*m ■ mr RESEARCHES THE STATE OF THE HEART, USE OF WINE IN TYPHUS FEVER. (X BY WILLIAM STOKES, M. D., M. R. I. A.,1 .£/f "xT/' Honorary Fellow of the King and Queen's College of Physicians, &c. &c. &c. - . ' >" («ft Before T enter on the investigations which form the basis of this paper, I may premise, that I consider typhous fever as an essential disease, not symptomatic of any known local lesion. To British readers this may appear unnecessary, as it is only the expression of opinions entertained by our most learned and experienced physi- cians. But as on the continent a different doctrine is held by some eminent pathologists, and as I have found it necessary to state to many continental physicians who have honoured the Meath Hos- pital with their presence, that we were opposed to the doctrine of localisation, I trust that the expression of these opinions will not be considered unnecessary or egotistical by my readers at home. There can be no doubt that the typhus of Great Britain and Ireland is a disease of the whole system, not symptomatic of any particular local lesion ; showing on the one hand a tendency to a favourable termination, after a period which varies indefinitely; and on the other, being capable of destroying life with various lesions, or without any appreciable change in the solids. It is a disease on which anatomy sheds but a negative light, not telling us what it is, but rather what it is not. With respect to the organic lesions, I consider them as much secondary to the general disease, as the pustule in small-pox is to the disease of variola. Their not unfrequent absence in the worst cases of the disease proves that they are not the cause of typhus, while in cases where they do occur, we observe a signal want of proportion between their amount and the severity of the symptoms. They are in the fullest sense inconstant in their seat and extent, 1 Dublin Journal of Medical Science, March, 1839. 1 mon a C-t-t/^W / /wv-w^ -* aH-^i* r'£->Hx v' ^y7i,. Ui. «Cx4r 2 STOKES ON THE STATE OP THE HEART, AND incompetent to the explanation of symptoms, and unnecessary to the characteristic phenomena of the disease. In making these observations I do not mean to throw the slightest doubt on the accuracy of those observations, which, accu- mulating for many years, have shown the singular frequency of intestinal ulceration in the fever at Paris and other situations on the continent. That there exists a much greater disposition to these forms of disease in those situations must be admitted, a fre- quency almost sufficient to justify the doctrine of the justly cele- brated Broussais, that typhus was but a gastro-enteric irritation. But as my excellent friend, Dr. Staberoh, has well remarked, we must study disease in various countries before we come to any conclusions as to its nature. Had Broussais examined the typhus of Great Britain and Ireland, he would never have formed his theory of fever.1 If we compare the inexperienced man with him who has had a long continued practice in fever, we may often observe that the former employs a too vigorous antiphlogistic treatment in the com- mencement of the disease, and delays the exhibition of stimulants until the powers of life are sunk too low, while the latter is much more cautious in husbanding the strengh of his patient, and shows much less fear of resorting to wine and other stimulants. It is in determining on the use of wine in fever that the junior or inexpe- rienced man feels the greatest difficulty; it is in its exhibition that he betrays the greatest uncertainty and fear. This is to be ex- plained by referring to the general character of the doctrines which have prevailed within the last quarter of a century, and which are only now beginning to yield to a more rational pathology. The doctrine of an exclusive, or almost exclusive, solidism, which 1 Dr. Lombard, of Geneva, has lately endeavoured to show that the typhus fever of Ireland is a peculiar affection, differing from that of the continent in the absence of ulcerations. (See Dublin Medical Journal vol. x. pp. 17, 101.) But the fact is, that intestinal ulcerations have been repeatedly observed in the typhus of Ireland, their amount and frequency varying with the epidemic influence. Of this we have abundant evidence in Doctor Cheyne's Reports. (See Dublin Hospital Reports, vols. i. and ii ) And in the epidemic of 1826 and 1827 we observed the follicular ulcera- tions (dothinenteritis of the French) in the greater number of cases. In many instances perforation took place, and the whole group of vital and cadaveric phenomena, corresponded almost exactly to the dothinenteric typhus of the French authors. The prominent symptoms were thirst nausea, epigastric tenderness, vomiting, diarrhoea, and tympanitis and in almost every dissection we found the ulcerated patches of the small intes- tine. Since then no severe or decided epidemic of fever has occurred but cases of typhus are to be met with, with or without this peculiar lesion The researches of Dr. Bright and the others in London, and of Dr Staberoh in Glasgow, show, that ulcerations of the intestine occur not unfreciuentlv in the typhous fever in these situations. We cannot then found anv jWp ral distinction of British or continental fevers on this circumstance thJ difference is in the degree of liability. This may be explained bv local circumstances, and original dispositions inherent in particular races THE USE OP WINE IN TYPHUS FEVER. 3 referred all diseases to visible changes of organs, which taught that inflammation was the first and principal morbid phenomenon, and that fevers were always the result, or accompanied with, some local inflammation, was, however disguised under various denomi- nations, the doctrine taught to the majority of our students. Their ideas were thus exclusively anatomical; inflammation formed the basis of their limited pathology, and thus instructed, they entered on the wide field of practice, most of them having never even attended a fever hospital; utterly ignorant of the nature of essen- tial fevers, they applied, in the diseases of debility, the treatment of acute local inflammation, and delayed stimulation until nature could not be stimulated. Let it not be supposed that in this picture I seek to make a favourable contrast between the education which I myself received and that given to others. Far from it; I confess that it was not until several years after I commenced practice that I became fully aware of the erroneousness of what is termed the anatomical theory of disease; and I feel certain, humiliating though the con- fession may be, that the fear of stimulants in fever with which I was imbued, was the means of my losing many patients whose lives would have been saved, had I trusted less to the doctrine of inflammation, and more to the lessons of experience, given to us by men who observed and wrote before the times of Bichat or of Hunter. The hospital physician will be frequently asked by students to state the principle on which he administers wine in fever, I con- ceive that the question may be thus answered. Typhous fever is a disease which has a tendency to a spontaneous and favourable termination, but one in the course of which the powers of life are attacked by a most malignant influence. By wine, food, and other stimulants, we support nature, until the struggle is past, so that, to use the words of an ancient author, which embody a more pro- found principle than appears at first sight, we " cure the patient by preventing him from dying ;" that is to say, we prolong his existence until the natural and favourable termination of the disease arrives. We do not allow our patients to die of exhaus- tion, and bearing in mind the depressing influence they have to struggle with, we give stimulants at the proper time, and with a bold hand. We give our patients an artificial life, until the period arrives when nature and health resume their sway. Yet, though we may admire the practice of an experienced physi- cian in the use of wine in fever, it will often be found that he has a difficulty in expressing any exact reason for adopting the practice in a particular case. His practice is founded on a knowledge which is often incommunicable, an almost instinctive perception of the necessity for stimulation, characteristic of the great physician, and only to be obtained by a long and close familiarity with the disease. But is there any rule by which the inexperienced man can be guided; any one distinct phenomenon, the observation of 4 STOKES ON THE STATE OF THE HEART, AND which is easy, and leading to an intelligible and communicable rule of practice ? If the following statement of facts shall assist the inexperienced man in the treatment of a single case of fever, I shall feel more than rewarded, for I am convinced that it is to the fear of wine, or to ignorance of the principles of its exhibition, that we are to attribute the loss of many lives in the typhous fever of this country. I shall first speak of the influence of wine on the circulation in fever, and examine the phenomena of the pulse, the force of the heart, and the character of its sounds. We have long observed, that when under the influence of wine the pulse became less and less frequent, the termination of the case was generally favourable, and as might be expected, the contrary result led to a bad prognosis. This practical observation I do not put forward as original, but I wish to express my great confidence in its truth. Let us suppose a case of typhus on the tenth day of fever, and presenting severe symptoms of prostration, the pulse varying from 115 to 120. Wine is exhibited, and on the first day the pulse rises to 125, and on the second to 130, and if on the third day there is no diminution, we may make a bad prognosis; and thus the fol- lowing rule may be laid down, that when, in a case where the symptoms seem to indicate wine, the pulse either does not come down, or increases in frequency under its influence, we may expect a bad result. These facts naturally lead to the examination of the state of the heart in typhus fever, and the cases in this report are so arranged as to exhibit together the condition of the heart, and the amount of wine employed. In this investigation we have sought for an additional rule, drawn from the state of the heart itself, to guide the inexperienced man in the exhibition of wine, and I am not without hopes, that in the careful study of the cardiac phenomena, an indication hitherto unobserved will be obtained. In typhous fever two opposite conditions of the heart may be observed; in the one the impulse becomes extremely feeble, or altogether wanting, while the sounds are greatly diminished in intensity; while in the other, the heart's action and sounds con- tinue vigorous throughout the whole course of the disease. These opposite states are not necessarily revealed by the state of the pulse or the warmth of the surface. We may observe a hot skin, while the action of the heart is almost imperceptible, and on the other hand a patient may be pulseless, cold, and livid for days together, while the heart is acting with the greatest vigour. The condition of the heart must be determined by the applica- tion of the hand and stethoscope to the infra-mammary and sternal regions. Of this principle the following case is an illustration :— THE USE OF WINE IN TYPHOUS FEVER. 5 CASE I. Petechial typhous fever with extreme prostration—Failure of the pulse, and coldness of the breath and surface, with vigorous action of the heart- Liberal use of stimulants—Employment of transfusion of blood—Death- Absence of organic lesion. ' ' A middle aged woman was admitted into our wards in February 1837, at an early period of her fever. She had attended upon and washed the clothes of a person who had died of a peculiarly malig- nant fever, yet on admission, and for several days subsequently, she presented no symptom beyond those of an ordinary and rather mild case of maculated typhus. From the first, however, she had a strong presentiment of death, which nothing could shake ; she gradually became more and more collapsed ; the surface was of a violet hue; the countenance sunken ; and the skin and breath cold. From the eighth day no pulse could be perceived at the wrist, although the heart's impulse was strong, and the sounds remarkably distinct. She continued in this condition for some days, during which time stimulants of every kind were freely resorted to; on the fifteenth day, the surface being icy cold, but the heart still acting with vigour, while no evidence of organic disease could be found in the abdomen or head, I advised transfu- sion, which was performed by my colleague, Mr. Smyly. About six ounces of recently drawn blood were injected into the median basilic vein ; a slight reaction followed, and the breath, which had been cold for several days, became warm. The pulse, however, did not return, and she died three days after the operation. On dissection no organic lesion of any kind could be discovered in any part of the body; the heart was firm, and its muscular structure natural ; no obstruction existed in any artery, but the whole quantity of blood seemed much diminished ; the consistence of the blood was somewhat pitchy, and its colour very dark. The wound in the arm was still gaping, and did not present the slightest appearance of adhesion or inflammation. This was certainly a rare form of fever, but, nevertheless, it establishes the point, that without any mechanical obstruction, we may have in fever, absence of the pulse, while the heart continues to act with vigour, and the case is one out of several which go to establish the conclusion to which! think we must, arrive, that a vigorous action of the heart in typhus points out that stimulants will not have so beneficial effect as in the opposite case. I shall present other illustrations of this principle in the course of the paper. I now recur to the division of cases of typhus into those with and those without altered phenomena of the heart. In the first class we observe :— 1. Diminution and ultimate cessation of the impulse. 2. Diminution of the intensity of the sounds. 2__q* 1 mon b 6 STOKES ON THE STATE OF THE HEART, AND 3. Cessation of one of the sounds. These phenomena, hitherto undescribed, are among the most interesting of those connected with the heart which I have ever observed, and I shall be able to show that they have a most im- portant application in practice, as bearing directly on the question as to the use of stimulants in typhous fever. I shall now present a series of cases observed particularly with reference to the heart. They are so arranged as to show first, the general symptoms ; next, the phenomena of the heart and pulse ; and lastly, the amount of stimulants employed. CASE II. Severe catarrhal typhus—Failure of the circulation—Cessation of the first sound of the heart—Use of stimulants—Recovery. John Keefe, astat. 20, of rather muscular frame, was admitted on the 11th of April, the seventh day of fever, with severe nervous symptoms, and all the signs, both vital and physical, of an intense bronchial affection, predominating in the left lung. The skin was thickly covered with bright red petechias, which were confluent, forming large patches on the arms and thighs; respirations 28. laboured ; pulse 120, small and very weak. The heart's impulse was visible, and the contractions audible, but the second sound greatly predominated over the first. It was loud and distinct, while the first was very feeble, particularly at the left side of the heart. DATE. GENERAL SYMPTOMS. April 12. Delirium ; intense bronchial rales ; in- satiable thirst; diar- rhoea. " 14. Continual moaning ; petechias more dif- fused, and dark co- loured. " 15. Countenance im- proved ; much deli- rium; bronchitis les- sened ; diarrhoea con- tinues ; the marks of the cupping glasses are black. 16. Looks better; slept well ; diarrhoea less. PHENOMENA OF CIRCULATION. TREATMENT. Pulse 120, weaker than yes- Cupping ; terday; impulse less percep- blister to the tible ; first sound nearly inau- sternum ; ano- dible; carotid pulsations of dyne enema, good strength ; extremities and poultices warm. to the belly. Pulse about 112 ; impulse Wine 10 oz. barely perceptible ; over the arrow root, de- left cavities the first sound is coct. senegae. scarcely distinguishable, while over the right it is more so; second sound very clear. Pulse 112, contracted and Wine 16 oz. compressible; no impulse of Blister to ab- the heart under the mamma; domen ; ano- the first sound totally inaudi- dyne enema ; ble, second less distinct than beef tea. yesterday, on the left margin of the sternum nothing can be heard but the second sound, and this feebly. Pulse 108, stronger and Repeat all. fuller; first sound audible over the whole praecordial region, second more distinct. THE USE OF WINE IN TYPHOUS FEVER. 7 DATE. GENERAL SYMPTOMS. PHENOMENA OF CIRCULATION. TREATMENT. April 17. Pulse 100; respirations 28 ; Wine 12 oz. impulse again perceptible. " 18. Impulse still stronger, strik- Wine 12 oz.; ing over a greater surface; jelly 2 glasses. both sounds distinctly audible at the inferior part of led side, and also to the right of the sternum; pulse 96; respira- tions 32. " 19. Bronchitis much less; Pulse 76, full, of good Wine 6 oz, petechias fading; bovv- strength; heart's impulse more els regular. vigorous; sounds as yester- day. " 20. Pulse 88; phenomena of Wine 6 oz. heart natural. • " 21. Ditto, ditto. Wine 4 oz. " 23. Convalescent. Patient discharged on 2d May, perfectly well. In this case, and that which follows, we observe the remarkable and important peculiarity of the supervention of bad symptoms of prostration and putrescence at an unusually early period of the disease. This circumstance should always excite great apprehen- sion, and lead to the exhibition of stimulants, notwithstanding the existence of various local irritations. In both these cases the chest and abdomen were severely engaged, and in both the early exhibi- tion of wine not only did no harm, but was productive of the hap- piest effects. The existence of signs of bronchitis or enteritis in our maculated fever does not necessarily contra-indicate the free and early use of stimulants. In examining the efficacy of wine in typhus, if we compare the cases with predominance of enteric, and those with bronchial irrita- tion, we generally find that in the latter group the stimulant is better borne, and there is a class of cases in which wine is scarcely admissible. These cases present signs of enteric irritation of great severity, alternating with violent nervous symptoms, unaccompa- nied by petechiae, or other phenomena of putrescence. The use of wine is almost always injurious from its too violently exciting the brain. But in the bad petechial typhus with great prostration of strength, the existence of thirst, abdominal pain and tenderness, diarrhoea and tumefaction, should not prevent us from having recourse to wine. I beg to draw the particular attention of my readers to the car- diac phenomena in this case; it may be right to state, that the stethoscopic observations in this and the succeeding cases were made with the greatest care. We observed, in the first place, a progressively diminishing 8 STOKES ON THE STATE OF THE HEART, AND impulse; on the seventh day the impulse was visible at the side, but on the tenth was altogether wanting; it reappears on the twelfth, and continues to increase until the period of the patient's restoration to health. In the second place we find a singular modification of the sounds of the heart; the proportion between the two sounds was lost on the seventh day, the first being exceedingly feeble, the second comparatively strong; on the eighth day the first sound was scarcely audible, and on the tenth it became extinct, and we had the singular phenomenon, never before observed, of the heart in typhous fever giving but a single sound. On the eleventh day, under the influence of powerful stimulation, the first sound reap- pears, and the second has more vigour; on the twelfth day both sounds are distinctly audible, and on the fourteenth the phenomena of the heart are natural. We shall not here enter into speculations as to the cause of these phenomena, but proceed with a detail of facts. CASE III. Severe maculated fever, delirium, diminution of the first sound of the heart —Use of wine in large quantities—Recovery. Patrick Q,uin, ast. 20, was admitted on the 27th of February. It was stated that he had been ill but five days, but his appearance was that of a person after a much longer period of fever; he was collapsed, cold, and stupid, and covered with an abundant crop of dark livid maculas ; prostration extreme; eyes suffused; tongue covered with brown sordes; pulse 125, small and weak ; heart's action feeble ; respiration hurried. He was ordered four ounces of wine. DATE. GENERAL STATE. Feb. 28. Violent delirium during the night; he is now in a state of collapse, lying on his back ; constant jac- titation ; subsultus : cold extremities; re- tention of urine. March 1. Slept well; in other respects is nearly the same, but is more easily roused ; less suffusion of the eyes; considerable subsul- tus ; he passed urine involuntarily. " 2. Slept well; tongue moist ; respirations 30; macula; fading; extremities warm. PHENOMENA OF CIRCULATION. TREATMENT. Pulse 132, soft, small, and Wine 24oz. variable ; heart's impulse im- blister to the perceptible; sounds defined; head,turpen- the pulsations in the carotids tine enema. very feeble. Pulse 120, a shade stronger Wine 24oz. than yesterday ; the sounds of turpentine the heart are quite similar to enema. those of the fatal circulation. Pulse 130, fuller and strong- Wine 14 oz. er; heart's action stronger, and sounds much louder__ they approach to their natural character. THE USE OF WINE IN TYPHOUS FEVER. DATE. GENERAL STATE. March 3. Violent delirium through the night; skin hot; bowels con- fined. " 4. No change ; great thirst. " 5.' Patient worse; coun- tenance more collaps- ed; violent delirium ; picking of bed-clothes; subsultus ; sighing ; contraction of the pu- pils : incontinence of urine; skin hot and dry ; mouth covered with black sordes. " 6. Generally improved; slept well ; much more sensible. " 7. Complains of great thirst ; extremities warm; maculae bright red, and less abun- dant ; pupils natural ; tongue moist. " 8. Great improvement; desire for food ; skin cool. " 9. Skin cool; slept well. 12. PHENOMENA OF CIRCULATION. Pulse 104 ; heart's impulse stronger. Pulse 106. Impulse of the heart plainly perceptible ; second sound much louder than the first: pulse 120. Convalescence per- fect. Pulse 106. First sound of heart much stronger; pulse 96. Heart's action nearly natu- ral ; second sound much im- proved ; the abdominal aorta can be felt throbbing with force. Impulse of heart vigorous ; strong action in the arteries of the neck and abdominal aorta; pulse 88, strong and full. Sounds and impulse of heart natural; pulse 72. TREATMENT. Wine 12 oz. cnernu. Wine 12 oz. Wine 16 oz. Turpentine draught, with cam- phor, musk, and opium mixture ; beef tea; swathing with flannel. Wine 16 oz. Wine 16 oz. Wine 16 oz.; omit mix- ture. Omit wine. Full,diet. In this case, as in the one preceding, we observe the early super- vention of bad symptoms, producing the same necessity for early stimulation. Indeed it. has rarely happened, that we were obliged to exhibit so large a quantity of wine on the fifth day of the disease, and I am convinced that nothing else would have saved the patient's life. It is impossible to lay down any rule, as to when the exhibition of wine should be commenced in our typhus, but the point must be regulated, much less by the date of the fever, than by the actually existing condition of the patient. The cir- cumstances which lead to its exhibition on the fifth day were the great collapse, the colour of the petechiae, the coldness of the extremities, and the feebleness of the heart; on the following day the symptoms pointed out the necessity of a great increase of the stimulants ; the prostration was increased ; the rapidity of the 10 STOKES ON THE STATE OF THE HEART, AND pulse augmented, while the impulse of the heart had become im- perceptible. In two davs after this a distinct improvement com- menced. Yet, though phenomena of reaction showed themselves, the wine was continued, though in diminished doses, to the four- teenth day of the disease, and for the last three days its exhibition was combined with that of camphor, musk, and opium. 1 he latter remedies were resorted to from the increase of the nervous symp- toms on the eleventh day. The pulse on the day previous had been 106, it rose on the eleventh day to 120; it fell on the follow- ing day to its former standard, after which it gradually subsided to its natural rate. In most cases in which wine is found to answer, the pulse comes down under its influence gradually and steadily; this I have before alluded to. In a few, however, we observe remarkable variations in the rapidity of the pulse. Of this the preceding case is an example ; the increase of pulse, however, was met not by an augmentation of the wine, but by the exhibition of nervous medi- cines, which were productive of the happiest effect. Beef tea was also given, and the patient swathed with flannel, a measure of the greatest importance and value in the treatment of fevers with col- lapse, or with a tendency to bronchitis. As connected with the rising of the pulse in typhus, the follow- ing rules with reference to the use of wine will be often found applicable :— 1st. That the increase of rapidity is almost always an unfavour- able symptom. 2d. That when it occurs at an early period of the disease with a cool skin, and dark-coloured eruption, it is to be met by an increase of wine. 3d. That when it occurs in the latter period, accompanied by severe nervous symptoms, the patient using wine freely, we must carefully support the system, and exhibit, in conjunction with the wine, musk, camphor, and opium. On the seventh day, in this case, the impulse and sounds of the heart were remarkably modified, the first was singularly dimi- nished, and the sounds assumed characters closely resembling those of the fcetal heart; this modification is not very common in typhus. In most cases one of the sounds is much more influenced than the other, the proportion between them is thus greatly altered, and there is no resemblance whatever to the sounds of the fcetal circulation. But when there is a great diminution of the intensity of both sounds, and the pulsations vary from 125 to 135 in the minute, the sounds exactly simulate those of the fcetal heart. In this instance the proportion between the sounds was lost on the eleventh day, the first being exceedingly feeble, the second com- paratively louder ; this character disappeared on the thirteenth day, when the first sound regained its natural character, and it is a most interesting fact, that on the following day the second sound was observed to be exceedingly loud, while the abdominal aorta was throbbing with force. THE USE OF WINE IN TYPHOUS FEVER. 11 I shall state the order of occurrence of the cardiac phenomena in this case. 1. Diminished impulse. 2. Impulse imperceptible. 3. Sounds of heart equally diminished (fcetal character). 4. Impulse and sounds stronger. 5. Second sound proportionally louder than the first. 6. First sound stronger. 7. Sounds and impulse natural. We shall hereafter show the importance of these observations, as bearing on the theory of motions and sounds of the heart. CASE IV. Maculated typhus—Absence of the first sound of the heart—Extreme slow- ness of the pulse during convalescence—Use of wine in large quantities- Recovery. Matthew Hickey, set. 30, was admitted into hospital on the 15th of July, having had fever six days. Had been in the habit of drinking, but never to excess; he is the fifth of his family who has had severe maculated typhus ; at present his countenance is much flushed; eyes suffused; maculas abundant and of a bright red colour; tongue covered with a dirty brown fur, especially at the sides ; great abdominal tenderness, particularly in the region of the liver. The chest, on percussion, yields a clear sound, and there are no stethoscopic indications of disease in either lung; the im- pulse of heart is not perceptible; although both sounds are audible, the second is heard to preponderate distinctly; pulse 124; respira- tion easy and natural; bowels free. He was ordered—R. Solut. bicarb, ammonise, gvm.; acet. mor- phias, gr. i; tinct. hyosciam. Bi. Ft. mist, efferv. Capiat coch. amp. ii. tertiis horis. DATE. GENERAL SYMPTOMS. July 16. Slept well; bowels regu- lar; tongue thickly coat- ed and dry ; convulsive respiration ; skin pale and very clammy. 17. There is still some ab- dominal tenderness; slept pretty well; respirations 28; interrupted by fre- quent sighing, and partak- ing of the cerebral cha- racter. He got altogether yesterday 20 oz. of wine and a little brandy. PHENOMENA OF CIRCULATION. Impulse of the heart is quite imperceptible, even when he lies on the left side; to the right of the left nipple the second sound alone is audible; pulse 120, rather feebler; on sitting up the impulse is not rendered more evident. The impulse is felt at the apex, but the sounds are by no means in proportion to its vigour; they resemble those of the fcetal heart; between the fifth and sixth ribs the sounds are barely audible. TREATMENT. Wine 12 oz., blister over the heart, beef tea. Wine 24 oz., two glasses of brandy, arrow root, blister to th3 scalp; ene- ma emolliens. 12 STOKES ON THE STATE OF THE HEART, AND DATE. GENERAL SYMPTOMS. July 18. Very restless; has not slept ; frequently rises from his bed; passes water freely ; tongue red at the edges, and covered in the centre with dark brown fur; teeth coated with black sordes; lies on his back in a semi-stupified state; countenance col- lapsed and pale; maculae very livid; respirations 32; on the back there are a few ecchymotic patches; abdominal tenderness con- PHENOMENA OF CIRCULATION. The sounds of the heart very feeble; the first almost inaudible, the second is loud and clear, and at a point cen- tral between the nipple and sternum, this is much more marked ; the impulse can only be felt when the fingers are placed between the inter- costal spaces. TREATMENT. Wine 24 oz., poultices to the abdomen. 11 19. Skin cooler, moistened with perspiration ; the re- spiration although labour- ed has lost its cerebral character; the ecchymotic patches are fading; tongue cleaner; abdominal ten- derness less; is more ani- mated. " 20. The countenance has lost the peculiar typhoid expression ; the petechiae are fading ; breathing still laboured. " 21. Passed a restless night; breathing much easier. He is quite sensible. " 23. Countenance more ani- mated ; skin cool; ma- culae almost gone ; com- plains of thirst; passes large quantities of pale- coloured urine. Sleeps well; appetite good; petechias gone. Is allowed to sit up dur- ing the day ; is not fa- tigued ; appetite very good. " 4. Feels perfectly well. » 24. " 26. » 28. Aug. 1. Pulse 116 ; impulse of heart the same as yesterday, the first sound is entirely absent, the second is distinct. Impulse of the heart quite imperceptible; the first sound is just audible ; pulse 96. Pulse 80, and of good cha- racter ; the sounds at the upper portion of the chest are proportionate but feeble; at the apex, and nearer the ensiform cartilage, the se- cond sound still predomi- nates. Pulse 76 ; impulse of the heart perceptible ; sounds proportionate. Pulse 76. Pulse 60; of very good strength. Pulse 50. Pulse 32; counted most carefully twice over. He is sitting up in bed, and the pulse at this time is 32. Wine 24 oz., blister and poultice to the epigastrium. Wine 18 oz. Wine 12 oz. Wine 6 oz. Haustus Rhei. Wine 6 oz. Wine 6 oz. Wine 6 oz. Gets bread and milk. As yesterday. THE USE OF WINE IN TYPHOUS FEVER. 13 DATE. GENERAL SYMPTOMS. PHENOMENA OF CIRCULATION. TREATMENT. Aug. 6. He is now eating his break- fast ; pulse at this moment 56. Discharged in a few days. Pulse 60. This case was one of extreme interest; the severity of the symp- toms, the quantity of stimulants used, and the remarkable modifica- tions of the heart's action, all combined to render the patient an object of the greatest attention to the class. The diminution of the first sound of the heart was the circum- stance which led to the exhibition of stimulants boldly, at an early period of the case. We observed that on the seventh day the impulse was imperceptible, and the first sound was diminished. On the eighth, the first sound had disappeared, and although the other symptoms did not seem to call for active stimulation, we ordered wine in free doses from this indication alone, and the result justified the treatment. Here was a case of a young man of a good constitution, in which, from studying the action of the heart, we were able to anticipate the symptoms of general prostration, and by the early and bold use of wine, to prevent the fatal result which, it is almost certain, would otherwise have occurred. The order of the succession of the cardiac phenomena in this case was peculiar. We had 1st. The early subsidence of the first sound. 2d. Both sounds audible, but with the fcetal character. 3d. Predominance of the second sound. 4th. Complete absence of the first sound. 5th. Impulse imperceptible, with returning first sound. 6th. The sounds at the base of the heart proportionate, while at the apex the second predominates. 7th. The sounds natural. The pulse, too, presents some interesting points for consideration. Within a period of twenty days its rate was as follows: 7th day of fever . . 124 8th " " . . 120 11th " " . . 116 12th " " . . 96 13th « » . . 80 15th " " . . 76 17th " » . . 60 18th " « . . 50 22d " « . . 32 27th " " . . 56 In a few days it rose to 60. Laennec has suggested, that the rapidity of the pulse observed during the convalescence of fevers might depend on a softened con- dition of the heart. As I shall have occasion to notice his opinions on the state of the heart in typhous fever at greater length presently, I shall merely observe, that in those cases in which the pulse con- 14 STOKES ON THE STATE OF THE HEART, AND tinued rapid during convalescence, the fever was seldom of the petechial or putrid character ; and one of the most remarkable phe- nomena in our fevers during the last year, was the return of the pulse to its natural rate, even before the whole group of typhoid symptoms had disappeared; and so far from a quick pulse being common during the convalescence in cases which had shown the signs of putridity, we found more frequently a singular slowness continuing for several days, until the patient was able to leave his bed. CASE V. Maculated fever—Great feebleness of the heart's action—Free use of wine —Convalescence on the seventeenth day. Bryan Kean, ast. 24, of strong muscular development, was ad- mitted on the 25th of March, having been then nine days ill: his countenance is dull, stupid, and of a livid hue: eyes heavy and suffused ; he is in a state of great stupor and prostration ; decubitus on the back. Skin hot, dry, and covered with small livid petechiae ; tongue fissured, brown, and parched ; has great thirst, and suffers much pain from pressure on the epigastrium; respirations 40, not laboured, and a few bronchitic rSles can be heard in the left lung; the pulse 120, small and weak; the heart's impulse almost imper- ceptible, and the first sound so feeble as to be inaudible to the left of the mamma, but it can be distinguished between the mamma and sternum. Ten leeches were ordered to the epigastrium, turpentine enema, artificial heat to the extremities, and eight ounces of wine. DATE. GENERAL SYMPTOMS. PHENOMENA OF CIRCULATION. TREATMENT. Slept well; countenance Pulse 116, small and weak; Wine 16 oz. more livid; thirst insatia- impulse of the heart quite ble; teeth covered with imperceptible; sounds are sordes ; epigastrium less exceedingly feeble, they are painful; extremities per- almost inaudible below and fectly livid and cold. to the left of the mamma, so that it is very difficult to distinguish between the first and second sounds, the sounds as it were running one into the other ; between the mamma and sternum they are stronger, and bet- ter defined ; the second is much clearer than the first. If the rapidity of the heart was a little increased, no- thing could more closely re- semble the foetal circulation. Continued raving; in- Pulse 92, small but dis- Repeat wine voluntary evacuations ; tinct, stronger, and perfectly countenance improved ; regular; the action of the extremities cold and livid, heart can be seen between the fifth and sixth ribs, but can scarcely be felt; sounds of the left side remain as yesterday, those of the right are more distinct. THE USE OF WINE IN TYPHOUS FEVER. 15 DATE. March 28. 29. GENERAL SYMPTOMS. Continued low mutter- ing delirium ; great pros- tration; involuntary pas- sage of urine; extremities very cold, notwithstand- ing the use of artificial warmth; petechias livid; respirations 24; intelli- gence improved. Great improvement; extremities warm; pete- chiae of red colour; tongue cleaning; slept well; re- spirations 20. PHENOMENA OF CIRCULATION. Pulse 84; impulse of heart less perceptible, but the first sound has more vigour. 30. Pulse 84, firmer and stea- dier ; when he lies on the left side the impulse of the heart is very perceptible, when on the buck it is less so, but more evident to the touch than on yesterday ; sounds increased in strength and distinctness. Improvement continues, Pulse 72, fuller and stronger; but the lower extremities pulsations of the arteria in- are liable to become cold nominata are distinctly visi- when the artificial heat bleat the top of the sternum; is removed . the urgent impulse of heart as before, thirst remains ; tongue but the sounds have improv- still brown. ed in strength. April 1. Convalescent. Do. Pulse 72, full and com- pressible; heart's sounds strong and natural. Do. TREATMENT. Wine 16 oz., musk, cam- phor, and am- monia mix- ture ; two glasses of jel- -y. Wine 12 oz., omit mixture; to have beer' tea. Wine 8 oz., beef tea. Wine 4 oz., beef lea and chicken broth. Omit wine. We have here another case in which we were led to the use of wine on the ninth day of fever, almost wholly from the observation of the phenomena of the heart. Although the case had a generally bad aspect, yet I do not think that I would have been so bold in the exhibition of wine had the patient been admitted before these re- searches had been commenced. There were many circumstances which seemed to contra-indicate wine: the patient was a young and robust man ; his skin was hot and dry; his tongue brown and parched ; he had extreme thirst, and great tenderness of the epigas- trium. Some years ago I would not have dared to have given this man wine, from the apprehension of its increasing gastric inflammation. On the other hand, he had great prostration, and the petechia? were of a livid hue: but it was on the cardiac signs that we relied; we had new and positive guides, and they did not deceive us. I greatly doubt whether there is any symptom which we can depend on as indicative of gastric inflammation in petechial typhus. That the condition of the tongue is fallacious has been established by Andral and Louis from numerous dissections, and the utility of wine and other stimulants, when the tongue is dry and brown, gives another and different description of proof. In a paper on the use of wine and opium in fever, published by my colleague, Dr. 16 STOKES ON THE STATE OF THE HEART, AND Graves, in the first volume of the Dublin Journal of Medical Science, he observes: " In the first place, as to the tongue, at an advanced period of fever, I have often derived the greatest advan- tage from wine and opium, although the tongue was dry, the colour of old mahogany, or else coated with a yellowish brown dry fur, and protruded with difficulty, while the teeth and gums were covered with sordes ; wine or porter, in moderate quantities, seem generally to agree with this tongue better than opium ; in some cases, however, the latter is indispensable. For fear of mis- leading the reader, I must again remark that I by no means wish to assert that such a tongue uniformly, or even frequently, indicates the use of these medicines : on the contrary, this state of the tongue and mouth will often be observed at a time when leeches and the antiphlogistic treatment are required. Let it be clearly understood, however, that at an advanced period of fever this state of tongue may exist, and yet wine and opium may be given boldly, provided, as I have said before, the general state of the patient seems to require it." Let it be recollected that in this case we had the symptoms of a dry and brown tongue, great thirst, epigastric tenderness, and heat of skin. On the first day of treatment leeches were applied to the epigastrium, and wine exhibited to the amount of eight ounces. I have frequently leeched the epigastrium, and ordered wine on the same day, and with benefit. In our case the epigastric tenderness was lessened, but the thirst continued insatiable: the quantity of wine was doubled. Two circumstances led to this, one the ex- treme coldness and lividity of the extremities; and the other, the increasing indications of debility of the heart, as shown by the great indistinctness of the first sound, and the approach of the stethoscopic phenomena to what we term the fcetal character. On the third day of the use of wine, and eleventh of the disease, the pulse fell from 116 to 92, and the first sound began to recover its natural intensity: this change was first perceived over the right cavities of the heart. This curious fact I have repeatedly observed and I think it may be stated, that in all cases in which the first sound is lessened or obliterated, the return to the natural character is first perceived over the right side of the heart. Whatever be the cause of these interesting phenomena, it seems much more to engage the arterial than the venous side of the heart. CASE VI. Maculated typhus, with diminution of the first sound of the heart—Use of wine and brandy. John Smyth was admitted into the Meath Hospital on the 19th of May ; the tenth day of his fever. He is a strong, powerful man • has been accustomed to drink ardent spirits, but was not very fre- quently intoxicated; at present is very low: he was last nio-ht constantly getting out of bed; passes his water under him- the THE USE OF WINE IN TYPHOUS FEVER. 17 petechial eruption is thickly diffused over his body: tongue dry, and red in the centre; intellect this morning clear; pulse 124, very small, and easily compressed; the impulse of heart feebly perceptible ; the first sound very indistinct, the second clear ; above the mamma the first, sound is scarcely audible. Ordered wine gviii. DATE. GENERAL SYMPTOMS. May 20. Passed a good night, did not rave; respirations 36; retention of urine ; extre- mities cold. " 21. Slept well, no raving; petechial eruption livid: eyes suffused; respirations 36; tongue cleaner; re- tuntion of urine continues, requiring frequent use of the catheter; bowels re- gular; bronchitis very acute. " 22. Had some sleep, no rav- ing ; countenance improv- ed; eyes less suffused. PHENOMENA OF CIRCULATION. Impulse of the heart im- perceptible, second sound predominates over the first; pulse 124. Pulse 112 ; the impulse of the heart is perceptible when he lies on his left side; the second sound predomi- nates considerably over the first. Pulse 100, full and regu- lar, whereas before the addi- tional quantity of wine given yesterday it was intermit- ting ; sounds of heart feeble, second still predominates. TREATMENT. Wine 12 oz., glass of hot brandy punch. Wine 12 oz., dry cup- ping to chest extensively; blisters to the region of the heart. Wine 20oz. In consequence of his low state he was given 8 oz. of wine additionalyes- terday ; beef tea one pint; pulv. ipecac. gr. £; ammon. carb. gr. ii., ft. pi I. ter die su- mend. 23. Passes his urine and faeces under him; respira- tions 32, not so laboured ; extremities warmed by ar- tificial heat; great pros. t rati on. 24. Countenance much im- proved ; slept well; when he is raised in bed he complains of lightness of his head; bronchitis con- siderably better. 25. Passes his urine freely; had a quiet night; is much better. " 26. Scarcely any cough ; sleeps well. Pulse 84, small; the im- pulse of the heart is more distinct to-day ; the first sound is still below par. Pulse 80; impulse of heart perceptible, the first sound is stronger. Pulse 80, very good strength ; impulse of the heart natural, sounds pro- portionate. Pulse 70, regular; pheno- mena of heart us in last re- port. Wine 20 oz., beef tea 1 pt., jelly, a glass ; blisters over the heart and nape of neck. Wine 20 oz. Wine 16 oz. Wine 16 oz. " 27. Sat up yesterday; is still a little nervous. Pulse 72. Wine 6 oz. IS STOKES ON THE STATE OF THE HEART, AND DATE. " 28. GENERAL SYMPTOMS. PHENOMENA OF CIRCULATION. TREATMENT. Pulse 72; sounds and im- Wine 6 oz. pulse of heart perfectly natu- ral. " 29. Convalescent. CASE VII. Maculated fever, with severe gastro-catarrhal and nervous symptoms- Remarkable modification of the heart's actiou—Use of wine. Thomas Cavanagh. ast. 15, was admitted on the 14th of April, being then three days ill : he had a few indistinct pale spots on the back; excessive thirst; diarrhoea, and tenderness of the epigas- trium: there was slight cough, with abundant frothy mucous expectoration. Pulse 120, small and easily compressed ; but the impulse of the heart is strong, and the sounds distinctly heard over a large portion of the chest. The epigastrium was leeched, and effervescing draughts ordered. DATE. GENERAL SYMPTOMS. April 16. General symptoms con- tinue; respirations 32. 17. 18. Muculae more distinct; the abdominal symptoms continue; respirations36; some delirium. PHENOMENA OF CIRCULATION. Pulse 126; impulse of heart not so strong. Pulse 120, weaker; im- pulse of the heart scarcely visible, but is quite percepti- ble to the touch; sounds are natural. 19. 20. Copious sweating after Pulse 132, still weaker; im- the bath; he is worse this pulse of heart can be seen and morning; constant low de- felt; the sounds are exceed- lirium; countenance pale ingly weak, particularly the and depressed; less heat first, which is scarcely audi- of skin; maculae abun- ble. dant, and becoming livid ; tongue dry, *rown; great thirst; considerable ten- derness in the ileocaecal region. Debility increased; skin hot and dry; petechiae universally abundant, and of a dark livid hue; respi- rations 30, less laboured; great thirst. Slept better, less ra- ving ; countenance im- proved ; eyes less suffused; abdominal symptoms con- tinue; respirations 28, in- terrupted by frequent sigh- ing; sonorous and sibilous rales in posterior portion The sounds of the heart ex- actly resemble those of the fetus at the eighth month ; an exceedingly indistinct impulse can be felt at the end of expi- ration. Pulse 140,slightly improved in strength ; impulse of heart more perceptible, and its sounds can be heard to the right of the sternum. TREATMENT Four leeches to the epigas- trium ; enema emolliens. Hip bath ; poultice to the abdomen. Eight leeches to the abdo- men ; small do- ses of hydrarg. c. crela and Dover's pow- ders. Wine 3 oz.; arrow loot. W ine 3 oz. ; arrow root. THE USE OF WINE IN TYPHOUS FEVER. 19 DATE. April 21. GENERAL SYMPTOMS. of the chest; two small gangrenous spots on the left ear. PHENOMENA OF CIRCULATION. Slept well, and is more Pulse 132, fuller, more collected ; complains of firm; impulse of heart as yes- extreme thirst; respira- terday, but the sounds to the right of sternum arc not so distinct, particularly the first, which is remarkably feeble. TREATMENT. Wine 5 oz. tions 32; skin hot and dry; maculae unusually abundant, and livid; one of the ecchymosed spots on the ear has vesicated ; extremities warm. " 22. Symptoms as before ; Pulse 125 ; no change in the Wine 5 oz. respirations 40. heart. repeat rest. 23. Raving continues ; skin Pulse 135. When he lies Wine 5 oz. ; cooler; maculae not so on the left side, the impulse fetid enema. livid ; cough worse, with of the heart is strong, first much stuffing. sound more distinct. 24. The typhoid expression quite gone ; eye clear and sprightly. Convalescent. Pulse 110, soft and much improved ; impulse and sounds still stronger. Wine 5 oz.; Ipecac. & carb. ammonia in pills. The two preceding cases exhibit still the same phenomena, the diminution of the impulse of the heart and of its sounds, particu- larly the first. In the case of Cavanagh, we observed the change from the natural to the morbid condition, for the patient was ad- mitted at an unusually early period of fever. In that of Smith, the first sound of the heart was altered on admission. In bad cases, the alteration of the sounds may be expected on or about the fifth day. The change does not seem to be accompanied by any pecu- liar disturbance of the circulation. We have as yet recorded no evidences, physical or vital, of a local irritation accompanying or preceding the diminution of the first sound; and our dissections and those of Louis agree as to the absence of the usual appearances of carditis. In the case of Smyth, the quantity of wine employed was much greater than in that of Cavanagh ; for this there were several rea- sons : the greater age of the patient, and his having been addicted to ardent spirits being the principal: besides, we could not tell how long the morbid condition of the heart had existed before admission; and it was acting on the safe side to assume that it had continued for several days, a circumstance which would indicate great acti- vity in stimulation. In the fevers of children, and of persons but a few years beyond puberty, the necessity for the use of wine is seldom so urgent as in those beyond twenty, or twenty-five; but we have had several cases of maculated typhus in children, with such prostration as to demand 20 STOKES ON THE STATE OF THE HEART, AND a free use of wine, which had the best effect, notwithstanding the existence of what we consider local inflammations. CASE VIII. Maculated fever; with signs of bronchitis and enteritis—Purulent discharge from the nose—Great prostration—Use of wine—Recovery. Henrietta Wright, a3t. 13, was admitted on the 9th of April, after having been in fever upwards of a fortnight; her countenance was collapsed ; the face livid; nocturnal delirium; violent headach, with a copious purulent discharge from the nostrils; extreme thirst; she was constantly sobbing and moaning; skin hot, and covered with an abundant crop of small livid maculae. Intense bronchitis, unac- companied by expectoration; complains of pain on pressure of the epigastric region; pulse 120, exceedingly feeble; impulse of heart extremely weak, and more distinct with the second than the first sound; the second sound is very clear, the first scarcely audible; it is more distinct over the right than the left side. Ordered, wine 4 oz., blister over the epigastrium, and ipecac, and pil. hydrarg. four times in the day. PHENOMENA OF CIRCULATION. Pulse 125, very feeble; im- pulse of the heart as yester- day ; first sound improved. Pulse 120, stronger and fuller; sounds of the heart are more distinct; impulse can be felt. date. general symptoms. April 11. Low muttering dcliii- um ; eyes suffused ; coun- tenance depressed ; ten- derness of epigastrium increased; pain referred chiefly to forehead; mu- cous expectoration, with troublesome cough ; bow- els not opened since yes- terday ; respiration 46, hurried. " 12. General improvement at 4 o'clock p. m. ; yesterday her pulse was impercepti- ble, and extremities cold. Bronchial rales intense over the whole chest; dis- charge from the nose less profuse ; cough trouble- some ; expectoration co- pious. " 13. No improvement; con- stant sobbing; headach; abdomen hard, full and very tender; bronchitis continues intense and ge- neral ; respirations 48. " 14. The catarrhal and ner- Pulse 105, stronger than vous symptoms continue; yesterday; impulse can be she is continually turning felt, but the sounds are mask- up her eyes; respirations ed bv the bronchial rales 40, convulsive and hur- Pulsc 110; heart's action more vigorous. treatment. Wine 4 oz.; blisters to the head and legs; ice to the tem- ples ; turpen- tine enema jar- row root; barm. Wine 4 oz.; chicken brolh ; flannel waist- coat. Wine 4 oz. Blister be- tween shoul- ders ; poultice to the belly; chicken broth. Repeat cata- plasm, abdom. THE USE OF WINE IN TYPHOUS FEVER. 21 DATE. GENERAL SYMPTOMS. ricd, accompanied with sobbing; abdomen exqui- sitely tender; face more livid. April 15. She is much improved, maculae indistinct; abdo- men still very tender ; se- cretion from the nose has ceased; respirations 40. " 16. Improvement contin- ues ; abdominal tenderness nearly gone; lividity has disappeared ; respirations 50, yet not laborious ; mu- sical and crepitating rales predominating in left lung, which is clear on percus- sion. " 17. General improvement; respirations 55; perfectly PHENOMENA OF CIRCULATION. Pulse 110, Pulse 108; impulse and sounds more distinct. TREATMENT. Repeat all. Wine 4 antimonial lution. Pulse 84, soft and full. Wine as be- fore. 21. Complete convalescence. Pulse 56, Do. do. In this case, the circumstances which might seem to contra-indi- cate the exhibition of wine were, that the patient was not yet arrived at the age of puberty, the heat of the skin, and the violent symptoms of abdominal and thoracic irritation. On the other hand, she had been upwards of a fortnight ill; had a collapsed coun- tenance; the petechias were livid, and the first sound of the heart scarcely audible. To these indications must be added that of the purulent discharge from the nose, a symptom not by any means common, but one which doubtless pointed out a necessity for stimu- lation. I have seen this symptom in but two cases of typhous fever; it is a very peculiar, and in my opinion, alarming one. The pus runs from the nostrils in a copious and continued stream ; the nose is somewhat swelled, and the patient lying on the back, and in extreme prostration, presents a close resemblance to an individual labouring under glanders. It will be observed that on the 16th of April the antimonial solu- tion was ordered: this was done with the view of relieving the bronchial irritation; its exhibition, however, at this advanced period of the case involves a point of practice of great importance, namely that in certain cases the typhoid symptoms prevent us employing an antiphlogistic treatment for many days; a change then takes place, and the patient will bear a reducing treatment for the relief of local disease, which before would have been dangerous: to this I shall hereafter return. It will be seen, in the case under consider- ation, that while the antimony was ordered the wine was not dis- continued. Great advantage was obtained by poulticing the abdomen in this 2—e 1 mon c 22 STOKES ON THE STATE OF THE HEART, AND case; I have the greatest reliance on this treatment in the secondary abdominal irritations of fever. It was, I believe, first recommended by Broussais. It is particularly advantageous where the weakness of the patient forbids the use of leeches. In the same class of cases, my friend Dr. Lees has treated a great number of patients by the use of the hip bath. For the success of this treatment, in many of his cases, I can vouch ; and to his judg- ment, in the management of the remedy, I can bear full testimony. CASE IX. Petechial Fever, with Bronchitis; Diminution of the First Sound of the Heart; Use of Wine ; Recovery. Thomas Wallace, admitted on 10th May, eleventh day of his fever, complaining of intense headach; general eruption of pete- chias; the sounds of the heart were feeble, but proportionate; im- pulse imperceptible ; pulse 98, full but easily compressed. Ordered wine 8 oz., Mist. Camph. c. Carb. Amnion. DATE. May 11. 12. " 13. " 14. " 15. " 16. " 21. " 24. GENERAL SYMPTOMS. Pupils contracted; coun- lenance flushed ; decided bronchitic rales. The bronchitis more se- vere, but the countenance has a better expression. Bronchitis continues. Slept well; some apho- nia, with tenderness of the trachea on pressure; coun- tenance flushed. Bronchitis less : passed a good night. Bronchitis subsiding in the right lung, but enga- ging the minute tubes of the left to a considerable extent. On this day he was pro- nounced convalescent. PHENOMENA OF CIRCULATION. Impulse of heart just per- ceptible; the sounds are ac- quiring the fcetal character : between the fourth and fifth intercostal spaces scarcely any thing is heard but the second sound; pulse 92. The first sound is more distinct; at the mamma both sounds can be heard, although feebly; pulse 84. TREATMENT. Continue wine and mixture; cupping, and blister to the chest. Wine 12 oz., Decoct. Sene- gas, et Carb. Amnion.; dry cupping be- tween the shoulders. Both sounds are now dis- Wine 8 oz. tinctly audible under the rept. alia. mamma and below the ster- num. The impulse of heart just perceptible; sounds distinct, still feeble; pulse 92. Both sounds of the heart are proportionate; pulse 82. Both sounds proportionate and distinct; pulse 88. Impulse of the heart per- ceptible ; the sounds natural; pulse 60. Wine 8 oz.; Blister to throat. Wine 6 oz. Wine 6 oz. Dry cupping senega mix- ture, with an- timony. THE USE OF WINE IN TYPHOUS FEVER. 23 CASE X. Petechial fever—Diminution and temporary alteration of the first sound of the heart—Recovery. Thomas Devereux admitted into hospital on the 23rd of May; the eighth day of fever. Petechiae plentiful, but of healthy colour; respirations hurried; complains of cough, which is accompanied with a frothy mucous expectoration; bronchitic rales are only heard in the upper portion of the right lung,—is very low ; pressure on the abdomen gives pain; great thirst: the impulse of the heart is scarcely perceptible; the sounds are proportionate, but feeble; pulse 112. Ordered six leeches to the epigastrium; castor oil 3 oz., in emulsion, with tinct. opii ngiii. DATE. GENERAL SYMPTOMS. May 24. Complained of intense headach yesterday even- ing, which was relieved by epistaxis ; bronchitic rales very intense ; breath- ing laboured ; respirations 40. " 25. Bronchitic rales not so intense; respirations 48; countenance more anima- ted; abdominal tenderness completely gone; had slight epistaxis yesterday evening; some headach. " 26. Three leeches were ap- plied, and gave great re- lief; respirations 48; slept well. 27. Sbpt well ; bronchitis better; complains of stuff- ing in his head; counte- nance to-day is more flushed ; had slight epis- taxis yesterday evening; respirations 44. 28. Had slight epistaxis yes- terday evening; slept well. THENOMENA OF CIRCULATION. Sounds of the heart are feebler than yesterday ; pulse 116, fuller and stronger. Pulse 108; sounds of the heart somewhat louder over the apex; impulse perceptible. The pulse taken early in the morning was 108 ; later in the day 116; the sounds of the left cavities of the heart are exceedingly feeble, at the apex the first sound can be distin- guished, but at the mamma only the second is heard; the superiority of the second over the first is also perceived over the right cavities; impulse just perceptible. Pulse 100, soft and compres- sible ; impulse of the heart per- ceptible ; the sounds are feeble, the feeond still predominates over the first. The sounds of heart are yet feeble, the second predominat- ing over the first; pulse 96, good strength. TREATMENT. Wine 6 oz.; cupping to 8 oz.; emp. lyttae over the heart. Omit wine ; leeches to the temples. Mist, efferves. Omit mix- ture ; porter a pint ; arrow root diet. Senega mix- ture. 24 STOKES ON THE STATE OF THE HEART, AND DATE. GENERAL SYMPTOMS. May 29. Respirations 28, easy; no headach; slept well. 30. Respirations 28; tongue clean and moist; skin cool; slept well; counte- nance improved; still has slight bronchitis. 31. Much improved. June 1. Convalescent. PHENOMENA OF CIRCULATION. Sounds to the left of mamma very weak, distinct however; much stronger to the right. Pulse 76, soft; phenomena of the heart as before. Impulse of heart perceptible; the sounds over the left cavi- ties are stronger, the two sounds being now proportion- ate. Pulse 60, natural; the sounds of the heart are stronger ; im- pulse perceptible. TREATMENT. Continue. Continue; por- ter one pt. Porter one pt. Porter beef tea. and CASE XI. Petechial fever—Supervention of signs of bronchitis on the twelfth day— Slight change in the phenomena of the heart—Moderate use of wine— Recovery. Rose Devereux, admitted on the 23rd June; eight days ill; at present complains of great pain and soreness in all her limbs; head- ach ; pressure on the abdomen gives pain, especially in the epigas- trium and hepatic region ; no bronchitis; both sounds of the heart are natural; impulse perceptible ; pulse 100, feeble ; on being made to sit up in bed, she is obliged to cling for support to the bed-side, in consequence of a feeling of lightness in her head, and dimness of sight; respiration easy; tongue clean; no petechias. Hirudines x. Epigastrio. Haustus Efferves. DATE. June 25. 26. GENERAL SYMPTOMS. Intense headach; great thirst; nausea and retching whenever she attempts to sit up; no abdominal tender- ness ; bowels costive; respi- rations 40. PHENOMENA OF CIRCULATION. Pulse 112, compressible; both sounds of the heart are proportionate; impulse per- ceptible. Slept well; no headach; Pulse 116; impulse per- shght epistaxis yesterday ceptible ; both sounds of the evening; bowels free; no heart are natural and pro- bronchitis or cough. portionate. 29. Yesterday evening com- plained of great oppression in her breathing; on percussion the chest was clear, but a most intense bronchitis enga. ged the whole of left lung; did not sleep last night; The sounds of the heart are much obscured this morn- ing in consequence of the intensity of bronchitis; they are, however, sufficiently clear to enable us to deter- mine that they are propor- TREATMENT Tart, potass. et sodae, £ oz. enema pur- gans. Milk whev. Cupped free- ly yesterday evening. Pil. hydrarg. gr. iii., pulv. ipecac, com p. gr. ii., ft., pa. THE USE OF WINE IN TYPHOUS FEVER. GENERAL SYMPTOMS. PHENOMENA OF CIRCULATION. TREATMENT. countenance anxious; con- tionate; impulse percepti- quater in stant nausea; some cough; ble; pulse 124. sumend. sputa viscid ; bowels free ; respirations 36. June 30. Passed a tolerable night; cough not very troublesome ; tongue slightly furred ; skin cooler; bronchitis in both lungs; respirations 40 ; bow- els regular ; had some vomi- ting yesterday evening, of a greenish fluid; nausea con- tinues. July 1. Vomiting last night; the fluid thrown off the stomach is of a dirty green colour, tire consistence of treacle; no headach ; complains of great oppression in her chest; bronchitic rales are not so in- tense ; petechiae abundant. " 2. Bronchitis much better; she breathes very easily; vomiting this morning ; skin cool; petechiae paler than yesterday. " 3. Very much improved; slept well last night; complains of thirst; no headach ; respi- rations natural. " 4. Countenance much im- proved ; no headach; scarce- ly any bronchitis; respira- tions natural. " 5. As yesterday. Pulse 124; impulse of the Repeat pill. heart quite imperceptible; sounds hurried, feeble, but proportionate. Pulse 120 ; impulse im- Wine 6 oz. perceptible ; sounds very repeat pill. feeble, but proportionate. Pulse 96, feeble ; no im- Wine 6 oz.; pulse to be felt; sounds omit pills. stronger than yesterday i Pulse 76. Pulse 76; sounds propor- tionate, but the impulse cannot yet be felt. Pulse 60, tolerable strength; impulse of the heart is just perceptible. 6. Sat up in bed the greater Pulse 60, impulse of the part of yesterday without heart is perceptible; sounds any inconvenience ; appetite proportionate. very good. 7. Convalescent. Pulse 60; of good strength. In a few days was dis- charged cured. Wine as be- fore. Continue treat- ment. Repeat all. Repeat. Continue wine 6 oz. In the three preceding cases a general similarity may be observed: in all there was the petechial eruption, and the signs of bronchitis existed at some period of the cases respectively. In the two first, those of Wallace and Thomas Devereux, we had the peculiar phe- nomena of the heart well marked; while in the third—they were so slightly manifested, that it is difficult to say whether the patient 26 STOKES ON THE STATE OF THE HEART, AND really had any positive affection of the heart. It is remarkable, accordingly, that the necessity for the use of wine was by no means so great in her case. Indeed the quantity of wine employed in the female wards is greatly less than in the male; the phenomena of putrescence being much more often manifested in the male subject. In the case of her brother Thomas Devereux, the diminution of the first sound was most remarkable. The case illustrates some curious points. In the first place it shows how little we can judge of the actual condition of the heart by the examination of the pulse. On the ninth day the pulse had increased in frequency, volume, and strength; and yet the sounds were more feeble than on the day before. I have shown that we may have a vigorous heart with a feeble pulse, or even absence of pulse, and here we have the con- verse of the proposition. The sounds of the heart became more feeble while the pulse was stronger. Indeed we could never deter- mine from the pulse whether or not the phenomena of the heart were altered, and the fact is, that it is by the physical signs, and the application of the hand alone, that we can ascertain how far the heart is affected in typhous fever. In this case, however, the ful- ness and increased strength of the pulse preceded a certain degree of reaction; for on the next day the sounds were louder, the coun- tenance more animated, and there was headach: we then omitted the wine. The excitement, however, was but temporary, for in twenty-four hours the first sound was completely lost at the mamma. We sometimes meet with cases in which stimulation is necessary, yet the patients do not bear wine well. In such cases I exhibit porter, which answers well. CASE XII. Petechial typhus, with diarrhoea and bronchitis—Cessation of the first sound of the heart—Exhibition of wine delayed till the twelfth day—Return of the first sound on the fourteenth—Recovery. John M'Kone was admitted on the 1st May, on the eighth day of his fever; there is no petechial eruption ; complains of troublesome cough ; bronchial rales in both lungs; tongue covered with a brown crust; the impulse of the heart is perceptible ; the first sound is almost inaudible, the second is perfectly distinct; pulse small 120 Pil. hydrarg. gr. iii. Pulv. Doveri, gr. ii. ter die sumend. ' DATE. GENERAL SYMPTOMS. PHENOMENA OF CIRCULATION. TREATMENT May 2. Raved during the night; Pulse 120, small and quick; Repeat me got some sleep towards impulse of heart is still per- dicine morning; seems much de- ceptible ; the second sound Pressed- predominates considerably over the first. " 3. Passed a much quieter Pulse 120, and fuller • im Fw v, night than the last; raved pulse scarcely perceptible cyam gr. ^ THE USE OF WINE IN TYPHOUS FEVER. 27 DATE. GENERAL SYMPTOMS. a good deal towards morn- ing ; tongue very much furred; great thirst; bron- chitis continues; maculae are now very plentiful; headach. May 4. Raved much less last night; no headach ; eyes suffused; countenance rather flushed. " 5. The petechias are not more livid, nor are they pa- ler ; some purging yesterday and to-day. G. Has passed a great many bloody stools; much deliri- um ; his countenance, how- ever, is not expressive of great depression; rest broken by being obliged to leave his bed; petechiae have faded considerably. 7. Was exceedingly delirious the whole night, so much so as to render the strait-waist- coat necessary; has passed three motions not bloody; subsultus tendinum. 8. Did not rave at all; slept almost the whole night; countenance much more ani- mated ; speaks quite ration- ally ; bowels moved twice, faeces assuming their natural form; tongue cleaning and moist; but little thirst; he did not get the morphia ; pe- techias quite gone. 9. Slept very well; did not rave; says he could eat a bit of Iread if he had it; bowels much improved; two motions yesterday; is much better. 13. Convalescent. PHENOMENA OF CIRCULATION. Pulse 120; the first sound of the heart is almost lost; the second is distinct. Pulse 124, easily compress- ed ; the double character of the sounds of the heart is now completely lost; the se- cond alone being audible; the impulse is not to he felt. Pulse 112; the sounds and impulse as yesterday. Pulse 92 ; the impulse is yet imperceptible ; the first sound is again audible to day; the second distinct and clear. Pulse 80, of good strength; the impulse is perceptible; the first sound stronger to- day, giving less predomi- nance to the second. Pulse 80, and of good strength ; impulse percepti- ble ; there is very little dif- ference between the sounds of the heart. Pulse 76, natural. TREATMENT. pulv. ipecac. gr. ss., tertiis horis sumend. Beef tea. Wine 10 oz. chalk and opium mixture. Wine 10 oz.; repeat mixture; beef-tea. Wine 10 oz.; draught of mu- riate of mor- phia ; beef tea. Wine 5 oz.; arrow root diet. Continue wine 5 oz. Has had wine 5 oz., and beef tea daily since last report. This case is principally interesting from the complete disappear- ance of the first sound of the heart for at least forty-eight hours; the coming down of the pulse under wine preceded the return of the first sound and the impulse: throughout the whole of this case the second sound continued remarkably clear. The exhibition of wine was delayed too long in this case; we 28 STOKES ON THE STATE OF THE HEART, AND were misled by the absence of petechiae on the eighth day; they did not appear till the tenth day, an unusually late period. The next case is remarkable for its presenting the peculiar cardiac phenomena in fever, with a singular slowness of the pulse during the disease, and also in the convalescence. CASE XIII. Maculated fever, with bronchitis—Feebleness of the first sound—Slowness of pulse—Free use of wine—Recovery. Richard Edwards, aet. 26; admitted into hospital on 8th June, ten days ill; the petechias are very plentiful and of healthy colour; countenance much depressed; tongue very thickly coated; great thirst; did not sleep well last night, but was continually raving; complains of irritation in his throat, which is not inflamed; great oppression in his breathing; acute bronchitis in left lung; cough troublesome; expectoration viscid; abdomen full and tympanitic, but without pain on pressure; impulse of the heart is perceptible; the sounds are very weak, and the second predominates over the first; pulse 84, feeble ; bowels free ; respirations 48. To be cupped freely between the shoulders ; blister to the sternum ; senega mix- ture, wine viii. oz. date. June 10. " 11. GENERAL SYMPTOMS. Raved a good deal last night; countenance anxious; conjunctiva? infected; tongue much coated ; no headach ; cough not very troublesome; expectoration viscid and scanty ; respirations 48 ; bronchitis in both lungs; more severe in the left; bow- els rather too free; evacu- ations thin and watery; ex- tremities warm. Passed a good night; the blister was applied yesterday evening; is very weak this morning; countenance ex- pressive of great anxiety ; tongue coated ; breathes ea- sier ; coughs less ; expecto- ration profuse and thick; respirations 40; is not purg- ed, but passed two thin wa- tery stools. PHENOMENA OF CIRCULATION. Pulse 80, small and com- pressible ; the first sound of the heart is so feeble as to be almost inaudible; the se- cond is very clear; impulse just perceptible. Pulse 80, feeble ; we could not examine the state of the heart in consequence of the blistered surface being very painful. TREATMENT. Wine 24 oz.; repeat mix- ture ; blister over the heart in the even- ing, if neces- sary. Wine 24 repeat mixture. 12. Countenance much improv- Pulse 80, feeble ; the im- Wine 1R M ed this mormng; breathes pulse of the heart is percep- repeat 1 easily; bronchms better; did tible; the second sound is Ur7 not rave ; bowels moved still loudest. three times; character of THE USE OF WINE IN TYPHOUS FEVER. 29 GENERAL SYMPTOMS. PHENOMENA OF CIRCULATION. stools somewhat better ; res- pirations 36 ; expectoration not so profuse; coughs much less. TREATMENT. June 13. Countenance considerably improved, and he is much better this morning in every respect; sputa profuse again to-day; does not complain of much thirst; respirations26. tl 14. Slept very well; petechiae fading; tongue cleaning and moist; bronchitis much bet- ter. Pulse 80, and fuller ; im- Wine 12 oz= pulse and sounds as last re- port. Pulse 68, and of good Wine 12 oz. strength; impulse of heart perceptible ; sounds improv- ing ; the second yet predo- minates. * 15. Countenance more anima- Pulse 60, soft and com- Wine 12 oz. ted ; voice stronger; very little expectoration; bronchi- tic rales are still loud ; bow- els regular: no petechia. " 16. Bronchitis rapidly improv- ing ; respirations natural; converses rationally. " 17. Expectoration is scanty, and tinged slightly with blood; on carefully examin- ing the chest, no signs of pneumonia can be discover- ed ; and the bronchitis is much less intense. pressible ; the first sound of bark*mixture. the heart much improved in strength, giving little predo- minance to the second. Pulse 60 ; impulse of heart Wine 6 oz. very feeble ; the 2nd sound still predominates. Pulse 54, stronger; im- Wine 6 oz. pulse and sounds as last re- port. « 18. » 19. " 20. « 21. » 22. Sputa free from admix- ture with blood ; is consider- ably better; appetite good. Pulse 56, regular; impulse perceptible ; and the sounds of the heart are once more proportionate. Passed a very good night; Pulse 52 ; strong ; phe- tongue clean ; no cough ; nomena of heart natural. bowels regular ; skin cool. As last report. Quite convalescent. Pulse 46, and strong. Pulse 44, and of exceed- ingly good strength. Wine 6 oz. Wine 6 oz. Wine 6 oz. Wine 6 oz. He was out of bed for Pulse 44; on walking Mutton chop. the greater part of yester- across the ward and back day, and bore the exertion again, the pulse rose to 60. well. We have now recorded two cases, in which the phenomena in question coincided with a very slow action of the heart, and in which the pulse during convalescence became singularly diminished 30 STOKES ON THE STATE OF THE HEART, AND in frequency. To this I would particularly direct the attention of my readers, as it bears on a very important practical point, namely, the cause of the anormal conditions of the pulse in the convales- cence of fevers. In my remarks on the fourth case, (see page 13,) I have alluded to the opinion of Laennec, who, after describing the softened state of the heart in putrid fevers, inquires whether this condition could account for the frequency of pulse which exists, sometimes for seve- ral weeks, in convalescence from fevers, although the patient con- tinues to regain flesh and vigour.1 If the phenomena now described are connected with a softened state of the heart, it will appear that our experience in this matter is opposed to the idea above quoted. It will be observed that in most of the cases the pulse came down to its ordinary rate, and did not exhibit any unusual frequency during convalescence ; and that in several, and in two particularly, the pulse in convalescence fell far below its usual standard. And with respect to the frequency of pulse in convalescence, alluded to by Laennec, my experience at present is, that it is more likely to occur after fevers of & non-putrid character; and that it often points out the existence of some local irritation, or a tendency to it. Future observations must settle this point. I might add several other cases presenting analogous phenomena, but refrain from doing so, as they do not exhibit any features dif- ferent from those already described. It will be seen that, in all the preceding cases, the modifications of the heart's action was either the diminution or obliteration of the first sound, or the equable diminution of both, so as to produce the fcetal character: but there is another modification, which, thouo-h of rare occurrence, is most interesting : in this we find the first sound preponderates. Of this variety but two cases have been observed ■ the first occurred in my own practice, and the second was of a patient treated by Dr. Graves, for the history of which I am in- debted to one of our most accurate observers, Mr. William M Murphy. CASE XIV. Petechial fever with bronchitis and diarrhoea-Vio-orous action nf was admi«ed on £ J n 7' bfUllthm, nme da?s iU 5 he ™s abundantly macu- lated ; well marked bronchitic rales in both lungs- the act on of thl heart was vigorous, and both the sounds natural IslSfi?fnll l^t^Sed and blis-ed> -d ^ "f birpin^ ™: :, Art. Softening of the Heart.-See Dr. Forbes' Transit THE USE OF WINE IN TYPHOUS FEVER. 31 GENERAL SYMPTOMS. Severe diarrhoea. " 14. The diarrhoea continues ; maculae abundant and florid. " 15. The bronchitis is more PHENOMENA OF CIRCULATION. Pulse strong ; both sounds are distinct and proportion. ate, but they seem as if dis- tant. Sounds of the heart more feeble; the impulse is im- perceptible except at the termination of expiration; pulse 100, strong. Impulse quite impercep- tible ; both sounds feeble but distinct ; pulse 100, feeble. TREATMENT. Omit the pills ; poul- tices to the abdomen. Saline mix- ture ; arrow root. Wine 6 oz.; dry cupping ; blister to the chest; pills of ipecacuan. hyosciamus, and carb. am- monia. " 16. Pupils contracted ; bron- chitis continues; tongue glazed and red. Impulse imperceptible ; sounds as before ;' pulse 92, a shade stronger than yes- terday. Wine 12 oz.; beef tea ; an- timonial mix- ture, with 3 grains of tart. emet. «« 18. 19. Some diarrhoea ; no vomiting; bronchitis di- minished ; the petechiae are not more livid ; pupils less contracted ; tongue improving, becoming moist and pale at the edges; the wine was given warm. Tongue improving; pe- techiae fading. Slept well; diarrhsea con- tinues. Impulse again perceptible; pulse 82; both sounds of the heart can be heard. Sounds of the heart not so distinct as yesterday; the second can scarcely be heard; impulse perceptible. Sounds as yesterday ; im- pulse imperceptible. Wine 10 oz.; senega mix- ture ; musk and camphor pills. Repeat all. Wine 10 oz.; blister to the heart ; bark mixture. 21. General improvement; slept well ; perspiration. " 22. Improvement continues. " 23. Skin cool; appetite good ; no bronchial rales. Both sounds can now be heard; they are feeble but proportionate; impulse im- perceptible ; pulse 72. The sounds over the right cavities are proportionate; over the left the first is much more feeble than the second; ao impulse. First sound much more distinct; impulse plainly perceptible; pulse 72. Wine 8 oz.; repeat the mixture. Repeat all. Wine 4 oz. Convalescent. 32 STOKES ON THE STATE OF THE HEART. AND CASE XV. Petechial typhus with palpitation of the heart and bronchitis—Preponder- ance of the first sound of the heart—Recovery. William Hawkins, set. 34, tall, not very robust; admitted into hospital October 18th, L83S; eleven days ill. Illness commenced after exposure to a draught of air, by rigors, succeeded by heat, &c, also by violent palpitations of the heart, which he says lasted for seven days. On admission the pulse was intermitting; there was a strong action of the heart, but it was also intermitting. 19th, (twelfth day). Abundantly maculated, severe headach, impulse of the heart feeble, no intermission of sounds. First pre- ponderates considerably, most marked at the sternum ; abdomen tympanitic ; he is constipated; a blister was applied to the abdomen ; camphor mixture, chalk mixture, and rhubarb wine ordered, and a turpentine enema; the pulse was regular 100. 20th, (thirteenth day). The pulse was 104, stronger but inter- mitting; no impulse; the sounds more feeble, and intermitting syn- chronously with the pulse, first preponderating considerably; bronchitis in both lungs; was cupped, blistered, and ordered 5 grs. of hydrarg. c. cret. every fourth hour. Was visited in the evening, and the pulse and heart were regular. The bronchitis became very severe, for which he was repeatedly blistered, and the mercury pushed to slight salivation ; the pulse and heart continued without intermission, but the first sound preponderated all through. On the 24th, (seventeenth day of illness), he got 6 oz. of wine. On the 28th, (twenty-first day), the pulse was 64; no impulse of heart, the sounds became proportionate. On November 4, (twenty- ninth day), the impulse was felt, sounds proportionate, pulse 64. November 12th. Left the hospital quite well. We have thus two cases in which the first sound preponderated. In the first this peculiarity was not observed until the sixteenth day; while in the second it was recognized on admission, (the ninth day,) and the sounds did not become natural until after the twenty- first. In this case it will be observed, that the pulse was intermit- ting, and that the patient complained of palpitation from an earlv period of the fever. J Let us now examine the results of dissection in a few cases in which feebleness of the heart's action was recognized. CASE XVI. Severe maculated typhus complicated with intense bronchitis-Gastritis -Perspiration on the 13th—Employment of wine-Death hd?* *!Tril0f tUU Pluth?ric habit>M always enjoyed good health, and although in the habit of taking whiskey, never drank to excess ; has had fever for six days; his chest and arms are co vered with well defined bright red petechia, complains of much THE USE OF WINE IN TYPHOUS FEVER. 33 pain in the head and dimness of sight; tongue furred, epigastrium very tender on pressure, bowels constipated ; passes small quantity of urine; pulse 96, and full; respirations 28 ; some wheezing and sibilant ronchi are heard in anterior portion of lungs, face very much flushed. He was ordered efferv. draughts. DATE. GENERAL SYMPTOMS. June 8. Presents the same ap- pearance as yesterday ; slept badly ; bowels re- lieved. " 9. Has had another bad night; is very restless ; countenance flushed. " 10. Better night than he has yet had. 12. Did not sleep so well as on the previous night; extreme debility. PHENOMENA OF CIRCULATION. Pulse 96. Sounds of the heart very feeble; pulse small and com- pressible, 96. Pulse much stronger and fuller, 104, and by no means so compressible; sounds of heart a shade stronger than yesterday. Pulse 116; sounds of the heart precisely resemble those of the foetus in utero. TREATMENT. Wine 6 oz. Continue wine. Continue wine. To have a glass of hot punch imme- diately ; wine 12 oz.; blister between the shoulders and terebinthinate From this period the patient got worse. The bronchial disease became intense and general, so much so that it was hardly possible to make any accurate observation of the sounds of the heart; the impulse, however, was imperceptible; the pulse became intermit- ting, and increased in frequency to 120, and on the next day to 136. He died on the following day, the seventeenth of his disease. On the sixteenth day his extremities were cold. In this case active stimulation was employed. The patient got nearly eighty ounces of wine; he was dry-cupped and blistered, and used emetics, from which he experienced great relief three days before his death. Post Mortem, eleven Hours after Death.—The heart is of its natural size, livid, and feels extremely soft, pitting on pressure, par- ticularly over the left ventricle; some white patches maybe seen on the right ventricle; the lining membrane of the left auricle pre- sents nothing remarkable; the left ventricle was divided from its base to apex; the muscular substance presents a very singular ap- pearance, not a trace of fibre being visible ; and for more than two- thirds of its length, a layer presenting a darker colour and of more homogeneous appearance, of one-eighth of an inch in thickness, was found.3; into this layer it is very difficult to trace the muscular fibre. The substance of the ventricle is infiltrated with a gummy matter, causing the fingers to stick together; the structure has some resem- blance°to the cortical structure of the kidneys; a transverse section 34 STOKES ON THE STATE OF THE HEART, AND gave the same appearance. The net-work of fleshy fibres exhibits more firmness, though analogous in condition; the posterior columns seem but little altered, being only pale, their firmness re- maining perfect; the same may be said with respect to the anterior; the right ventricle is harder and firmer, and does not exhibit the same aspect as the left; the auricle of the same side contains a coagulum; nothing remarkable in the colour and appearance of the membrane; the septum cordis presents the same appearance as the left side. On examining the abdomen, nothing abnormal presented itself. The ileum is perfectly healthy; no enlargement of the glands. CASE XVII. Maculated typhus with severe nervous symptoms—Predominance of the second sound on the sixth day; complete absence of the first sound on the tenth day—Death—Softened state of heart—Ulceration of the ileum. Richard Cashel, aet. 46, admitted 5th November; six days ill; he complains of pain in back, neck, and extremities ; considerable pros- tration ; maculae abundant, of light colour on chest and abdomen, but much darker on back; slept very little last night; raved a good deal,but was not violent; has no headach ; pupils slightly contract- ed ; very little cough unaccompanied by expectoration; stools thin and watery; abdomen soft and tender on pressure; great thirst; tongue brown and dry in centre ; teeth covered with sordes ; pulse 116, rather feeble ; respirations 28 ; auscultation detects slight bron- chitis in both lungs ; while the patient lies on his back the impulse of the heart cannot be felt, but becomes imperceptible when he turns on his left side; both sounds are audible, and the second predomi- nates slightly over the first; ordered an anodyne enema. DATE. GENERAL SYMPTOMS. Nov. 7. Raved much ; skin hot and dry; maculae dark ; respirations 28. No raving; extreme prostration ; considerable fcetor from body; maculae very dark coloured ; sordes on teeth and tongue exces- sive ; is unable to raise himself without assistance. Was very restless all night; picking at the bed- clothes, and muttering constantly ; passes his wa- ter under him ; lies on his PHENOMENA OF CIRCULATION. TREATMENT. Pulse 116, as yesterday; Repeat wine, the impulse of the heart can- 8 oz. not be felt to-day; sounds more feeble than yesterday, scarcely audible above the mamma, and to the left: more so at the sternum ; the second preponderates. Pulse exceedingly feeble Wine 16oz.; and irregular, being from beef tea. about 116 to 124; no im- pulse of heart; sounds very feeble, almost inaudible to the right of nipple; the se- cond is still loudest. Pulse 120, exceedingly Wine 20 oz.; feeble, obliterated on the brandy 2 oz. slightest pressure; when lying on his left side the impulse could then be felt, THE USE OF WINE IN TYPHOUS FEVER. 35 DATE. GENERAL SYMPTOMS. PHENOMENA OF CIRCULATION. TREATMENT. side; maculae very abun- but on turning on his back dant, and quite livid on it was felt to be vigorous; the back. the double sound of the heart was completely lost, the dis- tinct clear "rop" of the se- cond alone being heard; most distinct also at the base of heart. " 10. Lies on his back; mouth Pulse 150, exceedingly wide open; constant spasm weak and irregular ; impulse of the muscles of lower of heart evident and pretty jaw; constant moaning; is strong ; in consequence of in profuse perspiration; his moaning, no accurate excessive fcetor from body ; accounts of the sounds could respiration 40 ; stools in- be taken. voluntary. Died at 1 o'clock, p. m. Dissection twenty Hours after Death.—The body was more than usually livid; the petechiae were pale on the forepart of the body, but very dark and livid on the back; abdomen tympanitic; the pericardium contained about half a pint of straw-coloured serum ; the heart was of large size, and so extremely flabby, that it was capable of retaining any shape in which we placed it; the right cavities were softer than natural, admitting the fingers through their walls without much resistance ; in the muscular struc- ture of the left cavities, however, this change was much more re- markable ; the weight of the finger was almost sufficient to pene- trate its walls, they were so exceedingly softened ; it is very easily torn, and the edges thus separated have no longer the moistened appearance, but seem as if quite dry. The septum cordis was equally softened ; there was some dark fluid blood in the right cavi- ties. The stomach presented some red patches, slightly elevated; towards the pylorus, the mucous membrane was thickened and softened, and was easily removed by the handle of the scalpel. The duodenum was tolerably healthy, having only in two or three places slight blushes of inflammation. The ileum was more extensively involved ■ this was particularly observable in the last two feet of its length near to the ileo-ca3cal valve: there were five ulcerated points' the superficies of the ulcers were covered by a delicate mem- brane 'beneath which there was a yellow-coloured fluid, resembling pus • the largest was about the size of a silver penny : round these infiltrated points the intestine was much inflamed, and several minutely injected capillaries were seen ramifying around these points, but they could not, even by the aid of a good lens, be traced into the ulcers ; when the membrane was removed under wa er and the puriform matter washed off, a decided depression was left, at the bottom of which was easily seen the muscular coat of the intestine: dispersed further throughout the intestine were several of the ellip- tical patches. The glandular aggregatae were very prominent in many places. / / . 36 STOKES ON THE STATE OF THE HEART, AND The general type of fever in this case did not at first seem worse than in many others in which recovery took place. But the patient had been greatly exhausted before admission by hypercatharsis, induced by two enormous doses of castor oil which he took on the second and fourth days of his disease. This circumstance is not unfrequently met with in our wards; and I do not know a worse preparation for the struggle in the advanced stage of typhus than over purging in the commencement. The medicine commonly employed is glauber salts, in a very large dose; this is taken inde- pendent of any medical advice, and in several cases the ulceration of the intestines seems to have been promoted by its action. The pulse in Cashel's case rose from 116 to 150, under the use of wine. This and the extreme fcetor of the body led to the worst prognosis. In the phenomena of circulation, the most interesting point is, that while the first sound was absent, the impulse continued. On the day of his death the impulse was very evident, and yet we found a softened left ventricle. We shall see that the diminution or cessation of the first sound, and of the impulse, are not always co-existent. It is hardly necessary to observe on the difference between these phenomena and those in the case in which wine was successfully employed. On two occasions we were forced to omit the wine, and ultimately we abandoned its use. In this case, also, the peculiar diminution of the first sound was not observed until the day before death ; and on the previous day, (two days before death,) the impulse and sounds were strong. I conceive that the morbid change in the left ventricle did not occur in this patient so early, or to the same extent, as in other cases. In observing on the cases of Cavanagh and Smyth, (see page 19,) I have stated that we have not yet recorded any instance in which the alteration of the first sound was accompanied with or preceded by signs of irritation. In this case, however, and in that commu- nicated by Mr. Murphy, where the first sound predominated, the symptom of irregularity of the heart existed; and in Mr. Murphy's case there was pain. How far these circumstances indicated in- flammation we cannot now determine; but it must be remarked, that the effect of wine was totally different in the two cases. CASE XVIII. Severe maculated typhus, with cerebral irritation, and great prostration- Diminution of the first sound of the heart on the day before death—Use of wine—Death on the nineteenth day. Catherine Murphy, set. 30, of good constitution ; six days ill on the 10th of June. She complains of pain of the forehead and temples, for which she was leeched, without relief. The petechia? are abundant, and very livid; no thoracic complaint; has much abdominal tenderness, and diarrhoea. Was ordered six leeches behind the ears. THE USE OF WINE IN TYPHOUS FEVER. 37 DATE. GENERAL SYMPTOMS. June 11. Tongue furred, and dry ; purging still continues; re- spirations 44. 12. Had a restless night; pass- es her urine involuntarily, and is much weaker than yesterday; pain of forehead and temples continues ; re- spirations 32. 13. Raved a good deal last night; after having taken eight ounces of wine, pulse rose to 130, and was very small; has no purging ; tongue coated, and dry. 14. ■ The blister was applied yesterday, but in conse- quence of her changing the position so very frequently, it did not rise; the acetate of cantharidts was then used and proved efficacious; very low ; respirations 32. 15. Raved all night; does not pass her water under her, but gets up whenever it is necessary. 16. Did not rave last night; the wine produced so much excitement yesterday after- noon, that it was found ne- cessary to stop its further exhibition. 17. Was again obliged to stop the wine; afier taking eight ounces ; buwels regular; tongue cleaning. 18. Raving and moaning throughout the night; re- spirations easy and natural. 19. Raving all night; on press- ing the larynx, she com- plains of pain, but will not allow an examination. 20. Did not rave last night; sacrum very sore; pupils contracted ; allowed her throat to be examined this morning, when several diph- theritic patches were seen. 22. Extreme prostration, but 2-f PHENOMENA OF CIRCULATION. Pulse 120, feeble; im- pulse of the heart percep- tible ; both sounds of the heart proportionate. Pulse 120; sounds of the heart louder than yes- terday. Pulse 130, very feeble ; sounds of the heart pro- portionate, but leebler than yesterday ; impulse scarcely perceptible. Pulse so irregular that it cannot be counted; im- pulse not perceptible ; sounds of heart as yester- day. Pulse 124, and full; impulse and sounds of ttie heart as yesterday. Pulse 112. Pulse 100; impulse of the heart again percepti- ble, and the sounds pro- portionate and stronger. Pulso 104; impulse and sounds of the heart as yesterday. Pulse 120, and full. Pulse feeble. 130, and very TREATMENT. Wine 4 ( arrow root. Wine 12 oz. Blister ap- plied ovit the sternum ; con- tinue wine as yesterday. Wine 24 oz. Continue treatment. Wine 12 oz. Omit beef tea. wine; Anodyne draught. Anodyne enema ; flannel waistcoat. The strong muriatic acid to bo applied to the throat; blister to neck. Pulse 120; heart's ac- Decoct, cin- 1 mon d 38 STOKES ON THE STATE OF THE HEART, AND GENERAL SYMPTOMS. PHENOMENA OF CIRCULATION. is perfectly sensible ; voice lion morbidly excited ; much clearer than yester- sounds proportionate. day; respirations 40. June 23. Ts still sensible; counte- nance expressive of great anxiety ; is very low ; moaning, and tossing her arms about considerably ; respirations hurried, 64 ; teeth thickly covered with brown sordes. 14 24. Died at half past one. The first sound of the heart is scarcely audible, while the second is dis- tinct and clear; pulse ex- tremely feeble, and so irregular that it cannot be counted, TREATMENT. chon. 6 oz. ; tinct. cinchon. 3 oz. ; sumat 3 i. secundia horis ; porter one pint, and beef tea. As yester- Dissection twenty hours after death.—The body presented an unusually livid appearance. On the abdomen were observed numberless minute vesicles, and on the sacrum there was a large sloughing sore. The muscular structure was firm and healthy. On opening the chest the lungs presented a healthy appearance; posteriorly they were rather congested, but this seemed to be the result of gravitation of blood. The pleurae were not adherent. On slitting up the pericardium it was found to contain about half a pint of straw coloured fluid; the covering itself seemed healthy. The heart was of small size; the muscular structure of the left ventricle was softened, but not to the same extent as in the preced- ing cases; on cutting into it, the fibres were perceptible, but they presented, nevertheless, a rather homogeneous appearance, and a peculiar glairy semi-gelatinous fluid was found between them; there was no valvular disease. The intestines were bound down by old adhesions, and were free from ulceration ; the smaller were much congested and softened. The circumstances worthy of remark in this case, are, that wine did not agree with the patient, and that the phenomena of the heart were very different from those detailed in most of the preceding cases. Under the use of wine the pulse rose from 120 to 130, and then became exceedingly irregular; it next fell to 124, and was full; it continued to diminish in frequency; again increased, and became irregular. Its rate was as follows :* Seventh day, 120. Eighth day, 120. Ninth day, 130. Tenth day, irregularity so great that it could not be counted. Eleventh day, 124. Twelfth day, 112. Thirteenth day, 100. Fourteenth day, 104. Fifteenth day, 120. THE USE OF WINE IN TYPHOUS FEVER. 39 Sixteenth day, 130. Seventeenth day, 120. Eighteenth day, irregularity as before. CASE xix. Petechial typhus, with severe nervous and catarrhal symptoms—Great feeble- ness of the heart on the twelfth day—Use of wine—Vigorous action of the heart for four days before death. Eliza Bourke, set. 35, admitted on the 7th March, the eleventh day of fever. On admission she was delirious; in a state of great collapse, with cold extremities, and miserable pulse. She was given 4 oz. of wine, and artificial heat applied to the feet; during the night she never ceased howling and screaming; lies on the back in an extreme state of prostration, raving immoderately, moaning, and sometimes screaming aloud. Countenance flushed, wild, and ferocious ; eyes suffused ; pupils natural; sordes on teeth and lips; she points to the head as the seat of much distress ; thirst urgent; skin hot, dry, and covered with livid coloured petechiae, evidently on the decline; tongue fissured and brown; pulse 136, small and weak; respirations 40, laboured and interrupted; intense general bronchitis ; impulse of the heart imperceptible ; no accurate obser- vations could be made as to the sounds, from the loudness of the rales. DATE. GENERAL SYMPTOMS. March 9. Thirteenth day of fever; slept well; delirium much less ; pupils somewhat contracted ; upper and lower extremities quite cold ; tongue covered with black crust; respirations 28. " 10. She ia more tranquil, but the countenance re- tains the wild expression ; extremities warm; respi- rations 32, laboured. 11. After each dose of wine, which has been given mulled, her general ap- pearance became much improved, but the bron- chitis is very intense; and in both lungs, inferiorly.a moist crepitating rale can be heard. PHENOMENA OF CIRCULATION. TREATMENT. Pulse 140, small and weak Wine 24 oz. but a degree stronger than turpentine yesterday; impulse of heart enema. slightly perceptible ; both sounds can now be heard below the mamma, and are much stronger than yesler- day. Pulse 128, much fuller and stronger; the impulse is much improved, and the heart can be felt pulsating over several squate inches; the sounds are louder, and the first sound has increased in strength. No change in impulse and sounds of heart; pulse 132. Repeat wine; blister to the head. Repeat wine. 12. Breathing more difficult The impulse of heart etill Repeat wine» and laboured; great wheez- more perceptible, but its pills of ipecac. 40 STOKES ON THE STATE OF THE HEART, AND DATE. GENERAL SYMPTOMS. PHENOMENA OF CIRCULATION. TREATMENT. ing in the throat; respira- sounds much obscured by carb. ammon., tions44; and lales in all the rales. & hyoscyam. parts of the chest more sonorous and intense. March 13. She is sinking rapidly; Pulse 124; no change of Wine 24 oz. respirations 64 in a mi- the impulse or sounds of the nute; congestion of the heart. lung much increased. » 14. Died. There were many circumstances which led us to form a bad prognosis in this case; I would particularly specify the advanced period of fever at which she was admitted, the violence of the bronchitis, and great rapidity of pulse. Among the secondary dis- eases of typhus, there are few more dangerous than the bronchial affection, or one that demands the same decision in treatment in the earlier periods of the case ; and there can be little doubt that had the chest been relieved by proper means, within the first week of this woman's illness, the chance of recovery would have been much greater. It will be recollected that the pulse, on the thirteenth day of fever, was 140; and that after 24 oz. of wine had been given, it fell to 128: so far there was evidence that the wine was acting well; and on the fourteenth and fifteenth days there was an im- provement in her condition generally. The respirations, however, became more and more difficult, and she sunk with all the symp- toms of suffocation. In the cases detailed in the beginning of this paper, it will be seen that the returning impulse and sounds were accompanied by other and decided marks of improvement; but here we had the action of the heart suddenly becoming less frequent and much more vigorous, with preservation of both sounds, while the catarrhal symptoms were increasing. The heart was not merely restored to its natural standard, so far as impulse and sounds were concerned, but it was obviously excited ; and this excitement continued for four days before death. The action of wine upon the heart in typhus may be said to be both sedative and stimulant; sedative in diminishing its frequency, stimulant in restoring its impulse and muscular sounds; but in its favourable action, the vigour of the impulse, and the intensity of the sounds do not pass the limits of health. There is a point where its stimulating effect should cease, and if this is passed, wine is either useless or injurious. I have now given such cases as I conceive are sufficient to intro- duce the subject of the state of the heart in typhous fever to the consideration of the profession. I might add other cases, but they do not elucidate any new point, and I have given the results of the fatal cases. If we examine authors on the subject of the state of the heart in THE USE OF WINE IN TYPHOUS FEVER. 41 typhus, we find, that, with the exception of Laennec and Louis there is but little information given. Laennec does not seem to have examined the point to any extent; and Louis contents himself with recording the state of the heart in a certain number of subjects who died of fever; but in neither author do we find observations on the physical phenomena of the heart during life. In his chapter on Softening of the Heart, Laennec writes as follows: " The variety of softening which accompanies idiopathic fevers does not in general present any change of colour in the heart, or it is attended with a deeper colour than natural, approaching purple ; sometimes, however, it is yellowish. I think it may be compared to that adhesive softness of the other muscles, often observed in these cases, and which is also accompanied by a degree of redness greater than natural. This softening of the heart, as well as the analogous gluey or fishy state of the muscles, is particularly ob- servable in putrid fevers, more especially when these exhibit the phenomena formerly considered as marks of putridity, viz. livid in- tumescence of the face; softening of the lips, gums, and internal membrane of the mouth ; black coating on the tongue and gums; earthy aspect of the skin; distended abdomen; and very foetid dejections. I cannot assert that this softening of the heart exists in all kinds of continued fevers, but I have met with it constantly in such cases as I have attended to; and I have always thought it more marked in proportion as the signs of an alteration in the fluids were more evident. Could it account for that frequency of pulse which exists sometimes for several weeks in convalescence from fevers, although the patient continues to regain flesh and vigour?" I shall next quote from Louis—Dr. Bowditch's translation : " The heart had the size, consistence, and colour natural to it in half of the cases, or in twenty-three subjects; rather less frequently, ceteris paribus, among those who died between the eighth and twentieth days of disease, than among those who died after this epoch. "It had less consistence than natural in twenty-four other sub- jects. This diminution of consistence was slight in seven cases, and as when in this degree one might consider it less as a morbid state than as a variety of the natural consistence, or as it is called, of its physiological state, I shall not consider these cases in what follows, and thus the number of patients we must examine is re- duced to seventeen. " The softening of the heart was, moreover, very slight in two of these cases. But as it was limited to the left, side of the organ, we cannot consider it as the result of natural disposition; but there is a still more important reason for this opinion, viz. it happens some- times, when the softening is considerable, that it is more so at the left than at the right. In the other cases, it was universal and very marked, the heart was very flaccid, so that in many cases it had no precise form, but like a wet cloth, retained any shape into which it 42 STOKES ON THE STATE OF THE HEART, AND mio-ht happen to be placed. Its substance, in these cases, had very little power of cohesion, was easily torn, and was very easily pene- trated by the finger. "At the same time that it was softened, the heart had less colour than usual in many cases; it was of an onion-peel colour, which varied in intensity, and was generally livid and purplish on its sur- face as in its substance. The internal face of the ventricles and auricles was, on the contrary, of a deep violet-red colour, which colour sometimes penetrated beyond the lining membrane, and appeared owing to an imbibition of blood, which it resembled more or less in colour. " When thus softened and pale, the heart had no longer, when cut, the slightly moistened aspect it has generally, but it was, as it were, dry and unpolished, such as we have seen the liver appear in analogous circumstances. Its size was not larger than usual, and it appeared smaller in two cases (Obs. 14, 33), and, therefore, it appears to me, we ought not to consider this as an effect of the soft- ening of the organ, but rather as a natural disposition which existed in other patients likewise, in whom the heart presented nothing else remarkable, (Obs. 31, 39, 41). "Another fact, which it is important to notice is this, viz., that in nearly all the cases of softening, the walls of the ventricles were evi- dently much less thick than usual, those of the left especially, which were often three lines thick only. And as this diminution of thick- ness was limited to cases of softening, we must consider it as a mor- bid affection. "If these facts are insufficient to enable us to discover the cause of the softening of the heart, at least they exclude the idea of one of those affections which usually cause a great number of affections, viz., inflammation. For how can we allow that inflammation is the cause of an acute softening, accompanied by a diminution of thick- ness, paleness of colour, and a kind of dryness of the texture which is the seat of it? Such a supposition would truly imply a contradic- tion, and, as I remarked in relation to the softening of the liver, if we knew any cause of disease exactly the reverse of inflammation it would be proper to refer this softening to it. "Other considerations which I have already given in relation to the spleen support these reflections. The walls of the heart, al- though more or less softened, had never any pus in them, and there was never any inflammation of the pericardium, which would have been the case rather frequently in softening of the heart, had this softening been caused by inflammation. And in opposition to this opinion, we cannot produce cases of pericarditis observed after other acute diseases, inasmuch as softening of the heart was found in two cases out of eight in which there was pericarditis. "Moreover, the frequency and severity of the softening were much more marked according as the disease was more early fatal. Thus the heart was softened in nearly half of those patients who died between the eighth and twentieth days of disease, in a third of THE USE OF WINE IN TYPHOUS FEVER. 43 those who died during the following period, and in a somewhat smaller proportion among those who died afterwards. Resides, in seven cases in which the softening was extreme, not one was rela- tive to individuals who died after the thirtieth day of the disease, and I found 4 out of 17 patients of the first and second series, 3 " 20 " third " " Hence we see, that whatever was the degree of softening, the proportion of cases in which it took place in the different series of patients was very nearly the same; and it was like that of the liver and spleen, more serious in those who died early in the disease, than in those who died after the twentieth day, and we did not find it at its maximum in patients belonging to the fourth series. The rapidity of its development showed the extreme violence of the cause to which it was owing in certain cases, and as other lesions of the same kind, it necessarily contributed much to produce death and hasten its arrival. " Another fact which seems to me to be not less remarkable than the rapid softening of the heart is this, viz., no similar lesion was found in any other muscular organ; as all the muscles which pre- side over voluntary motions preserved, amidst the general disorder, the consistence and colour which are natural to them."1 In these extracts I have given all that has been discovered on the subject; no series of observations on the action of the heart in typhous fever has been published; I have commenced this inquiry, and have sought to derive some important indications of treatment from the existence of the phenomena now described. In the pre- sent state of the inquiry I wish it to be understood, that my obser- vations are to be taken as referring principally to the epidemic of last year. Further researches must be made to establish how far they may be applicable to typhus in general; but I have little doubt from studying the researches of Louis, and connecting the facts relative to the anatomical state of the heart, with those now observed as to its vital phenomena, that my observations will be found to have a very extensive application. The epidemic of last year was marked by all the signs of putri- dity. Dark coloured and abundant petechiae; sordes of the mouth, foetor of the surface, extreme prostration, and stupor, were the pro- minent features of the disease; and in many cases bronchial and gastro-enteric irritation existed to a great degree. In many of the cases the bad symptoms were developed at an unusually early period, yet though recovery by crisis was by no means common, the convalescence was generally satisfactory, and the ultimate restoration to health complete. In several instances the disease was traceable to contagion. We may thus arrange the cardiac phenomena obtained in our typhous fever:— 1. Impulse and sounds remaining unaltered; the action of the 1 Louis. Bowditch's translation. 44 STOKES ON THE STATE OF THE HEART, AND heart corresponding with that of the pulse. 2. Vigorous impulse, with distinct and proportionate sounds, with absence of pulse for many days. 3. Diminution of both sounds of the heart, with absence of great diminution of the impulse, (foetal character). 4. Diminution of the first sound; with cessation or great feeble- ness of the impulse. 5. Complete extinction of the first sound, the second remaining clear. 6. Predominance of the first sound, the second being extremely feeble. Of these the fourth and fifth were the most common. I have before remarked, that in the progress of a single case we may observe first one and then another of these groups of signs. Thus in the third case, (see page 8,) the sounds on the seventh day were proportionate, but so much diminished as to resemble those of the fcetal heart. On the eighth day this character was lost, and both sounds were much louder, with returning impulse; while on the eleventh the second greatly preponderated. Nearly the same phenomena were observed in the fourth case, (see page 11,) and in he seventh, (page 18). In the case of T. Keefe the second sound was most distinct in the early periods of the case, while the first became predominant towards its close. In the great majority of cases, however, the phenomena were as follows:— I. Diminished impulse. II. Diminished first sound, particularly of the left cavities. With respect to the impulse we arrived at some unexpected re- sults. In most cases, considered through the whole progress, the diminution and return of the first sound were accompanied with the diminution arid return of the impulse. So far the phenomena were what we might expect. But in so?ne instances, at particu- lar periods of the case, this accordance between the impulse and sound did not exist. In the second case, (page 7,) the sounds became distinct before the impulse returned. In the third case, (see page 9,) the impulse became distinct on the eleventh day, while the second sound greatly predominated. In the fourth, (page 11,) we found that on the eighth day the sounds were not in pro- portion to the impulse; and on the tenth, the impulse continued, but the first sound was totally absent. On the next day no impulse could be felt, yet the first sound was feebly audible. In the fifth case, (page 15,) the impulse on the twelfth day was less perceptible than on the day previous, but the first sound had more strength. It is difficult, or impossible, in the present stage of the inquiry, to otter any satisfactory explanation of these apparent anomalies; but it seems certain, that under the influence of the typhoid condition, the heart may have sufficient force to give an impulse with little or no ound, on the one hand ; and on the other, its contractions rray be accompanied by a sound, although the impulse be abs, nt. Whether we are to explain these facts by referring to particular THE USE OF WINE IN TYPHOUS FEVER. 45 states of innervation of the heart, or to organic alteration in the muscular fibres, or their connecting cellular membrane, is still to be determined. My friend Mr. Hopper has suggested, that, if there be any anor- mal liquid secretion between the muscular fibres, the production of sound might be materially interfered with, though the muscle might contract with a certain degree of vigour. In two of our fatal cases, we found that there did exist a liquid tenacious secretion in the fibres of the left ventricle; and it becomes a question, whether the softening of the heart in typhus is dependent on an alteration of the muscle itself, or an infiltration between its fibres. Analogy would lead us to conclude, that in the early stages of the alteration at least, the fibre itself is but little affected ; and the fact of the rapid resto- ration of the functions of the organ, in the convalescence of fevers, and the occasional excitement of the heart before death, seem to point out, that in such cases the injury of the muscular fibre itself has not proceeded very far. That the cause of the want of impulse, and feebleness or cessa- tion of the first sound, is a softening of the heart, I have no doubt. The evidences in favour of this opinion may be thus stated:— I. That softening of the heart exists in typhous fever as a local disease, and without any analogous condition of the muscles of voluntary life. II. That in our dissections in the last epidemic, we met with this softening of the heart, in cases which during life had presented the phenomena in question. III. That the physical signs indicate a debility of the left ventri- cle principally, and it is this position of the organ which is most often altered in consistence. IV. Laennec has stated, that in proportion to the severity of the putrescent phenomena, is the liability to softening of the heart. And the same observation is found to be true of the physical signs now described. If this softening of the heart be one of the secondary diseases of typhus, we should, as in the case of other lesions, observe some- thing like periodicity in its phenomena. It should appear at a cer- tain time, and decline after its proper period had expired. 1 have analysed my cases with a view to these points, and the result is, that in most instances the signs of diminished impulse and first sound were developed at or about the sixth day, and the heart seemed again healthy at or about the fourteenth day. It is difficult to determine the period of the first development of the signs in many cases, as they existed on the admission of the patient, but still taking in these cases the dates of the disappearance of the signs, we get the following general results :— Average date of appearance, sixth day. " date of cessation, fourteenth day. One case has been excluded from this analysis; the patient was admitted on the tenth day, and the heart was not reported healthy till the twentieth. 46 STOKES ON THE STATE OF THE HEART, AND We thus get, as the duration of the phenomena, a period of about eight days. It is very probable, however, that the disease begins to be developed before the sixth, and that it subsides before the fourteenth day; for, as physical signs are our only means of detect- ing it, it is not likely that they would be well marked in its very first development, or indicate exactly the time of its subsidence. In the softened condition of the ventricle, particularly the left, we have the explanation of the diminished impulse and first sound, and a new evidence of the truth of the theory which attributes the first sound to the ventricular contraction ; and the theory which explains the second sound by the reaction of the arterial column of blood on the semilunar valves, receives also from these facts an additional though indirect verification. With respect to the second sound, we must consider it in two sets of cases : first, where both sounds were equally diminished, and secondly, where the first greatly predominated. The phenomena of the first class might seem explicable, by referring to the diminished vigour of the ven- tricular systole and diastole, which would affect the physical rela- tions of the arterial column, as noticed in the Report of the London Committee of the British Association, communicated at the meeting of 1837; but when we find, in many cases, that the first sound became greatly diminished, or even extinct, while the second re- mained clear, we encounter a difficulty. In the second class of cases, of which I have recorded but two examples, we have no means of explanation, unless by assuming that there existed a diminished resiliency of the arterial trunks. I am decidedly of opinion, that we cannot consider the softening of the heart in typhus as the result of carditis ; it seems rather to be one of that class of affections not yet sufficiently examined, in which an infiltration of some peculiar substance takes place under the influence of the typhoid condition.1 This occurring in the heart seems to impair its functions to a great degree ; but the rapid resto- ration of the heart to health points out that the disease has not ma- terially impaired its organic condition. It is obvious that we can never meet with the affection in a very advanced condition, for death by syncope would occur after the contractility of the heart had been altered up to a certain point. Finally, I would draw the particular attention of my readers to the fact, that in the great majority of these cases the use of wine was followed by the happiest effects. I may safely refer to the cases in proof of this proposition ; and I believe that in the diminished impulse, and in the feebleness or extinction of the first sound, we have a new, direct, and important indication for the use of wine in typhous fever. In some cases the existence of these phenomena at an early period of the disease, led us to anticipate the bad symp- toms, and to commence in good time the use of the great remedy; 1 On this point it will be seen that I adopt, with respect to the heart, the views which Dr. Staberoh, of Berlin, has put forward with reference to the follicular disease of the intestines in typhus. See his paper, Dublin Medi- cal Journal, vol. xiii. THE USE OF WINE IN TYPHOUS FEVER. 47 and in others, notwithstanding the existence of severe visceral irri- tations, the use of stimulants has been adopted with the best suc- cess, from the same indication. It will be seen that the quantity of wine employed in the foregoing cases was considerable. I shall exhibit in the following table the quantity given, the day on which its exhibition was commenced, and the period of the fever, as nearly as we could calculate it. NAME. Q.UANTITT OF WINE. DAT OF COMMENCE- DURATION OF FEYER. MENT 01 ' WINE. Cavanagh, 26 < ounces. 8th day. 13 days. Wright, 36 « 14th i( 22 " Devereux, 42 u 14th « 16 » McKone, 60 « 12th « 16 days; wine continued to the 20th day. Wallace, 66 M Uth « 18 days. Kain, 83 U 9th a 16 « Smyth, 144 « 10th c« 18 « Edwards, 156 It 10th « 20 " Quin, 158 11 5th <« 14 « Hickey, 170 ■ « 7th " 17 " These cases may serve as illustrating the line of treatment which we adopted in our last typhus. In no epidemic did I ever before give so much wine. I never had such success in treatment. The list might be greatly enlarged, but no advantage could be gained by so doing. One case, however, may be mentioned, in which the whole quantity of stimulants employed was greater than in any of those now detailed. The patient was an elderly woman, who was admitted after having been three weeks ill, in a state of extraordi- nary prostration. There were no decided petechiae, and the fever was of a more purely nervous character than is common. The disease ran on to nearly six weeks. The following is the account of the stimulants employed:—Wine, 292 oz.; brandy, 20 oz.; porter, 7 bottles; ethereal enemata, 2 ; jelly, beef tea, &c. Her recovery was perfect. The form of fever under which this woman laboured has been but rarely observed in our wards; it is characterised by extreme adynamia unaccompanied by the phenomena of putrescence; its duration is much longer than that of the ordinary disease, its ter- mination less critical, and it seems uncomplicated with any distinct visceral affection. If any disease deserves the name of a " pure nervous fever," this one does. The disease to which it is most closely allied is the febris lenta nervosa of Frank, but it differs in the absence of signs of abdominal irritations. In this patient the disease ran on to nearly six weeks ; the prin- cipal symptoms being extraordinary prostration, coldness of the surface, feebleness and irregularity of the heart's action; and it was not until the end of the eighth day of the exhibition of wine, and other stimulants in great quantities, that any favourable influ- ence was produced on the circulation; and the case strongly illus- trates the advantage of persisting in the supporting system, although no amendment seems at first to follow its employment. 48 STOKES ON THE STATE OF THE HEART. If, on the one hand, an inflammatory and excited'condition is not produced; and if, on the other, the vital powers, though greatly sunk, are preserved from further sinking, we have an indication that stimulants are to be continued iu their original, or in increasing doses. I'may now state the conclusions to which we have arrived from our investigations of last year:— 1. That the condition of the heart in typhous fever must be determined by the application of the hand and stethoscope, the pulse being an uncertain guide. 2. That a diminished impulse, or a complete absence of impulse, occurs in certain cases of typhous fever. 3. That in such cases we may observe a diminished first sound, or even an absence of the first sound. 4. That both these characters may exist with a distinct pulse. 5. That although in most cases the diminution of the impulse and first sound co-exists, yet that impulse may exist without cor- responding first sound, and conversely, that the first sound may be heard although unaccompanied by impulse. 6. That these phenomena are most evident as connected with the left side of the heart. 7. That when the impulse and first sound are lessened or lost, the return to the healthy character is observed first over the right cavities. 8. That in some cases both sounds are equally diminished. 9. That in a few cases the first sound preponderates. 10. That these phenomena indicate a debilitated state of the heart. 11. That they may occur at an early period of the disease, and thus enable us accordingly to anticipate the symptoms of general debility. 12. That the existence of these phenomena, in a case of macu- lated adynamic fever, may be considered as pointing out a softened state of the heart. 13. That this softening of the heart seems to be one of the secondary local lesions of typhus. 14. That the diminution or cessation of impulse, the propor- tionate diminution of both sounds, or the preponderance of the second sound, are direct and nearly certain indications for the use of wine in fever. I cannot conclude this paper without bearing testimony to the singular zeal displayed in this investigation, by many gentlemen who fulfilled the duties of clinical clerks during the last year. To Dr. Bovelle, of Barbadoes, and Mr. K. Kowalewski, of Warsaw, I am deeply indebted.. And I beg also to mention the name of Messrs. W. M. Murphy, Thomas Moore, James Brady, Thomas Rogers, and W. Barrington, gentlemen whose practical knowledge of medicine, charity to their patients, and devotion to science, have earned for them the respect and admiration of all who were cogni- sant of their unostentatious exertions and untiring zeal.