedient to adopt this plan of treatment, for it assu- redly offers no prospect of effecting either a speedy cure or a speedy convalescence, much less both together. It is worthy of remark that rheumatic patients sometimes exhibit a distinct tolerance of mercury, and are with difficulty salivated. The following case is an instance in point, affording, at the same time, but little encouragement to the supporters of the mercurial treatment, and yielding no evidence of the anti- rheumatic power of mercury. Case IX.1 (Vol. xv, p. 70.) John Smith, a lad, 15 years of age, after a day of unusual exertion, November 29th, 1845, went 1 Reported by my clinical clerk, Mr. Sturt. OF RHEUMATIC FEVER. 41 home and to bed very much fatigued, and awoke the following morning to find his knees and ankles painful, hot, and swollen. He rested all that day, and then returned to his work in much pain, with feverish symptoms, and general indisposition. On December 3d, the fourth day of the disease, he could not leave his bed, and the next day was sent to the hospital. When ad- mitted the same joints were still affected; pulse 100; respirations 38. The knees and ankles were wrapped in cotton wool, and he was ordered ten grains of Dover's powder in saline mixture three times a day, and a dose of the hospital white mixture. On the night of the 5th (sixth day), he perspired freely and rested well; but on the morning of the 6th (seventh day) he felt pain all over his chest, with difficulty of breathing, and an un- usual throbbing at his heart; his pulse had risen to 110. On the 8th_there was no improvement; the pain in his chest continued; his face wore a constrained appearance; he was breathing 36 times a minute, and his pulse was 104; some roughness of the first sound was heard towards the base of the heart; the urine gave a copious precipitate of lithates. He commenced taking a grain of calomel with each Dover's powder, the aperient mixture was repeated, and a blister applied over the heart. On the 9th, the tenth day of the disease, there was a general improvement, though the same symptoms remained. This con- tinued ten days, the articular affection subsiding, while our patient's general condition improved, and his pulse fell to the natural standard, so that on the 18th he was ordered two grains of the sulphate of quina three times a day. On the following day, the 19th, he was not so well, complaining of pain in his back and shoulders, palpitation, and difficulty in deeply respir- ing. A blister was applied to the chest, the quina discontinued, and the Dover's powder and calomel resumed, the dose of the calomel being increased from one to two grains. On the 20th he was better again; but a mitral systolic bellows sound was heard, and the blister was repeated, and afterwards dressed with a mixture of equal parts of mercurial and savin ointment. The improvement continued, and on the 26th he left off the calomel, after having taken it, with but one day's omission, for eighteen days without salivation. He then resumed the quina; and by the 7th of January was well enough to leave the hospital, after a residence there of about five weeks. 42 LECTURE II. He had not been away a week when he was again attacked with pain in his chest and palpitations, together with pain and swelling of the left knee; he was therefore readmitted on the 17th of January, and a blister applied to his chest. On the 18th, he commenced taking the alkaline mixture of the bicarbonate and nitrate of potass, which I now so constantly prescribe, with five grains of Dover's powder at night. On the 19th the blister was repeated, and three grains of calomel added to each Dover's powder; although better, he was still suffering from some arti- cular pains, from palpitation, and from symptoms of general disorder, with a rapid pulse of about 110. A rough systolic bel- lows sound was audible both at the base and apex of the heart on the 21st; and on the 24th a slight pericardial rubbing sound was also heard at the base. By the 27th he was free from pain and feverish symptoms, but his breathing remained quick, and the rubbing sound was still heard. The last note was taken between a fortnight and three weeks later, on the 14th of February. He had then been taking citrate of iron for some days, but was evidently much exhausted, as his pulse, which was 88 when reclining, rose to 108 on standing up. We have no record of the date of his discharge. 4. Another plan of treatment which has been proposed is by colchicum and by guaiacum. These drugs, but especially col- chicum, have long been considered to possess a specific influence over rheumatic and gouty affections; and it has been laid down that the rheumatic condition will be subdued in just such pro- portion as you get your patient under the influence of the col- chicum, somewhat in the same way as quinine exercises a spe- cific influence on ague. Now I think it requires only two or three cases to prove to a candid mind the fallacy of this doctrine. I myself have frequently given this remedy the fairest trials, but I could never discover any effect from it sufficient to entitle it to the character of a specific. That it is capable of exerting a re- markable influence, as well for evil as for good, on gout, I do not deny; but even this must be admitted with considerable limita- tion ; it is certainly far from exercising any similar or analogous influence in rheumatism, whether acute or chronic. The effect of guaiacum has also been supposed to be specific, and similar to that of colchicum; but it has even less claims than the latter. OF RHEUMATIC FEVER. 43 Both these medicines, when given in large doses, purge, and, in such doses, I have no doubt they may do some good, on the principle of eliminating the morbid material by the alimentary canal; but unless you give them in such quantity as to produce colliquative purging, you do but little towards cutting short the disease; and if you do give them in these large doses, you pro- duce a degree of prostration and debility which is sometimes more dangerous than the disease, and you leave your patient to linger through a tedious convalescence. Colchicum given- in small closes produces no good effect in rheumatic fever, according to my experience; on the contrary, I fear that in some cases it has a prejudicial influence on the nervous system, making it more irritable and susceptible of impressions, and rendering the patient more obnoxious to the various accidents that are liable to occur in the course of the disease. 5. Treatment by opium. This plan of treatment has been lately revived by a very able physician, Dr. Corrigan, of Dublin. It has much to recommend it, and, on the whole, you will find it extremely serviceable in practice ; but I do not recommend it alone: its great value consists in relieving suffering, and soothing the nervous system, while it promotes diaphoresis. The opium is given in large and frequently repeated doses, care being taken not to produce too much narcotism; but upon this point, in general, there is not much need for fear, as there seems to be in the generality of patients a remarkable tolerance of opium. Our patient, Elizabeth Stocking, whose case I have described in the last lecture, was ordered on the 23d a grain of opium, to be given every three hours, in addition to half a grain of the mu- riate of morphia, which she had previously been taking at night: in forty-eight hours she thus took sixteen grains of opium, ex- clusive of the morphia, yet her pupils were not at all contracted, nor was she in any degree narcotized. The effect upon her has been most beneficial: her nervous excitement has been calmed down, and her pain materially relieved. The same plan was pursued in the case of S. Green, also detailed in the last lecture: she had one grain of opium every three hours from January 8th to February 10th, excepting for one week, in which the dose was reduced to half a grain ; the same tolerance of the remedy was observed. It will not, however, do to employ this plan alone; 44 LECTURE II. it should be conjoined with other treatment. I do not recom- mend it by itself. I may here adduce another case in illustration of the benefit to be derived from opium, where there is much disturbance of the nervous system with restlessness and delirium. Case X.1 (Vol. xxxiii, p. 55.) George Binning, a tailor, 45 years of age, of intemperate habits, and with some history of rheumatism in his family, obtained admission to the hospital on February 12th, 1851, with severe pain and swelling of the knees, ankles, and wrists, and profuse sweats. He stated that these symptoms came on, with loss of appetite and confined bowels, ten days previously, after exposure to wet and cold. Blisters and cotton wool to the joints, nitrate of potass with liquor am- moniae citratis every four hours, and a dose of hospital white mixture, were prescribed. On the 13th, the day after admission, a slight systolic bruit was heard at the base of the heart; he was suffering rather less pain, but his tongue was coated, dry, and brown; the perspira- tion and urine were very acid; his thirst great, and appetite bad. Throughout the night he was delirious, and could get no sleep, and continued forgetful and talkative the next morning. The bellows sound was more marked on the 14th, and a blister was applied to the chest; the nitrate of potass was discontinued, and a grain of opium given every four hours. At night there was much less wandering, and towards the morning of the 15th he slept. During the day he was drowsy, and his pupils contracted, but there was much less pain, and general improvement. The opium was discontinued during the day, but repeated at night. The case afterwards followed an ordinary and favorable course. By the 5th of March he was able to sit up, and was discharged on the 8th. 6. A sixth plan of treatment, proposed long ago by Dr. Hay- garth, consists in giving bark in large doses, for which, more re- cently, the less bulky sulphate of quina has been substituted. Now just imagine the state in which the pathology of a disease must be, when measures so completely at the opposite extremes of our 1 This case was reported by Mr. E. Liddon. ON RHEUMATIC FEVER. 45 therapeutical resources are advocated for it—as venesection, to the amount of two or three pints, on the one hand, and large doses of quinine on the other; some would even give- as much as five or ten grains two or three times a day. Now I have tried both methods of treatment, and I approve of neither; but if I were tied down to one or other of them, I should not hesitate to choose that by bark. In cases where the sweating is colliquative, and the urine copious and pale, with abundant precipitates of pale lithates, I have seen great good done rapidly by the use of quinine; but I am not prepared to advise you to adopt this treat- ment from the beginning, because it tends to check secretion, and so may favor the development of internal inflammations. 7. The seventh and last mode of treatment that I shall men- tion to you is, that which you have seen me adopt frequently at this hospital, namely, the treatment by elimination. I give it this name, in order that you may keep well in view its main object— to promote the elimination of morbid matter by the various emunctories, and also that you may bear in mind the view of the pathology of the disease upon which it is founded. It is probable that the materies morbi in rheumatic fever is lactic acid, or some analogous agent. We know that the natural emunctory of this is the skin. Many chemists maintain that it will also escape by the kidneys; and if it ever does so, perhaps this is more likely during rheumatic fever than at any other time. Again, since vitiated digestion is apt to produce it in undue quantity, and it therefore is formed abundantly in the stomach, there is every reason to think a certain proportion of it may be carried off through the alimentary canal. The indi- cations are, then, to promote the action of the skin, the kid- neys, and the bowels; to use antacid remedies; and to give large quantities of fluid for the free dilution of the materies morbi, and to supply the waste caused by .the drainage from diaphoresis and diuresis. The best way to promote the action of the skin is by opium, especially if you combine with it nitre and ipecacuanha. For this purpose I sometimes use a compound which resembles the original Dover's powder, in containing nitrate of potass, instead of sulphate of potass, as prescribed in the compound ipecacuan powder of the Pharmacopoeia. Our usual prescription is one 46 LECTURE II. grain of opium, one grain of ipecacuanha, and five grains of nitre; this must be given every two, three, or four hours, ac- cording to the urgency of the symptoms, and the need the patient has for opium. This drug quiets the nervous system, and procures sleep, and with the ipecacuan promotes sweating; while the nitre acts upon the kidneys, and the ipecacuan may exercise some influence on the liver. The best alkali on the whole is the bicarbonate of potass, which maybe given in large and often-repeated doses—a scruple or half a drachm every third hour. Sometimes the acetate of potass answers very well in similar doses, and many physicians much .prefer it to any other alkaline salt. Next you must give purgatives to such an extent as to keep the bowTels in a loose state, taking care not to carry this treat- ment so far as to weaken your patient, or worry him by obliging him to be frequently moved in and out of bed. You will find it advantageous to use an alkaline purgative; and there cannot be a better medicine for this purpose than our hospital nostrum— the white mixture containing magnesia and sulphate of mag- nesia. Sometimes you may give the potassio-tartrate of anti- mony with advantage; but as it is a depressing remedy it is seldom advisable to use it. But while we are thus alkalizing our patient, and giving in- ternally sudorifics and diaphoretics, ought we not to attend to the state of the joints ? The diligent physician will tell you by all means to attack them at once: but there is such a thing as " nimium diligentiae" in physic as well as in other matters. Many will say, the best thing you can do is to leech a painful and swollen joint: I formerly tried this practice extensively, but for some time past I have not done so, as I generally found it either useless or injurious. You may apply leeches, and in a short- time after you will find the pain and^welling removed, and you may be disposed to say, " Here is a proof of their efficacy;" but wait twenty-four hours, and then you will gene- rally "find the pain and swelling as bad as ever, and the joint in just the same condition as before. Now apply leeches, and you will probably fail to give any relief. You have by the first application relieved the pain for a time, but you have produced no permanent good; you have rendered the disease more erratic, and less amenable to subsequent treatment. Frequently when ON RHEUMATIC FEVER. 47 you leech a joint, the pain and swelling subside, but its fellow becomes swollen ; leech it, and the swelling and pain return to the original joint. Nothing is more important to avoid, nor more troublesome if not prevented, than the erratic tendency of the rheumatic state. It will fly from joint to joint, and in pursu- ing it with leeches you only drive it out of one joint into another. I am satisfied that leeching the joints favors this erratic tendency. I am not prepared, however, to advise you to neglect the local treatment of the joints. When they are much swollen and pain- ful, you may give great ease to your patient by enveloping them in a large quantity of the soft carded cotton—commonly called cotton-wool. Over this you must wrap a sheet of oiled silk, so as to cover in the wool completely, taking care to have no part ot it exposed. By this air-tight covering you keep the joints in a complete vapor-bath; and when you come to remove the oiled silk and wool, after twelve or twenty-four hours, you find the wool completely saturated with moisture, which generally is strongly acid. You have seen this in Elizabeth Stocking's case. We find the plan so generally useful, that it is adopted in the hospital in nearly every case: it affords great relief, supports and keeps the limb steady, and at the same time promotes sweat- ing. I may just mention, that this plan of enveloping the joint in wool and oiled silk is also very beneficial in gout. In a few, and only a very few, cases, I have found the pain aggravated by the heat which this mode of wrapping generates; and in cases where it is desirable to keep down the sweating, it is not advantageous to carry this plan beyond a day or two. The best additional local treatment is that by blisters of small size, applied on or near the affected joints; they are very useful both in acute rheumatic and acute gouty joints. I shall refer to this subject again. (Vide infra.) You perceive that all the means employed in this mode of treatment tend to elimination, and to the relief of pain : the opiate sudorific affecting the skin; the nitre and alkaline salts acting on the kidneys; the purgatives on the mucous membrane of the bowels; the wool and blisters on the joints. During this treatment, while you allow your patients the liberal use of simple diluents, you must give a fair amount of nourish- ment from the first; and I think this may be best supplied by a small quantity of good beef tea, given frequently throughout the day. 48 LECTURE II. Often you will find it useful, and always when there is a ten- dency to delirium, to give stimulants, such as brandy or wine. A good example of the benefit from the timely use of stimulants is afforded by the following case :— Case XL1 (Vol. xxix, p. 236.) John Wilks, aet. 24, was ad- mitted February 9th, 1850. He had been attacked, about a fort- night before, with pain in his left great toe, soon followed by swelling; at the same time he began to suffer from languor, loss of appetite and thirst; he sweated much at night, and noticed that his urine was high-colored, and deposited a deep red sedi-# ment. Pain and swelling soon followed in most of the larger joints. When admitted, he was sweating profusely, and the perspira- tion had the peculiar odor and acid reaction so constant in acute rheumatism; the right ankle, the knees and wrists were painful and swollen, the least motion of the last causing excruciating pain; his pulse was 100; his tongue coated with a white fur. Fifteen grains of the bicarbonate with ten of the nitrate of potass, and five minims of tincture of opium, were given every four hours; and two blisters were applied to the wrists. A decided diminution of pain in the wrists followed the application of the blisters; at the same time the pulse became more frequent, and continued above 110; in other respects the symptoms remained the same on the 10th and 11th. On the night of the 11th he became delirious, and the delirium recurred the following night; he was therefore ordered half an ounce of brandy every two hours. There was no return of delirium. By the 15th, there was general improvement; on the 13th and 14th he had suffered from diarrhoea, but this had ceased; he was free from pain; his tongue moist and cleaning; he slept well, and his pulse had fallen to 84 and improved in tone. He continued to make favorable progress until the 5th of March, on which day he had a slight relapse, but soon recovered, and was discharged cured on the 16th. I have many more remarks to make on other points in the treatment of rheumatic fever; but must content myself now with having given you an outline of the eliminatory mode of treat- ment, and reserve my further observations for another lecture! 1 Reported by Mr. Dickinson. ON RHEUMATIC FEVER. 49 LECTURE III. On Rheumatic Fever. - In my last lecture, gentlemen, after having passed in review six different methods of treating rheumatic fever, I particularly recommended to your attention one which we have been in the ha*bit of using here, the object of which is to promote as much as possible the elimination of morbid matters from the system through the natural emunctories—through the skin, through the kidneys, through the bowels. I advised you to use opium freely, potass and nitre, to give alkaline purgatives, and to relieve the pain and swelling of the joints by enveloping them in cotton wool, surrounded by oiled silk. And all this I ventured to re- commend to you in preference either to the plan of treatment by venesection, or that by colchicum or guaiacum, or that by calomel. Now, it may sometimes happen that you will have to deal with a patient who is unable to take opium. What are you to do under these circumstances ? There is no reason why you should change the general plan of treatment—you may still give sudo- rifics—and if your patient will bear sedatives, you can give hyos- cyamus, or hop, or extract of lettuce. But it will, I believe, very seldom happen that, in this severe and painful malady, patients will be unable to bear opium in some shape or other; and the benefits to be derived from the proper use of this drug are so great that you ought to try it in various ways, and in different preparations, before you abandon it altogether. I think that practitioners often fail in obtaining all the good effects of opium from being too timid in the use of it, giving it in too small a dose, and employing it in a vacillating manner; you must give it in. a large dose, not less than a grain, frequently repeated, taking the state of the pupils as your guide to encourage in or deter from proceeding with it. You will of course proceed with 4 50 LECTURE III. great caution if you find a very contracted pupil in addition to some degree of narcotism. Before you abandon the use of opium, remember that you have a great variety of forms in which to prescribe it; you have,-among others, the compound camphor tincture, which is often borne when the other preparations fail; the acetate and muriate of morphia; Mr. Battley's liquor opii sedativus; and a preparation introduced by Mr. Squire, the solu- tion of the bimeconate of morphia, which may be given in the same doses as laudanum; and codeine, as prepared by Pelletier in Paris. Again, it may happen, and this is by no means of unfrequeoj occurrence, that the swollen and painful state of the joints does not yield to the cotton wool and oiled silk only, or that the heat, which that application generates, cannot be tolerated by the patient. What further treatment of the joints will you pursue ? I have no hesitation in advising you to apply blisters; and I would recommend you to use every means in your power to get them to rise well. I do not think it advisable to apply large blisters; on the contrary, they are injurious, and their use is to be deprecated. The plan I generally follow is this: I order a small mustard cataplasm to be applied to the affected joint, and to be kept on for half an hour to redden the skin ; after its re- moval the skin is to be carefully washed and dried, and the blister may then be applied; you must not let the size of this exceed that of a crown piece. It is better to apply two or three small blisters in rapid succession, and to different parts of the joint, than one large blister. After the blister has risen well, if the swelling of the joint subsides quickly, as it very frequently does, you may let the blister heal as fast as it will; but if the swelling has not subsided, then you had better cut away the cuticle com- pletely, and promote a free discharge from the blistered surface by dressing it with stimulating ointments. Some prefer to apply the blister above rather than over the joint. You need not be afraid to apply blisters in the early stages of the rheumatic inflammation of the joints. I believe the dread which some physicians had, and have, of applying blisters near inflamed parts—as near an inflamed lung, or pleura, or pericar-' dium—is due to their having used blisters of too great a size. I have applied them very early to rheumatic joints in numerous cases, and always with more or less advantage, provided the ON RHEUMATIC FEVER. 51 blisters have not been too large. A very large blister is very apt to do mischief, and augment the inflammation of the joint; but a small one, varying in size from that of a crown to a half-crown, is almost invariably beneficial. When a very copious effusion has taken place into a joint, the plan of applying two or three small blisters in succession, at different parts of the joint, pro- vided the first should fail in getting rid of the effusion, is pro- ductive of the best effects. I have seen excellent results from the application of blisters to gouty joints, even in the most acute stage. A discharge of a ferge quantity of serum from the vessels of a gouty joint has all the good effects of the abstraction of blood from it, without any of the evil consequences of that mode of treatment. You must exercise a proper caution not to carry the sweating or the purging process too far with your patients. It is impos- sible to lay down precise general rules on this subject: the state of the patient's pulse, his countenance, the mode in which he expresses his feelings, will sufficiently indicate the condition of his general powers to enable you to judge whether you are going too far or not. On this point of the treatment I would advise you to take as your motto—ne quid nimis; neither too much sweating, nor too much purging, nor too much opium. I shall not caution you against too much bleeding, but I deliberately, and without hesitation, advise you to omit that from your prac- tice altogether in the treatment of this malady; and I do this from a large experience and observation of its little efficacy for good, and its great liability to do serious mischief. All the world now knows how important it is in acute rheu- matic cases—and, I would add, even in chronic also—to pay close attention to the heart. You should watch it from day to day, and from the very commencement of the attack; and if you find the smallest indication of a departure from its normal mode of action, attack it specially and at once. I say you should watch the heart from the very first moment the patient comes under your charge; for the cardiac symptoms are apt to come on very early, and in some instances they precede the articular affection. In our patient, Elizabeth Stocking, the cardiac symptoms must have developed themselves very early, as they were already well marked on her admission into the hospital. The circumstances that will denote to you that the heart is 52 LECTURE III. beginning to suffer, are,—irregularity of the pulse in any way, either as affecting its force or its rhythm—i. e., whether the intermission be partial or complete: or its becoming suddenly quicker or slower. Should any of these signs present them- selves, you should at once institute the most minute scrutiny into the physical signs of the heart's action, and if you should find the slightest indication of a rubbing or bellows sound, you may infer that either the pericardium or endocardium, or both, are beginning to suffer. Disease of the endocardium is espe- cially to be feared if the bellows sound is mitral systolic, i. e., if it be heard most distinctly over the apex of the heart, and be- neath the left scapula behind, and accompany the first or systolic sound : under such circumstances, you may be sure that the endocardium is suffering, and that some portion of the mitral valve is implicated in the lesion. If, however, the. systolic bel- lows sound be heard most distinctly over the base of the heart, and along the course of the great vessels, and is therefore aortic, you must not at once infer that this is a sure sign of the existence of endocarditis, affecting the aortic valves: you must bear in mind that an aortic bellows sound may, and very frequently does, arise from an anaemic state of the system. I have already told you that the rheumatic state tends to diminish very much the proportion of the coloring matter of the blood, even in pa- tients who have not been bled, or otherwise roughly treated. The rheumatic state itself, then, by bleaching the blood, may give rise to aortic and even venous murmurs. How much more likely to be produced is the condition favorable to these mur- murs when bleeding has been practised. You must be very careful not to fall into the mistake of treating an aortic murmur as due to endocarditis, which is really the result of the already bleached state of the blood. Such a mistake is not unlikely to be made, as the diagnosis is difficult between the anaemic mur- mur and that from aortic obstruction; and you can readily un- derstand how an antiphlogistic process, especially if it included bleeding, would make matters infinitely worse in a case where the murmur was simply of the anaemic kind. The more you proceeded with such a treatment, the more, of course, would the conditions favorable to such a bellows murmur be developed, and the louder it would become. The following points will aid you in deciding upon the endocardial character of the murmur: t ON RHEUMATIC FEVER. 53 First, if the sound come on very early in the disease; second, if it be rough in character; third, if it be not accompanied with venous murmur; fourth, if the patient has not yet displayed much anaemia; lastly, the probability of an endocardial affection is much increased if the murmur have been ushered in with «ome disturbance of the heart's action, such as I have already referred to. It is important, especially with reference to prognosis, to keep in view that the mitral valves may be affected, first, so as to induce valvular imperfection; and, secondly, so as not in any def ree to impair the function of the valve. If the deposit of lymph take place on the auricular surface of either or both curtains of the valve, then you will have valvular imperfection: the curtains will not meet exactly, and a fissure will remain, of larger or smaller size, through which more or less of regurgitation, will take place into the auricle at each ventricular systole. But if the deposit take place on the ventricular surface of the valve,—and it generally does so on the ventricular surface of its inner curtain,—then you have no disturbance of valvular func- tion. In both cases, however, you have a systolic bellows sound; and in both cases that sound is best heard at the apex of the heart. How are you to distinguish the one from the other? If the bellows sound be purely regurgitant, its position is strictly at the apex ; .it becomes in a marked way faint as you proceed to the base of the heart, and it is distinctly audible beneath the left scapula; and, in addition, the sign pointed out by Skoda exists, namely, a marked intensification of the second sound. If the bellows sound be not regurgitant, you hear it wTell up to the base of the heart; you hear it only feebly, or not at all, at the left scapula, and there is no intensification of the second sound. I may add, that, in this latter case, the heart's disturbance, and the sufferings of the patient, are, in a marked manner, less than in the former. It must also not be lost sight of, that a bellows sound, now present, may be the result of a previous attack of rheumatic fever. You must rely mainly upon your knowledge of the patient, or upon such a history of his previous state as you can pick up by inquiry among his friends and relations, to distin- ■>! LECTURE III. guish whether the endocarditis is new or old. Of course, certain symptoms of newly-comc-on heart disturbance would favor the former view; but I know of no physical sign or sound which aids the diagnosis. In the treatment of the heart affection, I am in the habit of acting upon much the same principle as in that of the joints; and I trust to free vesication and the promotion of a copious discharge, serous or sero-purulent, as the local treatment. I shall describe to you the plan I am in the habit of following, and which we have used wTith the most satisfactory results in Eliza- beth Stocking's case. On the first indication or suspicion of heart affection, a large sinapism, made with flour of mustard and hot water, is applied over and beyond the region of the heart; this is to be kept on as long as possible. After its removal, and after the skin has been properly cleansed, put on a blister of good size; and you must be guided as to the dimensions of it by your opinion of the extent to which the heart is affected. You need not be afraid of large blisters here, as in the treatment of the joints, because the inflamed organ is much more distant from the surface than the synovial or other articular tissues. If you pursue the plan which I have thus pointed out, and have drawn a large quantity of blood to the surface by the long- continued stimulation of mustard, you will generally succeed in producing very free and large vesication, from which you may obtain a considerable quantity of serum,—or rather, I should say, of liquor sanguinis, for the fluid of the blister is serum con- taining more or less fibrine. If you examine the fluid from blisters, especially.when the skin has been previously irritated by mustard, you will almost invariably find that it contains more or less of fibrine. In very many instances, if not in all, the coagulated fibrine disposes itself in a membranous layer in immediate juxtaposition with the deep surface of the elevated cuticle. On removing the cuticle slowly and cautiously, the serum will not flow away; it is still retained by a very complete, but soft, moist, and almost spongy membrane. This is coagu- lated fibrine, which has entangled in it a large number of the white corpuscles. How these latter escape from the bloodvessels or whether they are not the result of the organizing tendency of the liquor sanguinis, I cannot pretend to decide. It is clear, however, that blisters will take away the liquor sanguinis with t ON RHEUMATIC FEVER. . 55 its dissolved elements, and perhaps the rudiments of the white corpuscles. By blistering you take away that part of the blood which is the great agent in the development of new formations, and these are what you have to guard against in the cardiac inflammations. Moreover, by blistering you spare that most important part of the blood, the coloring matter, which seems especially valuable for preserving the nervous functions in a state of integrity, and which is no less important for maintaining the healthy action of the heart. But some of you will say, "What! do you advise us to" lay aside that which has so long been regarded as the sheet-anchor in the treatment of inflammations,—namely, bleeding; and not only general bleeding, but topical bleeding likewise ? If we are neither to cup nor to leech in*pericarditis or endocarditis, what security, then, shall we have against the progress of inflam- mation,—against the formation of excrescences on the valves,— against ulcerative or suppurative processes being established in the heart, destroying its valves, and infecting the blood ?" I am quite aware that the doctrine which I recommend for your adop- tion is likely to be regarded as extremely heterodox by many; but I believe the number of those who think so is daily dimi- nishing. In the treatment of the cardiac affections which accompany rheumatic fever, you have two objects to keep in view; the first is, to check t]je morbid process completely, or to restrain it from producing such changes as may prove destructive to the tissues, and consequently to the mechanism of the heart: and the second, to obviate liquid effusions which may distend the pericardium, compress the heart, and so embarrass its actions, as well as the respiratory movements, as to prove seriously detrimental to life. Now, with regard to the first point, there can be little doubt that bleeding will not stop or prevent the formation of those fibrinous concretions which are so apt to form upon the valves. The formation of these con- cretions is in a great measure mechanical, and in certain states of the blood they would form around or upon any opposing material, just as fibrine will coagulate round the bunch of twigs by which blood is beaten as it flows from a vein. In this rheumatic state, the contractile tendency of fibrine is apparently increased, as is shown by the uniform formation of a tough buffy coat in the blood removed from rheumatic subjects; there 56 LECTURE III. is also a considerable increase in the number of white corpuscles; the bufiy coat is formed of these two constituents, and the con- stancy of its formation denotes a tendency in these two elements to separate from the other elements of the blood in the rheumatic state. Doubtless, a disturbed state of the nutrition of the serous membrane or the endocardium, or of certain parts of them, precedes the formation of fibrinous deposits upon them; and this disturbance of nutrition is caused by the accumulation of the rheumatic matter in the vessels of the part. The effect of this is analogous to, if not identical with that produced by a blister on the vessels of the skin, which I have just now described to you. The liquor sanguinis transudes through the parietes of the bloodvessels, and the plastic matter coagulates upon the sur- face of the endocardial and,the pericardial membrane, forming there a substance identical, or nearly so, with the buffy coat of the blood. In the endocardium, which is in contact with the blood as it flows through the heart, this layer of plastic matter forms a nucleus, around wrhich fibrine from the blood which flowrs over it may coagulate. Now, if this be a correct account of the manner in which the plastic concretions develop themselves in pericarditis and endo- carditis—and I believe it is that which is most consistent with our present improved-knowledge of the blood and of inflamma- tion—it is evident that the object o£the practitioner should be.to prevent the development of that altered state of nutrition which precedes the fibrinous formation, or to arrest it prior to the pour- ing out of the fibrine. Will bleeding do this ? I think our experience of the effects of bleeding upon the joints ought to convince us that it will not: for bleeding certainly will not re- move the rheumatic state from them; for, however it may relieve for a short time, by diminishing hyperaemia, or by some influence on the nervous system, the flow of blood speedily returns with as great, or greater activity than before. I apprehend that the state of the joints and that of the heart is as nearly as possible the same, the difference being that the nature of the synovial secretion offers a much greater physical impediment to the formation of fibrinous or plastic concretions in the joints than exists in the endocardium or in serous membranes. And I would put another question: Will bleeding cut short that state of blood which is so favorable to the formation of the ON RHEUMATIC FEVER. 57 plastic deposits ? To this I answer likewise in the negative. Among the best of the modern researches upon the relative quantities of the elements of the blood in various conditions of that fluid, are those of Becqtierel and Rodier. What do these observers say as to the influence of bleeding upon the blood ? Why, that it considerably diminishes the red particles, that it very much augments the proportion of water, and that it affects but little or not at all the fibrine; thus, in short, you get a thin- ner liquor sanguinis, holding in solution the same, or nearly the same amount of fibrine. In other words, you get a state of liquor sanguinis very favorable to transudation, and therefore very favorable to plastic formations.1 If, then, bleeding will not stop the inflammatory state which creates the undue determination of. the blood to the pericardial and endocardial surfaces, and if it will not prevent the plastic • formations, but rather favor them, surely it is not the remedy for pericarditis and endocarditis. And if the effects of venesec- tion be,—as beyond all doubt they are,—to diminish all the solids of the blood but the fibrine, and to augment the water, surely the employment of this treatment is fraught with the greatest danger of creating liquid effusions into the serous and synovial sacs, which are so exposed to the action of the rheu- matic matter. #These are, as concisely as I can put them before you, the theoretical grounds upon which I object to the practice of bleed- ing, whether local or general, for the cardiac affections of rheu- matic fever. And my experience confirms me in the belief that the practice of bleeding is altogether unsatisfactory in its reme- dial results, and prejudicial in its consequences. I have likewise learned by experience that the practice of abstaining from this mode of treatment is. perfectly safe, and tends to the best results. By the general plan of elimination—locally, by blisters,—gene- rally, through the sweating and other augmented processes of secretion—you" divert the rheumatic matter very freely from those great central and highly vascular organs which we are so anxious to protect from mischief. 1 The analyses of Dr. Christison show an increase of fibrine under bleeding; and those of Dr. Beale show the same fact to a remarkable extent, in the blood of a dog bled on four successive days to the extent of six ounces each day. Vide Todd and Bowman's Physiology, p. 312, vol. ii. 58 LECTURE III. Besides the local treatment that I have prescribed, you must, when the, heart or any of the great internal organs is affected, still keep up the influence of opium upon your patient, whereby you secure a powerful means of keeping down excessive action of the heart, of calming the nervous system, and of promoting cutaneous elimination.1 You will bear in mind that both pneumonia and pleurisy are very common complications of rheumatic fever; but for the treatment of these affections I have nothing to add here to what I have said respecting the treatment of the cardiac affections. The treatment of both should be exactly the same, mutatis loch. There is a very formidable complication of rheumatic fever, respecting which I must say a few words. I allude to the de- lirium which is apt to manifest itself in the course of the attack; sometimes with thoracic inflammation, sometimes without it. It is very important that you should be prepared for this symp- tom, and that you should understand its nature, and its proper mode of treatment; it is not in itself a dangerous symptom, unless the practitioner fails in taking the precautions which are rendered imperative by its occurrence. The delirium of rheumatic fever sometimes comes on gradu- ally, the patient having been a little talkative and wandering for two or three nights; sometimes it comes on quite suddenly. In its general characters it resembles delirium tremens—generally, however, exhibiting less of the nervous tremor which belongs to intemperance. The patient is restless, busy, talkative, pick- 1 In the impression of this Lecture, which first appeared in the London Medical Gazette, for October 20th, 1848, the following paragraph appears:— " I know that there are many physicians who speak lightly of the remedial powers of mercury in these rheumatic affections. But I confess to you that I am not prepared to give up the dogma of Dr. FSrre, that mercuryjs opposed to, and breaks down, plastic formations. Still I must admit, and this is satisfactory for patients who may be prevented by idiosyncrasy from the use of mercury, that I have seen patients do extremely well without having taken a single grain of that medicine." I have omitted this paragraph from the text in this edition of the Lecture, because my subsequent experience has led me more and more to agree with those who repudiate the necessity for the employment of mercury in these affections ; and I feel myself justified in declaring my belief, that under the treatment described in the text, the results are more favorable, and altogether more satisfactory, as regards the future of the patient, than when mercury is used. At the same time, I am quite ready to use calomel or blue-pill as a purgative, whenaver either of them is suitable to the patient's condition. ON RHEUMATIC FEVER. 59 ing or pulling the bed-clothes, frequently rising in bed, and wanting to get out of bed, reaching out his hand as if. to catch hold of some object before or behind him, and sometimes—a most unfortunate symptom—obstinately refusing to take either food or medicine. In many instances, as I have already said, this delirium ushers in pericarditis, pleurisy, or pneumonia; frequently, however, it occurs after one or other of these maladies has set in, and some- times it occurs without them. It has, therefore, I think, no necessary connection with these internal inflammations, although it frequently accompanies them. Now, what is the nature of this delirium ? It used formerly to be viewed as a metastasis of rheumatism to the brain, and to be treated antiphlogistically. I have treated some cases in this way, and on this hypothesis, and I have had the opportunity, in consequence, I believe, of this treatment, of examining the state of the contents of the cranium in a few such cases. I can there- fore assure you that there is no more inflammation, either of the brain or its membranes, in these cases, than in delirium tremens. The membranes are perfectly free from abnormal deposit, the pia mater is pale, and the gray matter of the convolutions re- markably so, and the subarachnoid fluid is increased in quantity. These signs indicate not only that the brain has been imperfectly supplied with blood during life, but that the vascular pressure upon it is less than it ought to be, and that, consequently, an in- crease of the subarachnoid fluid has taken place. When, then, we consider the circumstances in which the brain is placed in these cases, we cannot wonder at its functions being disturbed. In the first place, the organ is supplied by a depraved blood—a blood deficient in its most important staminal principle, its coloring matter—a blood infected with an abnormal material, the rheumatic virus, whatever that may be; and a watery blood, which is the more apt to exist, if the patient, as is very often the case, have been treated by sanguineous depletions. Such a blood is ill suited for the proper stimulation of the heart, and conse- quently it is not propelled by that organ with its proper force, although the rapidity of the heart's action may be much in- creased ; and if the heart be inflamed, there can be no doubt that the effect of that inflammation will be to weaken still more the propelling power. Hence, in cases of this kind, the brain is 60 LECTURE III. feebly furnished with a blood, poisoned, poor in coloring matter, and abounding in wrater. I have met with a few cases in which the patient, having evinced previously little or no delirium, has become rapidly comatose, with dilated pupils, aud sunk quickly. And it some- times happens that patients who have been actively delirious will suddenly fall into coma and die'; and sometimes they die suddenly, while making some effort beyond their strength, in the midst of their delirious ravings. The state of the kidneys may have some influence in determining the mode of death in those patients who pass quickly into coma, as we know that defective action of those organs so often exercises a baneful influence on the brain. A case occurred to me in private practice, which shows how rapidly rheumatic fever will sometimes run through all its stages, and exhibit all its phenomena,—articular, cardiac, cerebral,— notwithstanding the active and early treatment by calomel, col- chicum, purging, &c. I will give you the case briefly. Case XII. A student of one of the universities, aged 22, had complained for two or three days of pain in the left foot. This became suddenly very much aggravated at the railway station, as he was starting for his college, on the 17th of April, 1855. He went to a hotel, and put it into mustard and water, but pro- ceeded next day to his destination. The rheumatic affection then extended to all the large joints; there was free sweating, and numerous sudamina made their appearance. He was treated by mercury, colchicum, liquor antimonialis, liquor amnionic acetatis, and latterly Dover's powder. I was telegraphed for to see him, and found him, on the evening of April 27th, extremely ill: much, purged,—passing watery stools, apparently from the liquor antimonialis; he had a full throbbing pulse, and soon be- came very restless and delirious. I saw him again at midnight, and detected a friction sound over the heart. The delirium had increased, with a comatose tendency ; but he could still be roused, and then recognized me and others about him. I or- dered him half a drachm of the bicarbonate of potass and a grain of opium every three hours, and a small quantity of brandy. In the night the delirium increased, and he refused to take food or medicine; his breathing became catching; pulse ON RHEUMATIC FEVER. 61 120; and soon after nine o'clock the next morning he died, eleven days from the supervention of the acute symptoms. If I were to treat such a case from the beginning, I should employ opium at once ; possibly, also, liquor ammoniae acetatis; or, more probably, large and frequent doses of bicarbonate of potass, wool or blisters to the joints, beef tea, and brandy or wine freely. Purgatives should be given carefully, but not so as to cause colliquative purging. Such a treatment would hus- band the strength, and enable the patient to resist the influence of a large accumulation of the rheumatic poison, such as must have been present in this case. You, will find a valuable collection of cases of delirium and other disturbances of the nervous system, in connection with rheumatic cardiac affections, in Dr. George Burrows's interesting and most valuable work on Disorders of the Cerebral Circula- tion. The evidence which Dr. Burrows has adduced in that work should teach us, that whenever we meet with a case of delirium, especially of rheumatic delirium, we should diligently explore the region of the heart, and watch the condition of that organ most carefully from day to day. But this delirium, as I have before said, has no necessary con- nection with the heart affection—at least, with endocarditis and pericarditis—for it occurs in cases of general gout, in which there are no such heart affections as those in rheumatic fever, and the delirium of gout resembles precisely that which I have described to you as belonging to rheumatic fever. I have seen, indeed, this delirium in persons of strongly marked rheumatic or gouty diathesis, accompanied by all the signs of rheumatic fever—the sweats, the furred tongue, and the lithic urine, and not only without cardiac, but even without ar- ticular affection. I may make this further remark, before I refer to the mode of treating this delirium, that what I have seen of it has strongly impressed me with the belief that it is much more apt to occur after bleeding, and in weakly subjects, than when depletion by bloodletting has not been employed, or in sthenic cases. It is also often an indication that your patient is being reduced too much by sweating, or purging, or some other means. The development of this delirium should be, as I have already remarked, a warning to the practitioner to look out for cardiac 62 LECTURE III. or other internal inflammations, as pneumonia or pleurisy, or even peritonitis—which sometimes, although rarely, occurs in rheumatic fever—if such have not been previously detected. But it should likewise be regarded as a signal of distress, denot- ing that the powers of the constitution are unequal to the severe trial through which the patient is passing; and he should imme- diately come to the patient's aid, and make arrangements for having him constantly watched by competent nurses or other attendants, taking care that the patient shall never be left alone. If he have been sweating freely, that must be checked; the amount of bed-clothes may be reduced; if his joints have been enveloped with wool, it must be removed. In like manner, any other too free evacuation must be stopped, as purging, or the too copious discharge from a blister. Nourishment must be given very frequently, but in small quantities, so as not to embarrass the stomach; and this should consist of beef tea, arrow-root, milk; and it will be always necessary to conjoin with this wine or brandy, or porter, when that has been an habitual beverage, also to be given in small and carefully-adjusted quantities. If the patient be wTakeful, sleep must be procured by the free ad- ministration of opium. These are the points to which you will have to direct your most watchful care. Provide against your patient being allowed to exert himself beyond his strength; remember that it is in this state that patients often die suddenly by syncope, and be careful to nourish and support them well. Eschew all local treatment to the head; even the application of ice is calculated to do mischief, by depressing the heart's action. When, however, the patient evinces a marked tendency to coma, then of course you will not use opium. I would advise you to shave the head, and to counter-irritate it and the back of the neck, by sinapisms first, and afterwards, if you find it neces- sary, by blisters, pursuing at the same time those measures for the support of the patient which I have already pointed out, and which, you may be assured, are not less necessary in the coma- tose cases than in those in which active delirium prevails. The two following cases afford interesting examples of the more severe forms of nervous symptoms—delirium, convulsions, and coma—as they occur in the course of rheumatic fever; and the post-mortem examinations are instructive, as pointing out the non-inflammatory nature of the brain affection. I bring ON RHEUMATIC FEVER. 63 them before you, with the view of illustrating the real nature of this delirium.1 The treatment was not such as I should adopt now. It was on the whole antiphlogistic (so called), although moderately so; negative, as I believe, so far as regards any good effects; but injurious, if not directly, yet by excluding other means which would have done good. Case XIII. (Vol. xii, p. 162.) The first of these cases is that of Maria Edwards, a servant, seventeen years of age, whose health had been previously good. On the 17th of October, 1844, she was seized with rigors, followed by a reaction, with pain in her limbs; at the same time she lost her appetite, became very thirsty, and suffered from headache and giddiness. On the fol- lowing day both ankles became hot, swollen, tender, and pain- ful ; subsequently other joints became painful, and she was adnlitted on the 25th, the ninth day of the attack, with all the symptoms of rheumatic fever. Both knees and ankles were then tender and painful, but not much swollen; the pulse was 120; the skin hot and perspiring; tongue furred. A systolic bellows sound was heard all over the praecordial region, and there was a slight catching pain in that situation. The urine was dark-colored, and loaded with lithates and phosphates. The joints were wrapped in cotton wool and oiled silk, a blister was applied to the chest, and some Dover's powder ordered to be taken every fourth hour. On the day after admission blisters were applied to both knees. By the 27th there was little alteration; she had no sleep at night. On the 28th she became delirious. For several days the same symptoms continued with but little variation, delirium recurring at night. On the 31st (the fifteenth day) a distinct to-and-fro rubbing sound was heard over a great extent of the cardiac region. On the 1st of November, despite of two grains of calomel with Dover's powder and a grain of digitalis every fourth hour, with forty minims of Battley's solution of opium at night, the deli- rium, which had hitherto been confined to the night, was pro- longed into the day. On the night of the 1st she was very rest- • x For a full discussion of the pathology of this and other forms of delirium, see the Lumleian Lectures, delivered at the College of Physicians, 1850, and published iu the London Medical Gazette of that year. 64 LECTURE III. less, wandered much, and would get out of bed. Three ounces of wine were administered, and a little sleep procured, but the delirium soon returned, and about noon on the 2d forty minims of the liquor opii sedativus were given; her pulse was then 124, weak and compressible; the rubbing sound remained ; her pupils wTere contracted; she was drowsy, and evidently much affected by the opium ; she also suffered severely from headache, for which ice was applied, apparently with benefit. On November 3d the delirium had ceased, and her pulse had fallen to 96, and improved in tone; the three ounces of wine were continued during the day, and thirty minims of the liquor opii sedativus were given at night. For several days our patient continued better, nearly free from pain, and sleeping more quietly at night; the rubbing sound being still audible. On the 8th her gums were found tender and white ; the saliva was slightly increased, but no fcetor was observed; the calomel was reduced. On the 11th (twenty-sixth day) there was an unfavorable change, marked by a return of pain in the spine, shoulders, and , right side, by restlessness and rambling talk at night, and by a weak and rapid pulse, numbering 140. These symptoms seemed to call loudly for supporting treatment; the daily supply of wine was therefore increased from three to five ounces (an insufficient quantity), and ten minims were added to the opiate at night. Some rest and comfort followed, and thus encouraged, we pushed the treatment a little further, giving half a drachm of the aromatic spirits of ammonia three times a day in camphor mixture, a grain of the sulphate of quina as often, and one ounce more wine. The blister to the chest was repeated, and after- wards dressed with mercurial and savine ointment. Though otherwise a little better, she continued to pass noisy, restless nights. The rubbing sound softened down, and nearly disap- peared, making a loud systolic bellows sound more plainly heard. On the 16th there was a fresh accession of praecordial pain, and a loud to-and-fro rubbing returned. The quina was doubled, and given every four hours with ten minims of tincture of opium. The record of the 18th is as follows : " She only slept two hours last night, and not at all for the twenty-four hours preceding. Pulse feeble, fluttering, 140; skin cool." At night she was delirious, chattering and singing, and got no sleep. On the 19th ON RHEUMATIC FEVER. 65 her pulse was 140, small and weak; her pupils contracted. Five ounces of brandy and some arrow-root were now given in the course of the day, and, to humor her fancy, a little fish was allowed; a grain of the muriate of morphia was given at night, and the quina was increased to four grains. In the evening the foot of the bed was raised, that her head might be lower, and a quieter night followed. The next day brandy was regularly administered every half hour in arrow-root. The last note was made on the 21st, after her death: " She was wandering all night; her pulse weak, quick, and fluttering. At seven o'clock this morning she changed for the worse; the rhonchus of the dying was heard; and, despite of brandy, administered at inter- vals through the night, she died at half-past ten this morning. Nitric and sulphuric aether were also given, in camphor mixture, through the night." The examination of the body was made twenty-seven hours after death. The brain was found healthy, but the gray sub- stance pale; there was no effusion on the surface or within the ventricles. The lungs were congested, but otherwise healthy. The opposed surfaces of the pericardium were adherent through- out by a layer of lymph, a quarter of an inch thick, but soft behind, and containing some fluid. The pleura, where in con- tact with the pericardium, was 'adherent, but there were no adhesions elsewhere. Warty excrescences of lymph were found on the margins of the aortic and mitral valves. Here was a case which exhibited very clearly the natural course of the^cute rheumatic disease with its complications. It was not likely that any part of the treatment would have mate- rially modified the phenomena. And while we found unequi- vocal marks of intense pericardial inflammation with abundant plastic deposits, there was not a sign of anything to indicate inflammation either of the substance or of the membranes of the brain. That organ was pale, poorly supplied with blood, and resembled the brain of an animal bled to death. Again, let me remind you that there was none of that serous effusion on the surface of the brain to which many attribute so prominent a part in the production of the phenomena of delirium and coma. These effusions, indeed, we now know are results of the dimi- nished size of the brain which follows its imperfect supply of 5 66 LECTURE III. blood, and its impaired nutrition, and as they do not exert any undue pressure on the brain or any part of it, they produce no symptoms during life. Case XIV. (Vol. xii, p. 57.) The second case is that of a single woman, Martha Mitchell, 34 years of age, who was ad- mitted into King's College Hospital on the 18th of June, 1844, with her third attack of rheumatic fever. She stated that her general health for many years had been far from good; that she had suffered, she believed, from attacks of acute inflammation of the liver, with pain in the right hypochondrium' and shoulders, and dyspeptic symptoms; that since her last attack of rheuma- tism, seven years previously, she had suffered from palpitation and dyspnoea on slight exertion. One evening, more than a week before her admission, she went to bed unwell, with pain and stiffness in the right hip, and a feeling of chilliness, and awoke in the morning with pain in all her joints, especially in the knees and ankles, which subse- quently became red and swollen; her appetite had completely failed, she had great thirst, and towards evening shivered vio- lently. Two days afterwards, she was suddenly seized with palpitation and dyspnoea. The articular affection continued up to the time of her admission ; she also perspired much towards night; the bowels became confined; the urine scanty and very dark. • When admitted, the joints of the arms, as well as the knees and ankles, were affected. There was pain in the praecordial region, and a systolic bellows sound was heard ov^r the base of the heart and in the course of the aorta. Dover's powder, with nitrate of potass, was given every four hours, and the joints were wrapped in cotton-wool. The next day, the 19th, the joints were less painful, her tongue 'covered with a yellowish-brown fur and red at the tip and edges, her pulse 120, and respirations 34. As there was still praecordial pain, a blister was applied, and two grains of calomel added to each powder. The case goes on as follows: "11 p.m., June 19th. Having continued up to this hour in the same state, complaining of little or no pain, the physician's assistant was called to her, and found her delirious, talking incoherently, and the delirium accom- ON RHEUMATIC FEVER. 67 panied with hallucinations; pulse somewhat increased in fre- quency, 128, weak and compressible; her skin hot and per- spiring. " She was ordered thirty minims of the liquor opii sedativus immediately. She slept after taking the opium; but at two o'clock a.m. the physician's assistant was again sent for, in con- sequence of her having had a convulsive fit affecting all her extremities. He found her lying on her back, her pupils very much contracted and insensible to strong light; pulse 132, weak but regular; her head hot, but the forehead perspiring; the respirations were 30, and of a croupy character. She was quite comatose. She had a return of the convulsions, screamed out, and died." The body was examined thirteen hours after death. The fol- lowing is the account from the case-book: " The body was very exsanguineous externally: the lips blue; the skin of the face and arms much freckled. The head, chest, and abdomen were examined. " The vessels of the pia mater were not more than ordinarily injected except on the left side—(hypostatic?). There was no fluid in the arachnoid or subarachnoid cavities; the surface of the arachnoid membrane was, however, moist. On dividing the hemispheres horizontally, the vascular pink points were rather numerous, but no trace of disease was discovered. " There was no fluid in the pleura, but adhesions around the apex of each lung, where there were also one or two caseous tubercles; the lungs were elsewhere healthy. " The pericardium was almost universally adherent, and the adhesions were organized. Besides these, however, there were traces throughout of fresh inflammation; -there were many flakes of soft lymph, and collections of a few drops of fluid here and there, with the surface much injected. The edges of the mitral valve were much thickened; all the other valves were healthy. " The liver was large, and broke down readily under pressure; its convex upper surface was covered with a distinct, though thin layer of apparently condensed cellular membrane, with one small patch of lymph. The remaining abdominal viscera were healthy." In the first of these cases, there was no evidence of any 68 LECTURE III. abnormal condition of the brain or its membranes, excepting, indeed, a slightly anaemic one. In the second, the congestion of one side of the pia mater was probably mechanical, and due to the gravitation of the fluid to the most depending part.after death The increase in the number of vascular pink points observed in the substance of the brain was probably connected with the mode of death,—in convulsions, which we well know congest the'brain. The next case is worthy your attention, illustrating as it does all the phenomena of rheumatic fever, the accompanying deli- rium, and the benefit likely to result in such cases from the early and liberal use of opium and stimulants, as I have recommended to you. Case XV.1 (vol. xxxiv, p. 166.)—George Gough, a footman, 19 years of age, of temperate habits, and usually enjoying excellent health, was taken ill, five days before his admission on the 10th of February, 1852, with general lassitude and aching of the limbs. The pains soon became localized in the joints with swelling; he also had pain in the left side of the chest. On admission, the ankles, knees, and wrists were swollen and painful, and the hip and shoulders also; perspiration was profuse and acid; the urine acid, high-colored, and full of urates; his pulse wTas 104, and respirations 30 ; his tongue white and furred; he had lost his appetite, and could not sleep. On examining the chest, there was a slight systolic bellows sound heard at the apex of the heart. He was ordered some of the usual mixture, con- taining fifteen grains of the bicarbonate with five of the nitrate of potass, and five minims of laudanum, every four hours. The joints were wrapped in cotton-wool and oiled silk, and a mustard plaster was applied over the heart. During the next two days there was not much alteration, and he passed sleepless nights, although the tincture of opium in the medicine had been increased to ten minims. The urine con- tinued loaded with lithates and phosphates, and its specific gravity was about 1030. A blister was applied to the left ankle, and mustard plasters to each hip. The medicine was now given every four hours, and the laudanum increased to twenty minims. record of this case I am indebted to my clinical clerk, Mr. Pearl. ON RHEUMATIC FEVER. . * 69 As his bowels were confined, he was ordered five grains of calo- mel, followed by a dose of hospital white mixture. On the 14th he was in less pain, and sudamina were observed scattered over his chest. That evening a to-and-fro rubbing sound was first observed over the base of the heart; this con- tinued, and the next day a blister was applied, and strong mer- curial ointment used in the dressing; his pulse remained as high as 126, and the respirations 40. On the night of the 15th he was for the first time delirious. On the 17th the whole body was covered with sudamina, and as the restlessness continued, he was ordered a night draught, containing half a drachm of tincture of opium; three grains of carbonate of ammonia were added to each dose of the mixture, and he began taking one ounce of wine every three hours (a quantity which, I think, was not adequate to the demands made upon the nervous power). That night, however, he was very delirious, trying to get out of. bed and leave the ward, without any corresponding increase in the severity of the other symptoms, there being, on the contrary, a general improvement, excepting that the pulse remained 120. On the following day he was ordered a pill, containing two grains of calomel and a quarter of a grain of opium, with each dose of the mixture. On the 19th the delirium was not confined to the night, but he continued muttering to himself in the day, unless aroused or spoken to. The opium in his medicine was increased by five minims, and he took it every three hours; mercury also was rubbed into the axillae. On the 20th the delirium still continued, and he seemed un- conscious of what was passing around him ; his pupils were con- tracted ; pulse 116, respirations 36. The mixture was omitted and five grains of carbonate of ammonia were given every two hours, together with half an ounce of brandy in beef tea every hour; the pill was continued every six hours. The favorable effect of this active stimulation was almost directly apparent:' that same night he was much quieter, and slept a little, and on the morning of the 21st his pulse had fallen to 104, and the respirations to 26; some swelling of the knee-joints, and a peri- cardial rubbing-sound, still remained. He again had a comfort- able night, and the next day, the 22d, his pulse was 96 and respirations 34. On the 23d he was going on most favorably: as his urine was alkaline, twenty-minim doses of chloric aether r-r, LECTURE III. i U were substituted for the ammonia, and the brandy was reduced. On tl 24th he was free from pain and progressing favorably; fc was then just a fortnight from his admission, and about eighieen or nineteen days from the commencement of his ill- ^After this he remained in the hospital about a month, regain- ing his strength under a course of tonics and good feeding; a rubbing-sound, and also a faint bellows-sound, continued to be heard for some time over the heart; there was also some chrome swelling of the knee. I have already told you that you must be careful to carry out this general plan of elimination with the closest attention and regard to the powers of your patient's constitution. I allude to this subject again, for the purpose of mentioning to you a sign which has, over and over again, proved most valuable to me, in leading me to pursue an altered course of treatment. When the patient has begun to pass pale urine, in good quantity, either without precipitate, or with a greater or less quantity of pale lithates, you will almost invariably find that he will be the better for a more generous treatment, even although the articu- lar affection still continue troublesome. You may give him ammonia, or quinine and sulphuric acid, and in many instances you may give wine or brandy; and I have been astonished at the rapidity of the progress of cases under this altered treatment; patients, whose symptoms had been stationary for two or three days, have, under the circumstances and treatment I have de- scribed, become convalescent in little more than forty-eight hours. The plan of treatment which I have now recommended to you, does not contain any new remedy, nor does it profess to point to any summary method of treating rheumatic fever; it is merely the application of old and well-appreciated remedies to the treatment of this formidable malady, in furtherance of a certain determinate object,—that of eliminating morbid matter, at various points and through different channels, from the cur- rent of the circulation. Since I have adopted this mode of treatment I have much more rarely met with those accidents of the disease,—pneumonia, pericarditis, delirium, &c, which are so formidable to both the patient and practitioner^ in the same ON RHEUMATIC FEVER. 71 severe form which I used to do under a more depleting treat- ment ; and when such severe cases do occur in the hospital, they are generally persons who have suffered from a depleting treat- ment prior to their admission, or who have been thrown into a very reduced state from other causes. Again, I find that under this treatment the duration of the disease does not exceed from ten days to three or four weeks, and that relapses, which were very frequent under the treatment by bleeding, are of rare occur- rence under this. Now it was formerly the dictum of an eminent physician, "that the only cure for rheumatic fever is six weeks." By this he meant that the disease would take its course, that time was its only cure, and that this time w^as not less than six weeks. But I should not attach much importance to a plan of treatment which failed to get patients into a good state in a much shorter time than that. Our patient, Elizabeth Stocking, whose case has been a severe one, and who has had pericarditis and slight delirium, has been in the hospital now just eleven days, and had been ill three days prior to admission, and you see that she is convalescent already. She has lost every rheumatic symptom ; all the pains in her joints have ceased; her tongue is clean, and I have no doubt that in two or three days more she will be struck off' the sick list altogether. And, as the last, though not least, advantage of this treatment, there is no fear of those unpleasant consequences which are so prone to follow in the wake of this disease: there is no fear of a tardy anaemic convalescence, for her blood has been spared; nor of a state of chronic rheumatism, for there is every indication that the whole of the morbid material has been eliminated from her system.1 1 The last note made before this patient left the hospital is dated June 17th, and is as follows: " She is improving in health and strength: appetite good: sleeps well." I must add here an allusion to the plan of administering acetate of potass as suggested by the late Dr. Golding Bird, and large and very frequent doses of bi- carbonate of potass as put in practice by Dr. Garrod. Both these physicians aim at making and keeping the urine alkaline. There is nothing in this treatment which militates against that which I have advocated in the foregoing lectures, and I may add that the free administration of alkalies is usually a very valuable practice, according to my experience. 72 LECTURE IV. LECTURE IV. On Continued Fever. Gentlemen : I wish to-day to call your attention to a case of common continued fever, with enteric disease, also called typhoid fever, which we have had lately in Rose Ward, and which we have watched with great interest, and not a little anxiety, for some days past. The case ended fatally, and for this reason I am the more desirous not to let it pass without some observa- tions upon it. And I shall take this opportunity of giving you the following piece of advice: never shrink from analyzing and carefully thinking over the cases which prove fatal under your care, with a view to inquire, whether by a little more care you might not have been more precise in your diagnosis, and whether you might not have been more watchful in your treat- ment, or have adopted .a more promising course. Such, an inquiry, if faithfully pursued, involves an amount of self-exami- nation which, in course of time, cannot but redound most bene- ficially to the character of the practitioner. It is a doctrine supported by our best physicians and highest authorities, that you cannot cure a fever; that is, that you cannot cut it short: you can guide it through its several stages, you can support the patient's strength, uphold his vital powers, until the influence of the poison is worn out, and combat any accidental affections which may arise in the course of the treatment, such as diarrhoea, pneumonia, &c.; and by such careful management you may save the patient, by preventing him from dying by ex- haustion, and you may shorten his convalescence considerably. This is a doctrine to the truth of which I have for many years given my full assent, not only as regards typhus and typhoid fever, but also with respect to other fevers,—those, for instance, connected with the exanthemata. And although many, from time to time, have professed by some heroic methoM, adopted ON CONTINUED FEVER. 73 very early, to cut the fever short, and thus to convert, what would otherwise have been a tedious and painful illness of three or four weeks, into a short attack of a few days, yet I have failed to convince myself, either by experience or reading, that any such important discovery has as yet been vouchsafed to us, as one calculated to destroy the venom of the typhus poison, and to check its ravages. All the cases in which it has been said that typhus has been cut short, as by a very large bleeding at the outset, or by free vomiting, or by some other means, are fairly open to the strong suspicion, if not the charge, of erroneous diagnosis. It is plain, if you think on the subject but for a moment, that without an exact diagnosis, this question of the early curability of typhus cannot be settled. Now, those who have seen most of this and other maladies know best how difficult, nay, how impossible it often is, in the first week or ten days, to predicate with certainty of this or that case, that it is typhus fever. And, therefore, if you deal candidly with yourselves and others, you must not affirm that you can cut short and cure typhus, unless you have the most unequivocal evidence that the cases in question have been examples of that disease. If these views be correct, you will perceive the necessity, when you come to treat a case of this nature, of not wasting time in trying this expedient and that medicine, but you will apply yourselves to provide for the due care and watching of your patient, and the careful administering to his wants and necessi- ties. In this respect the poor, who are inmates of our public hospitals, have often a great advantage over the patients we have to treat in private practice; for here we have trained attendants, always ready, experienced in the management of cases of this kind, and accustomed to obey orders. In private practice, we are too often obliged to trust to the timid and inexperienced nursing of relatives and friends, or perhaps of servants already over-burdened with other duties; or, if we do succeed in over- coming prejudices, and in inducing the friends to procure the assistance of a nurse, it is too often the case that she is accus- tomed only to act as a lying-in nurse, and has no experience in fever cases. I would gladly read for you here the remarks of the late Dr. Graves, one of the greatest authorities on the subject of the pathology and treatment of fevers, on the choice of a 74 LECTURE IV. nurse in cases of this kind; but I must content myself with referring you to the first volume of his valuable work on clinical medicine, where you will find them in the ninth lecture. Case XVI.1 (Vol. xxxii, p. 75.) And now for the particulars of the case. The patient was a man, named John Gavin, 32 years of age, a large, bony man, of strong build. He lay in Rose Ward. He is a printer, and had just come from Edinburgh to look for work in London. His illness probably commenced in Edinburgh, and developed itself immediately on his arrival in London. It is often extremely difficult to fix precisely the day on which a fever began,'partly from the imperfect recollection of patients, and partly because the symptoms often develop themselves so insidiously and gradually, that the patient cannot note exactly the time when he really began to be ill; he feels for many days languid and out of sorts, but is still able to get about, and, unless some such prominent synfptom as rigor has occurred, it is impossible to name one day more than another on which the fever began. Now, what we gather is this,—that on or about the 9th, as he was leaving Edinburgh, he caught cold, of which he has no other evidence than the existence of great languor and weakness, with a strong sense of fatigue upon the slightest exertion. On his arrival in London, he found him- self quite unequal to the task of looking out for work, and unable to follow his business if he had succeeded in securing employ- ment. All this looks very much as if he had caught the infection in Edinburgh, where, we know, fever is always more or less rife among the lower orders; its period of incubation being the day or two before he left that city, and the first few days after his arrival in London. During the first week of his arrival in town the sense of languor increased, and he felt very ill. On the 16th of January, 1851, sore throat came on, and he was attacked with several severe rigors, succeeded, on the 17th, by increased de- bility, vomiting, headache, and tinnitus aurium. On the 18th these symptoms had increased in severity, and his friends stated that he became stupid, and appeared as if drunk,-and at times he wandered a little. It was, then, on the 16th, that the more 1 Reported by my clinical clerk, Mr. J. H. Sylvester. ON CONTINUED FEVER. 75 decided symptoms of fever had developed themselves, although we cannot doubt that the poison had already begun to work in his system at least seven or eight days before that date. He was admitted into the hospifal on the evening of the 19th of January. On the 20th, the following report of his condition that day was entered in the case-book: " The patient is very thin and weak; has a dull, vacant look; is delirious, incoherent, and it is not without great difficulty that answers to questions can be elicited from him; he is, however, very quiet, and lies chiefly on his back; respiration hurried ; crepitation audible all over the posterior surface of both lungs, especially at their bases; the tongue is dry, but not coated; slight sordes on the lips and teeth; the abdomen slightly prominent and tympanitic; has had one loose motion in the night; no spots are observable; pulse 130, very compressible; respirations 44. He was ordered half an ounce of brandy with beef tea every two hours, and five grains of the ses'quicarbonate of ammonia, with half a drachm of chloric ether, in an ounce and a half of water, every six hours, and turpentine stupes to be applied freely to the back." On the 21st, his symptoms had not changed, and the pulse was 128; the respirations 40. Reckoning from the occurrence of the rigors, on the 16th, our patient must have been, at the earliest, in the fifth day of the .fever,—it might be the seventh or eighth. The description I have just read to you portrays, very accurately, the condition and the symptoms of a patient laboring under the most common form of continued fever now met with in London and our other great towns, about that period of the disease,— that is, not earlier than the fifth day. Now, from this time, the symptoms usually continue of much the same character, with more or less of exacerbation, till the 17th or 18th, or to the 21st or even the 28th day: the most important being those referable to the nervous system,—coma or delirium; to the lungs, conges- tion, or even pneumonia and pleurisy, which are less frequent; and to the bowels, the diarrhoea. When a case is about to terminate favorably, these symptoms gradually give way;—the pulse exhibits no tendency to quicken, but rather to fall in frequency; the bowel affection appears easily controllable; the tongue begins to clean at the tip and edges; the patient becomes less stupid; the comatose or delirious state diminishes; the pulse improves in quality, and the general 76 LECTURE IV. powers of the patient experience a gradual but manifest change for the better. These changes commence generally in or about the third week. But if the case is not about to end favorably, we shall find an aggravation of some of these symptoms about this period. .The pulse will increase in frequency, and its power will be much di- minished ; the delirium and other head symptoms will become more alarming; or the symptoms referable to the lungs may become more severe,—the breathing more rapid and feeble, and the bronchial tubes impeded by mucus, which the patient has not sufficient power to expel, and, in consequence, death may result from a slow asphyxia; or he may be run down by the con- stancy or profuseness of the diarrhoea, and perhaps by hemor- rhage from the bowels. Now let us see what was the further course of the symptoms in John Gavin's case. On the 23d of January he had in some degree recovered the exhaustion caused by his removal to the hospital. His pulse had fallen to 112, but the respirations continued at 48. He was purged four times in the day; the chest signs remained the same. An enema of starch and opium was ordered at night to coun- teract the diarrhoea, and his brandy, ammonia, and beef tea were continued as before. The motions became less frequent, and he remained without any change till the 27th. On this day we found the bowels with a tendency to be loose again; three motions in the day; abdomen tympanitic; pulse 120, and respirations 52. Many of you will remember, that I pointed out to you on this occasion a good mode of estimating the real power of the pulse in fever and other asthenic states, namely, by causing the patient to sit up in bed, and comparing the condition of the pulse in this semi-erect posture with its state in the horizontal position. It was not accelerated by the change from the horizontal position, but its strength and volume became most strikingly diminished; it became very small, and much more compressible, but immediately he returned to the horizon- tal position, it recovered itself. There cannot, I apprehend, be a more palpable or unequivocal sign of an enfeebled circulation, than this marked deterioration m the quality of the pulse, on the patient* assuming the semi- ON CONTINUED FEVER. 77 erect from the horizontal posture. It indicates very clearly how dangerous it is to remove patients in fever, or other low diseases, from one place to another, or to allow them to move themselves, and how necessary for them it is that they should be constantly attended upon, that every, even the slightest, exertion on their parts should be prevented as much as possible. . It was now evident, that what we had chiefly to deal with was the extreme debility, and the looseness of the bowels. The state of debility was the more fearful, inasmuch as it had come on notwithstanding the free use of stimulants; for since the 21st he had been taking brandy, at the rate of half an ounce every hour. I now doubled the quantity of brandy, and ordered the ammonia and chloric ether to be taken in an ounce and a half of infusion of rhatany every fourth hour. For the two days (28th and 29th) following this increase of the stimulants, he continued much in statu quo,—the pulse 120; respirations 50; "the purging diminished, so that he had only one stool in twenty-four hours. The rhonchus in the chest had increased, however, and the heart-sounds were very feeble, so that I felt it needful to increase the stimulant to five drachms every half hour, or thirty ounces in the day. On the 30th there was some improvement: he was more con- scious ; the breathing was more free, although still rapid, 50; the rhonchus somewhat less, but the pulse was still 120; he had one loose stool, and the belly was soft. On the 31st, a still more sensible improvement had taken place. He was much more conscious; the rhonchus was less; vesicular breathing became much more distinctly audible in the lungs; the pube had fallen .to 112, and beat at this rate in the semi-erect as well as in the horizontal posture, although in the former it became reduced in power; the respirations were 46, and the heart's action stronger. No movement of the bowels. On the following day, the 1st of February, the pulse was down to 100; respirations 45. The tongue was evidently cleaning; the heart's action was stronger; he coughed a good deal, and was rather drowsy. One loose stool. On the 2d, matters were much the same; pulse 100. On the 3d, a much more decided improvement had taken place than had yet been observed. The pulse was only 84, and the respirations 38; he was more conscious; the rhonchus was -g LECTURE IV. less, and he breathed more freely; the tongue was clean, the abdomen soft, and the bowels quiet. ™r™+w So far, then, we were in excellent spirits respecting our patient • All the niost important symptoms had improved under the high decree of stimulation to which he was subjected; and of these improvement* none was more important than the reduction of the pulse in frequency at the same time that it acquired more power. The least change for the better was found in his con- sciousness ; although he took more notice than before, and was less deaf, and answered questions more readily, he was still very heavy and stupid.' The continuance of this state of stupor led me, on the dd, to reduce, the quantity of his stimulants by six ounces, so that he now took an ounce every hour instead of ten drachms. The chloric ether was omitted. From this time, I regret to say, " a downward tendency," to borrow a mercantile phrase, became evident; the crepitation in the lungs increased, and he began to expectorate a large quantity of thick purulent fluid; his stupor did not diminish; and the pulse and respirations became each day more rapid than the previous one. On the 4th, the pulse was 116; the respirations 46. On the 5th, pulse 120; respirations 52. On the 6th, pulse 138; respi- rations 52. On the 7th, pulse 140; respirations 52. And these changes took place, notwithstanding that the largest quantity of stimulants was again administered,. and that the infusion of serpentary Avas substituted for rhatany, with increased quantities of ammonia and chloric ether. On the 7th, a very serious symptom showed itself, which in part explained the rapid declension of his powers. This was hemorrhage from the bowels. He passed on that day a large quantity of blood by stool, which evidently exhausted him very much. Turpentine was now administered in small and frequent doses, but on the 8th he passed some more blood. He was now evidently sinking, with an extremely rapid pulse and very quick breathing, and he died on the morning of the 9th, which must have been the thirtieth day of the fever. _ Here, then, was a case in which no pains were spared to save life, so far as diligent treatment and careful nursing could accomplish that object; it terminated, however, unsuccessfully, and the patient died evidently in a state of extreme exhaustion. ON CONTINUED FEVER. 79 The treatment consisted in the early and free administration of support and stimulants, and in the use of counter-irritation over the chest and abdomen; turpentine stupes were used daily to the front and back of the chest for some time, and afterwards large blisters were applied, and the abdomen was occasionally stuped with turpentine. Close attention was paid to the state of the bowels; astringents were given constantly; and, on one occa- sion, when the diarrhoea appeared most threatening, an opiate enema was administered; thus the tendency to looseness of the bowels was kept so completely under control, that his weak state could not have been attributed to this. He was supported by a full allowance of strong beef tea, besides milk and arrow-root, and stimulants were given in large quantity, as I have already described. Now, it behooves us to inquire, why did this patient die ? Was there here the nimia medici diligentia? Were the quantities of food and stimulants tdo much for him ? Was there any other treatment which we did not use, but which we ought to have had recourse to ? Or did death result from causes clearly beyond the control of all medical interference ? The post-mortem inspection showed that the morbid changes were limited to the chest and abdomen. In the former there was congestion of the lungs; but to an extent decidedly less than we had expected. The bronchial tubes, however, contained a considerable quantity of the thick yellow purulent matter which he was expectorating during the last few days of his life. But the most serious lesion was in the intestines. The lower part of the ileum contained numerous deep ulcers, some of which had eaten, through the coats of the intestine so as almost to per- forate.. These ulcers were placed on the free margin of the intestine, and occupied the position of Peyer's patches. In the lower three feet of the ileum, we counted as many as seventeen ulcers, some of which were larger than a shilling. The floors of some consisted only of peritoneum and a little lymph. One very large ulcer existed on the ileac side of the ileo-caecal valve. In addition, several of the solitary glands were enlarged, and some ulcerated, and the mesenteric glands were enlarged. I need hardly say, that from our experience of cases of this kind, and from the diarrhoea, controllable although it was, and the tympanitis, and the hemorrhage ultimately, we were quite 80 LECTURE IV. prepared to find ulcerative disease in the intestine; although, owing to the mildness of the symptoms referable to the bowels, we might well be surprised to find such large ulcers, and so many of them. This extensive lesion of the mucous membrane of a part of the intestinal canal so important to nutrition as the ileum, must have contributed mainly to the state of prostration of this patient, which persisted for so long a time, notwithstanding the abundant supplies of nourishment which were given him. And yet it is difficult to explain precisely how these ulcerations could have occasioned all this debility, inasmuch as there was no ex- cessive diarrhoea, no great drain from his system, nor did they interfere with the due digestion and absorption of his food, for the quantity of the faeces formed was not unusually great, nor out of proportion to the amount of food taken. It is plain enough, that notwithstanding the disease in the ileum, gastric and duodenal digestion, and chylous absorption in the jejunum, must have gone on sufficiently to admit of the appropriation of the greatest part of the food given. It cannot, then, be said, that this patient had too much food; if he had, surely we should have found in the bowels large quantities of faeces and portions of undigested food, and during life there undoubtedly would have been flatulence and distress, referable to the stomach, and other signs of indigestion, none of which existed. Nor can it be said that he had too much stimulant; for we had this most striking fact, that with the in- crease of stimulants the pulse on successive days fell from 120 to 84, and that with their diminution it rose again to 120 and 130. Under the highest stimulation, all the symptoms im- proved; the chest became more free, the head clearer, the fever less the tongue cleaner. It was quite evident that both the food *nd brandy were fully digested and absorbed. We cannot, therefore plead guilty to the charge of nimia medici diligentia. fonfd T i? 7 h?d' * am n0t aWare that an^4 else could have been done for him beside, that which was done. I know of no medicine or remedy more applicable to his symp- IrZe w7 1 C°nditi0n ^ tW Wl^ ™ ^d. Tnere to promote the healing of such ulcers as this man had in his neum. I confess my faith does not carry me so f^r; and 1 think ON CONTINUED FEVER. 81 most practical men nowadays would eschew the use of mercury, where they had reason to believe that the small intestine was ulcerated, or likely to become so. The rapid change for the w^orse which followed the hemorrhage from the bowels, indicated sufficiently that it was the immediate cause of death. If the hemorrhage had not taken place there can be no doubt that his life might have been prolonged a few days. But the small quantity of blood lost was quite insufficient to cause death, if there had not previously existed a state of great depression. I have frequently seen much more blood passed by patients who have afterwards perfectly recovered. I repeat, that were it not for our experience of the constant accompaniment of a state of prostration with a few ulcers of the small intestine, it would be impossible to believe that so grave an effect would follow such a cause. It is true that in this patient the ulcers were not few, but they were found in but a small portion of the #intestine, namely, in a space three feet in length, leaving twenty-seven feet of the highest part of the bowel intact. I have, however, seen a state of as great, if not greater prostration, where there were not more than four ulcers. What seems most essential to the production of this state of prostration is, that the sloughing and ulcerative process should be quick, and that it should be perforative in its tendency; that is, that it should eat quickly through the tunics of the bowel, as was the case with Gavin, in whom we found, that at several points the coats of the bowel had been so eaten through as to leave only a little lymph and a«thin film of peritoneum as their floors. But the ulcers are not the only mischief existing in connection with the bowels in these cases: the mesenteric glands are like- wise diseased, swollen, and evidently irritated by some abnormal matter passing through them. No doubt the state of these glands interferes with due chylous absorption, but still scarcely sufficiently so to account for the prostration, for the food is freely absorbed in the upper portion of the bowel, and a good deal of it is of a nature (as the oily matter of milk), which must assume the state of chyle, before it can be absorbed. It seems to me that the production of this state is due not so much to imperfect appropriation of food, as to the absorption of a matter from the ulcerated surfaces, which, circulating with the blood, exercises a poisonous and depressing influence on the 82 LECTURE IV. system: a matter of the nature of, if not identical with pus, which is absorbed by the lacteals, and perhaps also by the blood- vessels, but probably chiefly by the former, by which route it quickly reaches the lungs, without passing through the liver, where it may contribute to the increase of the bronchial con- gestion and irritation which so constantly accompany this typhoid state. This view I have often broached to you already at the bedside of patients suffering in this way. I show you here a preparation wdiich was put up for me some time ago by Dr. Beale.1 It exhibits a few well-marked deeply- perforating ulcers of the ileum, having much the appearance, from the thick, swollen, and red margins, that the process of sloughing and ulceration Avas a quick one. In this case (the patient was a young woman), the fever ran its course in about three weeks, the diarrhoea was almost none, and the chief symp- toms were a tympanitic abdomen, stupor (in fact coma), bronchial congestion, and extreme prostration. A short time ago, you may remember a woman of the name of Lock, who went off very quickly likewise with similar symptoms, the stupor being so great that I wTas afraid a few drops of laudanum, administered with starch to check diarrhoea, had narcotized her. There was in this case, in addition to the stupor, bronchial congestion and prostration, but the diarrhoea was very slight, and readily con- trollable. Now, that the absorption of pus is capable of producing these depressing effects, we have many proofs. First, in puerperal fever. In some cases tine absorption seems to take place rapidly, and in large quantity; and, under such circumstances, the 'patient succumbs in a few hours, from rapid prostration and pulmonary congestion, with more or less stupor. In other cases, the absorption seems more gradual, the typhoid condition is induced more slowly but very completely, and, after a time, purulent deposits are found in the joints and muscles, or elsewmere. Secondly, in cases of erysipelas, in which the suppurative pro- cess is rapid, we have typhoid and comatose symptoms, which 1 The patient's name was Ada Dacon, and the particulars of the case will be found in the next lecture, Case xxviii. ON CONTINUED FEVER. 83 are out' of proportion to the extent of lesion ; in such cases doubtless pus finds admission into the circulation. Thirdly, we sometimes have unequivocal evidence of the ab- sorption of pus, as well as to the source whence it comes as with respect to the secondary deposits. I remember attending a case in private practice, where the pus showed itself in the anterior chamber of the eye. This case presented all the symptoms of typhus fever; and for a day or two I viewed it as such. One day I was much surprised at finding pus in the anterior chamber, which increased in quantity very rapidly, and pus was afterwards found in the elbow and shoulder joints. When we came to exa- mine this patient, we found an ulcer in the heart, at the base of one of the mitral valves. Some years ago, we had a case in the hospital of a woman who was suffering from chronic bronchitis ; she suddenly became typhoid, and I looked upon it as a case of most aggravated character. She died in a few days, and we found an abscess in the septum of the heart, which had burst, and thus the pus had entered the very fountain of the circula- tion, producing symptoms nearly resembling those which come on in a case of low typhoid fever. There seem, then, sufficient grounds for explaining the pros- tration and fatal termination in Gavin's case, without ascribing any ill effects to either what had been done for him, or to what had been left undone. The sloughing and ulcerative process undoubtedly interferes, to a certain extent, with the function of the bowels, but it also furnishes a source of formation of a poi- sonous matter, which we know, by experience of analogous cases, when taken into the system, creates symptoms of the same cha- racter as those of these fatal instances* of typhoid fever. There is another mode of termination of these cases of typhoid or enteric fever, for which you should yourselves be prepared, and for which you should prepare the friends of the patient, when you may see sufficient reason to apprehend it: I mean, that *by perforation. One of those films of peritoneum, which I have already alluded to as forming 'the floor of many of the ulcers, gives way, and the contents of the bowel pass into the peritoneal sac. In some cases of long duration, when the patient seems to have struggled, day after day, against the assaults of death, rapid sinking immediately follows the perforation, and, indeed, signalizes its occurrence. No new pain is felt, but the S4 LECTURE IV. patient grows rapidly weaker; the pulse, too, fails, becomes rapid and fluttering, and death from exhaustion or fainting quickly ensues. In other cases, the occurrence of the perfora- tion is ushered in by severe pain in the abdomen ; sometimes vomiting; tenderness and pain on pressure; tympanitis; with also increased prostration: all signs of peritonitis, induced by the irritating influence of the" intestinal contents upon the peri- toneum. When these latter symptoms make their appearance, the free exhibition of opium, in large and frequently repeated doses, is the only measure to whioh the practitioner can have recourse with any hope of success. The following case will illustrate the last-mentioned mode of termination, although the direct evidence of perforation, by a post-mortem examination, was not obtainable. Case XVII. (Vol. xxxvi, p. 97.) Robert Neek applied as an out-patient at King's College Hospital on the 24th of July, 1852. He was then very weak; his tongue tremulous, coated with a brown fur, and deeply fissured, he was also suffering from diar- rhoea. He persisted in following his occupation as long as he could, and was therefore not admitted as an in-patient until the 31st; he was then deaf, and completely prostrate. Brandy and beef tea were ordered, and some days later chloric ether and rhatany. There was no great change in his condition for about a week; his pulse continued high, his bowels more or less relaxed, rhon- chus and sibilus were heard over the chest, and on the 5th and 6th there was slight delirium. On the 8th there was a considerable fall in the frequency of the pulse; and the record of the 9th is as follows: " Tongue much cleaner; he feels altogether better; the cough has quite left him; the bowels are no longer relaxed." On the 12th he was still doing very well, and was ordered a slice of mutton. He continued to make favorable progress *until the night of the 18th, when he complained of severe abdominal pain. On the 19th all the symptoms of peritonitis were pre- sent,—he was lying with his legs drawn up, and the whole abdo- men was exquisitely painful on pressure, A grain of opium was given, and ordered to be repeated. ON CONTINUED FEVER. 85 He passed a delirious, restless night, the same symptoms con- tinuing, and died on the 21st. Had our patient Gavin not been carried off by the exhaus- tion consequent on hemorrhage and purulent infection, it is very probable, from the state of the ulcers, that perforation must have taken place, of which he would have died in either of the two ways which I have described. A third mode of termination is by colliquative diarrhoea. The patient may be going on well, and the practitioner may even be sanguine in his expectations of a favorable result, when the diarrhoea may suddenly become colliquative, and a few discharges of large watery evacuations will terminate the case. But to return to the treatment of the patient Gavin. It may be said, surely the irritation of the bowels was kept up by all the stimulants (to say nothing of the food) which were given, and had they been more sparingly supplied, the ulcerative process in the ileum would not have gone so far. This notion respecting the injurious effects of alcoholic stimu- lants, in cases where there is a tendency to bowel affection, is, I think, partly founded upon a vague supposition that the alco- holic fluid comes in direct contact with the irritable mucous membrane. Now the reply to this is, that we have the strongest reason to conclude that fluids of this kind never, except when taken in very large quantity at one time, pass the pylorus, but are absorbed by the walls of the stomach. This is especially the case when they are administered in the way I recommend,— that in which they were given in Gavin's case,—namely, in small quantities, with intervals of not less than half an hour between each dose. Thus one dose is absorbed before the other is given. But it may be urged, that the alcohol gets into the blood, cir- culates with it, and so increases the tendency to ulceration. Upon this point we can only appeal to experience. The ad- ministration of alcohol to healthy persons does not prove inju- rious by any irritative effects it may produce on the bowels. Of all the ill consequences which the advocates of the teetotal sys- tem, in their most praiseworthy zeal, have summed up as likely to be caused by the use of alcohol, I do not find that diarrhoea or ulceration of the bowels is noticed; and were it a frequent 86 LECTURE IV. effect, it certainly would not have escaped the scrutiny of these gentlemen. It is true that a debauch, in which a man may drink at one sitting as much, or considerably more than we should think of giving in twenty-four hours, may sometimes disturb the liver, and, through its increased secretion of bile, the bowels; but the looseness thus excited seldom or never proves othei'wisc than salutary. Nor do we find that effects of this kind are apt to follow the liberal administration of alcoholic stimulants in other low dis- eases ; in erysipelas; in the diffuse .inflammation of the areolar tissue, whether traumatic or not; in puerperal cases; and we give it repeatedly in cases with threatened or actual ulceration of the bowels, without any increase, but, on the contrary, a marked diminution of the unfavorable symptoms. Such, indeed, was the case with our patient Gavin. On the first few days of his taking stimulants, a manifest improvement took place in all his symptoms, those affecting the bowels as well; so much so that until the post-mortem examination revealed the true state of matters, I blamed myself for diminishing his supply of stimu- lants on the third. Probably the good effects continued until the puriform matter had entered the circulation in sufficient quantity to produce its poisonous effects. I could enumerate many instances in which this mode of treatment, by free stimulation, was of great and signal advan- tage. But I must content myself with mentioning a few, refer- ring particularly to some cases of this kind which have lately been treated in the hospital. Case XVHT.1 (Vol. xxxi, A. p. 54.) Many of you will recol- lect the case of Lucy Wood, aged 14, who was in the house about three months ago. She took as much as an ounce and a half of brandy every hour for three days together, and for the next fortnight half an ounce was hourly administered; this latter quantity, however, being sometimes much increased as occasion required. Under this large amount of stimulants, her symptoms gradually improved, and she was discharged quite well on the 4th of December, having been about nine weeks under treat- ment. 1 From the notes of my clinical clerk, Mr. Simpson. ON CONTINUED FEVER. 87 This girl labored under the great disadvantage of heart dis- ease. A loud systolic bellows sound, heard most distinctly at the apex of the heart, was present when she came in, and re- sulted from an attack of rheumatic endocarditis, which occurred some time ago. She was admitted on September 26th, and on October the 4th her symptoms began to assume a very severe character, and she was evidently getting very low. At this time she was also suffering from diarrhoea, for which she was taking astringents with chloric ether, and on one occasion it was thought advisable to administer an opiate enema. On November 1st, she Avas in a state to warrant us in dimi- nishing the quantity of stimulants. The pulse had now fallen to 120; on the 4th it AAras 114. After she had recovered from the fever, a very painful node formed upon the anterior surface of the tibia, which ultimately did perfectly Avell. Case XIX.1 (Vol. xxxi, A. p. 57.) John Bigg, aet. 15, was admitted Avith fever, on the 3d of September, 1850. The attack had begun Avith shivering and the other usual symptoms five days before. He soon became delirious. A stimulating plan of treatment Avas commenced at once. On the next day, the 4th, his nose bled, and looseness of the boAvels came on; the urine contained a little albumen; the pulse numbered 112. Chloric ether and krameria were given, and in the evening the wine was increased to between five and six drachms every hour. On the 5th, rose spots were developed; the purging continued, and about a pint of blood Avas passed at stool. Enemata of starch and opium were administered, and ten-minim doses of turpen- tine Avere given every fourth hour. In the evening brandy Avas substituted for Avine. There was then great prostration, mutter- ing delirium, and cold feet; and as he had not slept since admis- sion,, ten grains of Dover's powder were given. The next day his pulse was 150. All the same symptoms continued, and there was still blood in his stools. During the 8th, 9th, and 10th, the symptoms were the same, but less severe. He complained, how- ever, of great abdominal pain and tenderness, for which turpen- 1 Reported by Mr. Simpson. 88 LECTURE IV. tine stupes were repeatedly applied, and the brandy increased to an ounce every hour. The albumen disappeared from the urine. On the 11th, a little blood again appeared in the motions. On the 12th, there AA~as a slight SAveating, apparently critical. On the 13th, he AA-as much better, and from that day continued to improve. The brandy Avas reduced gradually, and on the 24th he wTas convalescent and on full diet. Case XX.1 (Vol. xxxi, A. p. 67.) Elizabeth Bevan, thirty-six years of age, an overworked needle-Avoman, was attacked with the ordinary premonitory symptoms of fever, September 15th, 1850, and admitted in a semi-conscious state four days after. Half an ounce of brandy was given with strong beef tea every hour, as well as chloric ether and ammonia; and turpentine fomentations were applied to her belly and chest. The next day she lost about a pint of blood by stool, and_ became very pale and low. Pulse 122; respiration 33. Turpen- tine and krameria were administered, and enemata of starch and opium; the brandy also was increased to a drachm and a half every quarter of an hour, with beef tea of three times the usual strength. On the 19th there Avas little change : she was still purged, and vomited repeatedly, the latter symptom obliging us to administer • the stimulants only in still smaller quantities at a time and more frequently. Enemata of beef tea, quinia, starch, and opium Avere given, and afterwards of tannic acid and turpentine. Her pulse continued about 120. On the 20th, the diarrhoea abated: there remained however cough, difficult respiration, 34, and expectoration of tenacious mucus, while catarrhal sounds were heard over the chest. From this time she began to mend, although slowly; the brandy was reduced, but the pulse continued very quick for more than a week. On the 29th she was reported as " improv- ing generally," and on the 4th of October, as "rapidly recover- ing ;" she was then on full diet, and taking no medicine. On October 25th she was discharged cured. Case XXI. (Vol. xxxi, B. p. 162.) Charles Perugia, set. 20, Reported by Mr. Simpson. ON CONTINUED FEVER. 89 admitted July 3d, 1850. His illness began with shivering, fol- lowed by fever, about a week before admission, and the last three or four days he had suffered from purging. He was ordered half an ounce of wine every two hours, beef tea, and chloric ether in decoction of logwood. On the 4th, the fever continued; his tongue was half pro- truded, tremulous, and brown; he Avas restless, weak, and took little notice; a few small rose spots wrere apparent. Pulse 96. The diarrhoea had ceased. His head Avas shaved, and a third of an ounce of brandy given every hour. " On the 6th severe purging returned; and on the 8th he passed a good deal of blood in his motions; these symptoms were checked Avith difficulty by enemata of half a drachm of tannic acid, half a drachm of laudanum, and starch. Pills containing tannic acid and quinia were also given. By the 12th he 'was much better; his pulse 80; the motions natural. By the 15th, his appetite and hearing had returned; and by the 20th he was up and convalescent. All. these maybe called desperate cases, in which the pulse Avas very rapid and feeble, and the tendency to death from ex- haustion very great. All were accompanied by diarrhoea and hemorrhage, which in all became considerably less under astrin- gents and the largest doses of stimulants. A general dispo- sition to hemorrhage seems, in fact, to be a consequence of the deterioration, perhaps of the disorganization, of the blood by the typhoid poison; and this is manifested not only in the passage of blood by stools, which might otherwise be considered simply as a direct result of ulceration, but by hemorrhage from the nose and kidneys, by the presence of petechial spots in the skin, and occasionally, by extravasations of blood elsewhere. Associated, and possibly connected with this disposition to hemorrhage, we sometimes find, after death, a remarkable con- ditiQn of the spleen—that organ being softened, sometimes pulpy, and breaking down readily under pressure with the fingers. The case of Charles Andrews (Case xxxi), which I shall give in detail in my next lecture, and the tAVO following fatal cases, will illustrate these remarks, and the extent to which the hemor- rhagic tendency is sometimes developed. 90 LECTURE IV. Case XXn.1 (Vol. xli, p. 15.) Sarah Ann Chandler, a widoAv, 39 years of age, Avas admitted, May 10th, 1853, with symptoms of fever. Five days before she had been much shocked by sud- denly hearing of the death of her father, and to this she attri- buted the commencement of her illness: she said that she felt at first as though she had received a heavy bloAv. On the 11th her face looked flushed and anxious; her lips were dry and soiled; her tongue covered Avith a thick Avhite crust; the conjunctivae injected, and her eyes someAvhat suffused. There Avas cough and abundant frothy expectoration, with sharp shooting pain in her chest, and rhonchus and sibilus with some crepitation were heard. Pulse 136 ; respirations 36. Carbonate of ammonia and chloric ether were given. At night she passed three or four evacuations; and the next day her pulse rose to 180, and the respirations to 42. On the 13th she seemed worse; her pulse Avas very feeble and thrilling to the finger, and had fallen to 84. The respiration was more embarrassed, and, on auscultation, large crepitation could be heard all over the chest. She had ceased to cough and expectorate,—apparently from Avant of power. On the 14th she appeared sinking; she could hardly speak, and her pulse was scarcely perceptible. A blister was ordered. She died in the evening. At the post-mortem inspection, the lungs Avere found slightly congested, and the tubes much choked with secretion, but other- wise healthy. The heart was flabby and somewhat soft. Petechial extravasations of blood were found among some of the muscles of the chest, more or less symmetrically situated on either side. Neither Peyer's patches nor the solitary glands were found diseased. The spleen was a good deal softened, presenting much the same appearance as in the patient Charles Andrews (Case xxxi). Case XXIII.3 (Vol. xlvii, p. 15.) George Rose was admitted 1 From the notes of my clinical clerk, Mr. (now Dr.) Plowman. 2 Reported by Mr. Hardwich. ON CONTINUED FEVER. 91 May 10th, pale, exhausted, and only partially conscious, but with a rapid, feeble pulse, quick respiration, and hot skin. He had felt languid and Aveak for a fortnight, but had given up Avork only five days. Blood had been passed both by stool and urine. During the short time he survived his admission, two motions were passed approaching to a pitchy blackness, and one of a blood-red color, and also bloody urine. He Avas restless, moan- ing, and delirious. Towards evening, the exhaustion increased rapidly, and he died early on the morning of the 11th. At the post-mortem examination, the patches of Peyer wTere found ulcerated, especially at the loAvest part of the ileum. Many of them were covered with a red fungous mass; others simply enlarged and injected. I have felt it a duty to make these remarks to you upon the subject of the treatment of fever by stimulants (and they apply no less to the treatment of other exhausting diseases,—erysipelas, influenza, bronchitis, carbuncle, &c), because I Avish to caution you against the morbid fear of over-stimulation, which leads many to adopt an opposite or a vacillating course, and to alloAV their patients to die from exhaustion. This is the mode of death to which fever patients are peculiarly prone; and I hold that the lower you allow them to become at first, the more likely is the ulcerative process in the intestines to take head, just as it is apt to do in the bowels and in the corneae of the eyes, in cases where there is an insufficient supply of properly nutritious food. At the same time, I must beg that you will not run away with the notion, that every patient in fever, about whom you may be consulted, is, to be treated with thirty ounces of brandy a day. There are many cases in which no stimulant at all is necessary; others, again, in Avhich it is not needful to give more than four or six ounces a day. You must bear in mind that we have two classes of cases of fever to deal with, the mild and severe; or those which have had a large, and those which have had a small dose of the peculiar poison on which the "febrile state depends. Where a large dose of the poison has been received into the system, you will generally find it necessary to give large quanti- ties of alcoholic food, or the patient will not have sufficient vital power to resist its depressing effects. Some few instances, 92 LECTURE IV. indeed, there are, in which the dose of the poison is so large, that the patient never rallies from the state of almost complete paralysis which it induces; such cases run their course in twenty- four or forty-eight hours, or within a week. The case of S. A. Chandler (p. 90) Avas of this kind. But the mild cases,—and fortunately, in many epidemics, these, are the most numerous,— do perfectly well on a very moderate amount of nourishment, with little or no alcohol. The objections which some excellent practitioners have to the use of stimulants, apply Avith more justice to the slovenly mode in which they are too often given. Generally left altogether to the discretion of a nurse, they are given in large doses at one time, or with other food, or without reference to the medicines Avhich are being likewise administered; they consequently create derangement of the primary or stomach digestion, flatulence, and flushing. If you give alcohol, give it with due regard to its digestion by the stomach, and so as not to interfere with the other food or the medicines likeAvise being taken. I am convinced that it is much better to err on the side of over-stimulation than not to give enough ; for if we have over- stimulated a patient, it is very easy to pull him down again; there are plenty of appliances and means for this purpose; but if the patient sink too low, nothing is more difficult than to restore him. If by your feeding and stimulating, the thermo- meter of life has risen to too high a point, nothing is easier than to depress it; but if fallen below a certain point, then to raise it again, much more to restore it to the height from which it fell, hie labor, hoc opus est. In conclusion, let me say a word or two as to the treatment to be pursued, Avhen you have reason to fear that the" boAvels are ulcerated. It seems to me, that the great principle of treatment in such cases, is to keep down peristaltic action, which is best done by opium and astringents containing tannic or gallic acid. Many attach great value to the use of sulphate of copper; but as it is generally given with opium, and does not always agree Avithout opium, I think the latter drug has the largest claim to the good services often done by the combination. When hemor- rhage occurs, nothing is so effectual to restrain it as turpentine given in small doses, so as not to risk offending the stomach; ON CONTINUED FEVER. 93 even so small a dose as five minims is often sufficient; and I frequently apply it externally, as a stupe to the walls of the abdomen, with decided benefit. In dealing Avith these cases, you must not be timid as to allowing the bowels to remain inactive for even several days. I have never seen any bad con- sequence from their not acting even for four or six days; and when they are to be provoked to act, let that be done by some simple enema rather than by aperient medicine. 94 LECTURE V. LECTURE V. On Continued Fever. In offering to you to-day some remarks on those forms of con- tinued fever Avhich are most likely to come before you, let me first say a word or two respecting the intimate nature of the most prominent clinical feature of the disease before us, from which, indeed, it derives its name,—I mean fever; for it is of great practical importance to have something like definite views upon this point of pathology. You all know that fever is marked by a hot, sometimes burn- ing, often flushed, and generally dry skin; by a quickened pulse, loss of appetite, thirst, accelerated respiration, and more or less loaded urine; and these phenomena soon become accompanied by a manifest wasting of substance and loss of power. We can best explain these symptoms by supposing that a poison, circulating in the system, interferes with, and greatly modifies the processes of nutrition and secretion; what Dr. Prout has called the secondary destructive assimilation is exalted, and the elements of the tissues seem to undergo a rapid oxida- tion. The result is a rise in temperature throughout the sys- temic capillary circulation, generally wasting, and more or less rapid exhaustion of vital power. Now symptoms of this kind always follow the introduction of a poison into the system, and are indicative of a peculiar dis- turbance, whicm the presence of that foreign matter in the blood establishes. You have every day the experiment performed millions of times, of introducing into the t)lood a minute quan- tity of vaccine lymph, through a puncture in the arm. This, in a few days, establishes a definite form of fever, with certain local % phenomena in the shape of one or more pustules at the seat of the wound. So if the analogous poison of small-pox gets into the system, as we call it, or more correctly into the blood, a definite ON CONTINUED FEVER. 95 fever is established, with the local development of peculiar pustules on the skin and mucous membrane. The same may be said of all the fevers which we call exanthemata. In each there is a definite poison, and that poison produces definite febrile phenomena. If left to itself, the fever begins on a certain day and ends on a certain day, and affects the skin or mucous mem- brane, either gastro-intestinal or respiratory, or even genito- urinary, in a specific manner. Take, for instance, the poison of scarlatina: it quickly establishes an intense fever; it attacks the mucous membrane of the throat and that of the kidneys; it develops a peculiar rash on the skin, and more or less of irrita- tion and swelling of the cervical glands. In such cases, although the great intensity of the fever is in the early stages, it never- theless continues more or less in a chronic form until all local phenomena have disappeared.1 What the pathological significance of the local phenomena of fever may be, we are scarcely yet in a position to declare; but it seems very probable, that they have at least much to do with the process of elimination of the poison. Each poison has ap- parently an elective affinity for some particular structure or organ, and through it makes for itself a channel of escape out of the system. Thus it seems very reasonable to suppose that the cutaneous desquamation, which so often occurs in scarlet fever, is one medium for the extrication of at least a part of the poison from the blood. In like manner, the pustules of small- pox are, in all probability, due to a nisus of elimination, and each pustule is a point of exit of a certain quantity of poisonous matter. When there is so great a diversity of symptoms, it is not too much to suppose that the poisons, upon which these various forms of fever depend, are also essentially different from each other. There are, in fact, as many poisons as there are fevers. And the greatest number agree in this, that they give rise to a febrile state which is continuous, or, according to the medical term, continued, until, it exhausts the power of the patient, or if his strength will permit, until the poison is eliminated. One poison is distinguished by the extraordinary peculiarity, i Professor Parkes' invaluable " Lumleian Lectures on Pyrexia" deserve" careful study by all who take an interest in the pathological phenomena of fever.—Medical Times and Gazette, March 17th, 1855. 96 LECTURE V. that, after infecting the system for a certain time, giving faint or no indications of disturbance, a form of fever is engendered which is distinguished by more or lesfc complete remissions of the febrile state. These occur periodically, and form part of a peculiar train of phenomena, consisting of a cold or shiveriug state, a hot febrile state, and a sweating state or stage, out of which the patient gradually passes into a non-febrile state, or one of apyrexia, and remains quite well until an interval of twenty. four, or forty-eight, or seventy-two hours has passed by, when the same train of phenomena will be repeated. It would almost seem as if the marsh or paludal poison, upon which this fever depends, underwent, with varying rapidity, some increased development, at the acme of which the peculiar three-stage phenomena come on ; these subside Avith the elimi- , nation of a certain portion of the poison from the system by the sweating process, to be renewed when in due course a fresh development of the poison takes place. It seldom happens that the marsh poison, once admitted into the human system, ever becomes perfectly eliminated from it; and persons once infected, are for this reason ever after liable to renewed attacks, under even the slightest malarious influences. When that curious compound pus, a product of disintegrated tissue, enters the current of the circulation, it engenders a peculiar fever, of which the phenomena are increased heat of skin, accelerated pulse and respiration, and depression of nervous power, sometimes so great as to kill very quickly by sheer ex- ##j haustion. But, in most cases, the fever persists, and soon signs of elimination shoAV themselves in local collections of pus in various parts of the body. After these have been evacuated, if the vital powers of the patient are sufficient to. bear up against the trying and exhausting process, often of tedious duration, recovery takes place. I must limit my remarks on this occasion to the subject of continued fever. % Of this, it may now be, fairly admitted that there are three varieties, as proved by the excellent researches of Stewart, Jenner, and others in this country, America, and on # the Continent. These are the Typhoid, Typhus, and Relapsing fever, each produced by a distinct, although doubtless very similar poison. As the Relapsing fever is comparatively of rare ON CONTINUED FEVER. 97 occurrence, I shall confine myself to the Typhoid and Typhus varieties. The term Typhoid is applied to that kind of continued fever which is accompanied by catarrh, diarrhoea, or a tendency to it, and more or less abdominal tenderness and tympanitis; and in which, after death, Ave find a morbid condition of the solitary glands, and of Peyer's patches in the ileum, amounting some- times to irritation and enlargement only, in other cases to sloughing and ulceration. Another feature, characteristic of typhoid fever, is the development of a peculiar eruption of circular, slightly elevated, rose-colored spots, often of consider- able size, which fade or vanish momentarily under pressure; these make their appearance from the fifth to the twelfth day, or even later, and are generally confined to the chest, belly, or back. The appellation Typhus, on the other hand, is applied to those cases in which the symptoms of intestinal irritation are absent, and Avhich are marked by a copious eruption, consisting of small, irregular, reddish, or purplish spots, which generally run together so as to form irregular or crescentic patches, not confined to the chest and abdomen, but often to be found on the extremities, and indeed covering almost the entire surface, and on the whole nearly resembling the eruption of measles. The case of Gavin (Case XVI), which I detailed to you in my last lecture, is a good example of the Typhoid form of fever, excepting that the rose spots were not developed. The following case is, in some respects, a better illustration, as the catarrhal symptoms, the rose rash, and the diarrhoea Avere all Avell marked; it is also a good example of the treatment which I advocate in these cases. Case XXTV.1 (Vol. xxxix, p. 143.) M. A. Copstock, a nurse- maid, eighteen years of age, was admitted into King's College Hospital, February 5th, 1852. Her illness commenced eight days before, with pains in her limbs, which she attributed to some trifling exposure'to cold and night air. Carbonate of am- monia was administered in five-grain doses every third hour. • On the third day after admission, her condition was as fol- lows :— 1 Reported by Mr. (now Dr.) Plowman. 7 98 LECTURE V. Her face looked puffed and heavy, her eyes suffused ; she com- plained of headache, and seemed confused and drowsy; the skin felt hot and dry, and the tongue Avas coated Avith a Avhitish fur. There was a troublesome cough, Avith expectoration of-a scanty viscid mucus of rusty tinge. On listening to the chest, slight rhonchus and crepitation Avere heard here and there, both in front and behind. [There Avas considerable tenderness on making pressure over the belly, and she had passed three copious liquid evacuations during the night, and tAvo that morning. No spots were then found on the skin. Her pulse Avas 108, and respira-. tions 38. An enema of starch and opium was directed to be given after every loose stool, and turpentine stupes to be applied to the belly. On the next day, the 8th, beyond the check to the diarrhoea by the enemata, there was no distinct alteration, either for worse or better, in the general condition of our patient. Six drachms of brandy were ordered to be given every second hour. On the 9th, she Avas extremely droAvsy and unwilling to be disturbed. The brandy was increased to an ounce every hour. On the 10th, the fourteenth day of the disease, all the same symptoms continued, but on the Avhole she seemed better. A number of scattered rose-colored spots were observed, for the first time, on the chest and belly. She showed a great aversion to the brandy. There was no material change on the 11th and 12th, but as the diarrhoea continued, the ammonia was given in decoction of log- wood, and the starch and opium enemata Avere administered as before, with decided benefit. On the evening of the 12th, she seemed more prostrate, and the brandy was increased to an ounce every half hour. Her condition on the 14th Was scarcely better, the same symp- toms continued: breathing urgent, 48 times a minute; pulse 116 ; cough frequent and hard, with expectoration of simple mucus ; profusf liquid evacuations recurring from time to time, but kept in check by enemata ; the same drowsy condition and dislike to disturbance; the hot and dry skin, with scattered spots becoming fainter. She continued to exhibit the greatest aver- sion to the brandy and beef tea, swallowing very imperfectly what was put in her mouth, so that the proper amount of food ON CONTINUED FEVER. 99 and stimulants Avere administered with great difficulty. This is not an uncommon feature of such severe fever cases as that of this patient ; it demands»great firmness on the part of the prac- titioner, "and in no conjuncture will he more require the active co-operation of an experienced nurse; timid and anxious rela- tives and friends are not to be depended on in such emergencies. On the 15th, as there was some increase in the catarrhal sounds heard over the front of the chest, turpentine stupes were ordered night and morning. In the evening she became more drowsy; her head Avas therefore shaved, and acetum cantharidis applied to the scalp. On the 16th,-which Avas about the twentieth day of the dis- ease, a very decided improvement took place: she was more lively, slept quietly, and a profuse perspiration, in all probability critical, burst forth; her pulse fell to 112, and the respirations to 40. This improvement continued the next day ; her tongue and lips began to clean, and the eruption had disappeared from the skin. On visiting the hospital in the afternoon, I found her again more droAvsy, and thinking that the drowsiness indicated over-stimulation, I reduced the brandy from an ounce to six drachms every half hour. After this the drowsiness passed off, but for many days the improvement was slow ; her cough continued troublesome, the boAvels relaxed, and the pulse and breathing high. A second attempt to reduce the stimulants led only to their renewal in the previous doses. From the 25th (the twenty-eighth day of the fever) the pulse fell in frequency rapidly ; the brandy Avas reduced. It was not, hoAvever, until the 4th of March that the cough had given way: she then felt well and anxious to get up ; her pulse was 80 and respirations 30 ; she slept well and her appetite was good. She left the hospital on the 12th (forty-eighth day) quite recovered. You will not often meet with so severe a case as this ending in recovery. I cannot but believe that the favorable result Avas owing to the steady exhibition of support of all kinds, especially of Stimulants, from the earliest period of the disease. Still it is curious to observe, how about the twentieth day a marked favora- ble change took place, and was accompanied by a profuse sweat- ing, apparently of a critical nature. As a good example of the Typhus form of fever, allow me to 100 LECTURE V. direct your attention to the particulars of a case which proved fatal in the hospital in September, 1853, and which I shall have to refer to again. Case XXV.1 (Vol. xliii, p. 103.)' E. Church, a man, aged 50, was attacked with shivering and pains in his limbs. In the course of a few days he was too ill to remain up and about, and therefore took to his bed. He suffered chiefly from great pain in his head, and there Avas some delirium. He was admitted to the hospital, September 18th, 1853, about a week after the shivering. He Avas then not sufficiently conscious to understand Avhat Avas said; his tongue was dry and coated with broAvnish black sordes; pulse 100 ; a measly rash covered the whole front of the chest and abdomen. A blister Avas applied to the scalp, ten minims of chloric ether with five grains of carbonate of ammonia Avere given every four hours, and half an ounce of brandy with beef tea every-half hour. The brandy was increased to six drachms in the afternoon. He continued delirious through the night, and in the morning seemed more insensible ; he passed his urine unconsciously, and could with difficulty be made to take the brandy. There was con- tinual hiccough ; pulse 100. A large blister was allied so as to cover the loAver part of the chest and the stomach. On the 20th the delirium rapidly gave place to coma. The hiccough continued. Pulse 92. In the evening the urine Avas found to be albuminous and to contain blood casts; and on this account the physician's assistant discontinued the stimulants. At ten o'clock his pulse was much weaker, and had risen to 110; at eleven, it was imperceptible. Convulsions and death followed shortly afterwards, the disease having existed only ten days. On examining the body after death, a small quantity of serum was found under the arachnoid. The lungs Avere much congested and also the spleen. There Avas no evidence of kidney disease excepting a slightly granular appearance. It may be suggested that this was a case of uraemic poisoning from renal disease, and not typhus at all. The measly rash was sufficient evidence of typhus, which in this case may have at- tacked a subject suffering from diseased kidney in an early stage. No doubt the influence of the poison in this case Avould 1 Reported by Mr. C. Macnamara. ON CONTINUED FEVER. 101 embarrass the action of the kidneys more than it is well knoAvn to do even when those organs are healthy. Admitting as I do the existence among cases of continued fever of tAVO clinical • varieties, the typhoid and typhus, I am nevertheless convinced that instances every noAV and then occur, in which the distinction cannot be made, unless the presence or absence of enteric symptoms alone, or of some other single symptom, be taken as diagnostic. The following cases will serve to explain my meaning. Case XXVI.1 (Vol. xl, p. 264.) Daniel Ragen, aet. 24. His illness began on the 2d of March, 1854, with headache, but no distinct shivering ; and he Avas admitted on the 6th with fever, a rapid pulse, a broAvn and dry tongue, and suffering great pain in his head. Severe headache continued throughout, as a promi- nent feature of the case. On the evening of the 8th, he was tAvice purged, and a mix- ture .of chloric ether and decoction of logwood AATas ordered; also half an ounce of brandy every two hours, and beef tea. Some rose spots Avere observed thickly scattered over the belly and chest. Pulse, 104, respirations 22. The next day the purging had ceased, the other symptoms continued, and he coughed and expectorated some broAvnish mucus. It was thought advisable to shave his head on account of the pain. On the 10th a measly eruption was fully developed on his chest, belly, and back. A blister was applied to the scalp. On the 11th, the respiration was rapid and labored, 44 times in a minute; the pulse continued the same; there were some droAvsiness and delirium ; the diarrhoea returned, but Avas con- trolled by an enema of starch and opium. On the 15th, being the thirteenth day of the attack, the pulse had fallen to 96 ; there was great improvement in all the symp- toms, and the enema and logAVOod were discontinued. The fol- lowing day there was some return of diarrhoea, which was checked by a repetition of the enema. He expectorated, with difficulty, a viscid mucus, which seemed to choke up the lungs. General improvement continued; and by the 20th, his pulse had 1 Reported by my clinical clerk, Mr. Bird. 102 LECTURE V. fallen to 76. On trTe 22d, he was pronounced quite convalescent. He remained some time longer in the hospital, with pain in his side. # This, then, was a case in which, with a Avell-developed rubeo- loid eruption, enteric symptoms Avere nevertheless present; it had some features of typhus, and others more prominent of typhoid, and there was the occurrence of the two eruptions in one person. Case XXVH.1 (Vol. xliii, p. 39.) John Cahill, aged 42 years, was attacked June 16, 1853, Avith pain in his head and hips ; but, although ill, he continued his work until the 19th, when he Avas seized Avith shivering, and increased pain in his head and limb's, accompanied by total prostration of strength and loss of appe- tite. He had been purged excessively by a dose of salts. One of his children and several people in the same street were suffer- ing from fever. He Avas admitted on the 28th. On the 29th he complained of cough and sore throat; his boAvels had been tAvice moved: a number of deep rose-colored spots were observed covering his body. Pulse 104, respirations 28. He Avas ordered a mixture of chloric ether and ammonia, to be taken every third hour, and half an ounce of brandy every two hours. On the 30th the pulse and respirations Avere 100 and 24 re- spectively. BoAvels open once. By the 2d of July, the spots had almost died aAvay. Pulse 100, respirations 23. On the 3d, the pulse and respirations Avere 104 and 24; on the 4th, 112 and 28. The bowels continued regular. On the 5th, the pulse had fallen to 96, the respirations remained 28. He still complained of sore throat, for which a blister was applied over the larynx. On the 6th, about the twenty-first day of the disease, he was in every respect much better: his appetite good, pulse 90, respi- rations 24. From that time he made a rapid recovery. On the 8th, the pulse and respirations were 80 and 20 respectively; on the 10th, 78 and 20 ; and on the tAvelfth, 78 and 24. On the 24th, he was discharged well. Cases of fever are occasionally met with, which run their 1 Reported by Mr. C. Macnaraara. ON CONTINUED FEVER. 103 course and prove fatal, without the occurrence of any serious diarrhoea, and yet, on making a post-mortem examination, ex- tensive ulceration is found in the ileum. I Avell remember a, case of this kind Avhich proved fatal in the hospital as long ago as the beginning of 1850. . Case XXVni. (Vol. xxviii, p. 32.) The patient's name was Ada Dacon; she was eighteen years of age. Her illness com- menced in the ordinary Avay, with rigors and pain in her head, back, and limbs, and had lasted a fortnight when she first came under treatment, January 19th, 1850. She Avas then in a high state of fever, and complained of frontal pain, great depression, loss of sleep with frightful dreams ; there was some abdominal tenderness, but no relaxation of bowels. Her pulse and breath- ing were 120 and 30. On the 22d, some of the aromatic spirit of ammonia Avas or- dered to be given in camphor mixture every six hours, and six ounces of wine in the day. On the 24th, there were bronchial rales heard pretty exten- sively; she could not sleep, but lay drowsy and moaning. Pulse 130, respirations 32. A blister was applied to the back of the neck, and a mustard poultice to her chest. On the 25th, or the 21st day of the fever, she was much sunk ; her pulse and breathing Avere increased in frequency to 144 and 44; she had passed two relaxed motions, for which an astrin- gent and stimulating mixture was ordered. There was no return of diarrhoea, but she continued in much the same stSte until the 29th, Avhen she became rapidly AArorse and' insensible, and died the following morning. At the post-mortem examination, Ave found numerous well- defined ulcers, situated in the loAver part of the ileum, and one or tAvo large ones, involving the ileo-caecal A7alve. Besides such well-marked exceptional cases as XXVI and XXVII, Ave meet with others, from time to time, in which the eruption is not either of the typhus or typhoid kind, but some- thing intermediate ; and in which abdominal symptoms may or may not be present. Others again, though Avell-defined and even fatal cases of continued fever, will exhibit throughout no eruption of any kind.1 1 I may here notice very briefly two other cases to illustrate these exceptions. James Scott, set. 14, was admitted with fever, July 11th, 1855 (vol. xlviii, p. 104 LECTURE V. Besides the specific eruptions, Ave frequently meet Avith dark, purplish specks of a variable size, called petechia'; they are pro- duced by little extravasations of blood beneath the cuticle, and of course do not disappear on pressure. They are not peculiar to the fevers we are considering, but are common to them and to other fevers and diseases of debility. They were present in the following low typhoid case, and the spots in the patient Selby (Case XXXIV) had very much the petechial character. Case XXIX. (Vol. xxxvi, p. 24.) Emma Turner, ret. 17, was admitted a fortnight after shivering, Avith symptoms of Ioav typhoid fever. Her pulse was then weak and rapid, 128; respi- rations hurried, 36 ; her tongue was dry and brown, and her teeth and lips were covered with sordes. She Avas passing loose, dark, and extremely foetid motions, and complained of great abdominal tenderness. Petechiae Avere present on the abdomen and back. On listening to the chest, rhonchus Avas heard both in front and behind. She was constantly moaning, occasionally screaming out, and delirious. Half an ounce of brandy Avas given every two hours; also chloric ether and astringents, opiate enemata, and turpentine stupes to the belly and chest. For three days she remained in much the same state: the bowels continued relaxed and the motions were passed uncon- sciously, the pulse ran high, food and stimulants were adminis- tered Avith great difficulty. On the fourth day after admission, she sank into a state of stupor, and died at night. 106). He had then been ill about a fortnight. He was deaf, and his body covered with rather large rose-colored spots. Pulse 120. His bowels had been costive and were still confined. He was treated by moderate stimulation. On the 14th he was sweating freely ; pulse 92, He continued improving daily, and by the 20th was pronounced convalescent. There had been no looseness of the bowels throughout. Joseph Garland, set. 18 (vol. xlii, p. 85), was attacked with sickness, giddiness, pains in his limbs and bleeding from the nose ; and some days after by shivering, followed by severe fever and loose bowels. He was admitted on the 19th May, 1854,—the seventh day. His eyes were bloodshot and suffused, his throat sore, his breathing rapid ; an indistinct diffused rash covered his chest and arms. He con- tinued very ill and much purged for five days. Brandy and beef tea were regularly administered, and the diarrhoea restrained by opium enemata. On the 24th there was decided improvement, and by the 29th he was convalescent. ON CONTINUED FEVER. 105 There is yet another form of eruption, Avhich you will have frequent opportunities of seeing in fevers of this class—an erup- tion of minute, pearly vesicles, scattered in profusion on the skin of the neck, chest, &c.; these have been called miliaria or sudamina, and, as I mentioned in my lectures on rheumatic fever, are not peculiar to any one disease, but common to many, and indicative generally of a sweating state ; hence I prefer the term sudamina to miliaria. I may add that they do not require a general sweating for their development; a local sweating, such as may occur in a fissure betAveen folds of the skin, is often suffi- cient to bring them out there. I must now proceed to consider, briefly, the more common complications of fever: those involving the lungs, brain, bowels, or kidneys, which I have not yet mentioned; and the plan of treatment I usually pursue in each. Whenever the natural interchange of material between the blood and the tissues is imperfectly performed, the capillary force of the circulation is deficient, and the circulation through the capillaries becomes sluggish and imperfect. This is what occurs Avhen an unhealthy blood is circulated—blood, for ex- ample, charged with the poison of typhus, or with urea; and Ave consequently find, in all such poisoned conditions of the blood, a tendency to local congestions, often of vital organs. Hence it is that Ave meet Avith pulmonary congestion as a com- mon complication of continued fever; it is a purely passive con- gestion due to the altered quality of the blood, and it has no resemblance, except as regards the hyperaemia, to inflammatory congestion. When fairly established and persistent, it is marked by Avheezing, and more or less of crepitation, with increased bron- chial secretion of mucus, occasionally tinged with blood, which the patient coughs up. This condition was well marked in the patient Copstock (Case XXIV), also in Selby, to whom I have before referred, and whose case I will quote in detail presently (Case XXXTV). The case of Emma Turner (Case XXIX), just referred to, affords a third example. Instances might undoubtedly be found of the occurrence of a true inflammatory bronchitis, and even of pneumonia, in the course of continued fever; but these must be looked upon as extraordinary complications. I could instance several fatal cases of fever, in which patches of lung have been found carnified 106 LECTURE V. after death. In these cases, the congested state of the lungs was intense, and the solidification seemed due to the great en- gorgement and increased secretion, rather than to plastic exuda- tion. At the same time, this exudation now and then takes place both into the air-cells and on the pleural surface, but I doubt not that it is then simply the result of the mechanical retardation of the blood in the finest bloodvessels. Case XXX.1 (Vol. xli, p. 58.) Sarah Beeson, aged tAventy- three, an artificial flower maker, Avas admitted into King's Col- lege Hospital, July 9th, 1853. She had been living badly, and in the midst of bad smells, and working hard. On admission, she was scarcely able to stand; she complained of severe headache ; her eyes were suffused; her tongue coated, dry, and brown; her skin covered with a copious rubeoloid erup- tion ; her pulse numbered 130, and respirations 26. She was ordered ammonia, with chloric ether, and two drachms of brandy every hour. At night, she became delirious; and the delirium lasted through the next day, becoming worse at night, so that she could with difficulty by kept in bed. Her head was shaved and a blister applied. The other symptoms continued much the same as on admission, the pulse and respirations rather increas- ing in frequency. On the 11th, as she continued wild and delirious, tAVO doses of morphia were given, which procured' her some sleep. The fol- lowing day there was less active delirium and more droAvsiness. She was slightly purged, for which an opiate enema was admi- nistered ; and as exhaustion seemed increasing, an enema of quinine and beef tea was ordered every tAvo hours. On the 13th, she was no better, but remained in the same drowsy state; her breathing was hurried, and there was some recurrence of diarrhoea. Opium was added to each quinine enema, and an ounce of brandy given every half hour : turpen- tine stupes were also applied frequently to her belly and chest. On the 14th, her pulse and respiration had risen to 140 and 44; and the next day she died. On examining the body after death, the lungs were found to 1 From the notes of my clinical clerk, Mr. Colston. ON CONTINUED FEVER. 107 be much congested, and the lower lobe of the right lung solidi- fied, exhibiting a carnified rather than a hepatized appearance. The brain substance appeared healthy: there Avas a little fluid under the arachnoid. The spleen was greatly congested, and broke down easily under pressure. In the treatment of these local congestions, you will do Avell to keep in view their nature : that they are but symptomatic of the general disorder, the direct results of the vitiated state of the blood ; and that with a return of the latter to its normal condi- tion, a resolution of the congestion may be expected. I would not, therefore, advise you to be very anxious to adopt any specific measures beyond those which I have recommended for the treat- ment of fever cases generally: the due support of the patient by suitable food, and stimulants proportioned to the exigencies of the case. The local treatment need not on this account be neglected. You will- find as the most efficacious, and the least likely to be injurious, free counter-irritation by turpentine fomentations and occasional blisters of good size, and applied at various parts, such as we employed in the cases of .Copstock, Church, Turner, and Selby. The same cause which operates in the production of pulmonary congestion, is often effectual in producing a congested state of the brain, though of this almost the only evidence Ave have is de- rived from the post-mortem examination of fatal cases ; for the only symptom of a congested brain occurring during life, with which I am acquainted, is a soporose condition bordering on coma; but this might very well and generally does result directly from a poisoned condition of the brain itself, and not from a mere increase or stagnation of blood in the organ. It must not be lost sight of, that much of the congestion of the brain observed after death, is due to the mode of dying. When the breathing is hard, when the moribund state is tedious, and above all, when the pa- tient has been convulsed just before death, the greatest degree of congestion may be expected. I Avill quote tAVO cases illustrative of the greatest amount of morbid change which you are likely to find connected Avith the brain in those who have died of fever. In one we found the con- 108 LECTURE V. gested state marked by some darkening of the gray matter, and the occurrence of numerous bloody points in the white ; Avhile in the other a similar state had resulted in effusion into the ven- tricles. Case XXXI.1 (Vol. xli, p. 6.) Charles Andrews, a painter, of intemperate habits, but generally good health, Avas taken ill on the 1st of May, 1853, with shivering, folloAved by heat and perspiration. The following day he had Avhat his wife described as a fainting fit, and was insensible for some minutes. From the commencement of his illness, until his admission to the hospital on May 7th, he vomited constantly, and Avas also much purged. When admitted, he complained of feeling droAvsy and confused; considerable muscular tremors Avere present; he had almost en- tirely lost his memory, and showed a tendency to delirium. These symptoms, with the dry lips, furred tongue, suffused eyes, hot and dry skin, covered Avith an eruption of light-colored spots, resembling the eruption of measles, and the rapid pulse and re- spiration, told plainly enough the nature of his complaint, and the large dose of the poison Avhich he must have received. A mixture of chloric ether and ammonia, and half an ounce of brandy every hour, were prescribed. The next day his pulse and respirations had fallen from 100, and 44, to 96, and 36, respectively ; but the pulse was extremely feeble. There had been no recurrence of diarrhoea. At night, hoAvever, he passed five liquid evacuations; and an opiate enema was ordered. On the 10th, the brandy was doubled, his head shaved, and a mustard poultice applied to the scalp. His pulse rose to 116, and the respirations to 40. During the 11th and 12th, the same symptoms continued and increased, the most prominent were restlessness and delirium at night, jerking of the limbs, general and excessive muscular tre- mors, and relaxed bowels, or ineffectual efforts to pass an eva- cuation. The brandy was increased, and turpentine and catechu given, but he died on the morning of the 13th. At the post-mortem examination "no effusion was found be- neath the arachnoid, or in the ventricles ; the membranes of the 1 Reported by Mr. Plowman. ON CONTINUED FEVER. 109 brain appeared perfectly healthy." " The brain itself Avas some- what congested ; the veins were turgid Avith dark blood; the gray matter of the convolutions was slightly deepened in color, and very numerous bloody points Avere seen on slicing it so as to display the centrum ovale." " The brain substance Avas hard and firm." The spleen was very soft, almost of a creamy or pulpy consistence. In this case, the symptoms were due in my opinion to the poisoning of the nervous matter of the brain; in other Avords, to its perverted nutrition ; and the fatal result was much hastened by the diarrhoea Avhich showed itself so early. Case XXXH.1 (Vol. xviii, p. 9.) The other case is that of James Davis, set. twenty-four, a man of temperate habits, AArho was admitted, May 13th, 1846, with fever. The commencement had not been sudden or marked by any shivering, but gradual, with languor and pains in his limbs, head, and loins. He had been ill for more than a week before admission, and during the latter part of the time, delirious. Qn the day after admission, he was still delirious, passed some Avatery evacuations, complained of much abdominal pain, and Avas unable to empty his bladder, which became rapidly dis- tended and had to be emptied with a catheter. Pulse 104. His head was shaved; five grains of carbonate of ammonia were ordered three times a day, and half an ounce of Avine every two hours, with beef tea. The next day there was no return of purging, but the other symptoms continued and increased; his pupils were dilated, and he lay continually on his back. One ounce of brandy was now given, alternately with an ounce of Avine, every hour. On the 16th and 17th, he continued much the same; some rhonchus was heard in the chest, and his belly became tympa- nitic, and the mucous membrane of the mouth very foul with sordes. He died on the 18th. In this patient, as in Andrews, there was much subsultus ten- dinum. At the examination of the body after death, the membranes of the brain Avere found much" congested, as also the white sub- 1 Reported by Mr. R. D. Mills. 110 LECTURE V. stance of the hemispheres, which Avas thickly studded Avith red points; the Avhole brain was softer than natural; there was a large effusion of pale straw-colored fluid into thg ventricles. I have no doubt that in this case as in many others, the ven- tricular effusion Avas a passive dropsy consequent on the retarded cerebral circulation. There Avere evidences of tuberculous disease of the lungs and mesenteric glands. Peyer's patches were very prominent, and increased in size, but not ulcerated. The subarachnoid effusions Avhich Ave meet with noAv and then after fever are not of an active kind. They are the result of a certain shrinking of the brain, fluid being poured out to fill up space. Do not fall into the mistake of supposing that an effusion of this kind is instrumental in causing comatose symp- toms. It, in truth, exercises no more than the normal pressure Avhich seems a necessary condition of the brain's nutrition. Of the cerebral symptoms—delirium, coma, and convulsions —two of which, at least, are of frequent occurrence in continued fever, I can only repeat Avhat I said Avhen speaking of the same symptoms in my lectures on rheumatic fever—that we have no grounds at all for supposing them due to any inflammatory or congested condition of the brain or its membranes, but must rather consider them as t\e result of that perverted nutrition which is the necessary consequence of the poisoned condition of the nutrient fluid. With respect to the treatment of these symptoms, what I said in speaking <5f the treatment of pulmonary complications is ap- plicable here also ; you must treat them as part of the general disorder, not as distinct diseases. An increase of these symp- toms, especially of the delirium, usually indicates an increasing exhaustion, and therefore demands a larger supply of stimulants. Of local remedies, I find the application of blisters to the scalp and back of the neck, and the employment of a cold affusion either to the head, or over the whole body, the most efficient means of rousing a patient from a drowsy comatose state. The dpuche sometimes, acts like a charm; it is most applicable to cases in which a lethargic state supervenes early, and before ON CONTINUED FEVER. Ill there is great exhaustion ; and it should ahvays be employed with as little distress to the patient as possible. The three following cases are good examples of the occur- rence of cerebral symptoms, and of the treatment I have recom- mended. Case XXXIII.1 (Vol. xli, p. 197.) Zechariah Stilling, set. 26, an Irish laborer, of irregular and intemperate habits, was brought to the hospital, February 11th, 1854, Avith unequivocal symptoms of fever,—a hot and dry skin, brown and furred tongue, some stupor, loose watery evacuations, numerous rose-colored spots, disappearing or becoming pate on pressure, and harsh respira- tion heard over the front of the chest. The attack commenced about nine days before with shivering, headache, and consider- able diarrhoea. Half an ounce of brandy was given every three hours, and beef tea ; also some aromatic spirits of ammonia in decoction of logwood. From the 11th to the 14th there was no change; his pulse continued 116, and the prominent symptoms were a noisy, rest- less delirium, with an obstinate determination to get up and leave the hospital, and great pain in his head. On the 13th the brandy was increased to half an ounce every two hours; and on the 14th his skin was moist and his pulse had fallen to 100, and from that day to the 20th it gradually de- clined to 50. On the 15th and 16th he was still restless and wandering, with pain and noise in his head. Mustard poultices were applied to the scalp. All the bad symptoms, however, rapidly passed off; the brandy was gradually reduced; and by the 28th he was fairly convalescent. There had been no return of diarrhoea throughout. In this case the active stimulation had not been commenced sufficiently early. Had it been otherwise, the delirium would • have been less developed. Case XXXIV.2 (Vol. xxxix, p. 59.) John Selby, set. 27, a detective police officer, of temperate habits and previous good 1 Reported by Mr. Buzzard. s Reported by Dr. Plowman. 112 LECTURE V. health, Avas admitted to the hospital, December 11th, 1852, in a state of almost complete coma. It appeared, that about ten days previously he had been seized Avith severe rigors ; he then grew rapidly ill, suffered from considerable purging, and, during the two days preceding his admission, Avas delirious. I Avill read you the report made by my clinical clerk of his condition on admis- sion : " He appeared perfectly unconscious, and quite unable to SAvallow anything: AArhen it Avas attempted to give him fluids to drink, they simply collected in the mouth, scarcely any passing into the oesophagus, and were sloAvly ejected by each expiration. His abdomen Avas covered by a great number of small, circular, someAA^hat purplish or mulberry-colored spots, having much the character of petechiae, not raised, and not disappearing, though slightly fading at their circumferences, under pressure. There wras no marked tenderness of the abdomen. Pulse 140, respira- tions 30." Beef tea and half an ounce of brandy were administered every half hour, a mustard poultice was applied to the back of his neck, and a turpentine stupe between the shoulders. His head was shaved and a cold douche applied. The bladder was emptied by a catheter. Great benefit seemed to result immediately from this free counter-irritation and stimulation ; he Avas completely roused from his stupor and appeared altogether much better. On the folloAving day, the 12th, the improvement continued; his pulse and respiration had fallen to 112 and 24 respectively; he had passed his water freely, though involuntarily, and his bowels had moved, but the motions were not relaxed. Some of the acetum cantharidis Avas rubbed on the scalp. He passed a quiet night and slept well; but we were disap- pointed in the morning to find him decidedly weaker, his pulse" risen to 120 and the respirations to 30, his tongue dry, Avith a thick brown coat. This Avas explained by the discovery that he had been neglected by the night nurse, who had omitted to give him the brandy and beef tea regularly. He passed a quantity of dark-colored acid urine, and some dark liquid faeces, volun- tarily. The brandy was doubled, and a blister applied to the scalp. On the 14th, after a comfortable night, he Avas again better, ON CONTINUED FEVER. 113 but his pulse remained the same, and he complained of some slight abdominal pain. On the 15th, as there was some cough Avith a dark sanguine- ous expectoration, a turpentine stupe Avas ordered. By the evening his pulse and respiration had fallen considerably, num- bering 100 and 22 respectively. The folloAving note Avas made on the morning of the 16th:— " He remains much the same. Has still a little cough, but the sputum is clear; breathing natural; the spots are becoming faded, and much fewer. Pulse 96; respirations 24. The tongue is tremulous but much cleaner; there is still no purging, and he does not complain of any particular pain in his stomach." The brandy Avas reduced again t« an ounce every hour. From this time there was steady improvement. The respira- tion and pulse declined; the latter Avas 92 on the morning of the 17th, and 88 in the evening; 84 on the morning of the 18th. His tongue became cleaner, his urine natural, and he passed good nights. An equal amount of Avine was substituted for the brandy : that is to say, twenty-four ounces of wine were given him daily, and under this the pulse came down in the manner detailed. There was something like a critical sweating on the 18th, Avhich was also the 18th day of the disease : the perspiration was profuse, and continued through the 19th and 20th. On the 21st he felt himself to be much stronger. His pulse was 80, full, and fairly strong, though still compressible ; respi- rations 20. He only complained of some confusion of thought, and of a swimming sensation in his head, which disappeared in the course of a week or ten days, as his strength returned. The amount of wine was gradually reduced, and on the 28th a quinine mixture was ordered, and on this treatment, with a liberal diet, he made an excellent recovery. He remained in the hospital until January the 22d, when he was discharged quite well and in almost his former strength. Case XXXV.1 (Vol. xxxix, p. 213.) Thomas Keen, set. 33, was admitted March 26th, 1853. Ten days before he had been seized with shivering, and for a 1 Reported by Dr. Plowman. 8 114 • LECTURE V. week afterwards suffered from relaxed bowels; but, from the time of his admission until he left the hospital, he was quite free from any recurrence of looseness or abdominal symptoms. He was ordered some carbonate of ammonia with henbane in effervescing mixture, morphia at night, and an ounce of Avine every two hours, with beef tea. During the night of the 26th he wTas delirious, and had not recovered his consciousness by the morning of the 28th. His face was then flushed and his eyes suffused, his skin hot and dry, and the tongue presenting a brown central band. Pulse 92. On his back and abdomen were scattered a few distinct, non-elevated, rose-colored spots, rather smaller than a split pea, and some of them entirely disappearing on pressure. A great number of sudamina were also present on the belly at the upper part. He coughed frequently, and rhonchus and sibilus Avere heard in front. On the 29th, there was more wandering, with drowsiness and slightly stertorous breathing. Pulse 120; respirations 28. The other symptoms were but little altered. On the 30th, brandy was substituted for wine. He appeared to derive benefit from the change, for he slept better, and was less delirious and more conscious. On April 1st, the brandy was doubled, i. e., an ounce was given every hour, his head was shaved and a mustard poultice applied. On the 2d, a cold affusion was administered. On the 3d, there was a fall in the pulse from about 100 to 86, notwith- standing twenty-four ounces of brandy daily ; and on the 4th, which was the 21st day of the fever, it did not exceed 72. He was then sweating profusely, the moisture running off his fore- head. On the 5th, the pulse was as low as 52. The brandy was reduced to four ounces, and porter and quinine given. On the 12th, he was convalescent. In a former lecture, I spoke at length of the exhausting diar- rhoea or hemorrhage which is apt to accompany cases of typhoid fever, and also of the morbid appearances found after death in the intestine. I shall have to allude to this intestinal hemor- rhage again, as one of the critical discharges by Avhich the fever sometimes terminates. ON CONTINUED FEVER. 115 There is another abdominal symptom for which you must be prepared. The affection to which I allude is a form of tympa- nitis, or meteorism, as it is called. It consists in an inflation of the intestinal canal by gas more or less rapidly generated within it. In consequence of this inflation, the belly becomes very pro- minent, tense, and drummy, and is highly resonant on percus- sion at every point. There is no. sense of fluctuation present, excepting when there may have been liquid diarrhoea, and a con- siderable quantity of fluid remains in the bowels. Under these circumstances an obscure fluctuation is perceptible, Avhich you must not alloAV yourself to be misled into supposing to arise from fluid in the peritoneum. That the fluid is within the bowels along Avith the air, is proved by the borborygmi and other metallic sounds, which are audible under the influence of the peristaltic action of the boAvels, or under strong pressure or suc- cussion of the abdominal walls. This distended condition of the boAvel is due to a secretion of air from the mucous membrane, partly also, possibly, to a gene- ration of gas from decomposition of the contents of the gut. There is no doubt a very defective nervous influence, which regulates imperfectly both the secretions and the muscular motion of the boAvel. ' This meteorism occurs, so far as my experience teaches me, in all the forms of continued fever, and does not, as one might suppose a priori, especially belong to that in Avhich the bowels are so apt to be irritated, namely, the typhoid. On the contrary, I should say, it is of more frequent occurrence in typhus. I may remark that this symptom has not been nearly so often met with in my own practice, since I have adopted the plan of thoroughly upholding my patients from the commencement. This tympanitic state is by no means peculiar to typhus or. typhoid fever. It occurs in other diseases of defective nervous influence : in severe diseases of the spinal cord ; in affections of the brain, such as acute meningitis, and in peritonitis. In all such cases, the influence of the intestinal nerves must be im- paired • the muscular coat of the bowel must in great degree lose its tone, and allow the bowel to become full and distended, through the want of the resistance which a strong muscular coat would oppose to the accumulation of gas. The treatment which we adopt for this condition in typhoid 116 • LECTURE V. cases consists in the external application of turpentine, in the form of hot fomentations to the belly, the frequent use of ene- mata with confection of rue and turpentine, sometimes a mild warm aperient, and in extreme cases, galvanism. Another incidental feature of fever cases, allied to the last, is a more or less perfect paralysis of the bladder, so that Avhen it becomes full no active contraction of the detrusor muscle occurs, and the sphincter remaining closed, the urine is retained, and the bladder becomes distended. If this is alloAved to continue, the urine will dribble away, and it may be long before the bladder recovers its muscular poAver. We had illustrations of this condition in the patients Selby and Davis. Let me advise you w7hen attending a case of fever to make frequent inquiry respecting the condition of the bladder, and if you can feel it forming a tumor above tjie pubis, to draw off the water with a catheter as soon as you can. I can say of this symptom, as of tympanitis, that under good support and stimulation from the commencement, it is of far less frequent. occurrence. • An albuminous condition of the urine is occasionally found in cases of continued fever. When it occurs, Ave must consider it owing to a congested condition of the kidneys, arising not only from the general tendency to capillary congestion, but possibly also from a functional effort on their part to eliminate some of the poison from the system. The urine of the patient Church (Case XXV) was very albuminous, and revealed blood casts under the microscope. When you find albumen in the urine, you will naturally suggest to yourselves, is this due to diseased kidney or to a temporary congestion ? The answer cannot be given at once : to discover any morbid change you had better wait till the fever has gone off. Meantime no harm is experi- enced by the passage of the albumen, and if there be evidence of morbid change, it must be dealt with when the patient has thrown off the fever. I have yet a feAv remarks to make on the manner in Avhich cases of fever terminate. You have all heard of the turn of a fever: the idea is an old one, as old as Hippocrates, that fevers are wont to change suddenly for better or worse on certain days called critical days. In later times the notion was discarded as little better than an old wife's fable ; but more recent observa- ON CONTINUED FEVER. 117 tions go far to establish the truth of it. The crisis of a fever is frequently marked by the occurrence of some copious evacua- tion, either of a natural kind, such as free sweating, which is by far the most common, or by some unnatural one, such as a pro- fuse bronchial secretion of watery mucus, or the passage of a quantity of blood from the bowels. This is followed or accom- panied by a rapid diminution of the febrile symptoms, and in favorable cases by speedy genera! amendment. This is not, however, invariably the case: a avell-marked crisis may occur, and perhaps be folloAAred by an abatement of fever, and yet from that time the patient, instead of recovering, may grow more comatose or exhausted, and the case terminate fatally. I will give you three examples of well-marked crises, one of which was unfavorable. •♦ Case XXXVI. (Vol. xxvii, p. 164.) William Brown, a painter, tAventy-nine years of age, who had been living badly for some ' time, towards the close of a week of unusually hard work, felt weary and indisposed, and on Saturday night was attacked Avith a fit of shivering, feeling alternately hot and cold ; he continued chilly and shivering all Sunday, and Avas admitted into'the hos- pital on the next day, Monday, May 28th, 1849, suffering severe pain in his head, back, and extremities, and with all the symp- toms of fever—heat, thirst, loss of appetite, furred tongue. After having a warm bath there AATas some perspiration, and a copious eruption of spots, called in the record of the case, petechial (?), Avas observed. His pulse numbered 100. A saline mixture of citrate of ammonia, and nitrate of potass was ordered, and a very small allowance of Avine with plenty of beef tea. The fever continued high for four or five days; he became deaf, stupid, light-headed; he coughed a good deal, and the eruption remained fully developed. The wine was increased to half an ounce every two hours. On the 2d of June (the seventh day of the fever) his boAvels became relaxed, and he passed a watery evacuation; this was followed, the next day, by a remarkable cessation of fever, the pulse falling to 60. He seemed, nevertheless, so extremely low, that eight ounces of brandy were ordered to be given in the next twenty-four hours; an enema Avas also given to check the bowels, 118 LECTURE V. and a large mustard poultice applied to the belly. From this time, however, the amendment Avas rapid, and he Avas discharged on the 14th of June, the tAventieth day from the shivering. In this case the purging seemed to mark the crisis. Case XXXVII. (Vol. xl, p. 47.) Jane Green, thirty-eight years of age, from the parish of St. Giles, Avas admitted to the hospital, May 24th, 1853, with fever. She stated that she had never had a serious illness, but that her habit had been to live badly, and drink hard. Her illness began, May 14th, with shiverings, perspirations, numbness of the hands and feet, deafness, relaxed bowels and nausea ; Avith a hard cough and sense of weight in her chest. She first applied at the hospital as an out-patient, but becom- ing much worse she Avas taken in. The following was her condition on admission: "Her pulse Avas 140, her skin very hot, her arms and chest dotted all over Avith red spots, and her tongue and teeth were covered with some blackish blood Avhich she had vomited just before. Her boAvels had been recently moved, and the motion was dark-colored and offensive!" She wras ordered five grains of carbonate of ammonia and fifteen minims of chloric ether every three hours, an ounce of brandy every hour, and a morphine draught at night. Her head was shaved, and a mustard plaster applied to the chest. On the next day, the 25th, an enema often grains of quina in tAvo ounces of beef tea was ordered every two hours, and the morphine draught to be repeated at night. On the 26th, she appeared much better, complaining only of thirst. She slept a good deal, but wandered at times ; pulse 110; her urine was found to be albuminous, and the skin on the buttock seemed threatening to slough. Acetum cantharidis was applied to the scalp, so as to produce vesication, and the enema of quina and beef tea continued every four hours. In the evening, she teas purged three times, passing very dark and offensive motions, for which a starch and opium enema A\ras prescribed. On the 27th, she seemed better; her pulse was 108, her tongue red and moist, the quinine enema was discontinued. ON CONTINUED FEVER. 119 On the 28th, the fifteenth day of the fever, the pulse had fallen to 90, and the patient was sweating profusely. The brandy was reduced to half an ounce every hour. On the 30th, the pulse was 84; and on the 3d of June 75. Her tongue was then clean, and a chop was ordered and wine instead of brandy. In this case, although great care had been used, a sore had formed in the gluteal region, which required poultices and after- wards stimulating dressings, and detained her some Aveeks in the hospital. Case XXXVIII. (Vol. xliv, p. 81.) Sophia Bruce was ad- mitted Avith fever July 26th, 1854. There had been two or three cases of fever in the house from which she came. Her illness had commenced with shivering, and the usual symptoms, seven- teen days before her admission. Shortness of breath had oc- curred very early, and formed a prominent symptom when she was admitted; crepitation and rhonchus Avere then also heard both in front and behind ; the usual febrile symptoms were pre- sent, and an eruption of scattered rose spots on the abdomen. Half an ounce of brandy Avas given every hour, alfo chloric ether and'ammonia, and enemas of salicin and beef tea; and turpentine stupes Avere applied to the chest. She continued much the same for some days. Her breathing Avas extremly rapid, exceeding 50; her pulse about 100; but t*he heart's action on the 29th wras nearly twice as rapid as the pulse. The brandy was doubled, and quinine substituted for salicin. On the 30th, the 21st day from the shivering, she was sweating very profusely; but from that day she become worse, and on the 31st, Avas semi-comatose; some purging also occurred. These symptoms continued, the diarrhoea with some intermissions, until her death on the 9th. After the sweating on the 30th, the fever seems to have abated ; for on the 3d of August, Ave have the following note, " Her skin is cool and moist; the fever seems to have abated." It appears to me that the cause of the fatal termination was the excess of the critical discharges, Avhich with the diarrhoea ex- hausted the patient. No doubt the attempt at relief by the natural process may occur, unsuccessfully. And herein we 120 LECTURE V. learn the importance of upholding patients from the commence- ment, that these critical evacuations may not produce fatal ex- haustion. Sometimes a crisis, though favorable, is marked by a temporary exacerbation of the symptoms, as in