Dunglisori's American Medical Library. 
CLINICAL LECTURES 
DELIVERED 
DURING THE SESSIONS OF 1834-5 AND 1836-7. 
BY ROBERT J. GRAVES, M. D., M. R. I. A. 
PROFESSOR OF THE INSTITUTES OF MEDICINE IN THE SCHOOL OF PHYSIC, TRINITY COLLEGE, DUBLIN 
&C. &C. &.C. 
PHILADELPHIA : 
PUBLISHED BY ADAM WALDIE, NO. 46 CARPENTER STREET. 
' 1838. NOTICE. 
The following lectures have not previously been brought toge- 
ther. The first series was published in the “ London Medical 
and Surgical Journal,” and the second in the “ London Medical 
Gazette.” Some of them have been reprinted in the medical 
periodicals of this country, and have attracted considerable notice. 
The author is a learned and accurate observer, who has had 
multitudinous opportunities for experience, and has well profited 
by them. 
The editor of the “ American Medical Library” feels satisfied 
that no work which he could place before his readers is more 
worthy of their favour and attention. 
Robley Dunglison. 
Philadelphia, March 1, 1838, CONTENTS. 
FIRST SERIES. 
LECTURE I. 
PAGE 
General observations 1 
Case of chronic cough—Remarks on bronchial secretion—Expectoration never 
performed during sleep—Effects of catarrhal attacks frequently recurring—Ac- 
count of remedies employed—Great power of nitrate of potash, combined with 
tartar emetic, in subduing inflammation—Observations on the secretion of air 
from the mucous membrane of the intestines in certain pulmonary affections— 
Efficacy of sulphur in chronic bronchitis—Sensation of tickling which precedes 
cough—Cough from worms—Hysteric cough—Pulmonary irritation from a 
syphilitic taint—Pulmonary irritation connected with a gouty diathesis; with 
a scorbutic habit; with scrofula 11 
LECTURE II. 
Sleeplessness—Sleeplessness from anxiety, grief, &c.—Case of jaundice accom- 
panied by sleeplessness ; treatment—Remarks on purgative mixtures—On the 
proper time for administering opiates—Sleeplessness in delirium tremens— 
Chronic variety of delirium tremens; treatment—Sleeplessness in fever; case— 
Failure of different modes of treatment—Use of opiate injections—Delirium 
traumaticum—Constitutional irritation from blisters ; treatment—Sleeplessness 
in hypochondriacs and hysterical females—On the use and abuse of cold appli- 
cations to the head 25 
LECTURE III. 
LECTURE IV. 
Gangrene and pleuritis—Hepatisation of the lung—Erysipelas. ... 38 
LECTURE V. 
Case of suspected thoracic aneurism—(Edema of left arm and left side of the face; 
probable cause of—Relations of the left vena innominata to the arch of the aorta 
—Reasons for concluding that the symptoms are produced by a solid tumour ; 
its effects explained—Another reiparkable case of thoracic tumour related—Case 
of violent and extensive pulsation of the heart depending on cerebral disease— 
Laennec’s error concerning the indications for bleeding; case illustrative of; use 
of digitalis in such cases—Case of asthma, and treatment—St. John Long’s 
liniment—Dropsy treated by opium—Acupuncturation in anasarca. . . 48 
Case of secondary symptoms which made their appearance soon after a mercurial 
course; method of treatment—Case of syphilitic eruption—Mouth suddenly 
affected by a small quantity of mercury—Effects of this on the progress of the 
cure—Earache preceded by rigors coming on during the course of fever; dan- 
ger of; treatment—External tenderness; value of, as a symptom in inflamma- 
tions of brain, lungs, abdomen, &c. &c.—Vomiting considered as a symptom in 
fever ; its treatment—Chronic rheumatism ; successful treatment of—Obstinate 
case of arthritis; cure of by local applications—Observations on the effects of 
mercury applied locally—Case of syphilitic iritis; action of belladonna in . 59 
LECTURE VI. viii 
CONTENTS. 
FACE 
General remarks on the pathology of paralysis—Dr. Graves’s new views upon this 
subject—Their application to the study of several varieties of paraplegia—Ex- 
planation of Mr. Stanley’s cases of paraplegia; of Dr. Stokes’s cases—Two 
cases of paraplegia after enteritis—Paraplegia after metritis—Paraplegia the 
consequence of poisoning by lead; by arsenic—Paraplegia arising from irrita- 
tion of the urethra, (case communicated by Dr. Hutton.) .... 70 
LECTURE VII. 
Paraplegia 83 
LECTURE VIII. 
LECTURE IX. 
Case of peritonitis and enteritis terminating in fatal convulsions—Enormous accu- 
mulation of lumbrici in the bowels, producing death by convulsions—Causes of 
catarrhal affections of the bronchial tubes—On the rkles produced by bronchitis 
—Remarkable proportion between the frequency of the pulse and the respiration 
—Use of emetics and chalybeates in chronic bronchitis—Symptoms which con- 
tra-indicate chalybeates—Trismus from inflammation of the temporal muscles— 
Pain in the nerves of the face, simulating tic douloureux, and caused by a carious 
tooth—Case of jaundice, with remarks—Connection between arthritis, jaundice, 
and urticaria—Analogous series of affections often caused by eating fish. . 95 
On bed-sores in fever, and their treatment—Instances of fever spreading by con- 
tagion—Attacking a person whose mouth was affected by mercury—Observa- 
tions on the use of tartar emetic in fever—An account of the manner in which 
it is usually employed—New views upon this subject—Practice first introduced 
by Dr. Graves of giving tartar emetic, combined with opium, in the advanced 
stages of fever—Successful cases—Treatment of fever with profuse sweating in 
the commencement—Mr. Cookson’s case—Mr. Stephenson’s case—Mr. Knott’s 
case. ... 109 
LECTURE X. 
LECTURE XI. 
General account of the spotted fever epidemic in Dublin, in 1834-5—Its most 
remarkable features—Insidious character—Further explanation of the reasoning 
which led Dr. Graves to the discovery of the utility of tartar emetic in its latter 
stages—Dr. Nolan’s remarkable case of enteritis, with collapse, cured by enor- 
mous doses of opium—Cases of singular proportions between the frequency of 
the pulse and of respiration—Case of acute oesophagitis. .... 119 
LECTURE XII. 
Persesquinitrate of iron in chronic diarrhoea—Blueness of the fingers and toes in 
fever—Some account of the yellow fever which prevailed in Dublin in 1827— 
Newly observed affection of the thyroid gland in females—Its connection with 
palpitation; with fits of hysteria—Erysipelas—Remarks on the formation of 
acidity of the stomach in indigestion—Psoriasis—Treatment by arsenic. . 128 
LECTURE XIII. 
Case of long continued nervous fever; remarks on—Pleuro-pneumonia—Cases of 
latent pleurisy; of pneumonia—Phthisis; latent ulceration of the bowels in— 
Diarrhoea of phthisis—Observations on the stammering of paralytic persons— 
Its explanation—Very remarkable case of stuttering cured by chronic laryngitis 
—Treatment of hoarseness—Velpeau’s new method of treating sore throat. . ' 142 
LECTURE XIV. 
Amaurosis—Acetate of lead in cholera. 153 CONTENTS. 
IX 
PAGE 
Case of Phlebitis—Remarks on the symptoms and treatment of this disease—Patho- 
logy of phlegmasia dolens—Its treatment—Case of cancrum oris—Fatal termi- 
nation—Remedies employed—Case of ague cake—Observations on the different 
varieties of ague—True ague, or intermittent fever—Ague produced by inflam- 
mation of internal organs—Nervous ague—Hysterical ague—Treatment of ague 
cake 162 
LECTURE XV. 
LECTURE XVI. 
Nervous fevers—Chorea—Paralysis agitans~Diabetes 172 
LECTURE XVII. 
Scarlet fever—Blisters and stimulants in fevers—Dropsy ; treatment. . .182 
LECTURE XVIII. 
Scarlet fever—Gastric constitution—Nervous fever. 193 
Scarlatina. 201 
LECTURE XIX. 
LECTURE XX. 
Treatment of fever—Retention of urine 211 
LECTURE XXI. 
Double pneumonia—Abscess of the heart—Chronic laryngitis—Prurigo. . 221 
SECOND SERIES. 
LECTURE I. 
Introduction—Connection between diseases of different organs; between arthritis, 
jaundice, and urticaria ; between periostitis, produced by abuse of mercury, and 
hypertrophy of the liver—Details of cases illustrating this connection—Its ex- 
planation—Hypertrophy of the liver produced by scrofula—Enlargement and 
inflammation of the liver after scarlatina—Importance of recognising this 
disease. 233 
LECTURE II. 
Connection between disease of the liver and disease of the heart—Chronic hepatitis, 
from this source, curable in young persons—Enlargement of the spleen con- 
nected with superficial ulceration of the legs—Erysipelas and gangrene, some- 
times of a pseudo-inflammatory character—Treatment of this form of disease. 241 
LECTURE III. 
Erysipelas in an epidemic form—Symmetrical spread of erysipelas on the body— 
Maculated fever, and Irish typhus—Dr. Lombard’s remarks—Improved treat- 
ment of fever—Choice of a proper nurse and assistants—Air of the sick cham- 
ber—Necessity of attending to diet and nourishment. . . . . 249 
LECTURE IV. 
General treatment of fever—Dietetic management—The starvation system may 
produce organic disease—Proper food for fever patients and convalescents— 
Allaying of thirst—Sedatives—Expergefacients—Efficacy of green tea in a case 
of narcotism—Flagellation effectual in a case of poisoning with opium. . 259 X 
CONTENTS. 
PAGE 
Treatment of typhus fever—Tympanites often the consequence of inattention to 
diet or to overdosing with purgatives—Thirst in fever frequently dependent on 
the state of some internal organ—Blisters, employed as stimulants or evacuants, 
excite the vital action of the capillaries—An important remedy where cerebral 
affection is apprehended—Signs of approaching cerebral symptoms—Tartar 
emetic solution, and ointment—The latter used with success in some desperate 
cases 266 
LECTURE V. 
LECTURE VI. 
Further remarks on the treatment of fever—Management of delirious patients— 
Advantages of tartar emetic in the form of enema—Subsultus tendinum some- 
times from disturbance of the nervous extremities, independently of the brain or 
spinal cord—Vomiting and purging at the commencement of fever, indicative 
of cerebral affection—Scrofulous inflammation of the brain—Chronic scrofulous 
fever. 275 
Scarlatina without eruption, followed notwithstanding by desquamation—Thoughts 
on the nature of desquamation—Latent scarlatina, followed by anasarca—Gene- 
ral proposition respecting the symptoms of animal poisons—Morbid appearances 
after delirium in fever—Treatment in anticipation of cerebral symptoms—Great 
advantage of blisters judiciously employed—Notice ofthe old mode of blistering. 281 
• LECTURE VII. 
LECTURE VIII. 
Glanders and button-farcy in the human subject—Particulars of a case of glanders, 
with the post-mortem appearances—Remarks on the variety of skin diseases 
produced by the introduction of an animal poison into the system—Case of but- 
ton-farcy—Analogous appearances, where, as in typhus, an animal poison is 
sometimes generated in the body—Furuncular inflammation, or carbuncle, gene- 
rated by animal poison; also tubercles—Sometimes a preternatural whiteness 
precedes the purple hue of mortification—Remarks on phlegmasia dolens— 
Phlegmasia dolens of the eye. . 293 
LECTURE IX. 
On the use of emetics at the commencement of fever; not so well adapted to a 
later period—Domestic remedies for feverish colds; these colds prove to be 
fevers, and time is lost—Protest against the abuse of purgative medicine in fever 
—The idea of curing fever by purging is absurd—Treatment where the bowels 
have become almost paralysed from the cure of preceding diarrhoea—Venesec- 
tion as a means of checking fever—Beneficial even within the first twelve hours 
after seizure by typhus—Various cautions respecting leeching and cupping- 
glasses—Mode of applying leeches when pneumonia or hepatitis supervenes on 
fever 302 
LECTURE X. 
Abdominal aneurism—Effect of posture on the bruit de soufflet—Limitation of this 
sound to one spot in aneurism—Its extension in mere nervous affections—Let- 
ter from Dr. Corrigan on the subject—Case of diabetes—Discovery of casein in 
the urine—Different varieties of diabetes 311 
Fever—Application of cold to the head; particular apparatus for this—Warm 
applications recommended—Use of mercury in fever—Effects of intemperance 
—Illustrations afforded by particular cases—Necessity of active attention to 
cerebral symptoms—Occasional absence of morbid appearance after death— 
Contraction and dilatation of the pupils—Coup de soleil. .... 319 
LECTURE XI. CONTENTS. 
XI 
PAGE 
LECTURE XII. 
On constitutional inflammation in general—On fugitive swellings and pains— 
Curious case of erratic gout causing transient swellings—Gout affecting the 
lobe of the ear—Fatty hypertrophy of the ears—Gouty grinding of the teeth— 
Gouty neuralgia of the skin—Remarks connected with Dr. Kingston’s recent 
researches on consumption. 328 
LECTURE XIII. 
On paralysis in general—On paralysis depending on affections spreading from the 
extremities of the nervous system to its centre—Gouty ramollissement of the 
spinal marrow ; two remarkable cases of—History of this hitherto undescribed 
form of disease 336 
LECTURE XIV. 
Gout may affect the spinal marow—Combination of arthritic inflammation with 
bronchitis—Effects of various remedies, particularly mercury—Effects of this in 
chronic bronchitis—Dr. O’Bierne’s plan of rapid mercurialisation in certain 
affections of the joints—Application of the same method to inflammation of the 
lungs of scrofulous character—Cases in illustration 345 
Hydriodate of potash in rheumatism—Sarsaparilla and nitre in chronic cough— 
Remarks on percussion—Clear sound with solidified lung—Fever with cerebral 
irritation—Employment of tartar emetic and opium—Success of turpentine. 353 
LECTURE XV. 
LECTURE XVI. 
On the efficacy of tartar emetic and opium in fever with much cerebral disturb- 
ance ; illustrated by cases 369 
Supervention of other diseases on fever—Description of a peculiar form of low 
neuralgic inflammation, not identical with phlebitis—Local affections with mor- 
bid poison producing cutaneous eruption—Vesicles of Colles. . . . 367 
LECTURE XVII. 
LECTURE XVIII. 
Dropsy following scarlatina ; utility of bleeding—Albuminous urine not neceesa- 
sarily the result of diseased kidney—Pulmonary affection after fever; smilax 
aspera—Phlegmasia dolens not dependent on phlebitis; treatment—Case of 
metritis—Melsena; various kinds of black discharge from the bowels; green 
stools not always a sign of deranged liver 37& 
On the influenza—Course and progress—Effect of climate, locality, &c.—Mortality 
—Peculiarities of epidemic of 1837—Symptoms—Singular case with hernia. 385> 
LECTURE XIX. 
LECTURE XX. 
Influenza continued—History of the symptoms—Stethoscopic phenomena—Post- 
mortem appearances—Extent to which the nervous system is implicated—Cha- 
racter of the sputa—Appearances of the urine—Cerebral affections—Bleeding 
only to be employed at the onset—Opiates in conjunction with antimony or nitre 
—Blisters generally inefficient—Warm fomentations beneficial. - . . 334 CLINICAL LECTURES. 
FIRST SERIES. 1834-5. 
LECTURE I. 
GENERAL OBSERVATIONS. 
Gentlemen, 
As it is usual, at the commencement of a course of clinical in- 
struction, to devote the first lecture to a consideration of some 
general topics connected with the line of studies most proper to be 
pursued by those who wish to attain eminence; I have, in com- 
pliance with this custom, thought it right to lay before you some 
observations on the proper mode of studying physiology and 
morbid anatomy, with a view of showing how best to derive ad- 
vantages from these accessory but necessary sciences, sciences 
which, according to the manner in which they have been cultivated, 
have, at different periods, retarded or advanced that most important 
of all branches of professional knowledge, practical medicine. It 
is quite evident, that a knowledge of the functions and structure of 
the body in health is essential to him who undertakes the treatment 
of disease, and hence physiology has always occupied the atten- 
tion of physicians. Physiology, however, may be studied in very 
different ways, and with very different objects; and, until lately, 
all those who were engaged in the cultivation of this fascinating 
science, not contented with observing the state of the different parts 
and tissues during health, the nature and quality of the secretions, 
the mechanism and operation of the different organs, sought to 
ascend from a knowledge of effects to an investigation of causes, 
and, after they had classified the more obvious phenomena of living 
bodies, endeavoured to ascertain, if not the very principle of life, 
at least those motions and causes of motion which result imme- 
diately from the action of the living principle. Having thus, as 
they conceived, obtained a more accurate knowledge of the condi- 
tions of health, they proceeded to form general explanations of the 2 
GRAVES’S CLINICAL LECTURES. 
causes of disease, and frame general rules for their removal. This 
method, apparently so philosophical, and possessing so many attrac- 
tions from the generality and simplicity of its application, has, 
more than any other circumstance, contributed to retard the pro- 
gress of medicine. Gentlemen, this is not only an ancient, it is 
also a modern evil. We live among systems. It is true, that the 
practice, founded on the mechanical, mathematical, chemical, and 
humoral physiologies, has been long since abandoned ; but the de- 
structive system of Brown has not long quitted the stage, where its 
place is occupied on the continent by those of Broussais and Rasori, 
and in Great Britain by the system which derives all diseases from 
derangement of the digestive functions, or from inflammation. 
Physiology legitimately embraces, not the study of vital actions, 
but merely aims at ascertaining and arranging their effects. The 
important facts which its study discloses, are perhaps infinite in 
number. As long as we confine ourselves to these we advance at 
every step, and all is clear and intelligible; but the moment we 
attempt to enquire into the causes and modes of vital action, we 
begin to retrograde, and all becomes hypothesis and confusion. 
Thus, an examination of the organ of sight discovers a wonderful 
and beautiful optical arrangement, calculated to form on the retina 
a picture of external objects, exact both in its colouring and out- 
line. The physiologist, examining with attention the different 
parts of the eye, and the laws of their respective refractions, inves- 
tigates the means by which distinct vision is secured at different 
distances ; he compares the human eye and its appendages with 
that of animals which live in water, those which soar into the 
highest regions of the atmosphere, and those which burrow under 
ground. He considers the eye of the mole, feeble but protected 
against injuries likely to be encountered in carrying on its subter- 
raneous works • of the eagle who, poised high in mid-air, selects 
its victim from the distant pasture ; of the fly, whose microscopic 
organ, with a range of vision scarcely exceeding the limits of con- 
tact, distinguishes objects the most minute ; and in all he finds 
variations in the optical instrument at once curious and intelligible. 
But when he endeavours to advance further in his enquiry, and 
tries to explain how an image, painted on the retina, produces 
vision, whether by the means of undulations arising from the rays 
of light, and propagated along the optic nerve to the brain, or 
whether because the retina is a nervous expansion, highly organ- 
ised and framed, so as to feel the coloured image painted on it, he 
is at once arrested in his progress by the barrier which is every 
where interposed between physical and vital actions, between the 
mechanism of the organs of sense and the mode in which they pro- 
duce ideas between body and mind. 
But has he, therefore, gained no real knowledge applicable to 
practical purposes, or has his time been merely spent in a pleasing 
but useless study? By no means;—being acquainted with the 
mechanism and arrangement of the optical instrument, he is often 
enabled to remedy its accidental derangement. By means of a con- GENERAL OBSERVATIONS. 
3 
cave glass he corrects a too speedy, by a convex a too tardy, con- 
centration of the rays of light. When the crystalline lens become 
opaque, his knowledge of its connections, nature, and position, 
enables him either to remove it altogether, or to displace it from 
the axis of vision, or to promote its absorption, and, in order to 
effect the latter purpose, he mechanically irritates it, knowing by 
experience that, after such an irritation, the process of absorption 
commences, although he is quite ignorant of the connection between 
mechanical irritation and this vital process. He who enquires 
into the physiology of the brain and spinal marrow can never dis- 
cover the nature of nervous influence, or the manner in which 
pressure on these organs destroys, or irritation deranges, the mo- 
tions of the voluntary muscles, and yet the entire treatment of 
cerebral or spinal diseases, whether spontaneous or from the effects 
of injury, is grounded on a knowledge of this physical fact; with- 
out it we could not estimate the value or effects of morbid changes 
in the brain or spinal marrow. On this reposes the rationale of 
the treatment of all convulsive, paralytic, and apoplectic affections. 
Although we know not the manner in which the eighth pair of 
nerves superintends the respiratory process, although we under- 
stand not how the phrenic nerve influences the motion of the dia- 
phragm, yet a knowledge of these facts led to a relief of spasmodic 
asthma, and to the recovery of persons apparently asphyxiated, by 
means of the galvanic stimulus passed along the course of these 
nerves. Knowing that some of the nerves, distributed to the face, 
are destined for sensation, while others serve for muscular motion, 
in cases of tic douloureux we divide the sentient and not the mo- 
tive nerves. In these, and a thousand other instances, physical 
physiology supplies us with information at once interesting and 
practical; it would be still easier to prove, as in the cases of Brown 
and Broussais, that vital physiology, by involving us in the discus- 
sion of subjects beyond the powers of our reason, never fails to en- 
tangle its votaries in a labyrinth, amidst whose mazes they move 
without progressing, and consume in idle speculations that time 
and labour they ought to spend in the acquisition of useful know- 
ledge. But I trust the period is at length arrived when this error 
will be avoided; for, on the whole, it must be confessed, that in 
consequence of a wrong method of studying, and a misconception 
of the true objects of physiology, this science has in many instances 
retarded the progress of practical medicine. 
Let us next consider the connection of morbid anatomy with 
practical medicine. Many have mistaken the end and object of 
morbid anatomy, and there are not wanting some who even deny 
its utility, while others again, in their zeal for its improvement, 
have endeavoured to extend its limits, so as to make it comprehend 
and embrace in the explanations it affords all the phenomena of 
disease. It is not easy to determine which of these parties has 
most injured the cause of practical medicine. Morbid anatomy 
comprehends not merely decided and permanent structural altera- 
tion, but embraces, so far as they are capable of being detected, 4 
graves’s clinical lectures. 
even temporary physical changes in internal organs. In order 
justly to estimate its importance, we should recollect that the first 
alteration in the texture of a part is not the cause but the conse- 
quence of disease, for in every healthy organ the texture is natural, 
and as every change of texture is produced in consequence of de- 
rangement in the vital action of the vascular system of the part, it 
is obvious that structural alteration must, in the first instance, be 
always produced by functional derangement. Thus, the physical 
alterations which attend external inflammation—the tumefaction, 
the heat, the redness, are not the causes but the consequences of 
disease. But in thus reducing them to the rank of symptoms, do 
we diminish their importance ? Certainly not. For being imme- 
mediately connected, as effects, with the primary cause, they prove 
the most useful of all symptoms, in enabling us to ascertain the 
seat and progress of diseased action. In this respect they possess 
a manifest advantage over the general or constitutional symptoms. 
Thus, in cases of spontaneous gangrene, phlegmonous inflamma- 
tion, or erysipelas, what practitioner would be contented to draw 
his indications from the general symptoms, disregarding the appear- 
ance of the affected part? And yet this is exactly what those per- 
sons do, who refuse the aid of morbid anatomy in the treatment of 
internal disease. 
In external diseases most of the physical changes in the affected 
part can be at one recognised ; their diagnosis is therefore compara- 
tivelyeasy, and their treatment well established. In internal diseases 
the case is widely different, the physical alterations are here beyond 
the cognisance of our senses ; and, in order to ascertain their nature 
and situation, we must carefully compare the morbid appearances 
of internal organs, as revealed to us by dissection, with the symp- 
toms during life. Although alteration of structure is in the first 
instance produced by a disease in the vital action of the part, yet 
this structural alteration may itself become a new cause of mischief. 
Thus the vascular system of the lungs, from some unknown cause, 
assumes such a change of action as produces a deposition into the 
pulmonary texture of various fluid and solid products, by which 
the entrance of the air into its vesicles is prevented, and the respi- 
ratory function, one of the most important of the body, is thus con- 
siderably deranged. Again, whatever be the original vital derange- 
ment which causes scirrhus of the pylorus, the obstruction thus 
formed is a secondary cause of new and important symptoms. 
Another consideration, which enhances the value of morbid ana- 
tomy, arises from the fact, that when diseased action fixes itself in 
any part of the body, whether external or internal, and there gives 
rise to physical alterations, experience teaches us, that the progress 
of the disease may be often arrested by removing its effects. Thus, 
to recur to the example of external inflammation, the redness, the 
swelling, the heat of the part are but symptoms, and yet we find 
great benefit from the applications of remedies capable of diminish- 
ing them ; hence we leech, and apply cold lotions, &c. From all 
these considerations it is evident, that whenever disease is attended GENERAL OBSERVATIONS. 
5 
with either a temporary or a permanent alteration in the tissue of 
an internal organ, it will be of the greatest practical importance to 
ascertain the nature and extent of that alteration, and the progress 
of practical medicine will be exactly proportioned to the accuracy 
with which this can be accomplished. Thus, how much has the 
treatment of pectoral diseases been improved by the application of 
auscultation and percussion, means which are only useful by en- 
abling us to ascertain the physical alterations induced by the 
disease, or in other words, the morbid anatomy of the affected 
organ. Without their aid, how trace the progress and follow the 
increase or diminution of pulmonary inflammation ?—how demon- 
strate the existence of dropsical or pleuritic effusion within the 
chest?—how distinguish with certainty pleurodyne from pleurisy? 
I could prove the utter impossibility of distinguishing many cases 
of bronchitic from tubercular phthisis without their assistance. I 
might refer to chronic emphysema of the pulmonary tissue, a dis- 
ease of great importance, but actually unknown before the time of 
Laennec, who first accurately described it in the dead body; indeed, 
before the application of percussion and auscultation, a perfect 
knowledge of this derangement of the pulmonary structure in the 
dead body would not have assisted our diagnosis, for how recog- 
nise it during life? I might bring forward dilatation of the bron- 
chial tubes, another disease wholly unknown before Laennec’s 
time, and which, before his discovery, could not be recognised by 
the common method of observation. I might enlarge upon the 
great utility of attending- to the changes which take place within 
the chest in measles and scarlet fever, but the benefit resulting from 
an accurate acquaintance with the morbid anatomy of the thoracic 
cavity is now so generally acknowledged, that I shall rather choose 
my illustrations from other classes of diseases. 
Nosologists, until very lately, were agreed in attributing con- 
siderable frequency to those cases of apoplexy and paralysis which 
arise from serous effusion into the brain, or from a mere functional 
inaction or debility of the cerebral and nervous systems. This 
opinion was founded partly on speculative grounds, and partly on 
inadequate and imperfect post-mortem examinations, and in prac- 
tical books the symptoms supposed to announce sanguineous, serous, 
and nervous apoplexy, were dogmatically laid down. What was 
the consequence ?—Most disastrous, as I have had occasion to wit- 
ness, in some parts of the continent, where the elderly practitioners 
still adhered to the practice founded on this false pathology. What 
can be more melancholy than to see time wasted or misemployed 
in the exhibition of diuretics, to promote absorption of the serum 
effused into the brain, or of strong exciting remedies, such as 
arnica, camphor, &c., to overcome the nervous debility, in cases 
where copious depletion by the lancet and purgatives were urgently 
necessary. I do not deny that in some rare cases effusion into the 
brain is the cause of sudden death from apoplexy. I have seen 
such an event supervene in chronic dropsy, but there the termina- 
tion was very sudden, and the state of the case left no doubt as to G 
graves’s clinical lectures. 
the cause; but in the majority of the cases formerly treated as 
serous or nervous apoplexy a more careful examination would 
have detected marks of vascular excitement, or local inflammation, 
a subject I shall treat at large when on the pathology of the brain. 
A similar error in morbid anatomy led to a similarly erroneous 
practice in the treatment of hydrocephalus, and many cases of 
general and local dropsy. The effusion occupied the sole attention 
of pathologists ; the marks of preceding vascular excitement or 
inflammation escaped their notice. 
Time will not permit me to enlarge upon the light which morbid 
anatomy, rationally pursued, has shed upon diseases of the brain. 
It is sufficient to remark, that some of the most important modifica- 
tions of inflammation in that organ have been only lately discovered, 
and it is only lately that a minute and extensive examination of the 
different changes the brain undergoes in disease has begun to intro- 
duce a certain degree of regularity and precision into a department 
where all before was confusion and inaccuracy. Examples of the 
utility of morbid anatomy might be brought forward without num- 
ber :—the discovery of local inflammation being at times the cause 
of a disease in most of its symptoms resembling common ague ; the 
use of the lancet in the cold stage of ague, a practice which may 
be advantageously resorted to, in cases where each return of the 
fit is accompanied by a recurrence of inflammation in a vital organ, 
as the lungs or brain ; the connection between inflammation of the 
mucous membrane of the stomach, and some of those symptoms of 
fever formerly attributed to mere debility ; the influence of cerebral 
inflammation and congestion, in producing the symptoms formerly 
vaguely denominated typhus; the low character which fever as- 
sumes when accompanied by pneumonia (and that, too, often 
latent); the symptoms which are produced by follicular ulceration 
of the intestines, which so frequently occurs in the course of fever ; 
the diagnosis between the pain produced by neuralgia of the abdo- 
minal nerves, and that resulting from structural diseases of the 
intestinal canal; a more accurate knowledge of the state of the 
mucous membrane in the diarrhoea of phthisis, and in intestinal 
tympanitis; the numerous improvements in the treatment of dis- 
eases of the ear, which followed Itard’s investigations concerning 
the morbid anatomy of that organ ;—these and many other disco- 
veries, all replete with practical advantages, are the results of the 
attention of our cotemporaries to morbid anatomy; and, were I 
to appeal to the records of surgery, I might bring forward examples, 
if not more important, perhaps more evident and striking ; for the 
invention and success of most capital operations depend on a per- 
fect knowledge of the structural derangements, the removal or cure 
of which is attempted. Of this, examples suggest themselves on 
every side, but none is more striking than the one devised by 
Dupuytren for the cure of artificial anus, the most disgusting and 
loathsome malady to which human nature is subject, and deemed 
altogether incurable, until that excellent surgeon, by a combination 
of profound pathological and physiological knowledge, succeeded in GENERAL OBSERVATIONS. 
7 
planning and executing an operation, that were alone sufficient to 
immortalise his name. 
The study of morbid anatomy, however, is attended with no 
ordinary difficulties, and, when imperfectly understood, is liable to 
lead to erroneous results, for it requires much candour, much 
patience, and that experience which can be only acquired by long 
continued practice, to enable us to judge concerning diseased 
appearances. The power of accurately discriminating in the dead 
body the traces of disease cannot be suddenly acquired, and so 
numerous are the various errors to which superficial observers are 
liable, that much injury has thus resulted to medical science, dis- 
eased appearances being in some cases overlooked, and in others 
recorded where they did not exist. Those who are aware how 
often the congestion, which frequently takes place immediately 
before or after death, in the pulmonary tissue, in the mucous mem- 
brane of the lungs and alimentary canal, and who know how often 
this congestion alters the physical properties of these parts, so as 
almost exactly to simulate the vestiges of inflammation, will under- 
stand how it happens that in investigations connected with the 
real or supposed diseases of these parts, facts have been marshaled 
against facts, and observations arranged against observations, until 
the path which promised simplicity and order terminated in per- 
plexity and confusion. Hence the doctrines of Broussais received 
so many corroborations, and appeared to rest upon a numerous 
series of undoubted and well-authenticated facts. 
The morbid anatomist must of all things beware of seeing too 
much. He must avoid imposing on himself by every where seeing 
exactly what he expected to see, and above all things let him not 
always force himself to see something; for many diseases proceed 
to a fatal termination without having produced any evident morbid 
alteration. 
When I come to treat of the pathology of the brain and nervous 
system, I shall have occasion to advert to errors which late authors 
have committed from too great an anxiety on the one hand to reduce 
to a certain and definite system the morbid appearances of the brain 
and spinal marrow, as connected with their diseases, and, on the 
other, to find, in every case where the cerebral or nervous functions 
had been diseased, lesions of structure to account for the symptoms. 
Thus, to cite one of numerous instances, I shall have occasion to 
prove that epilepsy and mania often commence suddenly and vio- 
lently, without the existence of any organic alteration ; and, in- 
deed, that organic lesions are not necessarily connected with these 
formidable diseases is sufficiently proved by the occasional sudden 
manner in which they cease. Thus, a gentleman of great literary 
reputation was many years a patient of mine before his death, 
which happened in 1831, at the age of seventy. From the age of 
twenty-five to fifty-five he suffered from violent and frequently 
recurring fits of epilepsy; after having continued thirty years the 
disease ceased suddenly, without any assignable cause, and for the 
last fifteen years of his life he had not a single fit. I shall have 8 
GRAVES’s CLINICAL LECTURES. 
occasion to show you how fine-drawn and how ill-founded the 
observations of those who profess to account for every nervous dis- 
turbance during1 life by cerebral lesions, who profess to distinguish 
accurately during life inflammation and irritation of the arachnoid 
or dura mater from irritation or inflammation of the brain itself, 
who maintain that one series of symptoms is produced by inflam- 
mation of the cortical, and another by inflammation of the medul- 
lary, substance, who have strained their eyes to discover, and their 
veracity to impose upon us. proofs that inflammatory or other dis- 
eased states of certain portions of the brain caused invariably 
similar affections of certain mental functions. These errors of 
some, even of the most eminent French pathologists, it will be my 
duty to notice from time to time; but I am sorry to say that much 
more unpardonable errors and misstatements have found their way 
into English and Irish publications on the pathology of the brain, 
and which I shall be compelled to speak of hereafter. 
Having made the preceding observations on the dangers which 
arise from an ill-directed application of the studies of physiology 
and morbid anatomy to the practice of medicine and surgery, I feel 
myself imperatively called on to present the other side of the ques- 
tion to your view, in exposing the still more dangerous doctrine 
advocated by those who depreciate the value of pathology and 
morbid anatomy as only instructive after the death of the patient, 
and even then as not unfrequently calculated rather to mislead 
than to advance the interests of practical medicine. 
It must be conceded, that he who is only a physiologist, cannot 
hope to cure disease, and that the mere morbid anatomist will be 
often misled by post-mortem appearances, if he has not attentively 
watched the progress of symptoms, and the effects of medicines, 
during life; for, unless this be done, he will, as I have already said, 
often mistake secondary for primary lesions, will confound effects 
with their causes, and will refer to certain alterations of structure, 
that which had originated in a functional disorder, a morbid state 
of parts very different from that which is observed after death. 
But when, to an accurate knowledge of physiology and morbid 
anatomy is joined an extensive observation of the progress of symp- 
toms, and the effects of therapeutical agents, how much more 
certain and satisfactory will be our practical decisions, and how 
much more likely our efforts to be attended with success, than if 
we merely studied disease at the bed-side of the patient. In the 
latter case, we might, indeed, become expert nosologists, be accu- 
rately acquainted with certain groups of symptoms, and even not 
unfrequently adopt the proper method of treatment. These symp- 
toms, considered together, we would call by a certain name, and 
hand down to posterity this new acquisition of medical knowledge, 
perhaps clothed in the garb of a dead language, and invested with 
the false dignity of a learned tongue. But what have we really 
thus effected for posterity? Our followers read our definitions of 
disease with an acquiescing admiration, and, sure of the efficacy of 
the remedies we have recommended, they go forth with an over- GENERAL OBSERVATIONS. 
9 
weening confidence in quest of the group of symptoms we have 
described, and when they have met with them, they look upon 
their task as already half accomplished, and promise a successful 
termination of the disease. “ Tell me the name of the disease,” 
was the motto of the nosologist, “ and I will tell you the remedy 
but, gentlemen, I will engage to tell you the names of a hundred 
diseases, without your being able to name the proper method of 
treatment. I tell you a man has dropsy, his limbs are anusarcous, 
water is accumulated in the peritoneal cavity, his urine is scanty, 
and his thirst increased. Will you, from this very excellent noso- 
logical definition, venture to prescribe for this case of dropsy ? For 
the sake of the suffering patient, and your own conscience, pre- 
scribe not on such data. And yet I regret to be obliged to say, 
that such a method of procedure is by no means rare, nay, it is 
even a matter of daily occurrence. But this case of dropsy will 
not yield. Some other boasted specific hydragogue or diuretic is 
had recourse to; still the patient grows worse and worse, and 
finally dies, but his friends are not discontented with the medical 
attendant, who excuses himself by asserting that he has succes- 
sively resorted to every remedy which has been recommended in 
dropsy; and, in truth, if you look over the list of medicines exhi- 
bited in rapid succession, you will probably find that his excuse is 
not unsupported by facts. But these cases in which every thing 
has been tried, are exactly those in which nothing has been tried, 
in which medicine has followed medicine, and each symptom of 
disease has indiscriminately been the object of attack, until death 
approaches with accelerated step, and charitably closes a scene dis- 
tressing to humanity, and disgraceful to the cause—I was going to 
say—of science; but who will venture to give so ennobling a name 
to this pseudo-practical knowledge—this worse than absolute igno- 
rance 1 
Gentlemen, I am not combating phantoms; I do not, Quixote- 
like, contend with imaginary giants; no, what I have described, 
exists, the picture I have drawn has many an original. But let us 
have done with this subject; let us turn to the gratifying consider- 
ations of the progress which practical medicine is making under its 
parent science—physiology and morbid anatomy. 
The reason of man is now more fully employed than at any 
former period, a vast store of mental power, a vast mass of mind, is 
every where at work ; what formerly was vainly attempted by the 
labour of a few, is now easily accomplished by the exertions of the 
many. The empire of reason, extending from the old to the new 
world, from Europe to our Antipodes, has encircled the earth—the 
sun never sets upon her dominions—individuals must rest, but the 
collective intelligence of the species never sleeps; at the moment 
one nation, wearied by the toils of day, welcomes the shades of 
night, and lies down to seek repose, another rises to hail the light 
of morning, and, refreshed, speeds the noble work of science ! 
All enquiries commence, as it were, at the same point, as the 
labours of their predecessors are equally at the disposal of all, and, 10 
graves’s clinical lectures. 
consequently, it is not surprising we should often find them arriv- 
ing together at the same end; thence the numbers of simultaneous 
discoveries of the same fact now so common. It is not unusual to 
find the publications of France, Germany, Italy, and England, 
simultaneously announcing the same discovery, and each zealously 
claiming for their respective countrymen an honour which belongs 
equally to all. I am sorry to say that, with some splendid excep- 
tions, this interesting and innocent controversy has been carried on 
by other countries, while Ireland has put in no claim for a share of 
the literary honours awarded to the efforts of industry or genius. 
But, gentlemen. I hope that this state of inaction, this state of 
mental torpor, has ceased, and that the time has passed away when 
we could not point out among our brethren any who had advanced 
the boundaries of the medical sciences, and thus promoted the inte- 
rests of humanity. Already have the names of several of the senior 
members of the profession been spread abroad ; already has the 
scientific character of this city been elevated by such men as Dease, 
Blake, Colles, Carmichael, Cusack, Crampton, Marsh, and Kirby; 
and already have some of the junior members of the profession 
attached their names to discoveries which shall be commemorated 
as long as anatomical sciences are cultivated ; I need scarcely add 
that I allude to the names of Jacob and of Houston. The interest- 
ing descriptions given by these gentlemen of their respective disco- 
veries, in a department of human anatomy in which all further dis- 
covery was looked upon as hopeless, are probably known to you 
all, and therefore it is unnecessary now to enlarge upon them. 
Neither have we, at present, leisure to enter into the no less inte- 
resting field of investigation which Dr. Corrigan has opened, by 
the publication of his experiments on the sounds and motions of 
the heart—experiments leading to conclusions so novel, that most 
physiologists were at first incredulous, and many even ventured 
boldly to call into question their accuracy. Without, at present, 
venturing to decide whether Dr. Corrigan’s opinions be in every 
respect correct, I may assert that his paper is written in the true 
spirit of philosophical enquiry, and that he deserves opponents of 
a far higher grade than those who have endeavoured to refute his 
arguments in the English periodicals. 
With regard to the treatment of disease, we must not omit the 
discovery, by Mr. Carmichael, jun., of this city, of the curative 
effects of spirits of turpentine in iritis ; for although we were in pos- 
session of two valuable remedies for the cure of this disease, bella- 
donna and mercury, yet there are cases in which it is useful to be 
able to accomplish a cure without the aid of salivation. 
It is with feelings of the greatest satisfaction and pride, that 1 
claim the right of adding to this list the names of three gentlemen, 
whose friendship I have long enjoyed, Mr. Adams, Mr. M‘Dowell, 
and Dr. Stokes. Of the two former, it is unnecessary to speak, 
their contributions to science are so well and so duly appreciated. 
Concerning the latter, my colleague, Dr. William Stokes, I shall 
impose upon, myself an unwilling and constrained silence, partly CHRONIC BRONCHITIS. 
11 
because his merits claim a warmer and longer eulogy than would 
suit this time and place, but chiefly because his labours have placed 
him in a position, as, far elevated above the necessity of praise, as 
above the fear of censure. Neither shall I allow myself to eulogise, 
as they deserve, the talents and exertions in the cause of science 
rendered by Professors Apjohn, Harrison, Kane, Montgomery, and 
E. Kennedy. They all rank high among the successful cultivators 
of some of the most useful departments connected with our art; 
their names, associated with those already enumerated, form a cata- 
logue the subject of congratulation for the present, of happy augury 
for the future, for cold must be the breast of him who will not hail 
with joy every symptom of our country’s literary regeneration, dead 
the feelings which are not elated at the boon conferred on our 
species by every advance made by those who devote themselves to 
the grand, the noble pursuit of relieving the suffering, of healing 
the diseased ; but time bids me stop ; I shall, therefore, conclude by 
observing that the attention lately devoted to the distinctions be- 
tween real and pseudo morbid appearances, the diligent cultivation 
of morbid anatomy by men not the slaves of preconceived opinions, 
the abandonment of all systems whose baseless fabric rests on the 
phantoms of vital physiology, the importance now justly attached 
to medical statistics, to the study of endemic and epidemic mala- 
dies, to the operation of morbid poisons; these, and various other 
circumstances, give us reason to hope that the progress of the 
human mind, in investigating the means of preventing and curing 
diseases, will not be less rapid than it has been in the other depart- 
ments of knowledge; and thus it will be proved, that if man has 
passions which impel him to the destruction of man, if he be the 
only animal who, despising his natural weapons for attack or de- 
fence, has devised new means of destruction, he is also the only 
animal who has the desire, or the power, to relieve the sufferings 
of his fellow-creatures ; the only animal in whom the co-existence 
of reason and benevolence attests a moral as well as an intellectual 
superiority. 
LECTURE II. 
Case of chronic cough—Remarks on bronchial secretion—Expectoration never per- 
formed during sleep—Effects of catarrhal attacks frequently recurring—Account of 
remedies power of nitrate of potash, combined with tartar emetic, 
in subduing inflammation—Observations on the secretion of air from the mucous 
membrane of the intestines in certain pulmonary affections—Efficacy of sulphur in 
chronic bronchitis—Sensation of tickling which precedes cough—Cough from 
worms—Hysteric cough—Pulmonary irritation from a syphilitic taint—Pulmonary 
irritation connected with a gouty diathesis; with a scorbutic habit; with scrofula. 
Allow me to direct your attention to day to the case of J. Jowson 
in the chronic ward, labouring under an attack of exasperated 
chronic bronchitis—a disease which derives its chief importance 12 
graves’s clinical lectures. 
from the circumstance of being exceedingly common. There is 
no morbid affection of the system more frequent or more general 
than chronic bronchitis; it is of every-day occurrence in dispen- 
sary practice; it is one of those cases which you will be constantly 
called on to treat; and hence the study of its nature and treatment 
has strong claims on your attention. 
This man is, as you have seen, about the middle age in point of 
years, but he is old in constitution. In this country you will find 
most of the labouring poor exhibiting symptoms of premature old 
age—the combined result of poverty, intemperance, and hardship. 
Obliged to work in the open air in bad weather, they get catarrhal 
affections, which are renewed by repeated exposure, and prolonged 
for want of proper care. The natural effect of cold frequently 
renewed and generally neglected is, that a tendency is produced in 
the bronchial mucous membrane to become congested and inflamed 
with facility, until at length the derangement becomes permanent, 
and the mucous membrane no longer returns to its normal and 
healthy condition during the intervals. 
The secretion of the mucous membrane of the bronchial tubes, 
in a perfectly healthy person, is almost entirely destitute of matter 
to be expectorated. In the normal state, the secretion of the bron- 
chial mucous membrane, though continually going on, scarcely 
ever exists in superfluous quantity, for a certain proportion of it is 
carried off by exhalation or absorption; a'perfectly healthy person, 
breathing a pure air, has no expectoration whatsoever. The 
moisture secreted by his bronchial mucous membrane contains 
nothing that the expired air cannot carry away in vapour, without 
leaving any residuum which, gradually accumulating, would at 
length require to be expectorated. In this respect the bronchial 
mucus in the healthy state differs from the mucus of other mem- 
branes of the same class; but disease destroys this beautiful pro- 
vision, and gives rise to a secretion of morbid mucus which cannot 
be gotten rid of in the usual way, and which must therefore be 
expectorated. Hence it is that persons, in whom a chronic state of 
congestion of the bronchial membrane has been generated by re- 
peated colds, have a secretion of superfluous matter always going 
on, and are constantly expectorating. This may continue for seve- 
ral years without much inconvenience; the principal annoyance 
the patient suffers is in getting up the phlegm in the morning. At 
this period there is always an accumulation of fluid in the lungs 
after the night, during which the cough is less frequent, and expec- 
toration less copious. 
Here let me remark, that, although a person may cough violently 
during his sleep, he never expectorates. Expectoration is accom- 
plished by the attention being directed to the chest, by an act of 
volition being put in force, so as to cause a constriction of the 
bronchial tubes, and generate a current of air of sufficient strength 
to expel the mucus. To effect this, the mere act of coughing is 
not sufficient, and consequently we do not expectorate during sleep ; 
for this purpose it is necessary for the patient to be awake. CHRONIC BRONCHITIS. 
13 
Frequently recurring catarrhal affections, besides generating a 
state of chronic derangement of the mucous lining of the lungs, 
have a necessary tendency to produce other bad effects. Dyspnoea 
is an ordinary attendant on chronic bronchitis ; the vesicular tissue, 
enfeebled by disease, loses its natural elasticity; and hence the act 
of respiration is performed weakly, and with considerable diffi- 
culty. In addition to this, the stress thrown on the air cells and 
passages gives rise to emphysema and dilatation of the bronchial 
tubes. 
When this man came into the hospital, he was labouring under 
an exacerbation of his chronic bronchitis, from a fresh attack of 
cold; he also suffered from dyspncea with a tendency to emphy- 
sema, and had been much debilitated by the frequent recurrence of 
his pulmonary symptoms. I do not intend to make any particular 
observations here on acute bronchitis supervening on chronic ; it 
is a dangerous disease, requiring prompt and careful attention. I 
merely refer to this case to point out the remedies which were em- 
ployed, and the principles which guided me in their selection. 
At the time of our patient’s admission, the fever which accom- 
panied the acute attack had subsided. His pulse was tolerably 
quiet, neither did he present any derangement of the heart’s action, 
and, so far, had escaped one of the consequences of chronic disease 
of the lung—namely, dilatation and hypertrophy of the right ven- 
tricle. Observe, the most important features in this case, so far as 
treatment is concerned, were these: there was no general inflam- 
matory condition of the system present; he had neither hot skin 
nor quick pulse; his expectoration was copious; the chest sounded 
well on percussion, and the only stethoscopic phenomena observed 
were extensive minute and moist bronchial rales. The case then 
stood thus : extensive bronchial inflammation with copious expec- 
toration, unaccompanied by fever, and occurring in a debilitated 
constitution. All weakening measures were therefore contra-indi- 
cated. It is true that the man had dyspncea, and complained of 
tightness across his chest—circumstances which might appear to 
demand the use of the lancet or leeches; if these means had been 
employed, he would certainly have experienced some relief; but in 
the course of a few hours the symptoms of distress would have 
returned, the weakness superinduced by bleeding would give rise 
to increased secretion into the bronchial tubes, and the patient 
would be worse than before. Under these circumstances, we re- 
frained from using the lancet or leeches ; but, deeming it advisable 
to get rid of the last traces of inflammatory action, we gave the 
following mixture:— 
R. Misturae amygdalarum, gxij., 
Nitratis potassse, 3 ij-, 
. Tartar, emetici, gr. j., 
Tinctur. opii camphorat., 3 ss. 
Ft. mistura pectoralis, sumat cochleare j., amplum omni hor&, vel urgente 
tusse. 14 
GRAVES’S CLINICAL LECTURES. 
In explaining the rationale of this mixture, it is hardly necessary 
for me to state why the almond emulsion was used. In all cough 
bottles it is of importance that the basis should consist of some mild 
mucilaginous fluid; and hence we generally employ for this pur- 
pose demulcent syrups, emulsions made with olive oil, spermaceti, 
or almonds, or decoctions of mucilaginous seeds and roots. With 
the almond emulsion we combined tartar emetic and nitrate of 
potash—both antiphlogistic remedies, and calculated to act with 
peculiar effect in relieving congestion of the bronchial mucous 
membrane. You are aware that nitrate of potash in large doses is 
a powerful antiphlogistic, and you have seen it prescribed with 
excellent effects in cases of acute arthritis treated in this hospital. 
Nitrate of potash, when given to the amount of two or three drams 
in the day, combined with two or three grains of tartar emetic, is, 
next to bleeding, the most efficient means we possess of reducing 
inflammatory action; and were I to be asked what remedies I should 
employ in combating inflammation—supposing there were no such 
things as the lancet, or leeches, or calomel—I should certainly say 
nitrate of potash and tartar emetic. When given in small doses, 
this combination proves also extremely serviceable in less severe 
cases, and it was on this account we gave it in the present instance. 
To this we joined the camphorated tincture of opium, convinced 
that its stimulant properties could not prove injurious when com- 
bined with antiphlogistics, although it would be improper to admi- 
nister it alone. Experience has taught that when camphorated 
tincture of opium is given, in cases of chronic cough with expec- 
toration, it will (if much inflammatory action be present) check the 
expectoration and bring on dyspnoea. But when combined with 
nitrate of potash and tartar emetic, its bad effects are corrected, 
while its sedative influence remains unimpaired. 
In addition to this, I ordered the nitro-muriatic acid liniment to 
be rubbed over his chest. This liniment we are much in the habit 
of prescribing where a rubefacient is required. It is made by dili- 
gently mixing one dram of nitro-rpuriatic acid and one ounce of 
lard, by means of a wooden or ivory spatula. When this mixture 
is complete, two drams of spirits of turpentine are added; these 
ingredients soon separate from, and mutually react upon each 
other, so that the liniment is spoiled; we, therefore, never make it 
in large quantities. As his bowels were constipated, I gave him a 
pill composed of three grains of blue pill, quarter of a grain of col- 
chicum, two grains of scainmony, and half a grain of capsicum. 
Colchicum acts on the biliary secretion, particularly when combined 
with blue pill, and hence promotes the general action of the intes- 
tines. With these I combined a little capsicum, in consequence of 
the patient’s complaining of being annoyed by constant flatulence. 
It is a curious fact, that every chronic derangement of the bronchial 
mucous membrane is accompanied by flatulence. Whether this 
arises from the irritation of the bronchial membrane spreading by 
continuity of tissue, and rendering the tongue foul, the stomach 
weak, and the digestive function unnatural: or whether the de- CHRONIC BRONCHITIS. 
15 
rangement. of the bronchial mucous membrane, and the imperfect 
performance of the function of respiration, cause the secretion of 
air from the lungs to be diminished, in consequence of which air 
is secreted from the intestinal mucous membrane by a vicarious 
action—I cannot exactly state, but I think the latter hypothesis not 
very improbable. It is well known that the mucous membrane of 
the stomach and bowels enjoys the power of secreting and absorb- 
ing air; it secretes carbonic acid, nitrogen, and also other gases 
which seem peculiar to it—such as sulphuretted hydrogen. I am 
not aware that there is any distinct evidence that the last-named 
gas is ever secreted by the bronchial mucous membrane, but, as 
there are some cases in which the breath is remarkably fetid, I 
think it remains for future experiments to decide whether it may 
not be so under certain circumstances. It is, however, by no means 
improbable, that when an adequate cause produces considerable 
derangement in the respiratory function, and alters the nature of 
the aerial secretion from the lung, the mucous lining of the stomach 
and bowels may take on a vicarious action, and secrete gases ana- 
logous to those which in the normal state are secreted by the mucous 
membrane of the bronchial tubes. I think I have seen some well 
marked examples of this translation of the function of secreting 
air from the pulmonary to the intestinal mucous system in cases of 
spasmodic asthma and hysteria. I have seen patients who, pre- 
viously to an attack of asthma, had no symptoms of flatulence, and 
observed that, accordingly as the disease proceeded and the derange- 
ment of the respiratory function increased, the bowels became dis- 
tended with air. In hysteria, also, where derangement of the 
respiratory function is plainly denoted by the heaving of the chest, 
sighing, and dyspnoea, there is generally enormous and sudden 
inflation of the belly, loud borbyrygmi are heard, and there is a 
constant disengagement of air upwards and downwards. 
But to return to our patient. After we had removed all traces of 
active inflammation, and the case had been reduced to one of ordi- 
nary chronic bronchitis, we changed his cough mixture for the fol- 
lowing :— 
R. Misturse ammoniaci, 3 vj. 
Carbonatis sodae, 3 ss. 
Tincturae opii camphorat, 3 ss. 
hyoscyami, 3j. 
Vini ipecacuanhae, 3 ij- 
Fiat mistura pectoralis, sumat. cochl. j. amp. pro dose. 
The carbonate of soda was given with the view of removing some' 
acidity of stomach which he complained of; besides, it is a fact 
that alkalies produce good effects in many cases ef pulmonary irri- 
tation, as must have struck you from witnessing the success of the 
popular remedy for hooping-cough, recommended by Mr. Pearson. 
You will observe, gentlemen, how very different this cough mixture 
is from the former, it is much more stimulating, and, at the same 
time, more powerfully anodyne, the opium being here less diluted, 16 
graves’s clinical lectures. 
and being aided by henbane ; the addition of ipecacuanha was in- 
tended to prevent a too speedy action on the part of the other ingre- 
dients, in diminishing the expectoration and constipating the bowels. 
I wish to call your attention to the plan of treatment, not with 
reference to this case alone, but with respect to chronic bronchitis 
in general. We first gave a combination of nitrate of potash and 
tartar emetic, with the view of removing any remaining traces of 
inflammatory action ; we next prescribed the misturse ammoniaci, 
with camphorated tincture of opium and carbonate of soda, &c.; 
and, finally, when the cough became entirely chronic, we gave the 
compound iron mixture, with tincture of hyoscyamus, in draughts, 
and an electuary, consisting of sulphur, cream of tartar, and senna. 
I need not repeat what you will find in every treatise on materia 
medica, with respect to the use of the compound iron mixture ; it 
is not to be given until all traces of fever and local inflammation 
are removed, and never until the secretion from the lungs is copious, 
and expectoration free. In such cases, the patient is generally weak, 
and the inordinate secretion adds to his debility. Here the compound 
iron mixture proves extremely serviceable, but you should com- 
mence its use with caution. Some persons are in the habit of 
giving it in doses of half an ounce, two or three times a day; this I 
never do; I begin with a dram, twice or three times a day, in an 
ounce of spearmint water, and add from half a dram to a dram of 
tincture of hyoscyamus. The dilution with mint water, and the 
addition of tincture of hyoscyamus, render it more valuable, by 
causing it to be more easily borne by the system, and less likely to 
be rejected by the stomach. 
Let me now explain my reasons for ordering the following 
electuary:— 
R. Electuarii sennae, 3 iij. 
Pulveris supertart, potassse, 3 j- 
Sulphuris loti, 3 ss. 
Syrupi zingiberis, q. s. 
Ut fiat electuarium, sumat cochleare, j. parvum bis vel ter quotidie. 
In the first place, when giving any stimulant medicine internally, 
it is essentially necessary to attend to the state of the bowels; in 
the next place, keeping the bowels freely opened, has a very re- 
markable effect in diminishing inordinate secretion from the bron- 
chial tubes. Where the patient’s strength can bear it, I often 
diminish supersecretion from the lung by strong hydragogue pur- 
gatives, as you saw in the case of a patient in the chronic ward, 
who had orthopnoea, and such an excessive secretion into the bron- 
chial tubes as to threaten suffocation. The patient being a strong 
man, and having no symptom of intestinal irritation, I prescribed a 
bolus, composed of a grain of elaterium, two of calomel, ten of 
jalap, and five of scammony, forming a powerful hydragogue pur- 
gative, which produced several fluid discharges. The man bore 
its operation well, and 1 repeated it in two days with the most 
decided benefit; indeed, he experienced from it more complete CHRONIC BRONCHITIS. 
17 
relief than he would have done from bleeding', blistering, or any 
other remedial means. In some cases of bronchitis with excessive 
secretion, you will be able to produce very striking effects by the 
use of hydragogue purgatives; this, however, will require both 
judgment and discretion, and it should be borne in mind, that, in 
the majority of cases, there are many circumstances which contra- 
indicate their employment. 
With respect to the use of sulphur in this case, I was led to pre- 
scribe it, in this and many other similar cases, from observing that 
chronic cough, and long-continued congestion of the bronchial 
mucous membrane, were more effectually relieved by the use of 
sulphureous waters, such as the Lucan and Harrowgate Spas, than 
by any other remedy that could be devised. I may here also 
observe, that the Lucan waters produce very striking effects in dis- 
eases of the skin, and that I have seen intractable cases of psoriasis, 
which lasted for years, yield to the use of the Lucan waters. It 
would appear that sulphur, when taken into the system, is either 
eliminated by the kidneys in the form of sulphates, or exhaled 
from the skin and mucous tissues in the form of sulphuretted 
hydrogen, and in this way we arrive at some explanation of its 
action in diseases of the skin, and chronic irritation of the bronchial 
mucous membrane. In fact, paradoxical as it may appear, sul- 
phur, although evidently stimulating, is nevertheless very effica- 
cious in curing many diseases connected with, or depending on, 
inflammation or congestion. Thus exhibited internally and pro- 
perly combined, what remedy gives such prompt and certain relief 
in that painful affection, piles? How rapidly does the specific irri- 
tation of the skin, termed scabies, yield to its use ! These, and 
similar facts, which might be brought forward in abundance, ought 
to countenance the use of this medicine in certain chronic inflam- 
matory affections of the bronchial tubes. The celebrated Hoffman 
was in the habit of adding sulphur to his cough prescriptions in all 
cases of chronic bronchitis in the aged and debilitated; and I have 
no doubt that from five to ten grains of sulphur, taken three or four 
times in the day, is one of the best remedies that can be prescribed 
in cases of chronic cough, accompanied by constitutional debility 
and copious secretion into the bronchial tubes. Within the last 
four years, my attention has been particularly directed to the use 
of sulphur in this and other affections, and I can state from expe- 
rience that it is a most valuable remedy. As it has a tendency to 
produce elevation of the pulse, increased heat of skin, and sweating, 
it will be necessaay to temper its stimulant properties by combin- 
ing it with cream of tartar, which is a cooling aperient,- and has the 
additional advantages of determining gently to the kidneys.1 The 
addition of the electuary of senna gives additional value to the com- 
bination, and quickens its action on the intestines. 
Such, gentlemen, are the principles that guided me in prescribing 
for this man. The long continuance of the complaint, the serious 
'Baglivi has well said, “In morbis pectoris ad vias urinee ducendum est.” 18 
graves’s clinical lectures. 
and extensive derangement of the pulmonary mucous membrane, 
the age, debility, and impoverished circumstances of the patient, 
forbid me to hope for a perfect cure; but he has been much relieved, 
and the same remedies applied to less desperate cases would have 
produced very striking effects. Still, if fortune were this moment 
to prove favourable to the poor fellow, if, when he leaves the hos- 
pital. instead of returning to hardship and exposure, he had the 
means of living in comfort, taking proper care of himself, traveling 
for health and amusement, and using a course of chalybeate spa 
waters, I have little doubt that with these aids the reparative powers 
of nature would succeed in obliterating every trace of pulmonary 
derangement. 
Permit me, gentlemen, to make a few observations here on what 
is popularly termed, cough. What is cough ? A sudden and 
violent expulsion of air from the lungs, produced by forcible con- 
traction of the diaphragm, aided by the abdominal and other expi- 
ratory muscles. What is the cause of cough? Pulmonary irrita- 
tion. What is the nature of this pulmonary irritation ? 
Here, gentlemen, is a question which every practitioner should 
put to himself when called on to treat a case of cough, and what 
affection is there which so frequently demands our assistance, and 
tasks our ingenuity? How abundant, how varied, are the examples 
of cough we meet with in our daily practice ! How obscure do we 
not find its nature on many occasions, and how difficult and per- 
plexing its treatment! Where the source of irritation is manifest, 
where the nature of the disease is simple and easily detected, where, 
after a proper examination, we can point to some part of the respir- 
atory system, and say here is the seat of the disease; in such cases, 
indeed, our course is sufficiently clear ; we may proceed with con- 
fidence, and practise with success. But how often are we, after 
weeks and even months of close and painful attention, baffled in 
our best-directed efforts, and forced to admit the humbling convic- 
tion that all our remedies are inefficient and useless, and that our 
character, as well as that of the profession, is likely to suffer in 
public estimation ! How often, too, do we discover with surprise, 
that the cough which we have been treating for weeks as a pure 
pulmonary affection, depends not on any primary derangement of 
the respiratory system itself, but upon the irritation of some distant 
organ, or upon peculiar conditions of the whole economy ! 
Before I proceed to enquire into the nature of the various sources 
of pulmonary irritation producing cough, I wish to remark that the 
exciting cause, or, in other words, that which immediately precedes 
and seems to give rise to a tendency to cough, is a sensation of tickling 
in the mucous membrane of the trachea, close to its bifurcation, and 
opposite the hollow at the fore part of the neck. It is also a curious 
fact that this sensation of tickling or itching is peculiar to this situa- 
tion, being never felt in any other part of the pulmonary mucous sys- 
tem. Whether the disease be seated above, as in case of laryngeal 
affections, orwhether it be below, as in case of disease of the lining 
membrane or parenchyma of the lung, it is here alone that the tickling CHRONIC BRONCHITIS. 
19 
sensation is felt. Another circumstance equally remarkable, and 
equally difficult of explanation, is the effect of position in cough. 
Persons labouring under slight bronchitis, or rather slight inflam- 
mation of the trachea, who scarcely cough half a dozen times in the 
course of the day, will, the moment they lie down at night, be seized 
with a violent and harassing cough, which may last for several 
minutes, and sometimes for hours, with little intermission. We can 
easily understand why empyema or pneumonia of one side of the 
chest may produce cough in certain positions and not in others, for 
here we have an obvious physical cause ; the accumulated fluid in 
the pleural cavity in the one case, and the diseased lung, whose 
specific gravity has been much increased by solidification, in the 
other, exercise an inconvenient degree of pressure on the sound 
lung, and hence give rise to irritation and cough, particularly in 
those positions which favour the operation of these physical causes 
of irritation. Here, however, the cause of irritation is very obscure. 
It may (but this I merely offer as an hypothesis) depend on the 
fluid secreted by the mucous membrane trickling over that part of 
the trachea where the tickling sensation is felt, the flow of mucus 
to this part being favoured by the recumbent position. That it 
does not depend on any supposed temporary congestion and irrita- 
tion of the lung, from the impression made on the skin by cold 
bed-clothes, I am quite convinced, for I have repeatedly observed 
it in persons warmly dressed, from merely lying down on a sofa 
close to the fire. You will, therefore, bear in mind, gentlemen, 
that although usually, when coughing is induced by any sudden 
change of position, we may infer that it is connected with some 
serious lesion of the lungs or pleura, yet we must not attach too 
much importance to this symptom in arriving at this conclusion, 
for cases are occasionally met with, in which mere tracheal or 
bronchial inflammation is attended with the same symptom to a 
very remarkable degree. 
I may observe, en passant, that the sensation of tickling or itch- 
ing appears to be almost exclusively confined to the skin. Here 
it appears to be dependent on slight causes, apparently incapable of 
producing that modification of nervous sensation termed pain. In 
other cases it seems to be connected with the rise and decline of 
the phenomena which indicate inflammatory action, arising in the 
first case (where it is generally less observable) from that nervous 
modification which precedes inflammation, and in the second being 
connected with some change in the nerves of the part which pre- 
cedes its return to a healthy condition. It does not appear to affect 
the mucous tissues, except in a very slight degree, and under pecu- 
liar circumstances. It is not observed in the pulmonary mucous 
tissue, except at that part of the trachea which I have already men- 
tioned, and it does not occur in any part of the intestinal mucous 
membrane. The only parts connected with the intestinal tube, in 
which it is felt, are the nose and on the anus, and here it is within 
the reach of scratching, the ordinary mode of relief. This is a for- 
tunate circumstance, gentlemen, for if any part of your bowels 20 
graves’s clinical lectures. 
were to itch as your skin sometimes does the annoyance would be 
quite intolerable. If the presence of lumbrici in the small intes- 
tines, instead of producing a troublesome itching of the nose, as it 
often does,—if it produced, I say, a degree of itching equally intense 
in the mucous membrane of the bowels and stomach, what patient 
could endure greater torments than a person so afflicted? If 
ascarides gave rise to as intense a degree of itching within the 
colon, as they occasion at the verge of the anus, how dreadful 
would be the suffering thus induced ! 
Passing over the obvious and well known sources of pulmonary 
irritation, producing cough, such as bronchitis, pneumonia, &c., 
the first cause to which I shall direct your attention is one of not 
unfrequent occurrence, and where a mistake in diagnosis may lead 
to a practice useless to the patient and discreditable to the prac- 
titioner. The best mode of illustrating this is by giving a brief 
detail of a case which I attended with Dr. Shekleton. A young 
lady, residing in the neighbourhood of Dorset street, was attacked 
with symptoms of violent and alarming bronchitis. The fits of 
coughing went on for hours with extraordinary intensity ; it was 
dry, extremely loud, hollow, and repeated every five or six seconds, 
night and day, when she was asleep as well as when she was 
awake. Its violence was such that it threatened, to use a vulgar 
but expressive phrase, to tear her chest in pieces, and all her friends 
wondered how her frame could withstand so constant and so terri- 
ble an agitation ; and yet she fell not away proportionally in flesh, 
had no fever, and her chest exhibited nothing beyond the rales 
usually attendant on dry bronchitis. She was bled, leeched, blis- 
tered, and got the tartar-emetic mixture, but without experiencing 
the least relief. We next tried antispasmodics, varying and com- 
bining them in every way our ingenuity could suggest, still no 
change. We next had recourse to every species of narcotics, ex- 
hibiting in turn the various preparations of conium, hyoscyamus, 
opium, and prussic acid, but without the slightest benefit. Foiled 
in all our attempts we gave up the case in despair and discontinued 
our visits. Meeting Dr. Shekleton some time afterwards I enquired 
anxiously after our patient, and was surprised to hear that she was 
quite recovered and in the enjoyment of excellent health. She had 
been cured all at once by an old woman. This veteran prac- 
titioner, a servant in the family, suggested the exhibition of a large 
dose of spirits of turpentine, with castor oil, for the purpose of re- 
lieving a sudden attack of colic; two or three hours afterwards the 
young lady passed a large mass of tape worm, and from that mo- 
ment every symptom of pulmonary irritation disappeared. 
The next kind of cough, in which the cause of pulmonary irrita- 
tion is often misunderstood, is that which occurs in hysteric females. 
This kind of cough is one of the most alarming diseases in appear- 
ance you can possibly witness; in some it is loud, ringing, inces- 
sant, and so intensely violent, that one wonders how the air-cells, 
or blood-vessels, escape being ruptured. In others it is quite as 
incessant, occurring every two or three seconds, night and day, CHRONIC BRONCHITIS. 
21 
but is not very loud, and, indeed, in some it scarcely amounts to 
more than a constant teazing hem; in general the pulse is quick, 
but it is the quick pulse of hysteria, not of inflammation or fever. 
The patient suffers no aggravation of the cough from inspiring 
deeply, and her countenance exhibits no proof of malaeration of 
the blood, on the contrary it is blanched and pallid. She com- 
plains of variable or deficient appetite, headache, cold feet, and 
irregular or absent catamenia, although the cough continues for 
weeks, or even months, she does not emaciate like a person in 
incipient phthisis, although so much disturbed by the cough, and 
subsisting on so small a quantity of food. 
Here the history of the case, a knowledge of the patient’s habit, 
and the use of the stethoscope, are of great value. You will find 
that the patient is subject to hysteria, that she is generally pale and 
of a nervous habit, that the attack came on suddenly, and was 
superinduced by mental emotion, or some cause acting on the 
nervous system, or else arose gradually as one of the sequelae of 
catamenial disturbance, that the heat of skin and state of pulse are 
by no means proportioned to the violence of the symptoms, and 
the stethoscope will tell you that the signs of organic derangement 
of the lung are absent, you will thus be enabled to arrive at an 
accurate notion of the nature of the disease, and you will save the 
patient from the useless and often dangerous employment of anti- 
phlogistic means. Bleeding and leeching are, generally speaking, 
injurious ; such cases are best treated by stimulants, antispasmodics, 
and stimulant purgatives, together with the change of air, traveling, 
and the use of chalybeate spa waters. 
The third species of obscure cough, to which I shall direct your 
attention is one of deep importance for many reasons. It is that 
species of cough which depends upon pulmonary irritation con- 
nected with a venereal taint in the system. That syphilis may 
attack the pulmonary as well as the cutaneous, osseous, mucous, 
and other tissues, is not a discovery of modern times; it is a form 
of the disease long known, and you will find it mentioned by many 
of the old writers. Since syphilis has been classed by Willan and 
others among diseases of the skin, this notion seems to have been 
either abandoned or forgotten, but, as it strikes me, with very little 
justice. I entertain a firm conviction, that syphilis may affect the 
pulmonary as well as it does the cutaneous, or mucous, or osseous 
tissues, and that a patient, labouring under a venereal taint, may 
have irritation from this cause set up in the lung as well as in any 
of those organs in which it is usually manifested. The first per- 
son who mentioned this circumstance to me was the late Mr. 
Hewson, and since that time I have had repeated opportunities of 
confirming the truth of his opinion. Richter, Alibert, and Paget 
have well observed, that. Willan and Bateman’s classification of 
diseases of the skin is liable to the paramount objection, that it has 
no reference to the constitutional origin of cutaneous affections. I 
have the very same fault to find with modern treatises on diseases 
of the lungs. Pathologists have indeed enquired most accurately 22 
GRAVES’S CLINICAL LECTURES. 
into the numerous morbid changes to which the pulmonary tissue 
is subject, but they have omitted a no less important part of their 
task, which is to investigate the states of constitution which origi- 
nated these changes. The agency, indeed, of scrofula has been 
enquired into with care, but how little attention has been paid to 
rheumatism, gout, syphilis, and scurvy, the fruitful sources of nu- 
merous diseases of the chest. 
By far the most interesting point connected with this affection 
is its diagnosis ; on this every thing depends. The great import- 
ance attached to the diagnosis arises from the circumstance of this 
disease presenting symptoms analogous to, and consequently being 
frequently confounded with, phthisis. A patient comes to consult 
you for cough ; you find him pale, emaciated, and feeble ; he sleeps 
badly, and is feverish at night, and has a tendency to sweat. Here 
there may be a double source of error. If the disease be mistaken 
for tubercle, and mercury not given, bad consequences will result; 
on the other hand, if tubercles be present, the effect of administer- 
ing mercury will be to precipitate the disease to a fatal issue. 
What is the nature of this disease, and how are you to recognise 
it? Mainly, I answer, by the history of the disease. If the pa- 
tient’s sufferings have commenced at the period of time, after 
primary sores on the genitals, when secondary symptoms usually 
make their appearance ; if some of his complaints are clearly trace- 
able to this source ; if, along with debility, night-sweats, emaciation, 
nervous irritability, and broken rest at night, we find cough; and 
if this group of symptoms have associated themselves with others, 
evidently syphilitic—such as periostitis, sore throat, and eruption 
on the skin—then we may, with confidence, refer all to the same 
origin, and may look upon the patient as labouring under a syphi- 
litic cachexy, affecting the lungs as well as other parts. In forming 
this diagnosis much caution and care are necessary, and we must 
not draw our conclusion until we have repeatedly examined the 
chest by means of auscultation and percussion ; if these fail to 
detect any tangible signs of tubercles, we may then proceed to act 
upon our decision with greater confidence, and may advise a suffi- 
cient but cautious use of mercury. Under such circumstances, it 
is most pleasing to observe the speedy improvement in the patient’s 
looks and symptoms ; the fever, night-sweats, and watchfulness 
diminish; he begins to get flesh and strength, and, with the symp- 
toms of lues, the cough and pectoral affection disappear. I am not 
prepared to say which of the pulmonary tissues is most usually 
attacked by the venereal poison, but I believe that it chiefly tends 
to the bronchial mucous membrane, although, like other animal 
poisons—e. g., those of measles and scarlatina—it may also occa- 
sionally produce pneumonia. 
The fourth species of obscure pulmonary irritation, producing 
cough, is that which is connected with a gouty diathesis. Gout 
may attack almost every tissue in the body. We may have it in 
the joints, as you are all well aware of; we may have it in the 
muscles and muscular aponeuroses, forming what has been termed CHRONIC BRONCHITIS. 
23 
the rheumatic gout; it occurs frequently in the fibrous tissues, and 
I have several times observed it in the cellular substance of various 
parts of the body, forming either diffuse oedema or tumours, which 
are exceedingly tender to the touch, and which are removed by 
treatment calculated to relieve the constitutional affection. It may 
attack the heart, giving rise to true pericarditis, or else to a func- 
tional disease with palpitations—a sensation of fluttering and sink- 
ing about that organ, and very remarkable intermission of the 
pulse; or it may affect the stomach, occasioning dangerous spasm 
or various dyspeptic symptoms; or it may seize on the intestines, 
producing irritation, colic, and gouty diarrhoea. I remember a pa- 
tient, of a confirmed gouty habit, expressing a great deal of sur- 
prise at getting an attack of gout in the testicle, for he could not 
conceive how a disease which generally affects the joints could 
occur in an organ so different in its nature. I replied, that the 
matter could easily be explained; because fibrous tissue, which 
gout most frequently attacks, enters into the composition of the 
testicle as well as that of the joints. Indeed, the testicle, with refer- 
ence to the texture of its envelopes and the extent of motion it 
enjoys, may be said to be provided with a sac-like joint. In like 
manner, gout very frequently attacks the mucous membrane of the 
trachea or bronchial tubes, causing a dry, annoying, and often a 
very obstinate cough. Where this cough comes on along with the 
fit of inflammation of the joints, its true nature is frequently 
overlooked, and it is believed to have originated in cold and to 
be mere common bronchitis. No matter what be the cause of 
inflammation in a gouty habit—no matter what the organ attacked 
by the inflammation be—it almost invariably assumes the character 
of true gouty inflammation. If a gouty person sprains a toe or an 
ankle, matters, after progressing for a time in the ordinary way, are 
sure in the end to exhibit a change of character; and the inflamed 
parts are observed either to grow unexpectedly worse, or to become 
stationary, at a time when a speedy termination of the local affec- 
tion seemed approaching. This is owing to its being now modified 
by the constitutional tendency to gout, which localises itself in the 
affected part. Precisely the same relations may be often observed 
between common bronchitis, produced by cold in a gouty habit, and 
the gouty bronchitis it indirectly produces. Gouty bronchitis often 
becomes chronic, continuing until it is relieved by a regular fit of 
the gout in the extremities. 
The fifth species of pulmonary irritation, in which the source of 
the disease is more or less obscure, is that which is connected with 
the scorbutic diathesis. It is important to be aware of this, par- 
ticularly for those who have charge of the health of the poorer 
classes, which is almost of more value than that of the rich, for on 
it their labour and their means of support depend. Among the 
poor, particularly in cities where the majority live on salt pro- 
visions, the scorbutic diathesis is very prevalent. It manifests itself 
either in the form of purpura, or in tendencies to hemorrhage from 
the nose, stomach, bowels, and bladder. It sometimes attacks the 24 
graves’s clinical lectures. 
lungs, producing irritation of the bronchial mucous membrane, with 
cough and spitting of blood, and occasionally gives rise to pulmo- 
nary apoplexy. It is evident that pulmonic cases of this nature, 
originating in a scorbutic diathesis produced by confined air, damp 
lodging, and a salt diet, will require a treatment peculiar to them- 
selves, both during the attack and during convalescence. 
The last source of pulmonary irritation, to which I shall direct 
your attention, is that which proceeds from scrofula. You all know 
that scrofula has a tendency to attack every tissue in the body, but 
you may not perhaps be aware that it may affect those tissues in 
very different ways, and that scrofulous irritation may manifest 
itself in various forms, from the most trifling and transitory to the 
most extensive and permanent. I recollect a case I attended with 
Dr. Jacob, in which this fact struck me very forcibly. A fine boy, 
of high complexion, precocious intellect, and other marks of the 
scrofulous diathesis, got an attack of scrofulous ophthalmia of an 
intense character, and it required all the skill and ingenuity of Dr. 
Jacob to save him from blindness. During the period of our attend- 
ance, his brother (who was also of a strumous habit) began to com- 
plain of parts of his arm being sometimes a little sore. This 
circumstance attracted my attention, and on examination I found 
that several circular diffused swellings, of various sizes, often 
equaling half a crown in diameter, had successively appeared on 
different parts of his extremities and body. They evidently de- 
pended on inflammation of the sub-cutaneous cellular tissue, and 
exhibited a remarkable example of a most transitory local affection, 
produced by a constitutional cause—for these swellings arose, ar- 
rived at their acme, and subsided in the space of ten or twelve 
hours; they constituted, in truth, the first efforts of the scrofulous 
diathesis to localise itself, and, after a few weeks’ continuance, they 
were replaced by distinct and fixed, scrofulous inflammation of the 
metatarsal bones. 
Here was a very curious and instructive fact. A boy, evidently 
of a scrofulous diathesis, has circumscribed tumours, which arise, 
come to maturity of irritation, and subside in the course of a few 
hours. In some weeks afterwards, scrofulous irritation, in a decided 
and permanent form, fixes itself in the foot, producing inflamma- 
tion and ulceration. From this it may be inferred, that scrofula 
(for in this case I am firmly convinced these tumours were con- 
nected with strumous diathesis) may attack parts not only in its 
more permanent and destructive forms, but also in a manner so 
trifling and so transitory as to subside in a few hours, and leave no 
trace of its existence. The inferences deducible from this fact are 
numerous and important; for if scrofula may thus produce an 
acute and transitory inflammation of the sub-cutaneous cellular 
tissue, surely it may occasionally give rise to somewhat similar 
affections of internal organs—as the bowels, the lungs, &c.—and 
thus may occasion an acute bronchitis, a pneumonia, or an inflam- 
mation of the mucous membrane of the intestines, totally indepen- 
dent of the operation of cold, or the usual causes of such affections. SLEEPLESSNESS. 
25 
It has been too much the custom to refer merely chronic and fixed 
local inflammations to the agency of constitutional causes. The 
example before us proves that even the most transitory may have 
this origin. 
Scrofulous irritation may affect either the lining membrane or 
the parenchyma of the lung—giving rise in the one case to scrofu- 
lous bronchitis, in the other to scrofulous pneumonia; two affec- 
tions which may exist separately or combined, and either of which 
may prove fatal, with or without the development of tubercles in 
the lungs. Tubercles have, as I have elsewhere proved, too exclu- 
sively engrossed the attention of those who have investigated the 
pathology of phthisis; they are a very frequent product of the 
scrofulous diathesis, but the scrofulous bronchitis and scrofulous 
pneumonia are still more frequent and more important, and do not, 
as is falsely supposed, depend upon the presence of tubercles in the 
lungs. The pneumonia, the bronchitis, and the tubercles, where 
they occur together, are all produced by one common cause—scro- 
fula. Of this more hereafter. 
LECTURE III. 
Sleeplessness—Sleeplessness from anxiety, grief, &c.—Case of jaundice accompanied 
by sleeplessness ; treatment—Remarks on purgative mixtures—On the proper time 
for administering opiates—Sleeplessness in delirium tremens—Chronic variety of 
delirium tremens; treatment—Sleeplessness in fever; case—Failure of different 
modes of treatment—Use of opiate injections—Delirium traumaticum—Constitu- 
tional irritation from blisters; treatment—Sleeplessness in hypochondriacs and 
hysterical females—On the use and abuse of cold applications to the head. 
Two cases which have been recently under treatment in this 
hospital demand your particular attention,—the man who has 
been labouring under a severe attack of jaundice, and the boy who 
is recovering from fever. A remarkable symptom in both of these 
patients, and which must have repeatedly attracted your notice, 
was a total privation of sleep. In the former case the sleeplessness 
continued for a week, in the latter for nine or ten nights. 
Sleeplessness is a very curious result of disease. It accompa- 
nies certain morbid conditions of the system brought on by actual 
disease, or by grief, care, and various other forms of mental disturb- 
ance, continues to harass the unhappy sufferer night after night, 
and frequently resists the most powerful and decided narcotics. I 
do not intend to enter into any enquiry respecting the different 
states of the constitution in which it occurs; my purpose is merely 
to offer a few practical remarks on the more obvious and striking 
examples, with the view of illustrating the cases to which I have 
directed your attention. 
There is a form of sleeplessness which is frequently the pre- 
cursor of insanity, and which has been well described by my friend 26 
graves’s clinical lectures. 
Dr. Adair Crawford. The watchfulness in such cases is accom- 
panied by the well known symptoms of incipient mental derange- 
ment, and its treatment is therefore inseparably connected with that 
usually resorted to in cases of threatened insanity, and embraces 
the employment of means moral as well as physical. Of these it 
is not my intention to speak ; I may observe, however, that Dr. 
Crawford has found opium, gradually increased to very large and 
frequently repeated doses so as to produce sleep, the best remedy. 
In the case of jaundice, the patient passed several nights without 
any sleep. He was just beginning to recover from the jaundice 
when this new symptom appeared, and I directed your attention 
particularly to the circumstance, because every manifestation of 
nervous derangement connected with jaundice should be carefully 
watched. It frequently happens that jaundiced patients sleep too 
much, and in some cases the disease is accompanied by convulsions, 
succeeded by coma, most alarming symptoms, and almost invaria- 
bly the harbinger of a fatal termination. Dr. Marsh was the first 
who directed our attention to the great fatality of those cases of 
jaundice in which convulsions occur ; I have seen but one instance 
of recovery. It was in the case of a gentlemen labouring under 
icterus, very considerable hepatitis, with enlargement of the liver 
and anasarca, with ascites. He was treated by Dr. Osborne and 
myself, and had at least a dozen long and violent convulsive 
paroxysms, ending in coma, succeeded by temporary forgetfulness 
and fatuity. Repeated leeching of the right hypochondrium, active 
purgation, and mercurialisation of the system removed all the 
symptoms of disease, and he slowly but perfectly recovered. A 
very able and original writer, Dr. Griffin, of Limerick, has detailed 
the particulars of some interesting cases of this nature in the Dub- 
lin Medical Journal. You perceive, therefore, that in jaundice 
every thing denoting an unusual state of the nervous system, whe- 
ther it be too much sleep or too little, demands your attention. 
In this man’s case the jaundice was the result of an attack of 
hepatitis. We treated it with leeches, blisters, and the use of mer- 
cury, and in the course of a few days the stools became copiously 
tinged with bile, and symptoms of improving health appeared. At 
this stage, the dejections being bilious, but the jaundice still remain- 
ing, he began to exhibit symptoms of restlessness and nervous irri- 
tability, and finally became perfectly sleepless. Here, gentlemen, 
we had to deal with a new symptom, extremely harassing to the 
patient, and likely to react unfavourably on the orginal disease. 
As a preliminary step I determined to evacuate the bowels, and for 
this purpose I prescribed a purgative draught, consisting of five 
ounces of infusion of senna, half an ounce of sulphate of magnesia, 
a dram of tincture of senna, and a scruple of electuary of scam- 
mony. My object was to purge briskly, and then give a full nar- 
cotic. In all cases of jaundice depending on hepatic derangement, 
after you have succeeded in producing bilious evacuations, you 
should never omit prescribing an active aperient every second or 
third day for the space of ten days or a fortnight, with the view of SLEEPLESSNESS. 
27 
carrying off the remains of the disease so as to prevent the occur- 
rence of a relapse. Hence you will find such cases very much 
improved by the use of Cheltenham water, taken every day for 
three or four weeks after the reappearance of a bilious tinge in 
the alvine discharges. The stimulus of the purgative causes an 
increased flow of bile into the intestines, which removes the hepatic 
congestion, and carries off what is popularly termed the dregs of 
the disease, and promotes a rapid and complete recovery. It is a 
simple but successful practice, and I would advise you never to 
omit its employment in cases of this description. 
With respect to purgative mixtures, I may observe that you 
should prescribe a larger quantity of the infusion of senna than is 
generally ordered, if you wish to secure its certain and decided 
operation on the intestines. Hospital nurses, who reason from 
facts and experience, know this, and when directed to give a senna 
draught they always give a small teacupful. They administer 
from four to six ounces at a time, and I have observed that in this 
way the action of the medicine is more certain, and the benefit 
derived from it more extensive. I am convinced that the usual 
mode of giving this valuable purgative in private practice is bad; 
the quantity given is too small, and consequently it is necessary to 
repeat the dose several times, a mode of proceeding apt to occasion 
much nausea and griping; I would therefore recommend a quan- 
tity varying from three to six ounces, to be administered in all cases 
where the patient’s condition will admit of free purging. A most 
accurate observer of the effects of medicines, Mr. Kirby, is in the 
habit of ordering purgative mixtures in chronic cases to be taken 
at bed-time, and not, as is usually done, in the morning. He asserts 
that their action is milder and less irritating to the bowels when 
the patient lies in bed and is asleep until the period of their opera- 
tion, than if he were up and about. 
After the purgative had produced four copious discharges, I pre- 
scribed eight minims of black drop, to be taken at a late hour in 
the evening. Whenever I give opiates to procure sleep, I always 
observe the rule laid down by Dr. M‘Bride (a celebrated physician 
of this city), to select the period at which nature usually brings on 
sleep, and which varies according to circumstances and the habits 
of the patient. Whenever you have to deal with watchfulness in 
patients labouring under morbid states of the constitution, as, for 
instance, hectic, enquire when the tendency to sleep usually occurs, 
and administer your narcotic about an hour or two before its occur- 
rence. It is between three and five o’clock in the morning that the 
inclination to sleep is strongest; it is about this time that sentinels 
are most apt to slumber at their post, and consequently attacks 
upon camps or cities, made with the intention of effecting a sur- 
prise, are usually undertaken about this period of the morning. 
How well marked is the periodic tendency to sleep at this hour in 
all patients labouring under hectic fever produced by whatever 
cause. How often do we hear the poor sufferer complain of rest- 
lessly tossing about in his bed until three or four o’clock in the 28 
graves’s clinical lectures. 
morning, when at last sleep, welcome although uneasy, for a few 
hours separates the patient from his pains. If given at an early 
hour in the evening, the effect of the opiate is not coincident with 
this periodic attempt of the constitution, and it fails in producing 
sleep; but if exhibited at a late hour, it begins to produce its sporific 
effect at the very time when nature inclines the harassed sufferer 
to repose, and the result of these combined influences is a deep, 
tranquil, and refreshing sleep. By observing this simple rule, I 
have often succeeded in producing sleep in cases where various 
narcotics had not only failed, but even added considerably to the 
irritation and discomfort of the patient. 
In cases of sleeplessness, where you have administered an opiate 
with effect, be careful to follow it up for some time, and do not 
rest satisfied with having given a momentary check to the current 
of morbid action. To arrest it completely, you must persevere in 
the same plan of treatment for a few days, until the tendency to 
sleep at a fixed hour becomes decidedly established. You must 
give an opiate the next night and the night after, and so on for five 
or six nights in succession ; and where the watchfulness has been 
of an obstinate and persistent character, narcotics must be employed 
for a longer period and in undiminished doses. I do not allude 
here to the sleeplessness which accompanies confirmed hectic and 
other incurable diseases; such cases require a particular mode of 
treatment, and generally call for all the varied resources of medi- 
cine. But in those instances of watchfulness, which are frequently 
observed towards the termination of acute diseases, it is always 
necessary to repeat the opiate for some time after you have suc- 
ceeded in giving a check to this symptom. You need not be afraid 
of giving successive opiates lest the patient should become accus- 
tomed to them and a bad habit be generated, for the rapid conva- 
lescence and renewed health, which are wonderfully promoted by 
securing a sound and refreshing sleep, will soon enable him to 
dispense with the use of opiates. 
Another disease in which sleeplessness is a prominent symptom, 
is delirium tremens. We have had an example recently in our 
wards, and you have seen the means employed to overcome it. 
The patient came into hospital with symptoms of extreme nerv- 
ous excitement and watchfulness, which had continued for some 
time, and were brought on, as is most commonly the case, by 
repeated fits of intoxication, succeeded by a pause of perfect 
sobriety—in Irishmen the result of necessity or accident. In this 
man you must have remarked the signal benefit which attended 
the use of a combination of tartar emetic and opium, and how 
rapidly the watchfulness disappeared. I shall not enter into the 
details at present, as I purpose to return to this subject on a future 
occasion. 
There is, however, one form of nervous irritability, frequently 
observed in persons who are in the habit of drinking freely, but 
without running into excess, and presenting as it were a shadow 
of delirium tremens, on which [ shall make a few remarks. This SLEEPLESSNESS. 
29 
curious state of the nervous system is generally found to exist in 
men about the middle period of life, and who consume a larger 
quantity of spirituous liquors than they are able to bear. Such 
persons, without suffering in appearance, or losing flesh, get into a 
chronic state of disturbed health, manifested by nausea, and even 
dry retching in the morning, loss of appetite, and impaired diges- 
tion ; but in particular by a deranged and irritable state of the 
nervous system, and by watchfulness. This forms one of the most 
distressing symptoms, and the patient generally complains that he 
cannot get any sound and refreshing sleep, that he lays awake for 
hours together, and that when he slumbers his rest is disturbed by 
disagreeable dreams, or broken by slight noises. How are you to 
treat this affection ? I can give you a valuable remedy for this 
deranged state of constitution—one which I have often tried, and 
which, from experience, I can strongly recommend. It is a mix- 
ture composed of tincture of columbo, quassia, gentian, and bark— 
say an ounce of each; and to this is added a grain, or bven two, of 
morphia. A compound tincture, somewhat analogous to this, is 
much in use among military gentlemen, and others, who have 
resided for a considerable time in India, where, from the heat of 
the climate, and the prevalence of intemperate habits, the stomach 
becomes relaxed and the nervous system irritable, so as to repre- 
sent, in a minor degree, the symptoms which characterise delirium 
tremens. You perceive I combine several tonics to form this mix- 
ture, because they are well known to produce a more beneficial 
effect when combined than when administered singly ; and I add 
to these a narcotic, which has the property of allaying nervous 
excitement without derangement of the intestinal canal. The dose 
of this mixture is a teaspoonful three or four times a day, and the 
best time for taking it is about an hour before meals. It gradually 
removes the nausea and debility of stomach, lessens nervous irri- 
tability and watchfulness, and with a proper and well regulated diet, 
and attention to the state of the bowels, I have seen it produce 
excellent effects. In such persons much benefit is derived from 
the use of the tepid shower-bath. 
Fever is another disease in which sleeplessness is a symptom, 
frequently of an unmanageable character, and pregnant with dan- 
ger to the patient. You witnessed this in the case of the boy who 
lies in the small Fever Ward, next to the man who is at present 
labouring under general arthritis. This boy had fever of a mild 
description, and unattended with any bad symptoms. His case 
scarcely required any attention, and he had almost arrived at a 
state of convalescence without the aid of medicine, when he began 
to lose his rest, and absolutely became sleepless for several nights. 
I beg your attention to this case, for many reasons. In the first 
place, you have seen that we tried many remedies without success, 
and afterwards fortunately hit on one which answered our purpose 
completely. Let us examine the nature of the medicines prescribed, 
and our reasons for giving them. 
In the first place we gave, as in the case of jaundice, an aperient, 30 
graves’s clinical lectures. 
followed by a full dose of black drop. It failed in producing any 
sleep; we repeated it a second and a third time, but without the 
slightest benefit. I then remarked to the class, that, as I had 
noticed the good effects resulting from a combination of tartar 
emetic and opium in the case of delirium tremens, where opium 
alone failed in procuring sleep, it would be proper to give this 
remedy a trial. I observed, at the same time, that I was convinced 
that the preparations of antimony have a distinct narcotic effect, 
and that I had seen patients in fever whose watchfulness had been 
removed by antimony given in the form of tartar emetic or James’s 
powder. I said it was my firm impression that tartar emetic, along 
with its other effects, exerts a decided narcotic influence on the 
system, and that it is this which makes it so valuable a remedy in 
treating the sleeplessness of fever and delirium tremens. Hence 
I have been in the habit of giving tartar emetic, combined with 
opium, in fever, and, I must add, with very great success. Our 
predecessors were much in the habit of using antimonial mixtures 
in the treatment of fever; and they did this because they knew, by 
experience, that these remedies worked well. It is at present too 
much the fashion to decry their practice, and in this instance, I 
think, with very little justice. 
In this boy’s case, however, the combination of tartar emetic and 
opium did not succeed in producing sleep. Having thus failed in 
our first and second attempts, we had recourse to the liquor muri- 
atis morphias—a preparation first brought into use by Dr. Chris- 
tison, and which, in the form usually employed, is equal in strength 
to laudanum. It is an exceedingly valuable preparation for many 
reasons, and one which has the strongest claims to your notice. 
Being of the same strength as laudanum, it saves the trouble of 
learning and remembering new doses, and, in addition to this, it 
possesses the more important advantages of inducing sleep with 
more certainty, and not acting as an astringent on the bowels, or 
affecting the head so frequently as laudanum. You observe that I 
say so frequently ; I do so because cases now and then occur in 
which even moderate doses of the liquor of the muriate of mor- 
phia produce quite as much headache as laudanum. I prescribed 
the former in doses of fifteen drops every six hours, so as to give 
sixty drops in the day, and continued this practice for two days, but 
without the slightest effect. Here you see three modes of inducing 
sleep completely failed. The boy remained for a day without 
taking any medicine, and then we made another attempt, which 
was more successful. We first prescribed a purgative enema, and 
after this had operated he was ordered an opiate injection, consist- 
ing of four ounces of mucilage of starch and half a dram of laud- 
anum. He fell asleep shortly after using the opiate injection, and 
did not awake until the next morning. The following night the 
opiate was repeated in the same form, and with equal success; 
convalescence went on rapidly, and the boy’s health is now quite 
re-established. 
Here, then, is a singular fact attested by this case, that opiates in SLEEPLESSNESS. 
31 
the form of injection will succeed in producing sleep, where they 
have completely failed when administered even in large and re- 
peated doses by the mouth. Baron Dupuytren was the first who 
made this important observation, and proved that narcotics applied 
to the mucous surface of the rectum exercise a powerful influence 
on the nervous system, always equal, and very often superior, to 
the effect produced by taking them into the stomach. He maintains 
that, in delirium traumaticum and delirium tremens, a certain quan- 
tity of opium, when prescribed in the form of enema, will act with 
more decided effect in allaying nervous excitement than the same, 
or even a larger quantity, when taken by the mouth. I have no 
hesitation in giving full credit to this assertion, as the results of my 
experience tend strongly to confirm its truth. I have, not long 
since, published, in the Dublin Med. Journal, the case of a patient 
in Sir P. Dun’s Hospital, who was reduced to the last stage of debi- 
lity and emaciation from the combined effects of mercury and 
syphilis. The torture which this man endured from nocturnal 
pains, and a total deprivation of sleep, was such that he swallowed 
enormous doses of opium; in fact, he had, previously to his admis- 
sion into Sir P. Dun’s Hospital, exhausted all his means in pur- 
chasing opium. While in hospital, he used to take 150 drops of 
black drop in the course of a day, and yet, notwithstanding these 
excessive doses, he could only get a few minutes of unrefreshing 
slumber. After some time I changed the plan of treatment, and 
had the black drop administered in the form of enema. It suc- 
ceeded in producing a decided soporific effect, and in a short time 
he was able to enjoy a sufficient quantity of repose, from taking 
only one tenth of the quantity used by the mouth. I have also, in 
the same paper, adverted to the case of a medical gentleman who 
laboured under an affection of his joints, which was accompanied 
by spasms of the limbs and most excruciating pains. His agony 
was so intense that he used to swallow grain after grain of opium, 
until he had taken to the amount of thirty or forty grains, with 
the view of procuring some alleviation of his sufferings. He was 
prevailed on to give up altogether the use of opium by the mouth, 
and employ it in the form of enema, which he did with the most 
striking advantage—the quantity which succeeded in giving relief 
in this way being scarcely the twentieth part of what he ordinarily 
used. 
It is unnecessary for me to enter here into any discussion with 
respect to the nature and treatment of delirium traumaticum, and 
the sleeplessness which always accompanies it, as you will find 
this subject very ably treated in M. Dupuytren’s works, and in a 
very instructive and elegant lecture delivered by Mr. Crampton 
(the surgeon-general) in this hospital, and published in the last 
volume of the London Medical and Surgical Journal. There isT 
however, one kind of sleeplessness, arising from irritation of the 
skin produced by blisters, which frequently assumes a very serious 
character, and on which it may be necessary to offer a few observ- 
ations, as the subject has not been noticed sufficiently by practical 32 
graves’s clinical lectures. 
writers. Trifling as the irritation resulting from a blister may seem, 
yet, under certain circumstances, it is a symptom of highly dan- 
gerous aspect, and becomes a source of just alarm. I have wit- 
nessed the loss of some lives from this cause, and many patients 
have, to my knowledge, been rescued from impending danger, by 
an early and proper share of attention being directed to its pheno- 
mena and treatment. 
The bad effects on the nervous system, occasionally produced by 
the application of blisters, are somewhat analogous to those which 
result from wounds and other external injuries, and to be accounted 
for on the same principle. Wounds and injuries sometimes make 
an impression on the nervous system, by no means proportioned to 
the importance of the injured organ to life, or to the extent of the 
mischief. An injury, produced by a body which strikes the sen- 
tient extremities of the nerves with great force, will sometimes pro- 
duce very remarkable effects on the system. Thus, a musket-ball 
striking a limb may, without wounding any great artery or nerve, 
or destroying any part of importance to life, produce a train of 
nervous symptoms of an extraordinary character. The person, 
without feeling much pain, and scarcely knowing that he has been 
wounded, without being terrified or having his imagination excited 
by any apprehended dangers, turns pale, gets a tendency to faint, 
and sometimes actually dies from the impression made on the nerv- 
ous system. In the same way, an external injury reacting on the 
nerves may bring on high mental excitement, delirium, and a total 
privation of sleep, as we exemplified in delirium traumaticum. I 
mention this with the view of establishing the proposition, that 
impressions made on the sentient extremities of the nerves are 
sometimes reflected on the nervous centres, producing the most 
alarming effects. In this way we can understand how the irritation 
of blisters may produce sleeplessness, mental aberration, and a train 
of symptoms analogous to those which characterise delirium trau- 
maticum. 
The delirium and sleeplessness arising from the irritation of 
blisters is by no means an uncommon disease. I have seen many 
examples of it in private practice, and I am anxious that you should 
be acquainted with its nature and treatment. It is generally met 
with in the case of children, in whom the cutaneous surface is 
extremely tender and irritable. I could relate several instances in 
which I have been called on to visit children labouring under 
fever, where symptoms of high nervous excitement were present, 
and where I found the little patients delirious, screaming, and per- 
fectly sleepless from this cause. I have found this alarming affec- 
tion generally occurring at an advanced stage of fever, and exhibit- 
ing a train of symptoms which closely resemble hydrocephalus. I 
have observed that after the application of a blister to relieve some 
suspected cerebral or abdominal or thoracic affection, jactitation, 
restlessness, constant application of the hand to the head, and deli- 
rium have appeared, and that these symptoms had been mistaken 
for incipient cerebritis or hydrocephalus, and treated with leeches SLEEPLESSNESS. 
33 
and purgatives. When the blister has been applied to the nape of 
the neck, the soreness and irritation of the skin on that part cause 
the child to roll its head from side to side on the pillow, with that 
peculiar motion and scream, supposed to prove to a demonstration 
the existence of hydrocephalus. I have learned also, that the above 
measures, so far from giving relief, have only tended to produce an 
exacerbation of the disease, and that the medical attendant has 
given up the case in despair. Now, gentlemen, if called to such a 
case what should be your practice? In four cases of this kind I 
gave my opinion frankly to the medical attendant, and told him he 
was pursuing a wrong course, that the disease was analogous to 
delirium traumaticum, and not to be treated by leeches or purga- 
tives, and least of all by blisters. I observed to him that these 
symptoms had made their appearance shortly after the child had 
been blistered for suspected disease of the belly, or head, or chest; 
and that it was useless to attempt to remove the disease by leeches, 
or purgatives, or blisters. The remedy I always proposed was 
opium, and it was acknowledged in four or five cases, that this 
remedy had succeeded not merely in relieving the existing symp- 
toms, but in saving the patient’s life. In such cases, particularly 
in young children, the opium must be given in small but frequently 
repeated doses, so as to ensure its energetic but safe action, and the 
greatest care must be taken to soothe the irritated portion of the 
skin by ointments, poultices, &c., while unwearied diligence must 
be bestowed upon the task of preventing the child from scratching 
the blistered surface. To effect this the child’s hands must be 
muffled in appropriate gloves, and must be secured in the sleeves 
of a shirt made for the purpose. 
I beg your attention still further to this subject of sleeplessness 
and delirium. I wish to mention the case of a gentleman who was 
a pupil of mine. This gentleman studied hard, attended lectures 
regularly, and was constantly in the dissecting room. While thus 
occupied, he happened to wound one of his toes in paring a corn, 
and afterwards wore a tight shoe on the injured foot. A small 
imperfect abscess formed in the situation of the corn, which was 
opened by one of his fellow students ; the incision gave very great 
pain, and was not followed by any discharge of matter. Next day 
he was feverish, and the lymphatics of the injured limb became 
extensively engaged, the inflammation ascending towards the 
glands of the groin and having a tendency to form a chain of 
insulated patches in different parts of the leg and thigh along the 
course of the lymphatics. This you will generally find to be the 
case in inflammatory affections of the lymphatics; the inflamma- 
tion is seldom continuous, but, in the majority of cases, is developed 
at certain insulated points, where small diffuse suppurations form 
very rapidly. After a few days, this young gentleman’s fever 
increased to an alarming height, he became completely sleepless, 
and had incessant delirium. He was purged briskly, leeched ex- 
tensively and repeatedly, his head shaved, and cold applications so 
constantly applied, that he appeared half drowned and collapsed. 34 
graves’s clinical lectures. 
Notwithstanding this very active treatment not the slightest relief 
was obtained; neither were the symptoms mitigated by incisions 
made in the inflamed patches for the purpose of evacuating matter; 
the sleeplessness continued, and the delirium was as wild as ever. 
1 saw him on the seventh or eighth day, when all antiphlogistic 
measures had failed, and his friends were quite in despair. On 
being asked my opinion, 1 stated that I looked upon the case as 
one of delirium, not proceeding from any determination to the head 
or inflammation of the brain, but depending on a cause analogous to 
those which produce delirium traumaticum, and that instead of 
antiphlogistics I would recommend a large dose of opium and some 
porter to be immediately given. Mr. Cusack, who visited the 
patient after me, concurred in this view, and a full opiate was 
administered in repeated doses. It succeeded in producing sleep 
and tranquilising the nervous excitement. I may here observe 
that a few days afterwards this gentleman had a return of the 
symptoms of cerebral disturbance with sleeplessness, in conse- 
quence of omitting his opiate, and that the opiate and porter were 
again administered, and again succeeded in removing the delirium 
and watchfulness. By perseverance in the use of the same means, 
the disease was completely removed, and convalescence established. 
The last kind of sleeplessness to which I shall direct your atten- 
tion, is that which is frequently met with in persons of a nervous 
and irritable disposition, in hypochondriacs and hysterical females. 
You will find such persons, although of active habits and with 
tolerable appetites, complaining of a total privation of their natural 
rest, and it is astonishing to think how long they may continue 
subject to this harassing watchfulness. I have frequently observed 
this affection among females of nervous habit, who possessed strong 
feelings of attachment to the interest and welfare of their families, 
and who were remarkable for an exemplary and over anxious dis- 
charge of their domestic duties. It is also very often met with in 
the upper classes of life, where the susceptibility to nervous excite- 
ment is morbidly increased by fashionable habits. I shall not enter 
into the various moral causes which tend to produce this state of 
the nervous system, and will content myself for the present with 
giving you some hints for the treatment of this obscure affection. 
As yet I have not any distinct and accurate notions of the disease, 
and can only guess at the treatment; but this much I may state, that 
such cases are not to be cured by the means which I have already 
detailed. If they are to be cured by any means, I think it is by 
antispasmodics, and remedies which have a gentle stimulant, and, 
if I may so express myself, alterative effect on the nervous system. 
I have cured two cases of this kind by musk and assafoetida, where 
every other remedy had failed. To one of these I was called by 
my friend, Dr. Neason Adams; the patient was a lady of delicate 
constitution and hysterical habit; she was emaciated, and suffered 
from a total loss of rest, but had no other disease. All kinds of 
narcotics had been tried unsuccessfully, and opium in all its forms 
had failed in procuring sleep. I advised the use of musk in doses SLEEPLESSNESS. 
35 
of a grain every second hour, and this means proved eminently 
successful. In another case I succeeded by administering the same 
remedy in combination with assafcetida. I have also remarked 
that assafcetida alone, given in doses of two or three grains three 
times a day, has very considerable effect in calming nervous irrita- 
tion of this description, and restoring the patient to the enjoyment 
of more prolonged and refreshing sleep. In all such cases the phy- 
sician must be most careful to have the appearance of not thinking 
the loss of sleep as a matter of much consequence, and the family of 
the patient must be directed to speak as little about the matter in 
his presence as possible;—nay, so powerful is the operation of 
moral impressions, that in one case, which I attended along with 
Mr. Halahan, I succeeded in procuring sleep by ordering a musk 
pill to be given every second hour night and day, and by desiring 
the patient to be awakened, should she be asleep, at the time the 
pill was to be taken. I laid great stress on the importance of so 
proceeding, and thereby produced so strong an effect on the patient’s 
mind, and inspired so great a confidence in the efficacy of the medi- 
cine, that she went to bed, not so much afraid of lying awake as 
afraid of being asleep at the hours when she ought to take a pill. 
The idea which had hitherto fixedly occupied her mind was dis- 
placed by a new impression, and relief was obtained the very first 
night. 
In affections of the head occurring in acute diseases, and attended 
with raving and loss of rest, it is a very usual practice to direct the 
application of cold lotions to the shaved scalp. 
Permit me, gentlemen, to make a few remarks upon this im- 
portant subject. I wish I could make myself well understood on 
this point, for I have seldom met with any person who seemed 
to bear in mind the true principle upon which cold is applied 
as a means of repressing local heat. In cases of determination 
of blood to the head occurring in fever, the common practice 
is to have the head shaved and cold lotions applied. Enter the 
room of a patient who is using cold applications, and you will 
observe the process conducted with great apparent nicety; the 
head is accurately shaved and carefully covered with folds of linen 
wet with a lotion to which spirit of rosemary or some odoriferous 
tincture has communicated an agreeable and refreshing smell; but 
when you come to examine the patient, you find his head smoking 
and the heat of his scalp increased. The nurse applies the lotion 
once every half hour, or perhaps not so often ; indeed, she seldom 
repeats the application until her notice is attracted by the steam 
rising from the patient’s head, or until she herself, awaking from a 
comfortable sleep, and going over to examine the state of the 
patient’s head, find the folds of linen which cover it as hot and 
dry as if they had been hung before a fire. Whether applied to 
reduce local inflammation in any part of the body, or to cool the 
scalp in determination to the head, cold lotions as ordinarily em- 
ployed do infinitely more harm than good. The cold is applied 
at distant intervals, its effect soon ceases and reaction constantly 36 
graves’s clinical lectures. 
takes place, leaving the part as hot or even hotter than it was 
before. 
If you put your hand into snow for a few moments and then take 
it out, it quickly resumes its natural heat; and if you repeat this 
at considerable intervals, so as to give time for reaction to occur, 
the vessels assume a more energetic action, and it becomes hot and 
burning. If you continue to keep it in the snow for a long time, 
its heat becomes completely exhausted, reaction does not take 
place until after a considerable period, and very slowly, and the 
hand remains at a very low temperature for a good while. Bear 
this in mind, for it will direct you in the application of cold to 
reduce local heat. If cold applications be used at such intervals 
as to allow the scalp to react and resume its heat, rely upon it, it is 
much better to forbid them altogether. Where you wish to apply 
cold with effect, let it be done by relays of folded linen, wet with 
any frigorific mixture, and repeatedly applied to the scalp so as to 
leave no smoking, or, what is much better, get three or four blad- 
ders, put into each a quantity of pounded ice, and apply one over 
the crown of the head, one on each side, and lay one on the pillow 
for the back of the head to rest on. 
There is a vast difference between a thing being done and its 
being well done: so it is with regard to cold lotions ; so difficult is 
it to ensure their proper application, that I have entirely given them 
up in hospital practice, and rarely order them in private. I have 
been induced to abandon them in consequence of witnessing so 
many instances in which my directions were neglected, and con- 
sequently the cerebral congestion was augmented by their mal- 
application. Another serious inconvenience frequently arises from 
their use when applied in a slovenly manner, which is the danger 
of cold arising from the pillow and bed-clothes being wetted. 
It is a curious fact that the head is the only one of the three 
cavities with respect to which long established custom has laid 
down the maxim, that when its contents are inflamed we may cool 
the surface over it, while in inflammatory affections of the thoracic 
or abdominal viscera this practice is avoided as dangerous and 
inapplicable. Latterly, however, some medical men have been 
inclined to question the grounds on which cold applications have 
been rejected in the two latter cases, and some have even declared 
that they have used ice poultices in inflammations of the chest and 
belly with great success and perfect safety. I am not as yet pre- 
pared to adopt this practice, although I must confess that a review 
of the subject might incline me to give up my prejudices on this 
point. It is certainly but reasonable to think that what is true of 
the one may be also true of the other, and that the application of 
cold to the head and heat to the chest and belly has nothing in its 
favour beyond mere custom. It should be recollected, however, 
that the head and face are more accustomed to cold than the chest 
and belly, and hence are less liable to any mischief likely to arise 
from its application in an intense degree. Still I am inclined to 
think that there is much prejudice connected with the practice of COLD APPLICATIONS. 
37 
applying cold to the head; and I have very little doubt that if the 
matter was properly investigated, and a number of experiments 
made, it would lead to the abandonment of cold applications in most 
inflammatory diseases of the brain. In fevers, I can say positively 
that in the majority of cases they are positively injurious, as usually 
applied; sponging the bare scalp with tepid or warm vinegar and 
water, or even frequently repeated steeping of the head and tem- 
ples, will often succeed much better in abating the headache and 
restlessness of fever than any cold applications whatsoever. In 
1832, a violent influenza, accompanied by most distressing head- 
ache, attacked thousands in Dublin ; this intense pain in the head 
was relieved by nothing so effectually as by diligent steeping of the 
temples, forehead, occiput, and nape of the neck, with water as hot 
as could be borne. 
I do not speak here of the application of cold to the head for the 
purpose of relieving local heat and inflammation, but to produce an 
effect on the whole system. Cold thus applied is of decided and 
unequivocal value. You are aware that in cases of fever accom- 
panied by symptoms of high mental excitement and great heat of 
skin, the use of cold dashing has produced the most extraordinary 
effects. Again, if a patient has taken too large a dose of prussic 
acid or any other narcotic, the best mode of rousing him is by pour- 
ing water on his face or chest from a height. In Turkey, if a person 
happens to fall asleep in the neighbourhood of a poppy field, and 
the wind blows over it towards him, he becomes gradually nar- 
cotised, and would die, if the country people, who are well ac- 
quainted with this circumstance, did not bring him to the next well 
or stream, and empty pitcher after pitcher on his face and body. 
This occurred to my friend, Dr. Oppenheim, during his residence 
in Turkey, and he owes his life to this simple but effectual treatment. 
To conclude, gentlemen, I may observe that sleeplessness in a 
chronic form is often produced by dyspepsia, and can only be 
relieved by the means suited to indigestion. Here it is that small 
doses of blue pill and tonic purgatives are of infinite service, com- 
bined with change of air, of scene, and an appropriate diet. In 
many females, sleeplessness is combined with menstrual irregularity, 
and can only be cured by means calculated to invigorate the health 
and restore the catamenial discharge to its natural periods and 
quantity, for the nervous system suffers equally whether they be 
suppressed or over abundant. It is singular how long sleeplessness 
often continues in chlorosis without inducing those serious conse- 
quences that are produced by this symptom in other morbid states 
of the system. In such cases much is sometimes accomplished by 
means of the common preparations of morphia, or by the use of 
Hoffman’s liquor (liquor asthereus oleosus), camphor, and other 
medicines that act upon the nervous system. It must be confessed, 
however, that these and every other expedient to obtain sleep often 
fail in chlorotic and hysterical females, in whom relief is only 
obtained by a gradual improvement of the general health and 
menstrual function. 38 
graves’s clinical lectures. 
LECTURE IV. 
GANGRENE AND PLEURITIS. 
I have here the lungs of a patient who died yesterday in the 
fever ward, and to whose case I have frequently directed your at- 
tention. They present some pathological phenomena of consi- 
derable interest, and I would advise you to examine them carefully 
after lecture. 
The patient, who was advanced in life and of a feeble constitu- 
tion, had been ill for a week before his admission, with symptoms 
of dyspnoea, cough, and pain in the left side, which appeared 
shortly after his recovery from an attack of fever. On examining 
him the morning after his admission, we found the interior part of 
the left lung dull on percussion, the dnlness extending much 
higher up posteriorly than anteriorly. On applying the stetho- 
scope, we observed that, over a space about the size of two palms, 
no sound, morbid or otherwise, could be heard ; but above the line 
which bounded this space there were crepitating rales and bronchial 
respiration. We had, therefore, a twofold affection of the lung, 
pleuritis, as indicated by the pain in the side, dulness on percussion, 
and absence of all sound over a certain portion of the chest; and 
pneumonia, as indicated by cough and expectoration of viscid 
sputa, tinged with blood, dulness of sound on percussion, bronchial 
respiration, and crepitating rales. It is unnecessary for me to reca- 
pitulate all his symptoms, as I have, while visiting the wards, 
mentioned them in detail, and I shall merely state, that our exami- 
nation showed that this man, in the first place, was labouring under 
pleuritis, and that it was of that kind which is called dry pleurisy, 
and where there is no tendency to considerable effusion ; and, in 
the next place, that he had pneumonia of the inferior lobe of the 
left lung, extending up into the middle lobe posteriorly. You will 
recollect that, at the time of our examination, I marked on his skin 
with a pen the extent of the pleuritic inflammation as well as of 
the pneumonia, and you will find, by examining this lung, that my 
diagnosis was correct. You will observe the pleura presenting, 
over its inferior part, laterally and posteriorly, an effusion of lymph, 
with a very small quantity of sero-purulent fluid ; and here is the 
seat of the pneumonia, which occupied precisely the portion I 
pointed out and no more. 
With respect to treatment, it was antiphlogistic, pushed as far as 
the advanced stage of the disease and the age and debility of the 
patient permitted. He was leeched and blistered, and this was im- 
mediately followed up by the use of calomel and opium, and the 
application of mercurial ointment over the affected portion of the 
chest. This treatment appeared to check the disease and stop the 
progress of disorganisation in the lung ; at least it certainly arrested 
the pleuritis. The pulse became more tranquil, and what encou- 
raged us to entertain some slight hopes was, that the difficulty of GANGRENE AND PLEURITIS. 
39 
breathing subsided, and respiration became less frequent, although 
it was never reduced to any thing like the natural standard. I have 
already told you, that in studying acute and chronic affections of 
the chest, the two chief symptoms to be attended to, are the num- 
ber of respirations which occur in a minute, and the amount of 
dyspnoea complained of by the patient. Here, though the respira- 
tions sank from forty to thirty, still they were nearly double the 
natural frequency; and this, coupled with the age and debility of 
the patient, forbade us to hope for a cure. Though the pulse had 
become more tranquil, and the bloody expectoration had ceased, 
though dyspnoea was no longer complained of, and the frequency 
of respiration had become reduced, still the man’s countenance ex- 
hibited strong marks of suffering and debility, and the stethoscope 
showed that the disease still continued, and there was no tendency 
to resolution in the affected lung. Here the stethoscope was of 
great value. A person ignorant of its use, observing the tranquil 
state of the pulse, the diminution in the frequency of respiration 
and the cessation of dyspnoea, might be led to believe that the man 
was getting better, and to pronounce that the period of convales- 
cence was near. But the stethoscope told us that the hepatisation 
of the lung had no tendency to resolution, and when we observed, 
after a week, that it was still undiminished in extent, we were led 
to form an unfavourable prognosis. We knew that matters could 
not remain long in this state ; we knew that the disorganised lung 
acted as an irritant tending to keep up disease, and that the man 
was every moment liable to a fresh attack of inflammation. 
In the mean time the patient caught a fresh cold, from being 
exposed to the thorough air of our too well ventilated wards. This 
fell on his larynx, producing hoarseness, stridulous breathing, and 
copious expectoration. When an old person, reduced by some 
previous disease, catches cold, and gets, in consequence, a sudden 
and remarkable hoarseness, so that he can only speak in whispers; 
when, in addition to this, he has cough, stridulous breathing, and 
copious muco-purulent expectoration, you may be sure that the 
case is a bad one, and the patient in most imminent danger. In- 
flammation of the larynx in children is, you all know, a violent 
disease, it terminates in an effusion of lymph which, if not pre- 
vented, or remedied, by the most prompt and decided measures, too 
often produces fatal obstruction to the entrance of air, and death 
from asphyxia. In the adult, laryngitis does not, except in a very few 
instances, cause an effusion of lymph; still it is a severe disease, 
and well calculated to excite alarm. In the aged it is accompanied 
by considerable fever, and, what you would suppose likely to give 
relief, copious expectoration, evidently derived from the larynx 
itself;—and yet I do not recollect that I have ever seen a case of 
this kind that did not terminate fatally. I have very recently 
visited a case of this description, which occurred in the person of 
an eminent country practitioner, who had jyst come up to Dublin. 
He got an attack of cold, followed by hoarseness, which went on 
for two or three days without being attended to, until one evening 40 
graves’s clinical lectures. 
he suddenly became alarmingly ill, and was obliged to send for his 
friend, Dr. Evanson, who prescribed and called on me the next 
day. I found him labouring under stridulous breathing, constant 
laryngeal cough, prostration of strength, and enormous muco- 
purulent expectoration. His pulse was very rapid, he complained 
much of oppression of the chest, and died the following night, more 
with symptoms of exhaustion than of asphyxia. 
The symptoms of laryngitis, which arose thus suddenly in our 
patient, were quickly succeeded by others. On Saturday morning 
we found him much worse, his countenance was sunk and livid, 
and his breath had become extremely fetid. His expectoration also 
exhibited a very remarkable change ; it was greenish, ichorous, and 
had a most intolerable fetor. He now began to manifest symptoms 
of awful prostration, his distress of respiration became intense, his 
eyes fixed, his extremities cold, and he expired in about forty hours 
from the commencement of the attack. 
Here, gentlemen, a man, after fever, gets an attack of pleuro- 
pneumonia, this is relieved to a certain extent by treatment, but the 
hepatisation remains unresolved. At the end of three weeks he 
gets an attack of laryngitis ; in addition to this, gangrene seizes on 
the diseased lung, and he sinks with great rapidity. Where gan- 
grene attacks the limbs it may creep on slowly, and life may be 
prolonged for a considerable time, but when it fixes on internal 
organs its course is rapid, and generally proves fatal in a few days. 
In the lung, unless the patient’s constitution is unimpaired and the 
disease limited, it will terminate quickly in death, and you have 
seen that, in this case, it only lasted from Saturday until Monday 
morning, that is to say about forty hours. After the acute stage of 
pneumonia had passed away, as denoted by the absence of fever 
and bloody sputa, and diminution of dyspnoea, and frequency of 
respiration, the case assumes a chronic character, which continues 
for nearly a fortnight, and then a new order of symptoms appears, 
manifested by fetid breath and expectoration, sudden prostration of 
strength, Hippocratic face, and cold extremities. Those who have 
watched this case must have been struck with these three remark- 
able stages : the first stage of inflammation, the succeeding one of 
chronic disease, and the termination in gangrene. It is not usual 
to find gangrene of the lung supervening on inflammation which 
is arrived at the chronic stage ; it is most commonly the result of 
acute inflammation of intense character, and comes on at a very 
early period of the disease. 
How are we to account for this sudden supervention of gangrene ? 
There was nothing in the nature of the pneumonic inflammation 
to dispose it to terminate in this way. It had lasted for three weeks, 
and had arrived at a stage in which inflammation very rarely 
assumes the gangrenous character. To what, then, are we to attri- 
bute it ? Partly to the debility of the man’s constitution, and partly 
to an erysipelatous tendency in the air, which is now very prevalent. 
Except there was something to dispose the lung to gangrenous 
disease, as an enfeebled habit and a vitiated quality of atmosphere, GANGRENE AND PLEURITIS. 
41 
we could not, under the existing circumstances, have expected 
such a termination. That this view of the subject is correct, is 
shown by the simultaneous occurrence of gangrene in another part, 
which had not been previously diseased, or subject to inflammation, 
except shortly before the man’s death,—I allude to the larynx. If 
you examine the larynx you will find the mucous membrane at the 
posterior surface, and where it invests the chord® vocales, destroyed 
by gangrenous sloughing. You perceive, then, we had gangrene 
in the larynx and lung, simultaneously. The gangrene of the 
lung was not therefore attributable to the occurrence of local in- 
flammation having a tendency to gangrene, but dependent upon a 
constitutional affection produced by debility and a vitiated state of 
atmosphere. If this man had chanced to get a wound on any part 
of his body, T have no doubt but that it would exhibit a gangrenous 
character, and, in the same way, if he happened to get inflamma- 
tion of the bowels, it is most probable that this also would have 
ended in gangrene. I have frequently, in the advanced stage of 
fever, where the patient is much reduced, and where signs of a 
morbid condition of the fluids are present, seen gangrene occur 
simultaneously in various parts of the body. What I wish to 
impress on you is, that though the inflammation of the lung ended 
suddenly in gangrene, it was not in consequence of the inflamma- 
tion having in itself any such tendency, but in consequence of a 
change produced in the man’s constitution by atmospheric influence, 
and which was favoured by his advanced age and great debility. 
The inference to be drawn from the sudden occurrence of gan- 
grene in this case is, that it does not depend merely on violence of 
inflammation. At one time pathologists were inclined to believe 
that gangrene was invariably the result of excessive inflammation, 
or at least of inflammatory action disproportioned to the vitality of 
the parts attacked, and that it was possible to prevent any inflam- 
mation from ending in gangrene by prompt and active treatment. 
But there are certain states of the constitution which have a ten- 
dency to convert every form of inflammation into gangrene, and 
that wholly independent of the violence of the local inflammatory 
action. Thus, a person reduced by fever, small-pox, or malignant 
scarlatina, becomes liable to be attacked with gangrene in various 
parts of the body from the slightest causes. In all parts which are 
exposed to any degree of pressure, you will, under such circum- 
stances, have gangrenous sores formed; and. even in parts where no 
degree of pressure has been exercised, sphacelus is not unfrequently 
produced, as we see in many cases of confluent small-pox, and in 
the mortification of the pudenda in female children, which some- 
times occurs in bad measles. In such instances, gangrene is not 
preceded by symptoms of inflammatory action; and. in the present 
case, it is very probable that no inflammation of the lung, properly 
so called, preceded the gangrenous affection which terminated life. 
Permit me now to direct your attention to the case of a man 
named T. Kelly, who lies in the upper fever ward, and has been 
under the care of Mr. Knott. He is at present labouring under an 42 
graves’s clinical lectures. 
attack of pleuritis and pneumonia, each modifying the other—the 
pleuritis being here also of that nature which is, by contra-distinc- 
tion, termed dry. A few particulars in this case demand our notice. 
In the first place, from looking at this man and examining his pulse, 
you would never suppose that he was labouring under a formidable 
disease. A careless observer, finding the pulse to be soft, regular, 
and only seventy-two in a minute—that respiration was tolerably 
free, and the skin cool—might here very easily overlook the true 
nature of the disease, and say this man has no fever, no inflamma- 
tion of any internal organ. Yet a careful examination shows that 
the right lung and pleura are extensively engaged. In the next 
place, we find that the pleuro-pneumonia has attacked the upper 
part of the lung instead of the lower. Pneumonia has a great ten- 
dency to attack the lower and posterior parts of the lung; indeed, 
so frequently do we meet it in this situation, that we look upon its 
occurrence in the upper part of the lung as a rare exception to a 
general rule. The third point connected with this case is, that, 
though the patient is labouring under pleuritis and pneumonia, his 
blood does not exhibit the slightest symptom of being affected by 
this combination of violent inflammations. When drawn from the 
arm, it separated very imperfectly into crassamentum and serum, 
and there was no deposition of that buffy coat which has been so 
often noticed by our ancestors as occurring in pleuritis, and hence 
termed crusta pleuritica. Here, from observing that there was no 
formation of coagulum—no cupped or buffed appearance in the 
blood, and that the pulse was soft and regular—some persons would 
have argued that no inflammation was present; but how false and 
dangerous such a conclusion would be, any one may convince him- 
self by making a careful stethoscopic examination. The fourth 
point (which was first observed by Mr. Knott) is, that there is a 
considerable disproportion in the size of the sides of the chest; the 
right side measuring better than two inches and a half more than 
the left. Now, there must be some cause for this ; and as the man 
has pleuritis on this side, it would be natural to infer that there is a 
considerable effusion of fluid in the cavity of the pleura, and that 
the dilatation of the side is produced by empyema. There are 
some circumstances, however, in this case which forbid us to adopt 
such a conclusion. In the first place, this great increase of size in 
one side of the chest would indicate a very considerable effusion. 
By empyema, I do not mean the effusion of a quantity of lymph, 
which does not push back the lung more than a line, but an effu- 
sion of fluids of various densities, and in large quantity, exercising 
very considerable pressure on the lung, and pushing it back towards 
its root. There are two circumstances in this case which should 
be attended to; first, the man is a labourer, and in such persons 
the chest, measured across the pectoral muscles, is always found to 
be on the right side half an inch, and sometimes nearly an inch, 
larger than it is on the left. This is accounted for by the increased 
development of the muscles of the right side from constant use. 
In the next place, we find that this man has not only pneumonia GANGRENE AND PLEURITIS. 
43 
and pleuritis, but also a tendency to superficial inflammation occu- 
pying the parietes and integuments of the chest, as indicated by a 
feeling of pain and soreness in various regions of that side, but 
particularly at the lower part, where the sound is clear on percus- 
sion. Now, where the sound is clear on percussion, you are aware 
that no effusion of fluid exists. The fact is, that, in addition to 
pleuritis and pneumonia, the man is labouring under pleurodynia, 
with a tendency to inflammation in the superficial parts of the 
chest. Under these circumstances, we should not be surprised to 
find some oedema of the parts; and here we have a second cause 
for the greater measurement of the right side of the chest. 
These are the only points connected with this case to which I 
shall advert at present, except to mention that the treatment was 
obviously indicated to be antiphlogistic. You might perhaps think 
that in treating this man it was a matter of indifference whether 
you had recourse to tartar emetic, either alone or in combination 
with nitrate of potash, or to calomel and opium; but you may lay 
it down as a rule now firmly established, that, in cases like this, 
the mercurial plan answers much better than tartar emetic. After 
bleeding this man, then, we gave him mercury in such doses as to 
affect his system as rapidly as possible, and we followed up our 
general means of depletion by the application of leeches, which, in 
all inflammatory affections of the chest, are indicated in propor- 
tion to the pain and tenderness of the chest complained of by the 
patient. Indeed, something similar must guide us in judging how 
far we are likely to procure relief, in cases of inflammation of any 
internal organ, by means of the application of leeches to the sur- 
face over the organ affected. No good is ever obtained by their 
application, unless tenderness or soreness on pressure be distinctly 
observable, and the relief obtained is always proportioned to the 
diminution of this tenderness where it existed ; where it does not 
exist, the application of leeches only leads to loss of time, and we 
must employ other remedies in such cases. 
There is another symptom in this case which might deceive you 
into the belief that empyema is present; the motions of the right 
side of the chest are much more limited than those of the left. 
When you look at him stripped, you perceive an obvious difference 
between the respiratory motions on each side; the motions of the 
unaffected are free, and much more extensive than those of the dis- 
eased side. Now, generally speaking, this is a symptom most com- 
monly observed in empyema and a few other diseases. It may 
also exist where there is extensive hepatisation of one lung, for, in 
proportion to the impossibility of air entering the diseased lung, 
will the motions of the corresponding side of the chest be dimi- 
nished. How are we to account for it in this man’s case ? The 
pneumonia is not extensive enough to cause it. and we have no 
evidence of the existence of any effusion into the pleural sac suffi- 
cient to explain it. The only way we can account for it is by 
recollecting that the man has pleurodynia; and, as every attempt 
at dilating the chest gives him pain, he endeavours to control its 44 
graves’s clinical lectures. 
motions oil that side as much as he possibly can. This is a fact 
well worthy of notice. It exhibits to us a beautiful provision of 
nature, which enables a person, by an intense discharge of the 
respiratory function in one lung, to compensate himself for a limited 
and imperfect performance of it in that half of the chest where it 
is limited by pain, paralysis, or disorganisation. 
As I am on the subject of pneumonia, it may be necessary to 
make a few remarks on some points connected with it, and first 
with respect to the expectoration. With the characters of true 
pneumonic sputa, I suppose, you are sufficiently acquainted; you 
had many opportunities of examining the expectoration of the pa- 
tient who died of gangrene of the lung at the time he was labour- 
ing under acute pneumonia, and while hepatisation was still going 
on. But I wish to observe—and I beg you will impress this on 
your minds—that there may be cases of extensive pneumonia 
without any expectoration from the commencement of the disease 
to the period of complete resolution. A case occurred in this hos- 
pital, of a young woman, named Mary Nowlan, who had half one 
lung and the lower third of the other hepatised during a severe 
attack of pneumonia, and yet it was not accompanied at its com- 
mencement by expectoration ; there was no expectoration during 
its continuance, and resolution went on, and the was restored 
to its healthy condition without any expectoration. She remained 
in the hospital for two months, the lung being extensively engaged; 
and during this time she was carefully watched, but we never could 
discover any thing like sputa from the beginning to the end of the 
disease. This is a very singular but instructive case. Another 
fact with regard to expectoration. A man may get an attack of 
pneumonia, and, in consequence of the rush of blood which accom- 
panies the first access of inflammatory action in the lung, may have 
at the beginning some bloody expectoration, but after a day or two 
this subsides ; and though the lung is extensively engaged, the pa- 
tient may not have any expectoration whatever throughout the 
whole course of the disease up to the period of total resolution. I 
have seen this occurrence most distinctly marked in a case which 
I attended with Dr. Marsh. A gentleman, who had got an attack 
of acute pneumonia, had bloody expectoration for the first and 
second day, but on the third, when I saw him, it had ceased, and 
all expectoration continued absent for five weeks, at the end of 
which he completely recovered. He was an intelligent and scien- 
tific man—knew well what was the matter with him, and enter- 
tained the old notion that all inflammatory affections of the lungs 
resolve themselves by expectoration. Hence he looked day and 
night for its occurrence with considerable anxiety, but not the least 
sign of sputa appeared. In this case the hepatisation, which was 
very extensive, became completely resolved in the course of five 
weeks, and yet it is a singular fact that there was no expectoration 
whatever, from the commencement of resolution to its termination. 
Hence you may perceive, that in pneumonia the sputa may be 
absent from the beginning to the end of the disease; and that, HEPATISATION OF THE LUNG. 
45 
though the hepatisation may be very extensive, still resolution will 
occur without the slightest expectoration. Again, inflammation 
may attack a considerable portion of the lung, and the patient may 
have bloody expectoration for the first two or three days, or during 
the stage of congestion ; this may cease altogether, and the patient 
have no sign of sputa of any description up to the period of com- 
plete resolution. These are, no doubt, rare exceptions to the gene- 
ral law which regulates the course of pneumonic inflammation, in 
which we have sputa of one kind or other at every period of the 
disease; but they possess a considerable degree of interest, and it 
is of some importance to be acquainted with them. 
Allow me to repeat here an observation I have already made. 
The lung becomes attacked by inflammation, this goes on to hepa- 
tisation, that is, a certain portion of the pulmonary tissue which 
had been before pervious, becomes impervious ; instead of being a 
soft, elastic, crepitating, sponge-like body, it becomes solid, inelastic, 
and very like that organ from which this condition derives its name, 
the liver. One of the most curious things, the knowledge of 
which we have arrived at by the discovery of the stethoscope, is, 
that not only small, but even very extensive, portions of the lung 
may become thus solidified and altered in their texture, so that a 
return to the normal condition would seem almost impossible, and. 
yet we know that a person may have nearly two thirds of one 
lung reduced to this state of solidification, and still become after- 
wards as-healthy as ever. Now, if you read Laermec’s admirable 
remarks on pneumonia, and other treatises on the same subject, you 
will find that the circumstances which indicate the resolution of 
pneumonia, are sputa of a certain character, and the reappearance 
of crepitus. I need not repeat here what I suppose you are all 
aware of, that crepitus commences before hepatisation, ceases on’'its 
appearance, and returns again when resolution take place. The 
latter kind is what has been termed by Laermec, crepitus redux. 
Nature accomplishes the resolution of pneumonia not only by ab- 
sorption of those particles which the process of morbid action has 
deposited in the tissue of the lung, but by secretion into the air 
cells and minute bronchial tubes, and it is the presence of this 
secretion which gives rise to the crepitus redux. Now, the obser- 
vations which T have made with respect to the total absence of 
expectoration in some cases of pneumonia, apply here also; for where 
all sputa are absent, where there is no expectoration from the be- 
ginning to the end of the disease, you can have no crepitus redux. 
This observation I have made in several cases. The fact which I 
wish to impress on your attention is, that in some cases of pneu- 
monia expectoration may be completely absent; here the crepitus 
redux is never heard. Thus, in the case of Mary Nowlan, resolu- 
tion went on to the re-establishment of the healthy and normal 
condition of the lung, without the slightest crepitus being heard. 
The same thing has been observed in two or three cases by my 
friend Mr. Dwyer. It is not necessary for the resolution of hepa- 
tisation, that there should be increased excretion into the bronchial 46 
graves’s clinical lectures. 
tubes, during the time nature is employed in absorbing the matter 
deposited in the lung. In the ordinary way it is removed partly 
by absorption and partly by excretion into the bronchial tubes. 
Sometimes, however, interstitial absorption alone seems to be suffi- 
cient for this purpose, and the cases I have mentioned prove that it 
is in the power of nature to remove the morbid product in this way, 
without calling in the aid of the bronchial tubes. I may, however, 
remark that such cases are rare, and that resolution proceeds much 
more slowly than where free expectoration is present. 
Before I conclude, I wish to make a few observations on a case 
of erysipelas which has recently occurred in our wards. Indeed 
we have had within the last two days three cases of erysipelas, the 
disease, in two instances, attacking patients who lay close to each 
other. Erysipelas is at present epidemic, and has been so for some 
time. Its character and mode of treatment have been well de- 
scribed by Mr. M‘Dowel, in a late paper, published in the Dublin 
Medical and Chemical Journal, which I would recommend you 
to peruse attentively. It has been observed by Ur. Cusack and 
others, that when erysipelas prevails as an epidemic we may expect 
puerperal fever, and scarlatina of a bad and dangerous type. Hence 
it would appear that the same noxious quality of atmosphere which 
generates one disease, may give additional malignity to others. 
One of these cases of erysipelas occurred, in the fever ward, 
under peculiar circumstances. A young woman was admitted 
some time ago, labouring under spotted fever; she had been many 
days ill before her admission, and continued for a considerable time 
in an uncertain state. It is unnecessary for me to enter into any 
details regarding her treatment; but after the more obvious indica- 
tions were answered, she was ordered to use the liquor chlorid. 
sodae, and became convalescent, or quam proxime so. Her tongue 
began to clean, the abdomen was soft, the bowels natural, the skin 
cool, and the pulse about eighty. One evening she got fresh symp- 
toms of fever, raved during the night, and next morning, when we 
visited the wards, we found her pulse accelerated, her tongue dry, 
black in the centre, and dusky red at the edges and tip, and, in 
addition to this, she had some diarrhoea. The nostrils were filled 
with a semicoucrete mucus, exhaling a most offensive odour ; in 
fact, one could hardly approach her bed without experiencing 
nausea from its extreme fetor. The inside of the nares was red 
and swollen ; in short, erysipelas was seen occupying the nose, 
upper part of the face, and forehead. It had first attacked the skin 
and subcutaneous cellular tissue, producing considerable oedema, 
and from this it had extended to the mucous membrane of the nose. 
Erysipelas generally commences in the skin, but sometimes it has 
its origin in the mucous membrane. 
I need not tell you that erysipelas of this oedematous character, 
accompanied by such a remarkable change in the secretion of the 
nostrils, and occurring in a person weakened by fever, was to be 
looked upon as a dangerous disease. I have not time to enter into 
any further observations on this subject, and will proceed at once ERYSIPELAS. 
47 
to mention our plan of treatment. How did we treat this case? 
Not by the usual antiphlogistic means, for the patient was greatly 
debilitated. Blood-letting, leeching, emetics, and purgatives, were 
here out of the question ; however valuable they may be in ordinary 
cases, we could not use them here without risking the patient’s life. 
You might think that an emetic or a purgative could do very little 
harm, and might effect much good, but you are to recollect that 
the girl had nausea, thirst, bowel complaint, and great prostration 
of strength. What then was to be done ? First, we applied a 
blister to the nape of the neck, to act partly on the brain and pre- 
vent delirium, and partly on the erysipelatous inflammation of the 
nose and forehead. How blisters act in this case I do not exactly 
know, but you are all aware that a blister applied in the neighbour- 
hood of a patch of this kind of oedematous erysipelas, is often fol- 
lowed by very good effects. Whether it is by exciting a new 
irritation, or by directing the current of the cutaneous circulation 
to another part, and causing a flow of serum thither, I cannot tell, 
but blisters certainly do give very considerable relief. So much 
for external means. 
Now with respect to internal, the only one we could give here, 
with any prospect of benefit, was the sulphate of quinine. But the 
patient had nausea, thirst, and diarrhoea, and if you administer 
quinine by the mouth, under such circumstances, you will do more 
harm than good. I therefore prescribed it in the form of enema, 
directing five grains of quinine, combined with four of tincture of 
opium, and two ounces of mucilage of starch, to be thrown up the 
rectum every fourth hour. Under this treatment the girl began to 
improve rapidly, the erysipelas faded away, the fever declined, and 
she is now once more convalescent. I also ordered her nostrils to 
be repeatedly syringed with warm water and vinegar. 
Here, gentlemen, you perceive our treatment has been successful 
in a case occurring under very unfavourable circumstances. It is 
a case, the study of which will afford you some instruction, parti- 
cularly if you compare its symptoms, progress, and treatment, with 
the case of erysipelas which occurred in the strong healthy girl 
who is lying near, and which we are at present treating on the 
emetico-carthartic plan. 48 
graves’s clinical lectures. 
Case of suspected thoracic aneurism—CEdema of left arm and left side of the face; 
probable cause of—Relations of the left vena innominata to the arch of the aorta— 
Reasons for concluding that the symptoms are produced by a solid tumour; its 
effects explained—Another remarkable case of thoracic tumour related—Case of 
violent and extensive pulsation of the heart depending on cerebral disease—Laen- 
nec’s error concerning the indications for bleeding; case illustrative of; use of digi- 
talis in such cases—Case of asthma, and treatment—St. John Long’s liniment— 
Dropsy treated by opium—Acupuncturation in anasarca. 
LECTURE Y. 
The object of clinical instruction being the study of diseases— 
their nature and their treatment—it is our duty to apply that study 
in the manner most likely to encourage the accumulation of prac- 
tical knowledge. In accordance with this view, and in order to 
prepare you for the various emergencies that may hereafter demand 
the application of that knowledge, I shall proceed to select, from 
the cases at present in the house, such as, from their singularity, 
interest, or importance, seem to claim something more than a mere 
passing notice. 
A man named James Byrne, who lies next the door in the chro- 
nic ward, and has been supposed to labour under aneurism of the 
thoracic aorta, leaves the hospital to-day. It is very probable, how- 
ever, that he will hereafter be forced to return ; for, whatever be 
the nature of his disease, it is incurable, and depends on some 
profound organic lesion. I would advise any gentleman, who has 
not attended to this very obscure case before, to take the opportunity 
of making an accurate examination of the patient during the short 
time he remains in the hospital. 
While the phenomena of this case are still fresh in our minds, 
let us briefly discuss the question, whether this man really has 
aneurism of the thoracic aorta, and enquire whether there may not 
be some other cause to which his symptoms might be attributed 
with a more reasonable degree of probability. He was admitted 
on tlTe 23d of October, 1834, and had been in the hospital before 
for a considerable time. He states that, eighteen months previously 
to his last admission, he was exposed to wet and cold, which pro- 
duced a feverish attack, with symptoms of local inflammation in 
the lung, manifested by cough and difficulty of breathing. These 
were soon afterwards followed by dropsical swelling, and he applied 
at this hospital for relief. After remaining under treatment for 
about two months he began to improve, and left the hospital, as he 
states, quite relieved. He enjoyed tolerably good health, and con- 
tinued to work at his trade as a bricklayer until about five weeks 
before his last admission, when he was again attacked with cough 
and difficulty of breathing, accompanied by oedema of the left side 
of the chest and left arm. On examining him after his admission, 
the following phenomena were observed:—The left side of the face 
and neck was slightly oedematous; the left external jugular vein, 
with its immediate branches, engorged and very prominent; the THORACIC ANEURISM. 
49 
left arm and left side of the chest cedematous, and pitting on pres- 
sure ; no affection of the bronchial mucous membrane, or paren- 
chyma of the lungs, sufficient to account for the cough, can be 
detected by auscultation. Considerable dulness over the situation 
of the heart, and extending upwards over the sternal region on the 
left side ; the right sternal region sounds clear and natural. The 
heart has not been removed from its normal situation ; its pulsa- 
tions can be felt over the ordinary extent, and no more, and they 
communicate a natural impulse to the finger. On applying the 
stethoscope over the heart its sounds were found to be regular and 
natural, but on placing it higher up, over that part of the sternal 
region which was dull on percussion, a loud bruit de rape was 
heard. 
Let us analyse these symptoms. In the first place, we found the 
anasarcous swelling occupying the left side of the chest and the 
corresponding arm, and in a slight degree the left side of the neck 
and face, accompanied by a turgid state of the jugular vein. Now, 
you may lay it down as a general rule, that where one side of the 
chest and the corresponding upper extremity is affected by ana- 
sarca, it proceeds from some cause residing in the chest. I have 
told you before that in all cases of dropsy, whether acute or chro- 
nic—whether accompanied by ascites or not—when anasarcous 
swelling appears in the trunk and upper extremities before it is 
observed in the abdomen or lower extremities, the dropsy in gene- 
ral is inflammatory, or, when not so and chronic, it proceeds from 
disease of some of the thoracic viscera, and it is in the chest alone 
that we are to look for its cause and origin. Now, applying this 
rule to the present case, we are led to enquire what is it that, by 
pressing on the veins within the chest, gives rise to engorgement 
of the superficial vessels on the left side of the neck, and to ana- 
sarcous swelling of the left arm and left side of the chest. The 
pressure must, in our patient, be applied to a portion of the venous 
system, which carries blood from the left side of the head and the 
left upper extremity ; in short, it must be applied to the great vein 
formed by the junction of the left subclavian and left jugulars. 
Now, this left vena innominata sive vena brachio- cephalic a differs 
considerably from its fellow on the right side, which is very short, 
and nearly vertical in direction. The vein on the left side is three 
times longer, and directed transversely to the right, inclining at 
the same time downwards. It crosses behind the first bone of the 
sternum, lying in front of the three primary branches given off 
from the transverse portion of the arch of the aorta. You per- 
ceive, therefore, that it lies in a position most convenient to receive 
pressure in consequence of aneurism in any of these great vessels. 
This vein receives, before joining the cava, the internal mammary 
vein of the left side ; you understand, now, why any thing pressing 
on it is apt to produce engorgement of the superficial veins on the 
left side of the chest and trunk, together with oedema of these parts. 
That we are not to look for the cause of the disease in the heart 
itself, appears from various circumstances. The situation of that 50 
graves’s clinical lectures. 
organ is not changed; its beating can be felt only over the usual 
extent of surface ; it communicates a natural impulse to the finger, 
and when examined with the stethoscope its sounds are discovered 
to be normal and regular. Neither can we attribute the disease to 
any affection of the mucous lining or parenchyma of the lung; the 
only morbid sounds which can be detected in the respiratory organs 
being a few slight bronchial rales. 
Now, it is sufficiently obvious that the situation of the part 
which sounds dull on percussion would suggest the idea of aneu- 
rismal dilatation of the arch of the aorta, or some of its immediate 
branches. But had dillness over so large a space of the chest, 
embracing nearly the whole left sternal region, been produced by 
aneurism of the aorta, or any of its branches, it is evident that the 
aneurismal sac must be very large. Where an aneurism gives rise 
to extensive dulness of the chest, you may be always certain that 
it has arrived at a very considerable size; for the dulness is caused 
by the immediate contiguity of the aneurismal sac to the parietes 
of' the chest, and hence the dulness is always in proportion to the 
amount of lung displaced. When you applied your hand over the 
sac, in such a case as that which we are now7 considering, where 
the aneurism was of large size and closely applied to the parietes 
of the thorax, you would feel a very remarkable pulsation ; your 
hand would be, as it were, lifted from the chest by each impulse 
communicated to the sac, and you would have palpable, unequivo- 
cal evidence of the cause of the dulness on percussion. Now, in 
the case before us, there was no such pulsation observed—whether 
we examined him while lying quietly in bed, or after he had 
walked briskly about for some time so as to excite the action of the 
heart and arterial system. Again, aneurismal sacs, as you are all 
aware of, before they produce extensive dulness of any portion of 
the parietes of the chest, point, as it were, in some particular situa- 
tion, becoming distinctly prominent, and producing an eccentric 
motion around them, in consequence of the thoracic parietes being 
absorbed, or yielding at the point of greatest pressure. 
From these circumstances, considerable doubts have arisen in 
my mind as to the cause of this man’s symptoms being connected 
with aneurismal disease of the great vessels of the thorax. I am 
rather inclined to attribute the bruit de rape, and dulness of sound 
on percussion, to a lesion of a different character. Let us suppose 
that in this case a tumour has been developed in the cellular or 
glandular substances, situated in or towards the left side of the 
chest, occupying the anterior mediastinum, pushing back the lung, 
and pressing on the large vessels connected with the base of the 
heart; what are the phenomena it would naturally present? First, 
we should have dulness of sound on percussion, corresponding in 
extent with that portion of the chest to which the tumour was 
applied ; secondly, we should have bruit de sovfflet, and probably 
bruit de rape, in consequence of the pressure of the tumour on the 
aorta; thirdly, a tumour in this situation would necessarily com- 
press some of the larger bronchial tubes, and thus give rise to THORACIC ANEURISM. 
51 
cough and dyspnoea. If a tumour presses on the trachea, or one 
of the larger bronchial tubes, why does it produce pulmonary irri- 
tation? Not by mere pressure on the part—for the pressure is 
applied so gradually, and with such a broad surface, that its effects 
could be scarcely felt; and it might go on to produce complete 
obliteration of the tube without giving rise to any inflammation, if 
its action were limited exclusively to the part compressed. But it 
strangles, as it were, that portion of lung to which the tube be- 
longs ; a certain portion of a large bronchial tube is considerably 
narrowed by the pressure of the tumour, the free entrance and exit 
of air are impeded, and consequently that portion of the lung, 
which may be very large, is greatly deranged in its functions. 
Hence arises that sensation of distress termed dyspnoea. Again, as 
soon as the free ingress and egress of air are prevented, we have 
not only the occurrence of dyspnoea, but also other effects equally 
referable to the same cause; the blood circulating through that 
part of the pulmonary tissue is imperfectly aerated, and does not 
undergo the necessary change; the secretions and exhalations from 
that part are altered and unnatural, and consequently it becomes 
engorged, giving rise to irritation, cough, and expectoration. To 
understand this aright, you should bear in mind that this portion 
of the lung undergoes the same changes that the whole of the 
lung undergoes in persons who are asphyxiated; that is, it becomes 
gorged with blood—for the moment that the black venous blood, 
which is carried into the pulmonary tissue from the right side of 
the heart, ceases to be properly aerated, that moment it stagnates in 
the lung, and soon renders it engorged. This is precisely the state 
of lungs which occurs in the posterior portions of those organs in 
persons who die a lingering death, and which has most absurdly 
been termed the pneumonia of the dying. 
But, to return to this man’s case, I am inclined to think that the 
symptoms here present may with more colour of probability be 
attributed to the presence of a solid tumour developed in the chest, 
the nature of which I can only guess at, and that it is situated in 
the anterior mediastinum, close to the origin of the aorta. Some 
of these tumours which have been discovered in the chest are of 
an adipose nature; some of them resemble the cerebral substance 
in colour and consistence, and others are like the steatomatous 
tumours formed in other parts of the body. 
A few months ago, Surgeon Blackley was consulted about a 
young gentleman who had been gradually attacked with symptoms 
of pulmonary irritation, cough, and difficulty of breathing. The 
disease was supposed by some to be consumption, and a physician 
who had been in attendance thought it depended chiefly on de- 
rangement of the stomach. Mr. Blackley had his doubts with 
respect to both of these opinions, and requested of me to visit and 
examine the patient. I could not detect any rales indicating the 
existence of tubercles, but over a large portion of the chest, and 
nearly corresponding with that part which sounds morbidly in the 
patient Byrne, there was dulness on percussion, the young gentle- 52 
GRAVEs’s CLINICAL LECTURES. 
man had fits of cough and dyspnoea, and now and then difficulty 
of swallowing ; a bruit de soufflet could be heard over the dull por- 
tion of the chest, but the sounds and impulse of the heart were 
regular and natural. I expressed a very doubtful opinion of the 
case, but at the same time stated my belief that the case was not 
one of tubercular phthisis, of empyema, or of pneumonia ; and I 
also said that it did not seem to be produced by disease of the heart 
itself. I dwelt especially on the existence of bruit de soufflet in 
the region which was dull on percussion, and which was some- 
what removed from the heart, and which, from its situation, I inter- 
preted as indicating something pressing either the arch of the aorta, 
or some of its branches. I was not able to detect pulsation or any 
other symptom of aneurism, and consequently professed myself 
unable to say what that something was. The result proved that, 
although the true cause of the disease did not occur to me, I had 
nevertheless approached the discovery as nearly as could be done 
without actually making it; for, soon after this, the young gentle- 
man died, and on opening the chest a large tumour of a steatoma- 
tous character was discovered pressing on the divisions of the 
trachea, of the aorta, and on the oesophagus. Another case of the 
same kind was published some time ago in the Dublin Medical 
Journal. We are, I believe, still in the infancy of diagnosis, so 
far as regards tumours developed in the chest, producing anoma- 
lous symptoms, and giving rise to suspicions of aneurismal or 
tubercular disease. With respect to the patient Byrne, I am in- 
clined to think that the morbid phenomena are referable to a tumour 
of this description, and I ground my diagnosis chiefly on the 
absence of pulsation, which should be distinctly present if the dul- 
ness on percussion, here observable, depended on the proximity of 
an aneurismal sac to the parietes of the thorax. 
As I am speaking of pulsation, permit me to observe that, in 
some cases, where there is no actual disease present, the pulsations 
of the heart are visible over a very large extent of surface, so as to 
convey the impression that aneurismal dilatation exists. Of this 
I have lately seen a very remarkable example. In a case which I 
saw this week with Mr. Cusack, the patient’s heart could be ob- 
served beating violently over the whole chest, and Mr. Cusack, 
when he laid his hand on the patient’s chest, said he could not 
divest himself of the idea that there was some unnatural condition 
of the heart and great vessels. Now the violence of the heart’s 
action in this case depended on disease of the brain. In some 
inflammatory or congestive diseases of the brain with a tendency 
to coma the heart labours intensely, its pulsations are quite awful, 
and it seems as if it were about to burst through the parietes of the 
chest. Again, this extraordinary action of the heart occurring in 
cerebral disease is almost invariably accompanied by a hard bound- 
ing pulse. I mention these circumstances for the purpose of putting 
you on your guard, and that you should not in such cases allow 
yourselves to be deceived, and suppose that the symptoms are to be 
met in every instance by copious blood-letting. Some cases of this THORACIC ANEURISM. 
53 
description will bear depletion well, others will not. Yon know it 
was a maxim of Laennec’s, that in bleeding we are to be guided 
more by the strength of the heart’s action than by that of the pulse. 
I have already shown that this test does not always hold good. 
You recollect the patient who was under treatment here some time 
ago, with violent action of the heart and a hard bounding pulse. 
This patient, a strong healthy man, had just disembarked, after a 
rough passage from Liverpool, during which he vomited much, 
and suffered intensely from headache, which he ascribed to the 
violence of retching. Walking along the quay, he was suddenly 
attacked with hemiplegia, and was immediately brought into the 
hospital, where he was bled and purged. Next day we found him 
still hemiplegic, and complaining of violent pain in the head. 
Active antiphlogistic treatment was used, but on the third day he 
became comatose, and was convulsed in the limbs of the healthy 
side. His face was flushed, his temporal arteries were dilated and 
pulsated violently, and his pulse was hard, while the heart pulsated 
with great strength. This attack came on during our visit, and I 
ordered a vein to be opened immediately. The blood flowed freely. 
When about fourteen ounces were taken the pulse suddenly flagged 
and grew extremely weak, and never again rose. He died in about 
two hours, and an ignorant person would have ascribed his death 
to the bleeding. On examination, sixteen hours after death, we 
found extensive puriform effusion on the surface of the brain, to- 
gether with a large clot of blood and surrounding ramollissement. 
This was a very remarkable case, and conveyed a very important 
lesson, teaching us not to be too much led away by the violence of 
the heart’s action ; for I have no doubt that here the use of the 
lancet shortened the man’s life. Had such a case as this occurred 
to any of you in private practice, it would be almost fatal to your 
reputation. Here we have a patient with his face flushed, his skin 
hot, his temporal arteries throbbing violently, and his pulse feeling 
like a piece of whip-cord ; he is blooded, and up to a certain point 
the pulse remains firm; he then begins to sink rapidly, and expires 
in two or three hours. Bear in mind, then, that a state of the sys- 
tem may exist, in which the heart’s action is intense, and the pulse 
hard and bounding, and yet where bleeding to any amount will be 
badly borne. Such cases are generally connected with inflamma- 
tion of the brain, accompanied by a tendency to coma. Here you 
must bleed with great caution, let the quantity you take away be 
moderate, and rather rely upon large relays of leeches and strong 
purgatives for removing the cerebral symptoms. You may after- 
wards endeavour to moderate the heart’s action by the use of digi- 
talis and opium ; a grain of the former, and one twelfth of a grain 
of the latter, made into a pill with some extract of hops, may be 
given every second hour, until it begins to produce some effect on 
the heart’s action, when it may be either discontinued or given at 
longer intervals, as the circumstances of the case may require. 
Where, after bleeding and other antiphlogistic measures, the pulse 
continues high, and the action of the heart violent, I can recom- 54 
graves’s clinical lectures. 
mend digitalis very strongly, and the small portion of opium here 
combined with it can do no harm. Combined in small quantities 
with digitalis, opium does not produce any tendency to determina- 
tion to the head, and it prevents the digitalis from sickening the 
stomach. I have frequently employed it, and found great benefit 
from its exhibition. I may observe, that when you are anxious to 
secure the full sedative effects of digitalis on the heart and pulse, 
you must give it in large doses. In small quantities it does not act 
well, and seems rather to produce a tendency to excitement of the 
heart. 
There is another patient about to leave the hospital to-day, on 
whose case I wish to make some observations. This young man, 
whom you have seen lying in the chronic ward, in the bed next 
but one to Byrne’s, caught cold about seven or eight months ago, 
followed by cough, wheezing, and dyspnoea, which, after a month 
or six weeks, subsided. About two months before he came into 
the hospital, he renewed his cold, and with it the cough and dys- 
pnoea returned. On his admission he complained of difficulty of 
breathing, which attacked him every night; he went to bed well, 
and slept tranquilly for two or three hours, and then was awakened 
by pain and sense of tightness in the chest, with great dyspnoea. 
When the paroxysm came on, it compelled him to get up and walk 
about the room gasping for breath; and, after continuing for two 
or three hours with great dyspnoea, wheezing, anxiety, and cough, 
went off with free expectoration and sweating. As soon as the 
sweating and expectoration appeared, he lay down without any 
inconvenience, and slept quietly until morning. The only addi- 
tional symptom he complained of was palpitation of the heart, 
which sometimes affected him when employed at hard labour. On 
examining the lungs there was nothing found except a few bron- 
chitic rales. The heart was normal in its action, and no morbid 
sound could be detected by the stethoscope. In addition to this, you 
will recollect that the man was in the prime of life, had a full and 
well-formed chest, a quiet pulse, regular bowels, and a good appetite. 
Here you perceive a man from repeated colds gets chronic irri- 
tation of the bronchial tubes, and this induces asthmatic paroxysms, 
which come on, as is usual in such cases, at a certain hour of the 
night. It was plain, therefore, that he was labouring under a well 
marked form of asthma, a disease which, in its pure and simple 
state, is seldom met with in hospitals, being generally observed in 
connection with disease of the heart, or long-continued bronchitis 
in old persons. Chronic bronchitis is one of the most common 
causes of asthma; indeed, you will scarcely ever meet a patient 
who has been subject to chronic irritation of the bronchial tubes, 
who does not also labour under more or less asthmatic dyspncea. 
The disease is generally met with in persons advanced in life, and 
who have suffered from repeated attacks of bronchitis ; it is not 
usual to find it in so young a man as this patient, and presenting, 
as he does, such very slight symptoms of derangement of the bron- 
chial mucous membrane. ST. JOHN LONG’S LINIMENT. 
55 
This case exhibits a remarkable proof of what may be done by 
simple means in relieving an urgent disease. The man was, with 
the exception of asthma, in good health ; his bowels were regular, 
his appetite good, his pulse tranquil, and the signs of pulmonary 
irritation trifling. There was no necessity, then, for administering 
remedies to improve the tone of the digestive organs, nor were we 
authorised to use the lancet or apply leeches. I therefore confined 
my attention to two points : the application of irritants to the neck 
and chest externally, and the internal use of remedies calculated to 
relieve bronchial irritation. I ordered him to rub the nape and 
sides of the neck, and the fore part of the chest, with a liniment 
composed of strong acetic acid, 3ss, spirit of turpentine, 3iij, rose 
water, 3 iiss, essential oil of lemons a few drops, and yolk of egg 
in sufficient quantity to suspend the turpentine. This liniment is 
an imitation of the celebrated liniment of St. John Long. I gave 
a bottle of the real liniment to Dr. Apjohn, to analyse, and he thinks 
it consists of acetic acid, spirit of turpentine, and two animal mat- 
ters, one containing azote, the other not; the latter probably some 
species of fat, probably goose-grease. Now this fat did not exist 
in St. John Long’s liniment in the form of soap, it was evidently 
some kind of fatty matter blended with water, probably by means 
of trituration with yolk of egg. The active ingredients are spirits of 
turpentine and strong acetic acid. This liniment should be applied 
by means of a sponge. It acts as a rubefacient, and generally in- 
duces an eruption of small pimples after a few applications. The 
spirit of turpentine must be well mixed with the water (which 
ought to be added to it gradually) by means of yolk of egg, before 
the acetic acid is added. 
With this liniment our patient was desired to rub the fore part of 
the chest, and the nape and sides of the neck. It was applied to 
the chest with the view of relieving the bronchial irritation, and 
we ordered it to be rubbed over the nape of the neck, along the 
course of the cervical portion of the spinal marrow, and over the 
sides of the neck along the course of the pneumogastric nerve, 
because all the organs to which the latter nerve is distributed, are 
evidently affected in cases of spasmodic asthma. Thus a paroxysm 
of asthma is not only attended with increased action of the heart, 
dyspnoea, and hurried breathing, but also with marked derangement 
of the stomach, particularly towards the termination of the fit, 
when the patient generally has a feeling of uneasiness in the sto- 
mach, with flatulence and a sense of ’fulness, induced probably by 
the derangement of circulation in the lung. You are aware of 
the close sympathy which exists between the stomach and lungs, 
and you must have been struck with the fact, that stimulant and 
irritating remedies applied to the epigastrium often relieve affections 
of the lung more completely than when applied to the chest. Thus 
in using the tartar emetic ointment for the relief of hooping-cough, 
it has been found to act most beneficially when applied over the 
region of the stomach ; and the same thing may be said of Roche’s 
embrocation, which does more good when rubbed over the spine 56 
graves’s clinical lectures. 
or epigastrium, than when applied to the parietes of the thorax. 
On these principles, I ordered the counter-irritation to be applied 
over the course of the cervico-spinal and pneumogastric nerves, 
over the chest, and subsecpiently over the stomach. 
This liniment in a very short time produces redness and heat of 
the parts to which it is applied, and it is more than probable that its 
effects are not limited to temporary rubefacience, but that it also 
acts on the nervous system. We have innumerable proofs that 
turpentine exercises a special influence over the nervous system, 
and we know that it is rapidly absorbed even without the aid of 
friction. I fear, however, that we shall never be able to confer on 
our liniment all the wonderful properties attributed to that of St. 
John Long. You know it has been asserted that St. John Long’s 
liniment never reddened the skin, except over the exact spot where 
disease was situated. 1 was assured by a young lady who used 
this liniment, that she rubbed it all over the chest, and that it pro- 
duced no discoloration of skin, except in two spots where she felt 
pain. She at first mentioned but one spot which was painful, but 
St. John Long, having applied the liniment himself, told her she 
had deceived him, and that there was pain in another spot. It had 
other effects equally miraculous. An eminent Dublin lawyer de- 
clared that it drew nearly a pint of water from his head, and Lord 
Ingestre testified that it extracted quicksilver from his brain ! 
These, and other wonderful stories, told by several persons of dis- 
tinction with a full belief in their authenticity, furnish a useful 
lesson to mankind, showing that gross credulity is not confined 
exclusively to the poor and the ignorant, but may be found among 
the highest classes of society. It is a singular fact also, and illus- 
trative of the tendency which exists in human nature to deceive 
and be deceived, that notwithstanding the repeated failure, and even 
fatal effects, of St. John Long’s applications, many persons still 
regard his opinion as oracular, and look upon his remedies as ines- 
timable discoveries. When I mentioned to the gentleman who 
brought me the bottle of liniment, that St. John Long himself died 
of phthisis, and brought this forward as a strong argument against 
the infallible efficacy of his remedies, he said that this very circum- 
stance was one of the most remarkable proofs of his sagacity, for 
St. John Long had always maintained that the liniment was not 
suited to his own case, and that there was something in his consti- 
tution which neutralised its good effects; and so it happened, for 
when he applied the liniment to his skin it did not produce the red 
spots which usually resulted from its application in other persons. 
In fact, such was the credulity of St. John Long’s patients, that his 
death passed among them as the strongest proof of the infallibility 
of his medicines. Indeed he is considered by many of our nobility 
as a sort of medical martyr, who, having sacrificed life in the 
accomplishment of his mission, rising from earth, let his prophetic 
mantle fall on the highest bidder ! 
But to return to our patient. In this case the liniment did a 
great deal of good, but it was not the only means we employed. CHRONIC BRONCHITIS. 
57 
We observed that the asthmatic paroxysm came on every night, 
continued for two or three hours, and then went off with free ex- 
pectoration and sweating. In order to prevent this, we gave him a 
draught, which he was to take when awakened by the pain and 
sense of tightness in his chest. He took this, and it had the effect 
of arresting the paroxysms, so that he no longer found it necessary 
to leave his bed. That this remedy had succeeded in averting the 
disease, was plain from the following circumstance:—one day the 
clinical clerk had omitted to repeat his draught, and he consequently 
got no medicine; on that night the asthmatic paroxysm returned 
and went through its usual course as before. This draught was 
very simple, being composed of half a dram of tincture of hyos- 
cyamus, half a dram of vinegar of squills, and the same quan- 
tity of ipecacuanha wine in an ounce of camphor mixture. It is 
scarcely necessary for me to explain the nature of the ingredients. 
The tincture of hyoscyamus possesses narcotic and antispasmodic 
properties, and ipecacuanha and squill are known to have great 
efficacy in disease of the bronchial mucous membrane, being both 
promoters of expectoration, and the latter also acting on the urinary 
organs. Without, however, attempting to explain the precise 
mode in which each of these ingredients acted, it will be sufficient 
to state that the combination had a beneficial effect, and checked 
the asthmatic paroxysms. We persevered in using it, as well as 
the liniment, until all tendency to asthma had disappeared, and the 
normal state of the function of respiration became perfectly re- 
established. 
There is in the male chronic ward a patient named Garret Kane, 
to whose case I shall for a few moments draw your attention. This 
man is about forty-five, and, like most of his countrymen who have 
been addicted to whiskey, he is beginning to show the fatal effects 
of intemperance. He had been ill for several months before he 
came into the hospital, and is at present labouring under general 
anasarca, affecting the chest, upper and lower extremities, accom- 
panied by an accumulation of fluid, but not very extensive, in the 
cavity of the peritoneum. I do not intend here to enter into the 
general pathology of dropsy, or to enquire what was its origin in 
this instance ; I shall confine myself to an explanation of the rea- 
sons which have induced me to select the plan of treatment I have 
adopted. In the first place, it is a case of chronic dropsy ; secondly, 
it is unattended by fever; thirdly, it is a case in which mercury 
has been used with some temporary relief, but the disease returned 
afterwards in a worse form; lastly, it is dropsy accompanied by 
obstinate diarrhoea, and therefore contra-indicating the use of pur- 
gatives or even of diuretics, for you are aware that the whole class 
of diuretic medicines acts more or less on the intestinal canal. I 
may mention here, acetate and nitrate of potash, turpentine, colchi- 
cum, squill, and many other remedies of the same kind. All 
diuretics act either as purgatives, or they have a stimulant and irri- 
tating effect on the bowels. This patient has bowel complaint, 
and therefore we are prevented from giving diuretics or purgatives ; 58 
graves’s clinical lectures. 
and the absence of inflammatory symptoms precludes the employ- 
ment of the lancet or cupping-glasses. You perceive that our field 
for practice is extremely limited ; we dare not bleed, cup, purge, 
give mercury, or diuretics ; the nature of the case contra-indicates 
the use of all these remedies, and hence we are deprived of the 
power of using the most energetic agents employed in the treat- 
ment of dropsy. What then is to be done ? Having observed that 
the man’s appetite and thirst are very great, and that his urine con- 
tains a large quantity of albumen, that he has no fever, and no 
symptoms of local inflammation, 1 decided at once on trying the 
efficacy of Dover’s powder in doses of a scruple in the day, divided 
into four pills, and gradually increased until it amounts to half a 
dram, or two scruples, in the twenty-four hours. A species of 
analogy exists between cases of this kind and cases of diabetes; in 
both there is the same tendency in the blood to part with its watery 
constituents, in both the same inordinate thirst and craving appetite 
are observed, and in both there is the same deposition of animal 
matter in the urine. The principal difference between them is, 
that in one case the watery fluid is effused into the cellular sub- 
stance and peritoneal cavity, while in the other it is eliminated 
from the system through the medium of the kidneys. It was this 
analogy which led me to adopt Dover’s powder in the treatment of 
this man’s case. Last year we had a patient here under treatment 
who was dropsical, and at the same time passed five quarts of urine 
daily ; before I had recourse to the ordinary treatment for dropsy, 
I determined to try the use of Dover’s powder. The disease yielded 
rapidly to this plan of treatment, and the man left the hospital quite 
relieved. 
In the patient Kane a small sore has formed on one of the lower 
extremities, perforating the skin and cellular substance to the depth 
of two or three lines; through this aperture a great deal of the 
anasarcous fluid has drained, and still continues to flow oft’. This 
is a very fortunate circumstance, as it will tend to prevent any ex- 
cessive accumulation in the cellular membrane. Previous to its 
occurrence I had ordered the scrotum and prepuce, which were 
enormously distended, to be punctured with a needle. The best 
mode of doing this is to prick the part quickly, so as to give as 
little pain as possible, the point of the needle should merely pene- 
trate the true skin, the punctures should vary in number from 
twenty to fifty or sixty, according to the size of the part and the 
extent of the effusion, and they should be at least half an inch 
asunder. By observing these rules you will succeed in evacuating 
the water without running the risk of exciting erysipelas, which 
in such cases frequently leads to disastrous consequences. Punc- 
turing with a lancet is not so good as with a needle, it is much 
more apt to excite irritation in the parts, and thus lead to the super- 
vention of erysipelatous inflammation. The judicious application 
of acupuncturation, in cases of chronic dropsy, often accomplishes 
a great deal, for when the external anasarcous oedema is thus 
drained away, the fluid in the peritoneal cavity is more rapidly SECONDARY SYPHILIS. 
59 
absorbed; in some cases, indeed, the good effects of external drain- 
age on the ascites are so rapid, that we are almost tempted to 
believe that some direct communication may exist between the 
subcutaneous tissue and the apparently shut sac of the peritoneum. 
Be this as it may, the good effects in some cases are as decisive as 
if such a communication existed. This phenomenon countenances 
the hypothesis of the possibility of fluids percolating through lining 
membranes. 
Note.—In the foregoing lecture I have adverted to a subject not 
hitherto sufficiently considered by pathologists, viz., the immediate 
effects produced in the bronchial tubes and pulmonary tissue when 
an internal tumour presses on one of the bronchi. The result is a 
certain degree of cough, expectoration, and dyspnoea. In some 
cases the bronchial inflammation thus produced may go on to 
actual ulceration, which authors have been too much disposed to 
regard as being mechanically produced by the local irritation of 
pressure. Professor Albers, of Bonn, cites one case in which a 
scirrhous tumour of the oesophagus produced ulceration of the 
neighbouring compressed bronchus, but he says nothing of the 
manner in which this effect was accomplished. In some cases, no 
doubt, inflammation may be propagated from the morbid growth, 
but in the tumours I speak of, no evidence of inflammation existed. 
Professor Albers’s observations on this subject may be seen in his 
paper on Widening of the Pulmonary Artery, Rust’s Magazin 
fur die gesammte Heilkunde, 42 Band, 1 Heft, p. 177. 
Case of secondary symptoms which made their appearance soon after a mercurial 
course; method of treatment—Case of syphilitic eruption—Mouth suddenly affected 
by a small quantity of mercury—Effects of this on the progress of the cure—Ear- 
ache preceded by rigors coming on during the course of fever; danger of; treatment 
—External tenderness; value of, as a symptom in inflammations of brain, lungs, 
abdomen, &c. &c.—Vomiting considered as a symptom in fever; its treatment— 
Chronic rheumatism; successful treatment of—Obstinate case of arthritis; cure of 
by local applications—Observations on the effects of mercury applied locally—Case 
of syphilitic iritis; action of belladonna in. 
LECTURE YI. 
You have observed that we have two cases of syphilis under 
treatment—one in the female, the other in the male chronic ward. 
They possess no peculiar interest beyond the ordinary run of syphi- 
litic affections, still they deserve a share of your attention ; for it is 
on your experience of individual cases, much more than on the 
knowledge derived from books, that your treatment of this obscure 
and Protean malady will depend. 
It is now more than a year since the female patient received the 
syphilitic poison into her constitution. What the nature of the 
primary sore was we cannot ascertain, but, from the account she 
has given, it seems to have been true chancre. Some time effer 60 
graves’s clinical lectures. 
this occurred, she got sore throat, articular pains, and an eruption, 
for which she was treated in this hospital about ten months since, 
and dismissed apparently cured. The disease, however, returned 
in a few weeks, and she has been labouring under its effects up to 
the present moment. Three circumstances in this case demand 
our attention: first, the re-appearance of syphilis after a mercurial 
course—for she was mercurialised here soon after her first admis- 
sion ; secondly, she exhibits a degree of syphilitic cachexy, being 
rather pale and emaciated; and, thirdly, the slow progress which 
the disease has made in her system, being limited to a few blotches 
on the skin, some periostitic swelling of the bones of the leg, pains, 
and slight arthritis. 
In treating this case I intend to give mercury, so as to affect her 
system; and, having accomplished this, I shall keep her under its 
influence for some time. I shall also, should it appear necessary, 
order her a free allowance of the decoction of sarsaparilla. Under 
this treatment you will find that the eruption will soon disappear, 
the periostitic pains and swelling be removed, and the constitution 
begin to improve. She has been ordered three grains of blue pill, 
and half a grain of calomel, three times a day—a quantity which 
you will generally find sufficient to bring on mercurial action in 
females. I have no doubt but that the disease will, in this case, 
yield to mercury in a very short time, and. that her health will be 
completely restored. The failure of mercury in producing a per- 
manent cure, on a former occasion, is no argument against its 
employment here; if there were no syphilitic taint in question, I 
do not know any remedy by which the cutaneous affection and the 
periostitis could be more effectually relieved. On another occasion 
I shall speak more at large upon this important subject, and shall 
bring forward facts in proof of the assertion, that mercury may 
fail to eradicate the effects of the venereal poison at a certain period 
of the disease, and may nevertheless be capable of curing the dis- 
ease effectually at a future time. This may appear paradoxical, 
but it is not the less true. 
The other patient, John Kelly, presents an eruption of red scaly 
blotches, extensively diffused over the trunk and extremities, and 
closely resembling psoriasis. This man, like many others, denies 
the occurrence of a recent syphilitic taint, and gravely states that 
it is some years since he exposed himself to infection. Instances 
of this kind are to be met with every day; patients will not tell the 
truth about these matters, and false statements tend to throw a 
darker shadow over a disease in itself sufficiently obscure. How- 
ever, in this case, the poison seems to have confined its effects to 
the cutaneous surface; there is no affection of the throat, perios- 
teum, or joints. The eruption covers almost every portion of his 
body; it made its appearance two months before admission, and 
was preceded by feverish symptoms and pains in the larger articu- 
lations. 
In undertaking the treatment of this case, there is one practical 
point to be held in view. The man’s general health is good, his 61 
SYPHILITIC ERUPTION. 
strength undiminished, and his circulation active. I therefore 
ordered him to be blooded, and have kept him for eight or nine days 
on antimonials and low diet. By preparing him in this way, I 
knew that the mercury which I intended to give him would act 
more rapidly on his system; and such was the case—for on the 
second day after he commenced using it his mouth became affected. 
But here a difficulty arose, which, in cases of this description, is 
apt to embarrass our treatment: the mercurial influence appeared 
much sooner than I expected or wished. He had been ordered 
three grains of blue pill, and half a grain of calomel three times a 
day ; and on the second day, before he had taken six pills, saliva- 
tion commenced. Now, in all cases where mercury affects the 
mouth sooner than you desire, and as it were in spite of you, it 
will not do as much good as where its action proceeds regularly 
and in accordance with your purpose. It is a general rule, that 
most benefit is to be expected from mercury where its action is 
regularly progressive, or where the quantity taken is in proportion 
to the effect produced on the system. Hence we look upon it as an 
unfavourable occurrence, when a small quantity of mercury occa- 
sions sudden and copious salivation ; such an event deranges our 
calculations, and tends to embarrass our practice. Now, in this 
case the patient, after taking five pills, became salivated on the 
second day. We found we had been going on too fast; it was 
necessary therefore to pause, but not desist. We accordingly re- 
duced the quantity of mercury to three grains of blue pill, and half 
a grain of calomel, to be taken every second night. By these means 
we kept up a slight discharge of saliva, and the man’s symptoms 
began to improve. The eruption is now disappearing rapidly, and 
it is to this point I wish to call your attention. What are the 
marks which indicate the subsidence of an eruption of this kind, 
and by what criterion are you enabled to judge of the progress of 
the cure ? When the parts are about to return to their healthy 
condition, three circumstances occur; first, the vivid red or copper 
colour of the eruption begins to fade; secondly, the heat of the 
affected parts becomes reduced; thirdly, the excessive secretion of 
morbid cuticle is arrested, and the quantity of minute scales cover 
ing the blotches diminished. In such cases, the affected parts of 
the skin are highly vascular, and the secretion of cuticle is mor- 
bidly excessive in quantity; hence the continued desquamation 
from the surface of the blotches. You should, therefore, attend 
not merely to the colour of the eruption, but also to the quantity of 
minute scales on each blotch, when you wish to ascertain whether 
an eruption is fading or not. You can judge of this by your eye, 
or you can tell it by passing your finger over the diseased surfaces. 
The fading of the colour of the eruption, the decrease of the eleva- 
tion and roughness in the blotches, and the gradual disappearance 
of the minute scales—these are the circumstances by which you 
can ascertain the subsidence of a syphilitic eruption. As the cure 
progresses, you find the parts assuming a more natural appearance; 
the same quantity of morbid cuticle is no longer thrown out by the 62 
graves’s clinical lectures. 
affected spots of corium; the blotches become smooth and lose their 
elevation, and, finally, the red colour of the skin disappears. Of 
all the symptoms, discoloration of skin is the last to recede, and 
it generally happens that enough has been done in the way of treat- 
ment long before the skin resumes its natural complexion. If you 
were to continue the administration of mercury until the natural 
colour returned, you would very often push it to a useless and even 
dangerous extent. In such cases, a faded brownish or dirty tinge 
remains long after the re-establishment of healthy action. 
There is a case in the female fever ward which requires a pass- 
ing observation. A young woman, previously in the enjoyment of 
good health, was seized with symptoms of fever after exposure to 
cold ; she got rigors, followed by headache, hot skin, thirst, nausea, 
and acceleration of pulse. It is unnecessary for me to detail the 
symptoms which attended her illness during the past week; I shall 
content myself with pointing out the symptoms which particularly 
attracted my attention to her case on Saturday morning. At that 
time her fever had increased; she complained of severe headache 
and restlessness; had foul tongue, thirst, and symptoms of gastro- 
intestinal irritation. Such matters, however, demand no very par- 
ticular consideration; what chiefly fixed my attention was the 
occurrence of slight and transient rigors during my examination : 
I observed her shuddering three or four times in the space of a few 
minutes. On questioning her respecting these brief rigors, she in- 
formed me that they had occurred with more or less frequency for 
the last three days. Now. wdienever you meet with a symptom of 
this description in fever, be on your guard; watch the case with 
anxious, unremitting attention, and never omit making a careful 
examination. It is in this way that one of the worst complications 
of fever—treacherous and fatal disease of the brain—very often 
commences. On examining this girl, we found that she had not 
only headache, but also acute pain referred to the left ear, the exter- 
nal meatus of which was observed to be hot and tender to the touch. 
In addition to this, we were informed by the nurse that she had 
been seized with a sudden fit of vomiting shortly after we left the 
ward on the day before. Here was an array of threatening symp- 
toms calculated to awaken attention in any, even the most heedless 
observer. A patient, after exposure to cold, is attacked with symp- 
toms of fever ; she has headache and restlessness : she then begins 
to complain of acute pain in the ear, darting inwardly towards the 
brain ; and, finally, is seized with sudden vomiting. Under these 
circumstances, it is not difficult to form a diagnosis, and there can 
be little doubt but that the phenomena here present were indicative 
of incipient inflammation of the membranes of the brain. It is not 
easy to say whether in such cases the inflammatory affection of the 
membranes precedes the external otitis, or whether the inflamma- 
tion commences in the external ear and spreads inwards, though I 
am inclined to adopt the latter supposition, and the circumstance 
of the fever and earache arising from cold seems to give an addi- 
tional degree of probability to this view of the question. Be this INFLAMMATION OF THE BRAIN. 
63 
tis it may, there could be no doubt but that this girl was, on Satur- 
day, labouring under incipient inflammation of the membranes of 
the brain, as denoted by headache, rigors, acute pain in the ear, 
and vomiting. 
Here let me observe, gentlemen, that, in cases of this description, 
I look on the occurrence of external tenderness, not merely as an 
indication of internal disease, but also as a favourable symptom. 
I have remarked that in all cases where this happens, the physician 
becomes more speedily and sensibly aware of the existence of inter- 
nal disease, and the remedial means employed act with a more de- 
cidedly beneficial effect. I would prefer having to deal with an 
inflammatory affection of the brain or bowels, accompanied by 
external tenderness, and would feel much more certain as to the 
result, than if this symptom were but faintly marked, or totally 
absent. This observation is founded on experience. 
In treating this case, you have seen that I have ordered relays of 
leeches to be applied in the vicinity of the affected ear until the 
earache has ceased. I have long followed this practice of applying 
a number of leeches in succession for the relief of local inflamma- 
tion, and I can state with confidence that the result has been, in the 
majority of cases, highly satisfactory. Some prefer the application 
of a great many leeches at once; but my experience speaks strongly 
in favour of the practice of applying a small number, repeated at 
short intervals, until the violence of the local inflammation is sub- 
dued. Relays of six or eight leeches will suffice in the majority of 
cases of pectoral, cerebral, or abdominal inflammation. In some, 
however, when the attack is violent, fifteen or twenty must be 
applied at once; each succeeding relay may consist of a smaller 
number than that which preceded it. In this manner I have main- 
tained a constant oozing of blood from the integuments over an 
inflamed organ for twenty-four, or even thirty-six hours. In addi- 
tion to this, I determined to bring her system rapidly under the in- 
fluence of mercury, and, with this intent, administered calomel to 
the amount of a scruple in the twenty-four hours. These means 
have acted favourably, and she feels much better to-day. (This 
patient perfectly recovered.) 
Allow me to make one observation more which this case suggests. 
This young woman, you recollect, had, on her admission, some 
epigastric tenderness, which we removed by leeching, and she 
remained free from any symptoms of gastric irritation until last 
Saturday, when she got a sudden attack of vomiting. Now, in all 
feverish complaints, where, during the course of the disease, the 
stomach becomes irritable ivithout any obvious cause, and where 
vomiting occurs ivithout any epigastric tenderness, you may 
expect congestion, or incipient inflammation, of the brain or its 
membranes. If called to a case of scarlatina, where there is severe 
vomiting, and perhaps diarrhoea, unaccompanied by thirst or 
epigastric tenderness, what should your practice be? Are yon to 
direct your attention to the alimentary canal, and endeavour to 
arrest these symptoms? No. The vomiting here depends on 64 
GRAVEs’s CLINICAL LECTURES. 
active congestion of the head, and such cases are very apt to end 
in coma, convulsions, or death, from disease of the brain. You 
are all aware, that in cases of injuries of the head, followed by 
congestion of the brain, vomiting is one of the most prominent 
symptoms. The same thing occurs in febrile affections, attended 
with determination to the head. You are not to conclude that a 
fever is gastric, because it commences with nausea and vomiting; 
this is a serious, and very often a fatal, mistake; yet I am sorry to 
say it has been committed by many practitioners, and I have been 
guilty of it myself. In such cases, you should not waste time in 
attempting to relieve gastric irritation by cold drinks, and leeches 
to the epigastrium, or to check diarrhoea by chalk mixture and 
opiates; you should direct your attention at once to the seat and 
origin of the mischief, and employ prompt and effectual means to 
relieve the cerebral congestion. Where the disease sets in with 
severe vomiting, unaccompanied by distinct evidences of gastric 
inflammation, whether it be common fever, or scarlatina, or 
measles, or small-pox, I commence the treatment by applying 
leeches to the head, convinced that in this way I shall be most 
likely to prevent an approaching dangerous congestion of the brain. 
I am anxious to impress this observation on your minds, because 
I am fully sensible of its importance, and feel certain that you will 
derive much advantage from bearing it in recollection during the 
course of your future practice. 
The next affection to which I shall draw your attention is chro- 
nic rheumatism, of which we have a well-marked instance in the 
man who lies in the chronic ward immediately under the window. 
He complains of pain, weakness, and numbness of the lower extre- 
mities, for which he used the decoction of sarsaparilla and minute 
doses of corrosive sublimate, for a fortnight, without any obvious 
improvement in his symptoms. His complaint is of considerable 
duration, it being now fifteen weeks since he was first attacked. 
This, I need not tell you, is a very unpromising feature in his case. 
When rheumatism has continued for three or four months, it be- 
comes a very intractable disease; indeed, there is scarcely any 
affection which tasks the ingenuity, and tries the patience, of a 
medical man more than chronic rheumatism. In this case, how- 
ever, we have been so fortunate as to hit on a remedy suited to the 
complaint; the man has been rapidly improving within the last 
fortnight, and is now nearly well. You will recollect that, when I 
undertook the treatment of this case, the patient was free from 
fever, his general health but little impaired, his pulse tranquil, his 
appetite good, no remarkable tenderness or redness of the joints— 
in fact, nothing to indicate the existence of acute local inflamma- 
tion ; consequently, it would have been useless to have recourse to 
leeches or blood-letting, or to administer antimonials, nitre, or col- 
chicum. In such cases as this a different line of practice must be 
followed; you must have recourse to stimulant diaphoretics—reme- 
dies which will increase the secretion from the skin, at the same 
time that they exercise a stimulating action on the nervous and CHRONIC RHEUMATISM. 
65 
capillary systems. Accordingly we prescribed for this man the fol- 
lowing electuary, of which he was to take a teaspoonful three 
times a dayPowdered bark 3j, powdered guaiacum 3j, cream 
of tartar 3j, flower of sulphur 3ss, powdered ginger 3j, to be made 
into an electuary with the common syrup used in hospitals. The 
guaiacum not only acts on the nerves, tending to remove chronic 
pains, but also acts on the skin: you will find these, and other pro- 
perties possessed by it, detailed at large in your works on Materia 
Medica. Whether given in the form of powder or tincture, it often 
proves an extremely useful remedy in cases of chronic rheumatism, 
where no symptoms of active local inflammation or general fever 
exist; where either of these are present it is inadmissible. Ginger 
has also a stimulant effect, although its action is much more limited. 
It is a favourite domestic remedy, and is very frequently prescribed 
by our rival candidates for therapeutic celebrity—old ladies—in 
cases of chronic, or, as they term it, cold rheumatism; and I must 
confess that I have seen some benefit derived from their specific— 
ginger tea. With these we combined sulphur, which exerts a pecu- 
liar stimulant operation on the skin and alimentary canal. Sulphur 
is an extremely active remedy, and singularly penetrating in its 
nature, finding its way into many of the secretions and most of the 
tissues of the body. You will find it in the urine in the form of 
sulphates, and it is exhaled from the skin and mucous membrane 
of the bowels in the form of sulphuretted hydrogen. Having said 
so much respecting sulphur, you will perhaps enquire why I pre- 
scribed the bark ? It is not easy to give a satisfactory explanation 
of this; but we know, from experience, that in cases of rheumatism, 
after fever and local inflammation are removed, bark and other 
tonics have been found extremely valuable. The cream of tartar 
is given with the view of tempering the other stimulant remedies, 
it being known to possess cooling and aperient properties. The 
whole form a combination which is similar in its composition to a 
well-known popular remedy for rheumatism—the Chelsea Pen- 
sioner. 
Having thus explained the general tendency of these medicines, 
and mentioned that they are to be made up into an electuary, it 
only remains to speak of the effect produced, and the dose or quan- 
tity to be given. I have stated that the ordinary dose is a teaspoon- 
ful three times a day; this, however, will be too much for some, 
and too little for others. The object in every case should be to 
keep up a mild but steady action on the bowels, and to procure a 
full alvine discharge at least once a day. If the dose mentioned 
already does not answer this purpose, it must be increased; if the 
bowels are too free, it must be diminished. You should never omit 
making regular enquiries after the state of the bowels, while the 
patient is using this electuary; for, if these matters are neglected, 
the patient will not obtain the full benefit to be derived from it. 
Besides opening the bowels, this electuary acts on the skin, and fre- 
quently causes a rapid disappearance of the disease. I need not 
say that, in addition to this, I ordered warm baths; they coincide 66 
graves’s clinical lectures. 
in effect with the electuary, acting on the skin, and tending to 
relieve the rheumatic pains. 
There is another very remarkable case bearing some affinity to 
the preceding, on which it may be necessary to offer a few remarks; 
I allude to the patient with sweating arthritis, to whom I drew your 
attention this morning. This poor man. who is somewhat advanced 
in life, has been labouring for several months under inflammation 
of the joints of a rheumatic character, manifesting itself by pain, 
stiffness, swelling, and probably some slight effusion into the syno- 
vial membranes. These symptoms were accompanied by profuse 
and constant perspirations, with a tendency to diarrhoea—circum- 
stances which caused a manifest deterioration of his health and 
strength ; he became pale, cachectic, and emaciated. His case had 
been very tedious and intractable; he had been a long time in the 
hospital, and had used all the most appropriate remedies, but with- 
out any appreciable improvement; his joints remained stiff, painful, 
and almost useless; he was greatly reduced in strength, and entirely 
confined to his bed. In addition to this, his pulse continued unre- 
duced in frequency, and this is always a bad sign; cases of rheu- 
matic arthritis, attended by prolonged excitement of the circulation 
and copious sweating, are generally found to exhibit an intractable 
chronicity, and too often terminate in rendering the unfortunate 
patient a cripple for life. 
Now in this case many remedies had been tried without effect, 
and the state of the man’s constitution, combined with the circum- 
stance of his having a tendency to bowel complaint, contributed to 
reduce still further the scanty list of our remedial agents. Altera- 
tive remedies, to affect the general system, were almost entirely out 
of the question, and a vast number of local applications had proved 
unsuccessful. It occurred to me here, that some benefit might be 
derived from mercurial ointment, gently rubbed over the affected 
parts, assisting its action by the use of rollers applied round the 
joints. Fortunately, the experiment proved successful; in the 
course of a week or ten days, the swelling diminished considerably, 
the pain is nearly gone, and the power of motion is returning. 
His mouth has become affected, but the relief experienced appears 
to be proportioned, not to the influence of mercury on the general 
system, but to its effect on each individual joint. As a proof of 
this, I may state that the man has been mercurialised before, but 
without any favourable result. 
Here, gentlemen, is an important point for consideration. A 
patient labours under a certain number of local inflammations, for 
which mercury is given internally, so as to affect the mouth, but 
without any manifest improvement of symptoms; we afterwards 
try the same remedy in another form; we apply it locally, in the 
shape of ointment, rubbed into the skin over the diseased parts, and 
we succeed in giving relief. This is a fact deserving of attention. 
You will perhaps ask me to explain this—I cannot do it; but I can 
bring forward many other analogous examples. If you refer to Mr. 
M‘Dowel’s valuable paper on Erysipelas, published in a late number ARTHRITIS. 
67 
of the Dublin Medical and Chemical Journal, you will find that 
many cases of this affection derived great benefit from the use of 
mercurial ointment; in fact, much more than they could by giving 
mercury internally. In the next place, I have met with many 
cases of enteritis and peritonitis, where the disease continued after 
the system became affected by mercury; and I have observed that 
these cases yielded rapidly to blistering the abdomen, and dressing 
the raw surfaces with mercurial ointment. Dr. Marsh and I 
attended a young gentleman lately, who had low fever, accompa- 
nied by a quick but feeble pulse, and great restlessness. About 
the tenth day, his belly became tender and exquisitely painful; he 
had thirst, diarrhoea, and other symptoms of enteric and peritoneal 
inflammation. Before his illness, he had been of rather delicate 
habit, and had further impaired his health by close study. He 
was therefore unfit for depletion, and of this we were convinced by 
the debility which followed the application of a few leeches. 
Under these circumstances, we ordered a large blister to be applied 
to the abdomen, and the vesicated surface to be dressed with mer- 
curial ointment. This proved eminently successful; the perito- 
nitis, enteric irritation, and fever, soon disappeared, and the young 
gentleman recovered completely. The same thing is seen in many 
cases of pleuritis; the constitutional effect of mercury will fail in 
removing the affection of the pleura until it is applied locally. I 
might also refer to instances of common inflammation of the 
testicle, in which mercurial ointment, smeared over the part, has 
been found decidedly beneficial. It is unnecessary for me, how- 
ever, to multiply examples; what I have stated give ample proof of 
the utility of mercury applied locally. When I was a student, it 
was the fashion to scout the doctrine that any distinct effect could 
be produced by the local application of mercury; our teachers laid 
it down as an axiom, that, to produce any sensible effect, it was 
necessary that it should first enter the system through the lym- 
phatics. Thus, when you mb mercurial ointment over the liver 
to remove hepatic derangement, they said, before it could exert any 
influence on the liver, it had to pass along the thoracic duct, be- 
come mixed with the circulation, and manifest its peculiar action 
on the whole economy. Hence, in a case of hepatitis or testitis, it 
was deemed useless to apply mercurial ointment over the liver or 
testicle, since it had, as they expressed it, to go its rounds through 
the whole system, before it could affect either of these organs. 
This reasoning has an appearance of plausibility, but it is con- 
tradicted by facts. Numerous examples might be cited to prove 
that the greatest advantage may be derived from the local applica- 
tion of mercury, independent of any effect produced by it on the 
general system. How often do we see an incipient bubo dispersed 
by mercurial frictions, before any constitutional effects occur? 
How frequently do we see laryngeal and hepatic inflammation 
relieved by the use of mercurial ointment without salivation ? Do 
the beneficial effects, which we so often observe from the emplas- 
trum ammoniaci cum hydrargyro, depend necessarily upon the 68 
graves’s clinical lectures. 
mouth being affected ? Is the relief which follows the use of mer- 
curial ointment in erysipelas or testitis, unattainable unless pre- 
ceded by mercurial action in the whole system? Indeed, any 
person who reviews this subject dispassionately, will see that the 
doctrine of a preliminary constitutional affection being absolutely 
necessary, in order to obtain the specific action of mercury on any 
particular organ, is wholly untenable; while, on the other hand, 
there is a host of evidence to prove that, locally applied, it produces 
a primary and distinct effect, totally independent of its action on the 
general economy. 
The last case to which I shall direct your attention, is one of 
syphilitic iritis. A young man has been admitted this morning, 
presenting symptoms of secondary syphilis in a well marked form, 
but simple and incomplicated by any previous treatment. He took 
no medicine for the primary or secondary symptoms, except two 
pills, which he got at a dispensary about two months ago, and 
which were not followed by any sensible effect. The secondary 
symptoms came on with pains and feverishness, and are at present 
extensively diffused over his body in the form of elevated blotches, 
of a character intermediate between the papular and squamous. 
About four or five days back, he was advised to take a warm bath 
for his pains, but having to walk a considerable distance afterwards, 
the day also happening to be chilly and sharp, he got cold in re- 
turning home, and soon after experienced pain in the left eye, with 
lachrymation, and diminution of the power of vision. Had he been 
exposed in the same way while in health, he would probably get 
slight conjunctivitis, or sore throat, or bronchitis; but the case was 
altogether different with a man labouring under a constitutional affec- 
tion, having a tendency to manifest itself in almost every tissue of 
the body, and prepared to modify every form of inflammation to 
which accident might give rise. Again, if the man’s constitution 
was in a sound state, his feverish cold, or conjunctivitis, or sore 
throat, could be removed by very simple means, such as bathing 
the feet, taking a little warm whey on going to bed, and some 
opening medicine the next morning. But here the state of the 
constitution occasions the substitution of syphilitic iritis for simple 
conjunctival inflammation, and demands a peculiar plan of treat- 
ment. You are all aware, that persons who have taken mercury 
for syphilis, without being entirely cured, are very liable to get 
iritis on slight exposures. Some persons attribute this entirely to 
the mercury; but mercury, in such cases, merely acts by rendering 
the patient more liable to cold, so that when iritis occurs in a 
patient who has been under a mercurial course, it is not in conse- 
quence of the direct operation of mercury, but by its increasing his 
liability to be affected by impressions from cold. For the same 
reason, the circumstance of his having taken mercury before, is 
not, as some persons maintain, any argument against his using it a 
second time. 
On examining this man, we found that he had some pain re- 
ferred to the eyebrow ; the eye also is more vascular than natural, SYPHILITIC IRITIS. 
69 
and presents that appearance which is so characteristic of iritis ; 
there is some alteration in the colour of the iris along its free 
margin, but no irregularity of pupil. Along with these symptoms, 
there is dimness of vision, and objects appear as if seen through a 
veil. This arises not from any opacity of the cornea, or opales- 
cence of the aqueous or vitreous humours, but from inflammation 
affecting the iris, ciliary zone, and, probably, the coats of the retina. 
In such cases, where the inflammation spreads from the iris to the 
ciliary zone, it would appear that the ciliary nerves and retina par- 
take in the mischief, for vision becomes affected before we can dis- 
cover any appearance of derangement in the optical instrument. 
The peculiar appearance of the eye in this man, the change of 
colour in the free margin of the iris, and the diminution of the 
power of vision co-existing with an eruption of the skin, point out 
the nature of the disease, and show that the affection of the eye, 
though proceeding from a common cold, has been modified by the 
syphilitic taint in the constitution. 
We next come to consider the plan of treatment to be pursued. 
In order to prepare his system for mercury, I have ordered him to 
be blooded, purged, and put on the use of antimonials for two or 
three days. Venesection, purging, and tartar emetic, may be of 
some use in relieving or arresting the symptoms of iritis, but I do 
not place any great reliance on them for removing the disease ; 
I merely employ them as auxiliaries, depending on mercury for 
the cure. Here it may be necessary to observe, that there is con- 
siderable variety in cases of iritis. Some are extremely mild; 
there is no palpable sign of acute inflammation present, and the 
chief symptom is diminution of the power of vision. Such attacks 
are sometimes not perceived by the patient until some accident 
informs him that the sight of one eye is nearly gone. In other 
cases, after reaching a certain point, it begins to decline, and fre- 
quently terminates spontaneously. Others present symptoms of a 
more decided character, but still are free from danger. Every 
attack, however, where the inflammation is at all of an intense 
character, will go on to destroy vision, unless met by prompt and 
efficacious treatment. Tn this man’s case the symptoms are not 
very acute, and hence there is no necessity for having recourse to 
mercury at once; the disease might certainly terminate in disor- 
ganisation of the eye, but it would be some weeks before this would 
be accomplished. On the other hand, there are cases which, if 
neglected, would destroy vision irremediably in the space of three 
or four days. Such cases require extremely prompt and energetic 
measures. But where iritis is not of a violent kind, you need not 
depart from the plan of treatment you would have laid down for 
the cure of syphilitic affections where no iritis existed. Here you 
bleed, purge, give antimonials and mercury, and you find that the 
syphilitic eruption and iritis disappear together. But where the 
symptoms of iritis are so severe as to threaten rapid disorganisation 
of the eye, you disregard the syphilitic affection, and direct your 
entire attention to the preservation of the eye. Here you bleed, 70 
graves’s clinical lectures. 
leech, apply belladonna to the eye, and give calomel, in doses of 
ten grains or a scruple, every third or fourth hour, so as to bring 
the system as rapidly as possible under the influence of mercury. 
With respect to belladonna, I believe you are all aware of its 
value in iritis. Some think that its action is merely mechanical, 
that it dilates the pupil and no more; but I am firmly convinced 
that its influence is not limited to mere dilatation of the pupil. I 
believe that it acts on the vitality of the eye, and that when 
employed externally or internally, it possesses the properties of 
diminishing the irritability of that organ, and thus tends indirectly 
to remove local inflammation. In scrofulous ophthalmia, where 
the eye is exquisitely sensible, where the slightest exposure to light 
causes intense pain, and copious lachrymation, one of the best 
remedies I am acquainted with is belladonna, given internally. 
Thus, you perceive that belladonna has not only a mechanical 
action, producing dilatation of the pupil, and tending to prevent 
adhesions, but also, by its influence on the retina and ciliary 
nerves, diminishes the irritability of the eye, and aids materially in 
effecting the removal of local inflammation. 
LECTURE VII. 
General remaiks on the pathology of paralysis—Dr. Graves’s new views upon this sub- 
ject—Their application to the study of several varieties of paraplegia—Explanation 
of Mr. Stanley’s cases of paraplegia; of Dr. Stokes’s cases—Two cases of paraplegia 
after enteritis—Paraplegia after metritis—Paraplegia the consequence of poisoning 
by lead; by arsenic—Paraplegia arising from irritation of the urethra, (case commu- 
nicated by Dr. Hutton.) 
Having recently met with some very interesting and remarkable 
cases of impairment of the muscular functions of the lower extre- 
mities, I am anxious to offer a few observations on paraplegia, par- 
ticularly while the subject is still fresh in my mind: we can resume 
the consideration of our clinical cases at a future opportunity. I 
would entreat your favourable attention on this occasion, while I 
lay before you some opinions on paraplegia peculiar to myself, and 
differing from the views entertained by the generality of medical 
writers; the subject, too, is one of extreme interest, involved in 
much obscurity, and offering an extensive field for investigation : I 
trust, however, I shall be able to communicate some new matter 
calculated to throw much additional light on the nature of this 
affection, and thus contribute to fill up the blanks which exist in 
an important department of pathological medicine. 
You are aware that by paraplegia is meant that species of para- 
lysis in which the lower extremities are affected—a paralysis fre- 
quently embracing loss of motion and loss of sensation in the lower 
extremities, accompanied in many instances with derangement of 
the motor power of the bladder and rectum. Now, I wish you PARAPLEGIA. 
71 
clearly to understand that it is not my intention to describe the 
symptoms, or discuss the causes, of those species of paraplegia 
which are well ascertained, and of which you will find satisfactory 
descriptions in your books: under this head may be classed all 
those cases which are produced by disease of the spinal marrow, 
its membranes, the vertebrae or their appendages, their ligaments, 
and diseases directly affecting the great nerves which supply the 
lower extremities. All these matters have been sufficiently studied, 
and require no additional observations from me; my object is to 
elucidate some of the obscurer varieties of paraplegia. I have 
touched on this topic before in my lectures delivered at the Meath 
Hospital, but since that time I have met with many cases, and 
made enquiries which tend to throw additional light on the subject. 
I have read, with the attention which it merits, a lecture on this 
subject, published by my colleague, Dr. Stokes, in Renshaw’s Lon- 
don Medical and Surgical Journal, and also Mr. Stanley’s inte- 
resting cases in the 18th volume of the Medico-Chirurgical Trans- 
actions, published in the year 1833. In Mr. Stanley’s paper, 
several cases of paraplegia are brought forward, the explanation of 
which had not been understood before or even at the time he wrote, 
but which I had given several months previously, as applied to 
paralysis in general, in two lectures in the 58th and 59th numbers 
of the London Medical and Surgical Journal, and which had 
been delivered at the Meath Hospital, in Nov. 1832, and were pub- 
lished immediately afterwards. In fact, the explanation offered by 
Mr. Stanley is merely a corollary of the propositions which I laid 
down at that time, and which I shall beg leave to repeat here. 
Before I commenced my investigations on the subject, patholo- 
gists, in endeavouring to ascertain the causes of paralysis, sought 
for the sources of the disease almost solely in the centres of the 
nervous system. They looked for the causes of paralysis in the 
brain or spinal cord, where they supposed it originated either in 
organic or functional derangement of these important organs. In 
the lectures to which I have already referred, I showed that this 
mode of accounting for all forms of paralysis, by referring them to 
original disease of the nervous centres, was in many instances in- 
correct, and proved, I think to the satisfaction of the class and 
those who read the lectures, that a most important and influential 
cause of paralysis had been hitherto nearly overlooked—a cause 
which, commencing its operation on the extremities, and not on the 
centres of the nervous system, might, by a reflex action, produce 
very remarkable effects on distant parts. I brought forward on that 
occasion many arguments, facts, and cases, to prove the possibility 
of such an occurrence—to show that it frequently happens that 
impressions made on the extremities of the nerves will generate a 
morbid action in them; that this morbid action will be conveyed 
along their branches and trunks to the spinal cord or brain ; and 
that, continuing its propagation, it may, by a retrograde course, be 
carried thence along the nerves to distant organs, and in this way 
give rise to disease in parts originally intact and healthy. I brought 72 
graves’s clinical lectures. 
forward several instances to prove that, when a certain portion of 
the extreme branches of the nervous tree has suffered an injury, 
the lesion is not confined merely to the part injured, but in many 
instances is propagated back towards the nervous centres; and 
that, in this way, not only the nervous filaments of the injured 
part may be affected, but also the main trunk of the nerve and 
other branches, or that the lesion may reach the brain or spinal 
cord, and thus produce still more extensive effects on the system. 
What I endeavoured to impress upon the class at that time was, 
that pain, numbness, spasm, and loss of the power of muscular 
motion, may be produced by causes acting on the extremities of the 
nerves; and that such affections, commencing in the extremities of 
the nerves, may be propagated towards their centres so as to be 
finally confounded with diseases originating in the centres them- 
selves. For a detailed account of my views on this subject, I beg 
leave to refer to the published lectures; at present I shall content 
myself with recapitulating a few of the facts on which these views 
were grounded. 
If you place your hand in snow or ice-cold water, you will find 
that it is not merely the parts subjected to the influence of cold that 
become numb, and that the diminution of power is not entirely 
limited to the muscles concerned in the peculiar motions of the 
fingers, but extends also to those of the fore-arm, by which the 
principal motions of the hand are performed. Here the impression 
of cold is found to affect not only the parts immediately exposed to 
it, but also parts that are quite removed from its influence and 
warmly covered. We see that not only the muscles attached to 
the fingers, but also those of the fore-arm, undergo from this cause 
a temporary paralysis. Now, if a cause of a trifling nature, and 
acting only for a time, can, when applied to a part, produce loss of 
power in another and more central part, we may infer that the 
same cause acting permanently might produce permanent paralysis 
of the latter. We can, therefore, conceive how in this case the 
agency of cold might travel upwards and reach the muscles of the 
arm also, and thus we should have a change, commencing in the 
tips of the fingers, propagated to parts at a considerable distance 
from the situation of the original lesion. Again, we find that an 
injury, affecting one branch of a nerve, will be propagated by a 
retrograde action so as to affect another and distinct branch, as was 
exemplified in a case mentioned in my former lectures on paralysis. 
A young lady, having wounded the inside of her ring finger with 
a blunt needle, observed that she had, in consequence of the injury, 
a considerable degree of numbness, not only in the wounded finger, 
but also in the little finger next to it. Here we find that an impres- 
sion made on the nerve of one finger not only affects that finger, 
but also travels backwards so as to operate on the branch given off 
by the ulnar nerve to supply the little finger—and given off\ ob- 
serve, above the place of the wound—so that the phenomena were 
identical with those which would arise from an injury inflicted on 
the branch which supplied both fingers. Within this last month, PARAPLEGIA. 
73 
I have had an opportunity of witnessing a very striking fact of this 
nature. A young gentleman, distinguished for the extent of his 
classical and mathematical acquirements, and who had just suc- 
ceeded in obtaining the senior wranglership, swallowed a small but 
angular piece of chicken-bone. It lodged low down in the oeso- 
phagus, and was not pushed, by means of a probang, into the 
stomach until after the lapse of more than an hour. Considerable 
inflammation of the pharynx, oesophagus, and surrounding tissues, 
was the consequence; on the third day of his illness he got a vio- 
lent, long continued, and ague-like rigor, which terminated in a 
profuse perspiration, and ushered in a well-marked inflammation of 
the neck of the bladder. In the next place, we find that impres- 
sions affecting the frontal branches of the fifth nerve may, by a 
reflex action, operate on the retina so as to cause blindness. Here 
the morbid action travels from the circumference towards the centre, 
and is again reflected towards the circumference so as to affect a 
separate and distinct part. Of this I lately saw a curious and 
instructive example. A medical student, traveling through Wales 
on the outside of the mail, was exposed for many hours to a keen 
northeasterly wind blowing directly in his face. When he arrived 
at the end of his journey, he found that his vision was impaired, 
and that every thing seemed as if he was looking through a gauze 
veil. There was no headache, no symptom of indigestion, to ac- 
count for this evidently slight degree of amaurosis, and yet he was 
recommended to use cupping to the nape of the neck, and strong 
purgatives. When he consulted me, which he did in the course of 
a few days afterwards, I at once saw that there was something un- 
usual in the case; and, after a careful examination, I at length 
elicited from him the fact of his having been exposed to the influ- 
ence of the cold wind. It was now apparent that the retina suffered 
in consequence of an impression made on the facial branches of 
the fifth pair. The cure was effected, not by a treatment directed 
to relieve cerebral congestion, but by stimulation of the skin of the 
face, forehead, temples, &c. 
It is, however, unnecessary to multiply examples to prove the 
truth of the proposition, that disease may commence in one portion 
of the nervous extremities, and be propagated towards the centre, 
and hence, by a reflex action, to other and distant parts. Bearing 
this in mind, we can explain why it is that disease commencing in 
one part of the system may produce morbid action in another and 
distinct part, and it certainly appears strange, that, with so many 
striking examples before them, pathologists should have so long 
overlooked this cause, when seeking to explain the nature of many 
forms of paralysis. If certain irritations of the nervous extremities 
in one part of the body are capable of giving rise to a derangement 
in the whole system of voluntary muscles; if a local affection may 
become the cause of exalting and rendering irregular the functions 
of every muscle in the body; then, surely, it is not difficult to con- 
ceive that a cause, local as the former, and tending not to exalt but 
to depress the motor function of the muscles, may likewise affect 74 
graves’s clinical lectures. 
not merely the nerves and muscles of the part, but also those of the 
whole body, or of distant organs, giving rise to paralysis. Now, 
pathologists have long recognised the fact, that general muscular 
excitement and spasm may arise from the operation of a local irri- 
tation. A man gets a contused wound on his thumb, or one of his 
fingers, and some superficial nerves are injured. In the course of 
a few days he begins to feel a degree of stiffness about the lower 
jaw and muscles of the neck, accompanied by a sense of constric- 
tion about the diaphragm. This increases gradually, all the volun- 
tary muscles are thrown into a state of fixed spasm, and he gets 
tetanus. Here a few trifling branches of the digital nerves are 
injured, the morbid action is conveyed from them along the nerves 
of the arm to the spinal cord and brain, and is thence, by a reflex 
action, propagated all over the body. A wound of the finger causes 
a morbid action in its nerves, and it has been acknowledged by 
pathologists that this, by acting on the brain and spinal cord, may 
give rise to a general morbid action of the muscular system. This 
being the case, there is nothing improbable in supposing that a 
cause affecting any portion of the branches of the nervous tree, and 
which produces effects of a paralytic nature, may likewise react 
backwards towards the nervous centres, and thence, by a reflex 
progress, may extend its influence to distant parts of the circumfe- 
rence. 
To give another instance : how often do we see irritation, com- 
mencing in the intestinal mucous membrane, propagated backwards 
towards the brain ? Take the familiar example of intestinal worms. 
A child labours under worms; here the irritation of the digestive 
mucous surface, whether it be produced by the worms, or by the 
indigestion which accompanies them, is propagated from the sto- 
mach and bowels to the brain, and thence reflected to the volun- 
tary muscles, causing general convulsions. 
Dr. William Stokes details the following case in his lectures. 
“ A young woman was admitted into one of the surgical wards of 
the Meath Hospital, for some injury of a trivial nature. While in 
the hospital, she got feverish symptoms, which were treated with 
purgatives, consisting of calomel, jalap, and the black bottle, a 
remedy which deserves the name of coffin bottle, perhaps, better 
than the pectoral mixture so liberally dealt out in our dispensaries 
as a cure for all cases of pulmonary disease. She was violently 
purged, the symptoms of fever subsided, and she was discharged. 
A few days afterwards, her mother applied to have her readmitted, 
and she was brought in again, and placed in one of the medical 
wards. Her state on admission was as follows :—She had fever, 
pain in the head, violent contractions in the fingers, and alternate 
contraction and extension of the wrist and fore-arm. These mus- 
cular spasms were so great, that the strongest man could scarcely 
control the motions of the left fore-arm. In addition to these 
symptoms, she had slight thirst, some diarrhoea, but no abdominal 
tenderness. On this occasion, a double plan of treatment was 
pursued, the therapeutic means being directed to the head, in con- PARAPLEGIA. 
75 
sequence of the marked symptoms of local disease of the brain, and 
to the belly, from the circumstance of abdominal derangement 
observed in this and her former illness. She died shortly after- 
wards, with violent spasms of the head and fore-arm; and as she 
had presented all the ordinary symptoms of a local inflammation 
of the opposite side of the brain, we naturally looked there first for 
the seat of disease. After a careful examination, however, no per- 
ceptible trace of disease could be found in the substance of the 
brain, which appeared all throughout remarkably healthy. She 
had all the symptoms which, according to Serres and Foville, would 
indicate disease of the optic thalamus or posterior lobe of the oppo- 
site side, yet we could not find any lesion whatever of its substance, 
after the most careful examination. But on opening the abdomen, 
we found evident marks of disease; the lower third of the ileum, 
for the length of six or eight inches, was one unbroken sheet of 
recent ulcerations.” This case, gentlemen, you will perceive just 
now, bears very strongly on the subject of paraplegia arising from 
enteritis. 
Again : how often do we see convulsions brought on in the same 
way by cutaneous irritation ? A child gets an attack of fever, 
accompanied by general irritability and restlessness. During the 
course of the disease, the lungs become affected, and the medical 
attendant applies a large blister, which is left on for several hours. 
Next day the symptoms of nervous irritation become more violent; 
the child is perfectly restless, or, if it dozes for a moment, awakes 
screaming, and is finally attacked with general convulsions. Many 
other examples could be brought to support this view of the ques- 
tion, and prove that morbidly increased action of the whole mus- 
cular system may be excited by a cause acting merely on some 
insulated portion of the nervous extremities. 
I think, therefore, that I am borne out by analogies strikingly 
exhibited by numberless examples, in asserting that the circumfe- 
rence of the nervous system has been too much neglected by patho- 
logists, in their explanations of the nature and causes of paralytic 
affections. I could give many instances of pains commencing in 
particular parts of the body, and traveling back towards the spine, 
so as to give rise to an affection of that organ, which has been too 
generally looked upon as the result of idiopathic disease. How 
often does this happen in hysteria? How often does it happen that 
the organ primarily engaged in hysterical cases becomes, during 
the attacks, acutely painful, and that, as the disease proceeds, the 
pain travels back towards the spine, until at length the spinal cord 
itself becomes affected, and we find acute pain and tenderness over 
some portion of its track ? I am fully persuaded that many modern 
authors, who have ascribed the phenomena of hysteria and other 
affections to spinal irritation, have been too hasty and indiscrimi- 
nate in their explanations. In the majority of cases, you will find 
hysteric patients complain at first, not of pain in any part of the 
spinal cord, but in the right side in the situation of the liver, in the 
region of the heart or stomach, or in the head, or the pelvic region. 76 
graves’s clinical lectures. 
At this period there is seldom any tenderness over the spinal cord; 
but, as the disease goes on, the irritation which existed in some of 
those situations to which I have referred, is extended to the spine, 
and pain and tenderness are now felt over some of the spinous pro- 
cesses of the vertebrae. When this has taken place, then the spinal 
irritation thus produced becomes itself a new cause of disease, from 
which, as a centre, the morbid influence is propagated to other 
organs. The profession owe much to Teale, Griffin, and other 
writers, who have pointed out the importance of attending to this 
spinal tenderness in cases of hysteria, &c. Still, however, like all 
those who have been employed in investigating a new subject, they 
have perhaps generalised too hastily, and have, in many cases, 
regarded this spinal tenderness as a cause, when it should have 
been merely considered as a consequence. 
Having thus endeavoured to explain some of the general prin- 
ciples which should guide us in the investigation of nervous dis- 
eases, I shall relate some cases of paraplegia, which, though differ- 
ing in their origin as to the organ inflamed, will strike you as 
exhibiting a close analogy to those published by Mr. Stanley. “In 
November, 1832, I attended, with Mr. Kirby and Mr. Cusack, a 
young gentlemen, aged fourteen, who was residing at a boarding 
school in the vicinity of Dublin. He had eaten a large quantity of 
nuts on the eve of Allhallows, and had, in consequence, obstruction 
of the bowels, attended with sense of weight and pain of the sto- 
mach, nausea, loss of appetite, and obstinate constipation. Active 
purgatives, of different kinds, were employed without effect, and 
the obstruction was only removed by the use of repeated enemata, 
thrown up with Read’s syringe, introduced as far into the cavity of 
the intestine as the circumstances of the case permitted. To these 
means, assisted by leeching and stuping, the constipation yielded; 
but its removal was followed by symptoms of enteric inflammation, 
embracing not one, but all the coats of the intestine—the mucous, 
the muscular, and certainly the peritoneal. The occurrence of a 
new and violent disease greatly impeded his cure; we had a long 
and anxious attendance, and the young gentleman escaped with 
great difficulty. However, the enteric symptoms at length gave 
way, convalescence became manifestly established, the patient was 
able to sit up in his bed, and as his strength and appetite were 
rapidly returning, he was informed that he might get up. On 
attempting to leave his bed, it was found that he had lost the power 
of using his lower extremities—in fact, he had become paraplegic. 
He had perfect power over his arms and trunk, but the lower extre- 
mities were quite useless. The paralysis, however, was entirely 
limited to the muscles; there was no diminution of sensibility in 
the limbs; no numbness, pain, or sensation of formication; and the 
muscular functions of the bladder and rectum were, apparently, 
uninjured. 
Before I enter on the explanation of this case, permit me to 
recite the following:—In the month of November last, I was 
called to visit a lady residing in the neighbourhood of Merrion PARAPLEGIA. 
77 
square, who was said to be labouring under symptoms of dyspepsia. 
She had a sense of weight about the stomach, nausea, tendency to 
vomit, epigastric and hypochondriac tenderness, (the latter situated 
in the right side,) but no fever or excitement of the circulation. In 
the course of two or three days, she became slightly jaundiced, and 
it was evident that the latent cause of her disease was, in all pro- 
bability, a gastro-duodenitis terminating in an affection of the liver. 
It is sufficient to say that this lady’s symptoms went on, and that 
the diseased action gradually extended to the whole intestinal tube, 
liver, and peritoneum. Her bowels became tympanitic, her belly 
extremely tender on pressure, she got low fever, with quick pulse 
and great restlessness, and was saved with difficulty by the repeated 
application of leeches, and the use of calomel so as to affect the 
mouth. She became convalescent; but with the return of health, 
it was found that she had lost the power of using her lower extre- 
mities. She still continues paraplegic. 
In the case of the young gentleman already detailed, you will 
recollect that the paralysis was entirely limited to the muscular 
functions of the lower limbs, and that there was no derangement 
of sensation, no lesion of the muscular powers of the rectum and 
bladder. The same thing occurred in this case. There was in 
the beginning no impairment of sensibility, and the power over the 
rectum and bladder was uninjured. “Within the last three weeks, 
however, she has complained of pain in the loins and bowels, and 
the muscular functions of the bladder are becoming deranged.”1 
Indeed, the case is rather unfavourable ; it has resisted the ordinary 
remedies, and threatens to become one of confirmed paraplegia. It 
is to be observed, that in this lady the loss of power was much 
more complete that in the young gentleman before referred to; his 
paraplegia was by no means perfect, and yielded to the employment 
of stimulating frictions to the extremities, combined with a cautious 
use of internal stimulants and tonics. In neither of these cases 
was the loss of muscular power so great as to deprive the patients 
of the use of their legs while lying in bed. They could then be 
raised, flexed, and extended with apparent ease and strength ; and 
yet, when the patient attempted to stand up or walk, he was totally 
unable to do either, his legs sinking under him; and even when 
supported by a person at each side, so as to take the greater part of 
the weight of the body of!'the limbs, he was still unable to advance 
one foot before another. I cannot understand why so great a dif- 
ference should exist between the muscular force of the legs in the 
one position and in the other. 
Here, you perceive, we have more or less complete loss of power 
of the lower extremities, supervening on inflammation of the gas- 
trointestinal mucous surface. Of this I have now witnessed seve- 
ral examples. How are we to account for this? In what way 
does paraplegia arise from inflammation of the bowels? The 
mode in which I would explain this phenomenon is as follows:— 
1 This sentence was inserted on the 23d March, 1835. Mr. Carmichael 
and Dr. Nalty have seen this lady repeatedly. 78 
GRAVE,s’s CLINICAL LECTURES. 
The impression made by inflammatory derangement on the nervous 
filaments distributed to the mucous coat of the intestines is propa- 
gated to the spinal cord, and from this reacts on the muscular func- 
tions of the lower extremities. It is true that the intestines, and 
most of the abdominal organs, are almost exclusively supplied with 
nerves from the great sympathetic; but you are to recollect that 
these communicate by numerous branches with the spinal nerves, 
and that, consequently, morbid impressions made on their extremi- 
ties may be rapidly and extensively propagated to the spinal cord, 
and from thence by a reflex action to the muscular nerves of the 
lower extremities. When I first met with cases of paraplegia after 
inflammation of the bowels, or fever with gastro-enteric symptoms, 
I thought that, owing to some peculiarity in the case, the great 
lumbar nerves had become implicated in the disease; that there 
was an actual inflammatory state of the neurilema, accompanied 
by thickening and effusion, which, by compressing the nervous 
matter, gave rise to the paraplegic symptoms. A more extensive 
review of the subject, however, has convinced me that this is not 
the fact; for, if it were, the affection of the nerves would naturally 
be attended with acute pains shooting in the direction of their 
course—for, as far as my experience goes, in every instance of in- 
flammation attacking the neurilema, intense pain is felt in the parts 
to which the branches of the affected nerve are distributed. Again, 
though this explanation might apply to cases in which the inflam- 
mation was general—as where enteric is combined with peritoneal 
inflammation—it would not apply to those cases in which the 
inflammatory action is localised. Thus, in Mr. Stanley’s cases, the 
paraplegia supervened on inflammation principally limited to the 
kidneys. In seven cases detailed in Mr. Stanley’s paper, we find 
paralytic symptoms produced, not by any derangement commenc- 
ing in the brain or spinal cord, but in consequence of an irritation 
having its seat and origin in the kidneys; and yet, in the majority 
of his patients, the paraplegia was as complete as if it had been 
produced by idiopathic disease of the cord or its investments. 
What was equally remarkable, many of those cases were accom- 
panied by spinal tenderness; so that the most experienced practi- 
tioners, on a review of the symptoms, were inclined to look upon 
them as cases of disease affecting the vertebras, or the spinal cord 
and its sheath. Yet on dissection there was no caries of the bones; 
no destruction of lisraments; no remarkable vascularity, softening, 
or suppuration of the spinal cord; no inflammation of its mem- 
branes, or effusion into its sheath. In almost all, the morbid phe- 
nomena were confined to the kidneys; there were depositions of 
pus dispersed through their substance, and the mucous lining of 
the infundibula, ureters, and bladder, was thickened and vascular. 
The formation of purulent matter was not, however, connected 
with the paraplegia further than as being, like it, produced by the 
same cause—inflammation of the kidney. In one case the para- 
plegia was very complete, and yet the inflammation of the kidney 
had not advanced to the stage of suppuration. PARAPLEGIA. 
79 
There can be little doubt that others have frequently noticed the 
occurrence of paraplegia after inflammation of the bowels, although 
no author has as yet written upon the subject. It is well to be ac- 
quainted with the occasional occurrence of so untoward and obsti- 
nate a sequela of enteric inflammation, in order that we may watch 
attentively the state of the lower extremities immediately after the 
inflammation of the bowels has been subdued. As the patient, in 
such cases, has no pains in his limbs, and is not conscious of any 
loss of power until he attempts to stand up—and as this attempt is 
not usually made for many days after the subsidence of the inflam- 
mation of the bowels, in consequence of the great debility which 
the disease and the active treatment necessarily resorted to produce 
—this variety of paraplegia is very liable to be overlooked in its 
commencement, and is thus neglected at the very period when 
treatment is most likely to prove beneficial. The foregoing observ- 
ations have, no doubt, excited a suspicion in the minds of some of 
you, that the paralysis so often observed to follow painter’s colic 
may be derived from a reaction of the nervous system of the bowels 
on that of the muscular system in general. Dr. Bright, indeed, 
has asserted that inflammation of the spinal marrow or sheath, as 
denoted by spinal tenderness, always precedes the paralysis pro- 
duced by lead. It often does, but by no means constantly; for I 
have pointed out to you several cases in this hospital in which not 
the slightest vestige of spinal tenderness could be detected either 
before the commencement, or during the progress, of the paralysis 
which so often follows painter’s colic. I am not inclined to adopt 
the supposition that the paralysis in such cases is merely secondary, 
and the result of the intestinal irritation. I think it much more 
probable that it depends on the poisonous effects of the lead acting 
directly on the nervous system. The same observation applies to 
the paralysis which so often occurs as a result of large doses of 
arsenic. Orfila has remarked that some of the dogs he experi- 
mented on, and which narrowly escaped dying in consequence of 
large doses of arsenic, became, when they recovered from the imme- 
diate effects of the poison, permanently paraplegic. I look upon 
this paralysis as a direct consequence of the deleterious action of 
arsenic on the nervous system, and not as the result of the gastro- 
enteritis it invariably produces. The fact, however, is well worthy 
of attention, that both arsenic and lead produce intestinal irritation 
in the first instance, and loss of muscular power in the second. A 
knowledge of this fact will prepare us for understanding the con- 
nection which appears to exist between intestinal irritation and 
paralysis. 
In a lecture published by my colleague, Dr. William Stokes, in 
the 137th number of the London Medical and Surgical Journal, 
he makes the following observations, which I shall beg leave to 
quote:—-Here, then, we have well-marked paraplegia without any 
perceptible organic change in the spinal cord or its investments, but 
presenting distinct traces of disease in the kidneys. This leads me 
to observe the very close connection which exists between the kid- 80 
graves’s clinical lectures. 
neys and spinal cord—a connection which has been long recognised 
by medical practitioners, but only in a limited point of view; for, 
though they were of opinion that disease of the kidneys and a dis- 
charge of ammoniacal urine were the results of spinal disease, 
they never seem to have reflected that the reverse of this might 
happen. It seems, however, now to be almost completely esta- 
blished, that disease of the kidneys may produce symptoms which 
are referable to disease of the spine. Medical men have been too 
much in the habit of looking at this matter only in one point of 
view. They know that disease of the spine will produce disease of 
the kidneys, and here they stop; but it has been shown that the 
reverse of this may happen, and that renal disease may produce 
very remarkable lesions in the functions of the spine. Of this very 
curious occurrence we have many analogies in pathology. Thus, 
for instance, in several cases of cerebral disease, but particularly in 
hydrocephalus, we have vomiting; here we have functional disease 
of the stomach depending on disease of the brain. Take the reverse 
of this,—observe the delirium which attends a case of gastroente- 
ritis ; here you have the functions of the brain deranged in a most 
remarkable manner, and this produced by sympathy with an in- 
flamed mucous membrane. The truth is, that in the spine and 
kidney, as well as in various parts of the body, we may have two 
organs so closely connected in sympathy, that disease of the one 
will bring on serious functional lesion of the other.” 
It will be seen that these observations coincide, in many points, 
with the principles I have laid down in the published lectures 
which I delivered on the subject of nervous pathology, and to 
which I have already referred. On this point Mr. Stanley makes 
the following remarks:—“In reflecting on the phenomena of the 
first series of cases which have been detailed in this paper, it might 
be thought improbable that irritation, commencing in the kidney or 
in the bladder, should be propagated through sentient nerves to the 
spinal cord, and that the impression should thence be transmitted 
through both the motive and sentient spinal nerves to the limbs— 
here occasioning an impairment both of sensation and of the power 
of motion. Some illustration of this subject seems to be furnished 
by the researches of experimental physiology. If, in an animal, ‘a 
few seconds after it has been deprived of life, the spinal cord be 
then divided in the middle of the neck, and again in the middle of 
the back, upon irritating a sentient organ connected with either 
isolated segment, muscular action is produced—that is to say, a 
sentient organ is excited—and an irritation is propagated through 
the sentient nerve to the isolated segment of the spinal marrow, 
where it gives rise to some change, which is followed by an impulse 
along the voluntary nerves to the muscles of the part.” In the 
instances which have been adduced, irritation, commencing in the 
nerves of an internal organ—the kidney—has been transmitted 
through the spinal cord to the motive and sentient nerves of the 
1 Outlines of Human Physiology, by H. Mayo. PARAPLEGIA. 
81 
lower extremities; but the same phenomena may occur in an oppo- 
site order, as in the case of a compound fracture or other severe 
injury of the lower extremity, followed by retention of urine from 
irritation arising in the anterior crural and ischiatic nerves, and 
communicated through the lumbar and sacral plexuses of spinal 
nerves to the nerves of the bladder. Extending these views to 
cases of neuralgia where there is no visible derangement of struc- 
ture or other local cause of excitement, it will always be difficult 
to determine whether the source of irritation be in the affected 
nerves, or in the central portion of the nervous system whence they 
are derived.” 
You will perceive that this explanation, as far as it goes, though 
not in the same words, is in meaning the same as that which I 
have given, with this exception—that it is only a corollary of the 
general principles which I had laid down in my lectures on the 
pathology of the nervous system. Long before the publication of 
Mr. Stanley’s paper, I had established the proposition that impres- 
sions made upon any portion of the nervous extremities may be 
propagated towards their centres, and thence by a reflex action 
transmitted to the nerves of other and distant parts, so as to give 
rise to morbid phenomena analogous to those which are produced 
by disease originating in the central parts themselves. Applying 
this principle to the subject of paraplegia, we shall find that, inde- 
pendently of cerebral or spinal disease, it may arise from a variety 
of causes, each referable to lesions commencing in distinct and iso- 
lated portions of the nervous extremities. Thus, in Mr. Stanley’s 
cases, the exciting cause seems to have originated in the urinary 
system; in the cases which I have detailed, where it supervened 
on inflammation of the bowels, it commenced in the digestive (and 
it appears, from a communication made to Mr. Stanley by Mr. Hunt, 
of Dartmouth, that the same thing may result from irritation exist- 
ing in the uterine) system. Mr. Hunt alludes to several cases of 
disease of the uterus being followed by such loss of power in the 
lower limbs, that the patients were entirely confined to bed; adding 
that there was no change of structure in the parts to which the 
symptoms referred as the source of irritation. Jn addition to these, 
I shall in my next lecture bring forward several cases to prove that 
a similar loss of power may be produced by the action of cold on 
the lower extremities. Indeed, the number of cases which I have 
recently met with, where paraplegia was evidently brought on by 
exposing the lower extremities to cold and wet, has very strongly 
directed my attention to this form of the disease; and I trust I shall 
be able, at our next meeting, to communicate some very interesting 
matter on the subject. 
I shall conclude this lecture by reading the following case, for 
which I have been indebted to the kindness of my friend Dr. 
Hutton. 
“ Richard M‘Nab, a sailor, aged thirty-eight, was admitted into 
the Richmond Hospital on the 16th of January, 1835, and placed 
under Dr. Hutton’s care. His previous history was briefly as 82 
graves’s clinical lectures. 
follows:—In the summer of 1826 he strained his back in leaping, 
and was confined to bed in consequence of the accident, but reco- 
vered in about twelve days. Shortly afterwards he contracted 
gonorrhoea, which was attended with hernia humoralis; this yielded 
to repeated local bleeding, but a gleet remained, and this, after con- 
tinuing for some time, disappeared under the use of sea-bathing. 
He then enjoyed good health, with the exception of occasional 
slight pain in the lumbar region, until October, 1830, when, being 
much exposed to cold and wet during a long and fatiguing voyage, 
he got an attack of piles, for which he was under medical treat- 
ment for seven months. During the continuance of this affection, 
he first observed a frequency in micturition, but had no retention 
or sensible obstruction of urine. After recovering from the hsemor- 
rhoidal attack, he enjoyed good health until September, 1834, when, 
coming from Cadiz to the port of Dublin in a very leaky vessel, he 
suffered greatly from cold, wet, and fatigue—being almost con- 
stantly engaged at the pumps, which could not be left for ten 
minutes at a time. In addition to this, being deprived of his usual 
allowance of spirits for thirty-two days, he found himself, on his 
arrival in Dublin, in a very weak state. He rested from his occu- 
pation for a fortnight after discharging his cargo, and states that 
during this time he drank from four to six glasses of whiskey daily. 
He then went on board the Elizabeth, of London, as chief mate, 
but after eight or nine days his back and lower extremities became 
affected with pain and weakness, which increased to such a degree 
that he was obliged to give up his occupation on the thirteenth day. 
He states that, during the time his back and legs were getting weak, 
he was obliged to pass water about three times in an hour, which 
he did with pain and tenesmus. On the 1st of January the pain 
of his back was very severe, and he lost the use of his limbs, but 
not completely, for he could support himself, and even walk a little 
with the aid of two sticks. 
“At the time of his admission he appeared somewhat broken 
down in his general health ; he was pale, emaciated, and laboured 
under derangement of his digestive organs. He suffered from 
occasional chills, succeeded by heats and sweating, which occurred 
at irregular periods; he also laboured under micturition, dysuria, 
and the stream of urine was much diminished ; the weakness and 
loss of power in his lower extremities as reported. 
“ His treatment was as follows :—First, cupping over the loins, 
then moxas in the same situation; attention to his digestive organs; 
diluents and opiates for the urethral symptoms. On the 26th of 
the same month, a very close stricture was found to exist in the 
membranous portion of the urethra. A small catgut bougie of 
double length was introduced, so that one half of it projected from 
the meatus; over this was slided a small gum-elastic catheter of 
ordinary length, and open at each end, until it traversed the stric- 
ture and reached the bladder; the catgut bougie was then with- 
drawn, and the gum-elastic catheter secured. A little constitutional 
disturbance followed, but soon subsided, and in a few days gum- PARAPLEGIA. 
83 
elastic catheters of a much increased size were introduced with 
facility. 
“ A very remarkable amendment took place in his back and 
lower extremities, in a very few days after the first introduction 
of the instrument; in fact, it teas almost sudden. Warm baths, 
friction to his limbs, &c., completed his cure. He was discharged 
on the 25th of February, at which time the power of his lower 
limbs was perfectly restored, and the symptoms affecting the urinary 
system had disappeared.” 
You at once perceive the extreme importance of this case; it 
bears directly on the question before us, and proves that urethral 
irritation may, as well as inflammation of the kidneys, give rise to 
paraplegia ; and it affords another striking illustration of the gene- 
ral proposition which I have laid down. 
LECTURE VIII. 
In my last lecture, I gave a brief summary of the opinions which 
I had published on the subject of nervous pathology, in the year 
1833, and showed that the principles there laid down were entitled 
to serious consideration, as connected with the explanation of many 
forms of paralysis hitherto not well understood. I trust I have 
proved, to your satisfaction, that the nervous extremities have been 
too much overlooked by medical writers in seeking to explain the 
source and origin of paralytic affections; and that many cases of loss 
of the power of motion and sensation can be clearly traced to the 
agency of causes acting primarily on the sentient extremities of the 
nervous system. I adduced numerous facts to show, that an impres- 
sion made upon some portion of the extremities of the nerves may 
be propagated towards their centres, and transmitted thence to other 
and distant parts, producing there pain, spasm, impairment of sen- 
sibility, and diminution or total loss of muscular power. With 
reference to the subject of paraplegia, I cited the cases published 
by Mr. Stanley, and expressed my opinion, that the loss of power 
in the lower extremities was the result of a morbid action com- 
mencing in the sentient nerves of the kidneys, and propagated 
through the medium of the spinal cord to the muscular and sentient 
nerves of the lower limbs; and I brought forward some new cases 
of paraplegia, supervening on inflammation of the bowels, with the 
view of illustrating the principles I had already laid down. 
In the next class of cases we have to consider, the cause of the 
paraplegia is extremely obscure—I mean those cases in which the 
paraplegia occurs during the course of fever. Here the other suf- 
ferings of the patient, and his general debility, attract our notice so 
exclusively, that the paralysis entirely escapes notice until conva- 
lescence is established—until, in fact, the patient wishes to support 84 
graves’s clinical lectures. 
himself on his legs. He then finds, much to his surprise, that his 
limbs collapse under him, and that he has little or no power over 
them; this appears to him the more extraordinary on account of 
his having recovered a good deal of strength in his upper extre- 
mities. Thus, a Miss F. was attacked in fever, while on a visit to 
a friend in Dublin. She was attended by Mr. Carmichael. Her 
fever was protracted and severe, and exhibited, during its progress, 
well marked symptoms of gastro-intestinal irritation and congestion, 
viz., tympanitis, epigastric and abdominal tenderness, &c. When 
her convalescence was established, her attendants found, to their 
great alarm, that she had no power in her legs. She complained 
of coldness and numbness in the lower extremities. This lady 
gradually recovered the use of her legs, but not until moxas, with- 
out number, had been applied along the course of the spinal 
column. The cure lasted about a year. No evidence could at 
any time be detected, indicating disease of the spinal bones or liga- 
ments. Mr. Carmichael has seen several cases of paraplegia fol- 
lowing the remittent gastric fever of children, totally unconnected 
with spinal disease. Such an occurrence is most usual in children 
of a scrofulous temperament, and is seldom, very seldom, remedied 
either by time or medicine. Two explanations suggest themselves 
as capable of accounting for the paraplegia after fever. The first 
rests upon the frequency of the occurrence of violent pain in the 
small of the back in the commencement of this disease. This pain 
in the back is often excruciating, and generally accompanied by 
proportionally violent pains in the lower extremities. I am quite 
as anxious to relieve the pain in the back in the beginning of fever, 
as I am to remove headache; one is almost as serious as the other, 
for the vital importance of the spinal marrow in the economy is 
scarcely less than that of the brain. 
In reference to this point of practice, I have been in the habit of 
using the expression, (in order to fix the attention of my pupils,) 
that such a patient has not any pain in his head, but he has gotten 
his headache in the small of his back. Now, when headache is 
the prominent feature of the first stage of fever, how few will omit 
bleeding, leeching, cupping,, cold or hot applications, &c. &c. 
When, on the contrary, the lumbar spinal marrow is the seat of 
the congestion, how generally do practitioners neglect the applica- 
tion of topical bleeding, and other appropriate remedies. Were such 
neglect of less frequent occurrence, it is probable that paraplegia 
after fever would not so often be met with. Some may be inclined 
to look for the source of the paraplegia which follows fever in the 
irritation of the gastro-intestinal mucous surface, propagated by a 
reflex progress of the spinal marrow. It is not easy to decide be- 
tween these two explanations, but I confess myself more inclined 
to adopt the former than the latter. 
I shall now proceed to lay before you some facts and cases illus- 
trating the nature of another form of paraplegia, a form of extreme 
interest, from the circumstance of its being hitherto but little under- 
stood, and not mentioned by any writer I am acquainted with, as PARAPLEGIA. 
85 
well as from the peculiar nature of its origin, and the frequency of 
its occurrence. I have, within a comparatively short period of 
time, met with several instances of this affection, and have some 
cases of it at present under treatment. 
Before I enter on this part of the subject, I may be allowed to 
remark that, in some cases, loss of the power of motion in a limb 
can evidently be traced to the operation of a cause whose action is 
confined altogether to the surface. Thus, in the case of a woman 
in Sir P. Dun’s Hospital, erysipelas occupied the calf and inside of 
the right 4eg, and occasioned some inflammation and tenderness 
along the chain of lymphatics extending to the groin, where one of 
the inguinal glands was slightly enlarged and painful. The 
erysipelas yielded to the employment of local and general remedies; 
but, for several days, and particularly while the disease was at its 
acme, she was altogether destitute of any power of motion in the 
affected limb; she could neither bend the leg on the thigh, nor 
could she raise the whole limb. This affection must have been 
produced by a reflex action propagated from the cutaneous branches 
to the larger muscular nerves. It is evident, that the muscles 
which move the leg on the thigh could have been affected only in 
this way, for they lay far above the part in which the erysipelatous 
inflammation existed. It is in the same way that we are to account 
for the paralysis observed in cases of phlegmasia dolens. 
Sometimes the reverse of this happens, and a single limb be- 
comes paralysed, on account of an injury done to one of its prin- 
cipal nerves by the application of sudden violence, or of pressure 
long continued. Thus, a case was related to my friend Dr. Bren- 
nan and myself, in which a robust gentleman, having been much 
fatigued during the day, fell asleep after dinner, his head resting 
on his arms, which were crossed on the table. In consequence of 
some unfortunate awkwardness in his position, one of the ulnar 
nerves was compressed during the time he slept, and, on awaking, 
his fore-arm and hand were completely powerless. Many remedies 
were tried in this case without success, and the paralysis continued 
until the day of his death, which occurred several years afterwards. 
A lady, not long since, was tripped in walking across the floor, and 
fell with considerable force. The parts which sustained the prin - 
cipal shock were the left hip and trochanter. From the moment of 
the accident, she lost all power in the left lower extremity, which 
remained permanently paralytic. Fracture or dislocation was sus- 
pected at first, but a minute and careful examination showed that 
the suspicion was groundless. No injury of the spine could be 
detected, and she had no numbness, pain, or formication, in the 
affected limb. After a month, she was placed under the judicious 
care of Mr. Kirby, who used every topical application likely to 
prove useful, but without the slightest benefit. She returned to 
the country, where she died shortly afterwards, quite unexpectedly, 
in the bloom of life, and without the occurrence of a single symp- 
tom indicative of approaching danger. No autopsy was permitted. 
I shall now, with the view of illustrating the form of paraplegia 86 
GRAVEs’s CLINICAL LECTURES. 
to which I have alluded, read the following very remarkable case, 
which I had an opportunity of tracing through all its stages, and 
which made a very considerable impression on me at the time. 
The history is chiefly derived from notes furnished by the patient 
himself before he became too weak to write; what relates to the 
latter stages of his complaint, is taken from my own case-book. 
Mr. B., aged twenty-three, was remarkably strong and healthy, 
though of a spare habit. He was able to take a great deal of exer- 
cise, capable of enduring much fatigue, and passionately fond of 
hunting, fishing, and shooting, particularly the latter ; and, in pur- 
suit of his favourite amusements, frequently exposed himself to wet 
feet during his excursions through bog lands, and when wading in 
the water. These habits, however, he laid aside after the occurrence 
of the first attack of his illness, which happened in 1829. He had 
for many years been of a costive habit, his bowels being frequently 
confined for a week at a time, but did not experience any sensible 
bad effects from this circumstance, and never took any aperient 
medicine. Since the first attack, in January, 1829, this state 
ceased, and his bowels became ever afterwards inclined to loose- 
ness, which always increased before the appearance of one of the 
attacks, accompanied by griping, nausea, and inclination to vomit. 
Each attack was generally preceded by a copious secretion of 
insipid watery fluid in the mouth, and then the characteristic 
symptoms of his disease commenced. These consisted in obstinate 
and protracted nausea and vomiting ; he first threw lip whatever 
happened to be on his stomach at the time, and afterwards every 
thing he swallowed, whether solid or liquid. The matter ejected 
was at first acid and afterwards bitter, varying in colour from 
mucous to bilious, but being generally of a greenish and occasion- 
ally of a bluish tinge. The greenish fluid annoyed him much 
from its extreme bitterness, and the quantity thrown up in the 
course of a day varied from three to four quarts of fluid. He 
complained also of pain, referred to the stomach or lower part of 
the chest, which continued throughout the attack, being most acute 
at its commencement; for the last year, this sensation had passed 
into a feeling of painful constriction, which he described as a “con- 
tracted feeling of his inside,” and compared it to something like the 
effects of a cord drawn tightly, so as to compress or strangulate his 
body exactly along the outline occupied by the insertions of the 
diaphragm. During the prevalence of the attack, he had profuse 
perspirations, particularly towards the termination of each paroxysm. 
The duration of the first attack did not exceed four or five day«, 
after which, he became quite well, and continued so for six or 
seven months, when his symptoms suddenly returned. He began 
to reject every thing from his stomach as before, but in the course 
of a few days the vomiting disappeared, and for a considerable 
interval he had no return of his complaint. In the year 1830, he 
had three attacks of a similar description ; from these he recovered 
also completely, and without remarking any diminution of power 
in his lower extremities. In 1831, however, the disease began to PARAPLEGIA. 
87 
assume a more serious aspect; the paroxysms became much in- 
creased in severity, lasted longer, and recurred at shorter intervals. 
For one of these attacks he took mercury, and was salivated. In 
1832, his symptoms became still more violent, and the duration of 
the paroxysms more protracted. He had one in March, a second 
in May, and a third in June, each of which was accompanied by 
some numbness and loss of power in the lower extremities; this, 
however, was slight, and disappeared altogether as the vomiting 
subsided. About this time, he noticed that his urine was scanty, 
and deposited more sediment than usually. He also complained 
of being very apt to catch cold whenever he got out of bed, and 
stated that he suffered occasionally from severe twitches and pains 
in his legs, thighs, arms, and other parts of his body, which were 
generally succeeded, and carried off, by profuse perspirations. 
In August, 1832, he had a violent attack, which lasted nearly a 
month. The vomiting was incessant, continuing night and day, 
and he suffered severely from the feeling of painful constriction 
already described. On getting up after this attack, his legs sud- 
denly failed him, and he dropped down on the floor quite powerless. 
The paralysis did not now disappear during the intervals, although 
it grew somewhat better after each fit of vomiting had ceased ; in- 
deed he used to improve in his walking after the paroxysm had 
entirely disappeared; and, aided by two sticks, supported himself 
so as to give some hopes of a recovery, until a recurrence of his 
attack reduced him again to a state of almost total paraplegia. 
His legs now began to waste sensibly, and he noticed that they had 
lost their feeling and were remarkably cold. He also complained 
of severe twitches of pain in various parts of his body, accom- 
panied by profuse night sweats, and turbid, scanty urine. 
For some months before his death he was completely paraplegic, 
and continued to be attacked with violent fits of vomiting. The 
vomiting went on night and day, and he was unable to retain the 
mildest and most soothing substances for a moment on his stomach. 
Mr. Crampton and Ur. Ireland attended him with me, and we had 
recourse to every thing we could think of to allay the irritability 
of his stomach, but in vain. After continuing to resist obstinately 
every form of treatment for five or six days and nights, the vomit- 
ing would suddenly cease, the gentleman would exclaim, “Now I am 
well,’’and he would then eat, with perfect impunity,substances which 
would prove irritating and indigestible to many stomachs. This 
was one of the most singular circumstances I ever witnessed. The 
transition from a state of deadly nausea and obstinate retching to 
a sharp feeling of hunger, used to occur quite suddenly. One hour 
he was the most miserable object you could behold, racked with 
painful constrictions across the epigastrium, alternately flushed or 
bathed with cold perspiration, and rejecting every thing from his 
stomach, the next found him eating with a voracious appetite 
whatever he could lay hold of, and digesting every thing with appa- 
rent facility. 
It may be observed that as the disease in this case proceeded, the 88 
graves’s clinical lectures. 
intervals between the attacks became diminished, while the parox- 
ysms became increased in duration. For the first two years they 
continued only for four or five days, and appeared at intervals of 
six or seven months ; latterly they used to last for eight or ten 
days, and returned every third or fourth week. During the parox- 
ysm the only thing which he took was a little cold water with some 
brandy and a few drops of laudanum, which remained longer on 
his stomach than any thing else, and enabled him to enjoy a few 
minutes’ sleep. He never complained of any headache, and his 
intellect was remarkably clear, and his memory good. 
No trace of organic disease could be detected in the abdominal 
viscera, and there was not the slightest tenderness over any part of 
the spine. He also retained to the last a complete power over the 
bladder and rectum. 
At length his system began to give way; long confinement to 
bed, and the frequent recurrence of these exhausting attacks, com- 
pletely wore him out, and he sank on the 30th September, 1833. 
A post mortem examination was allowed by his friends, and we 
scrutinised every part of his system with the most anxious care. 
The brain, cerebellum, spinal cord, and their investing membranes, 
were carefully inspected; we examined the large nervous trunks 
that supply the lower extremities, inspected the viscera of the 
thorax, and searched for evidences of disease in the stomach and 
intestinal tube: we could find none. There was no lesion of the 
brain or spinal cord, no thickening or vascularity of membranes, 
the large nerves exhibited their normal condition, the stomach was 
perfectly healthy, the intestinal canal natural, the liver and other 
glandular viscera of the abdomen without any trace of appreciable 
derangement. 
Here, then, was a case of perfect paraplegia, (I say perfect, for 
he had lost all power of his lower extremities for more than two 
months before his death) which may be fairly termed functional, 
inasmuch as there was no lesion of any part of the nervous cen- 
tres to explain the phenomena present. How then are we to 
account for them? The first symptoms were undoubtedly those of 
abdominal irritation, as manifested by the tendeney to diarrhoea in 
an originally costive habit, accompanied by violent paroxysms of 
vomiting, which recurred at distant intervals. Are we to attribute 
this diseased condition of the stomach and bowels, which, from the 
remarkable periodicity of its occurrence, was evidently functional, 
to irritation, congestion, or inflammation of the brain or spinal 
marrow? From the data we are in possession of, it appears that 
this question must be answered in the negative. There was no 
headache, heat of scalp, throbbing of the temporal arteries, or other 
sign of determination to the head ; or congestion, or inflammation 
of the brain, either before or during the attacks. The patient’s in- 
tellect was all throughout remarkably clear, and his memory good. 
Again, if we look for the origin of the disease in the spinal cord 
or its investments, we can find nothing to assist in explaining the 
phenomena. There was no pain in any portion of the spinal cord, PARAPLEGIA. 
89 
and at no period of his illness could we detect any tenderness over 
the spinous processes. The history of the case seems to prove 
that whatever was the cause which operated on the nerves of the 
stomach and intestines, it gradually extended the sphere of its 
morbid influence to the spinal cord, and, through it, implicated the 
nerves of the lower extremities. The case is in many respects 
highly interesting, and well worthy of the attention of the patho- 
logical enquirer. The dissection was conducted, in the presence 
of Dr. Ireland and myself, by my friend and former pupil, Mr. 
Harris, so advantageously known for his skill in morbid anatomy. 
It was not made in a hurried or careless manner, each organ was 
carefully examined, and the process occupied at least four hours. 
The next case to which I shall call your attention is one which 
I have already given in a former lecture: it seems, however, to be 
so similar in the nature of its exciting cause to the foregoing, though 
differing in some of its symptoms, that I shall beg leave to repeat it 
here. 
James Moore, aged 32, was admitted into the Meath Hospital on 
the third of March, 1833, under Dr. Stokes’s care, for an attack of 
paraplegia, which he attributed to cold and wet feet while engaged 
in working in a quarry. About a month before admission he per- 
ceived a stiffness of the great toe of his right foot, afterwards numb- 
ness and coldness of the sole, and then of the leg as far as the 
knee, and dragging of the limb in walking. During the progres- 
sion of the disease up along the thigh it commenced in the left foot, 
and, after a few days, he experienced almost complete paralysis of 
sensation in the right lower extremity, and a lesser degree in the 
left, accompanied by so much diminution of the power of motion, 
as to render him unable to walk without support. About three 
weeks after the appearance of paralysis in the lower extremities, 
the little finger of the right hand was attacked with numbness, 
which passed successively to the rest, attended by some loss of the 
sense of touch and power of grasping objects. He had also reten- 
tion of urine, and the bowels were obstinately constipated. There 
was no tenderness over any part of the spine. He had no pain in 
the head ; his pupils were natural; pulse, sleep, and appetite also 
natural. 
Here we have an instance of paraplegia apparently originating 
from an impression made on the nerves of the lower extremities. 
The man had been engaged in draining a quarry, and during his 
occupation was constantly exposed to wet; shortly after this he 
begins to complain of numbness and loss of power in the right 
lower extremity, and, during the progression of the disease up 
along the limb, the left becomes similarly engaged. About three 
weeks afterwards, the hands, which had been also, but not so fre- 
quently, exposed to the influence of cold and wet, begin to be 
affected with numbness, and the power of grasping objects becomes 
diminished. To what can we attribute these symptoms, except to 
the influence of cold acting on the nervous filaments of the 
cutaneous surface of the limbs, extending its morbid impression to 90 
graves’s clinical lectures. 
the spine, and thence reacting on the nerves, so as to produce im- 
pairment of the power of motion and diminished sensation ? The 
man certainly had no symptom of cerebral or spinal disease, nor 
was there any thing connected with the state of the nervous cen- 
tres which would lead to the supposition that paraplegia was the 
result of an irritation originally affecting the brain or spinal cord. 
It was on these grounds that I gave it as my opinion at the time, 
that the disease was an example of creeping paralysis, having its 
origin in an affection of the peripheral extremities of the nerves. 
The next case is one which was also under treatment in the 
Meath Hospital during the course of last winter : for the particulars 
I am indebted to my collegue, Ur. William Stokes. 
A robust, middle-aged man was admitted into the chronic ward 
of the Meath Hospital, in the latter end of February, 1834, labour- 
ing under paraplegia. He stated that he was generally employed 
as a boatman about the river and port, was frequently exposed to 
cold and wet, particularly in his lower extremities, and that He was 
in the habit of drinking freely. He had enjoyed good health until 
about seven weeks before admission, when he was seized with 
numbness of the feet and legs, which, after continuing for three or 
four days, was followed by tingling pains running along the course 
of the nerves. He then remarked that the power of his lower ex- 
tremities became much diminished, and this gradually increased so 
as to prevent him from walking or even standing without support. 
His bowels became obstinately costive, and about a month after the 
commencement of his attack, he perceived that his urine was dis- 
charged in smaller quantity than usual, and that he was much 
more frequently called on to pass it than before. He also men- 
tioned that he had gonorrhoea about six months before, and that he 
had used balsam copaiba and injections. Some time after this he said 
he noticed some white matter passing with the urine, but did not pay 
any particular attention to it as it gave him no inconvenience. 
His appetite was tolerably good, and he had no headache or any 
symptom of determination of blood to the brain. He denied having 
received any injury of the back, and there was no tenderness over 
the spinous processes of the vertebras. He had no pain in the spine, 
either before or since the occurrence of his illness, nor was there 
any symptom of inflammation of the substance or membranes of the 
spinal cord. When admitted, he had considerable diminution of 
sensation and complete loss of motion in one of the lower extremi- 
ties ; in the other he still retained some power. He had also reten- 
tion of urine, requiring the daily use of the catheter. 
The treatment was as follows :—He was placed on one of Dr. 
Arnott’s hydrostatic beds, as there was a great tendency to stripping 
over the hips and sacrum, a purgative pill was administered two or 
three times a day to remove the costiveness, and he was ordered to 
be cupped over the loins. The latter was done in consequence of 
his complaining of some tenderness on pressure in the situation of 
the kidneys. His symptoms, however, went on without any im- 
provement, and he died about a month after his admission. PARAPLEGIA. 
91 
On dissection the following phenomena were observed. The 
kidneys (which were first examined) appeared rather soft, and of a 
yellowish colour, blit there was no vascularity, suppuration, or 
other change of structure. The ureters were somewhat distended, 
but presented no other trace of disease. The bladder was contract- 
ed, its muscular coat thickened, and its mucous membrane very 
vascular. There was no affection of the prostate. On examining 
the spinal cord, Dr. Stokes observed that he thought the cauda 
equina appeared to be slightly softened, but remarked that from its 
appearance he could not state that it was actually diseased. The 
rest of the spinal cord appeared healthy and normal; there was no 
vascularity, effusion, or softening. External to the sheath of the 
cord there was a small, flattened, oval body, about the size of half 
a very small hazelnut, and of a consistence intermediate between 
lymph and fat. Around this there was some slight degree of vas- 
cularity. Dr. Stokes observed, that from the small size of this body, 
and the peculiarity of its texture, he entertained strong doubts as to 
its having any influence in the production of the symptoms noticed 
during life. He remarked, although it might have been originally 
the product of inflammation, and have existed in the form of an 
effusion of lymph, still the circumstance of its conversion into a 
fatty substance proved that it must have existed for a very con- 
siderable time, and the smallness of its size, as well as the obscurity 
of its origin, did not by any means satisfactorily explain the occur- 
rence of paraplegic symptoms. 
The next case which I have to lay before you, appears to be ana- 
logous in its mode of origin to the former:—“A gentleman of strong 
constitution, and extremely fond of field sports, particularly fishing 
and shooting, exposed himself repeatedly to wet feet at a time when 
he was labouring under the effects of a long mercurial course. 
Taking large quantities of blue pill, and exposing the lower ex- 
tremities to wet at the same time, are circumstances which have an 
obvious tendency to produce disease, and it is not to be wondered 
if this gentleman became the victim of his want of caution. He 
got numbness and weakness in his legs, which he at first attributed 
to fatigue and over exertion ; but as the disease went on, he became 
more and more powerless, and, finally, applied to me respecting 
his illness. On examination I found that he had no pain in the 
back, or tenderness on pressure; nothing, in fact, to indicate any 
original affection of the spinal cord. The functions of the brain 
also were natural, and there was nothing about him to lead me to 
suspect cerebral disease. He had, however, considerable impair- 
ment of the muscular functions of the lower extremities, and could 
not walk without the aid of crutches, or some person to support 
him. In treating this case, I looked upon it as an instance of 
imperfect paraplegia, in which the paralysis apparently rose from 
impressions made upon the sentient extremities of the nerves of the 
legs and feet, at a time when these nerves were particularly liable 
to be deranged in their functions from the previous use of mercury. 
| therefore had recourse to remedies directly applied to the extremi- 92 
Graves’s CLINICAL LECTURES. 
ties of those nerves, and fortunately succeeded in restoring this 
gentleman to the use of his limbs. The cure, however, was not 
perfect, for a very notable degree of weakness still remains. 
Of this form of paraplegia I have now witnessed many instances. 
In most cases I was induced to think that it arose from impressions 
made by cold and wet on the lower extremities. It is most com- 
monly observed in young gentlemen who are addicted to fishing 
and shooting, and who in pursuit of their amusements get wet feet 
repeatedly, from walking over boggy grounds, or wading in the 
water. It is also observed in labourers whose employment obliges 
them to stand in water for many hours together, as in draining, 
pump-sinking, and other similar occupations. In all cases it as- 
sumes the creeping form, and generally appears at first in one limb, 
and afterwards in the other. There is, however, considerable va- 
riety in the rate of its progress ; in some cases the patients become 
almost completely paraplegic in a few weeks from the commence- 
ment of the disease, in others it will go on for months, and even 
years, before the power of the lower extremities is completely de- 
stroyed. Where its progress is slow, it makes its approach in an 
insidious manner, and is at first scarcely noticed by the patient. Its 
latency is here further favoured by the absence of pain, numbness, 
or formication ; for it is only at the more advanced stages of such 
cases that derangement or diminution of sensation is noticed. It is 
only when making some unusual exertion, as in going up stairs or 
ascending a hill, that the patient finds a more than ordinary degree 
of weakness in the lower extremities. The first symptom which 
generally attracts his attention is an incapability of walking as far 
as he has been accustomed, but this is attributed to some temporary 
weakness, or is considered to be the result of previous fatigue. As 
the disease progresses, walking up an ascent becomes a matter of 
some difficulty, there is a shuffling motion of the legs, and the pa- 
tient is apt to stumble from slight obstructions. Gradually the loss 
of power becomes more manifest, it excites the attention and sur- 
prise of the patient, and he finds that he is no longer able to walk 
without the aid of a stick or some person to lean on. The paralysis 
is, however, seldom complete ; with the help of crutches the patient 
continues to hobble about, and it is only in bad cases, and at an 
advanced period of the disease, that he becomes completely para- 
plegic. The paralysis is never so sudden nor so complete in this 
form of paraplegia, as it is in cases of disease of the spinal cord, or 
scrofulous ulceration of the bones and ligaments. 
In other cases, however, the paraplegia, though evidently of the 
same origin, and having the same creeping character, advances 
with much more rapidity ; and the patient may, in a few weeks from 
the commencement of the attack, experience a very considerable 
diminution of power in the lower extremities. In such cases it 
will be generally found that one limb is much more affected than 
the other, the loss of power being most complete in the limb which 
was first engaged. 
With respect to sensation, it appears to be affected as well as PARAPLEGIA. 
93 
motion. In the slow and chronic form of this species of paraplegia, 
it does not attract the attention of the patient so quickly as the 
derangement of muscular power: it is generally some time before 
he notices any diminution of sensation, and then accidentally. In 
the more advanced stage, however, this becomes manifest, and is 
accompanied by a sensation of cold in the lower limbs, which sel- 
dom extends higher than the knees. In the more rapid and acute 
form, the derangement of sensation is much more obvious, and is 
generally the first symptom noticed by the patient. There is at 
first a feeling of numbness, which commences in the toes or feet, 
and extends up the limb : this, in the course of a few days, is fol- 
lowed by formication and tingling pains in the course of the nerves, 
and then loss of power and diminished sensation. There is, how- 
ever, in both these forms of paraplegia, much less impairment of 
sensation than of motion, and the loss of sensation is never so com- 
plete as in paraplegia from disease of the spine. 
There is one curious symptom occasionally observed in this dis- 
ease, which is that, before the appearance of any decided symptoms 
of loss of power in the lower extremity, irritation of the lower part 
of the digestive tube takes place; the rectum becomes morbidly 
excited ; the patient complains of tenesmus, and thinks he is about 
having an attack of piles. This was the first symptom observed in 
one of the cases I attended; the patient complained so much that 
we were induced to examine the state of the rectum, but could not 
find any thing to account for the morbid excitement. The same 
observations apply to the bladder, with this exception, that the 
morbid irritability of this organ occurs occasionally after the disease 
is confirmed and has made considerable progress. On the whole, 
however, affections of the bladder and rectum are rare in this form of 
paraplegia ; and it is only at the advanced stages that we sometimes 
meet with that derangement in the motor powers of the bladder and 
rectum, which occurs so frequently, and at such an early period, in 
the paraplegia from spinal disease. 
In cases of paraplegia from disease of the spinal cord or its 
investments, it has been observed that the urine becomes altered in 
its quality, and assumes an ammoniacal odour. I have not observed 
this occurrence in the forms of paraplegia that I have detailed. The 
urine is turbid, scanty, and voided oftener than usual; but I cannot 
say that I have seen it in any case decidedly ammoniacal, even in 
the advanced stages of the disease, and where the patient was com- 
pletely bed-ridden. Should future observations prove that this 
diagnostic mark is constant, it may be of some value in distinguish- 
ing this from other forms of paraplegia. 
In these cases there is scarcely any thing which would lead us 
to fix on the spine as the seat and origin of the disease; neither can 
we find any thing in the brain with which we can connect the 
paraplegic symptoms. There is no pain of the head or spine, very 
seldom any tenderness, the patients are in the full vigour of intel- 
lect, and all the organs of sense in their normal condition. The 
functions of respiration and circulation are unaffected; and it was 94 
graves’s clinical lectures. 
remarked in the first case which I have detailed, that there was no 
change in the pulse, either during the fits of vomiting, or the inter- 
vals of ease. The appetite also is generally good ; but, in almost 
every instance I have met with, there has been remarkably obsti- 
nate constipation. 
With respect to the prognosis and treatment of this form of para- 
plegia, I have but little to say. The prognosis is generally unfa- 
vourable, particularly where the disease has lasted for some time, 
and is accompanied by morbid irritation, or loss of power in the 
bladder or rectum. It is also bad in proportion to the slowness 
with which it has come on, and the absence of pain or formication 
of the lower extremities. With respect to treatment, I may observe 
that I have never seen any benefit derived from applications to the 
spine. The application of blisters or issues over the back or loins, 
does not appear to be productive of the least good effect; of the 
latter, I can speak positively from experience. They are an en- 
during source of annoyance to the patient, and never produce the 
least amelioration of symptoms. I am in the habit of applying my 
local remedies to the legs and thighs, selecting those parts in which 
the greatest cutaneous sensibility exists, What I generally do, is 
to keep up a succession of blisters along the inside of the legs, and 
over the anterior and inner parts of the thighs. The practice of 
medicine furnishes many proofs of the utility of stimulant applica- 
tions to the nervous branches, in case of disease affecting the larger 
trunks. Thus, in sciatica, a blister applied over the ham or calf of 
the leg, where many of the ultimate ramifications of that nerve are 
superficial, will frequently produce a much more decided effect than 
when applied over the origin of the nerve itself. Liniments of a 
stimulating kind, and blisters repeatedly applied, are the local 
means on which I chiefly rely in the treatment of this form of para- 
plegia. After some time, I commence with the use of strychnine, 
and continue it until some sensible effect on the system is produced, 
when I omit its further use, and have recourse to the exhibition of 
sulphur. These are the two internal remedies from which I have 
derived most benefit. I have in such cases seen very good effects 
from a perseverance in the use of the sulphur electuary, of which I 
have given a formula in one of my published lectures. Much also 
will be accomplished by the external use of sulphur, in the form of 
baths, and hence cases of paraplegia of this kind might be mate- 
rially benefited by the internal and external use of the waters of 
Lucan, Harrogate, Baden, Barege, &c. With respect to the use of 
mercury, it appears to be decidedly injurious. I have seen it given 
in three cases; in all it did much more harm than good. 
This is all I have to say at present on the subject of paraplegia. 
I fear much that many omissions, and considerable deficiency of 
materials, will be observed in the statements I have laid before you, 
I hope, on some future occasion, to be able to communicate a more 
minute and better digested series of observations on this obscure 
form of disease. The subject, however, is in itself so interesting, 
and so important, that I have been tempted to bring it before you, PERITONITIS AND ENTERITIS. 
95 
perhaps prematurely. My anxiety to excite discussion, and attract 
further attention to a department of practical medicine hitherto 
quite neglected, must on this occasion plead my excuse. 
LECTURE IX. 
Case of peritonitis and enteritis terminating- in fatal convulsions—Enormous accumu- 
lation of lumbrici in the bowels, producing death by convulsions—Causes of catarrhal 
affections of the bronchial tubes—On the rd,les produced by bronchitis—Remarkable 
proportion between the frequency of the pulse and the respiration—Use of emetics 
and chalybeates in chronic bronchitis—Symptoms which contra-indicate chalybeates 
—Trismus from inflammation of the temporal muscles—Pain in the nerves of the 
face, simulating tic douloureux, and caused by a carious tooth—Case of jaundice, 
with remarks—Connection between arthritis, jaundice, and urticaria—Analogous 
series of affections often caused by eating fish. 
Let me direct your attention for a few moments to a case which 
presents some interest, as connected with the obscurity of its nature; 
I allude to that of the young woman. Moran, who died this morning. 
She came in, on Monday week last, with symptoms of ordinary con- 
tinued fever, for which the only remedies employed were effer- 
vescing draughts, diluents, and a proper attention with regard to 
diet. She had some headache, which went away a few days after 
her admission; and, as she made no other complaint, her case was 
looked upon as one of simple fever. Some time afterwards, it was 
observed that her abdomen was tympanitic, and that she had 
diarrhoea; but she persisted in denying that she had any abdominal 
pain or tenderness. In addition to this, symptoms of bronchial in- 
flammation set in, but without any remarkable distress of respira- 
tion, or acceleration of pulse. She made no complaint whatever, 
and seemed extremely unwilling to communicate any information 
respecting her condition. Under these circumstances, all that could 
be done was to treat the symptoms as they became manifest, and, 
accordingly, after having leeched the belly, I ordered a large blister 
to be applied so as to cover the epigastrium and lower part of the 
chest anteriorly. The only thing remarkable in her case, and to 
which I should have called your attention more particularly, was 
the repeated occurrence of rigors. It appeared, from the account 
given by the nurse, that she had frequent attacks of shivering on 
last Friday, and the two preceding days ; and I have already told 
you, that where this occurs, you should always suspect the exist- 
ence of some local inflammation. 
Such were the principal phenomena observed in this case. On 
Saturday, she stated that she felt better after the application of 
leeches, and had no pain or tenderness whatever in the belly; but 
still it was observed that the tympanitis was undiminished, and that 
she was not by any means improving. This morning she called to 
the nurse to assist her in getting to the night-chair, when, after a 96 
graves’s clinical lectures. 
few minutes, she was suddenly seized with a violent convulsive fit, 
and expired. 
I may observe, that there was nothing in this case which would 
lead one to suspect the existence of cerebral inflammation. The 
fever was of the ordinary kind ; there was no remarkable accelera- 
tion of pulse (the number of beats in the minute being only 84 when 
we examined her on Saturday); she had some headache, but this 
did not continue; and there was no flushing of the face, redness or 
suffusion of the eyes, heat of scalp, or throbbing of the temporal 
arteries. There was nothing to inform us that disease was going 
on in the brain, and yet the patient dies violently convulsed. 
Under these circumstances, how are we to explain the manner of 
her death ? At present, I believe it would be better not to enter on 
any enquiry respecting this point. I shall endeavour to procure an 
examination of the body, and, until then, shall make no further ob- 
servation. 
On opening the body the next day, no trace of disease could be 
found in the brain. The thoracic viscera were also healthy, with 
the exception of some vascularity and congestion of the bronchial 
mucous membrane. In the abdomen there were ample marks of 
extensive inflammation. The cavity of the peritoneum contained 
a quantity of serous fluid; the intestines were glued together by 
lymph at almost every point of contact; and the serous membrane 
was highly vascular. The mucous membrane of the intestines 
was extensively inflamed, and there were numerous small ulcers in 
the situation of the glands of Peyer. The uterus, with its append- 
ages, was in a state of intense inflammation, and presented marks 
of recent delivery. It appeared afterwards, that she had been 
delivered of a male infant, the fruit of an illicit intercourse, a few 
days before her admission into the hospital. Under the influence 
of shame, and a desire to conceal her condition, she had, through- 
out her illness, persisted in strongly denying the existence of any 
abdominal symptoms whatever. 
Here this question,—whether the disease might have been cured 
had its true nature been discovered on her admission,—naturally 
suggests itself. I must candidly confess that I think it might; and 
I regret extremely that the peculiar circumstances of the case ren- 
dered her anxious to conceal the existence of the symptoms of 
abdominal inflammation ; for had it been otherwise, a more active 
antiphlogistic and mercurial treatment might, perhaps, have been 
successfully applied. 
This case affords another example of the truth of what I endea- 
voured to establish in a former lecture, concerning the effects which 
irritations of the periphery are capable of producing on the central 
portions of the nervous system; for here death was induced by con- 
vulsions, the mediate cause of which was situated not in the brain 
but in the abdomen. A very remarkable and striking case of a 
somewhat similar nature, has been lately published by Dr. Eber- 
maier, in Rust's Magazine (Vol. 42, Part I., p. 52, et seq.), in 
which the abdominal irritation, caused by an enormous collection BRONCHITIS. 
97 
of lumbrici in the small intestines, occasioned, in a child who had 
previously enjoyed good health, a sudden attack of pain in the 
belly, and vomiting terminating speedily in fatal convulsions. The 
intestines were not inflamed, but were completely obstructed, in 
many parts of the ileum, by successive round masses, formed by 
agglomerations of lumbrici, rolled up together, and enveloped in an 
adhesive paste formed of half-digested bread, cemented by a tena- 
cious mucus. The worms were too numerous to count, amounting 
to many hundreds. 
A man named Murray, of middle age and rather strong constitu- 
tion, has been recently admitted into the small chronic ward, with 
bronchitis of long standing, and frequent exacerbations. It is a 
case in which I am afraid a permanent cure is out of the question, 
and so far it is unsatisfactory; still it is necessary to be acquainted 
with such cases, for it is a matter of some importance to be able to 
inform a patient whether his disease is curable or not, and how far 
it admits of being relieved by treatment. 
Bronchitis is an affection which generally arises from impressions 
made by cold, either on the skin or on the mucous membrane of the 
lung. I think it extremely probable that, when a person gets a 
catarrhal affection from exposure to cold, it is not always in conse- 
quence of an impression made on some part of the cutaneous sur- 
face. Indeed, it appears reasonable to believe that an attack of 
bronchial inflammation may be equally the result of an impression 
made directly on the mucous lining of the lung; and that a person 
exposed to sudden change of temperature, as in passing from a 
heated room into the cold air, may get inflammation of the mucous 
membrane of the bronchial tubes, for the same reasons that, under 
similar circumstances, inflammation may be generated in the mu- 
cous membrane of the eye, giving rise to conjunctivitis. We know 
well that one of the most common causes of inflammation of the 
conjunctiva, is the sudden exposure of the eye to cold sharp air, 
after it has been for some time submitted to the relaxing influences 
of strong heat and light; and there is no reason why the same rapid 
change of temperature, under similar predisposing causes, should 
not originate disease in the mucous membrane of the bronchial 
tubes. It is true, indeed, that nature has taken especial pains to 
maintain an equable temperature in the air admitted into the chest 
at each respiration; the passage of this air through the mouth, nose, 
and pharynx, where it is warmed by the contact of an extensive 
mucous surface, and the small proportion which it bears to the 
residual air remaining in the lungs after an ordinary expiration, 
are circumstances that must powerfully counteract the low tempe- 
rature of air inspired in very cold weather. Still a considerable 
difference of temperature must exist between the inspired and ex- 
pired air, and consequently the air passages are exposed, more than 
any other tissue of the body, to successive and rapid alternations, 
which never cease from infancy to old age. Nature has, of course, 
wisely accommodated the vitality of the bronchial mucous mem- 
brane to the circumstances in which it is placed, and the force of a 98 
GRAVES’S CLINICAL LECTURES. 
never-ceasing habit still further enables it to sustain rapid vicissi- 
tudes of temperature with impunity. In this it is probably equaled 
by the surface of the eyeball, which, alternately covered, warmed, 
and moistened by the eyelids during the act of winking, and ex- 
posed to the cold of the air, increased by a rapid evaporation from 
its own surface while the eye is open, must, indeed, undergo rapid 
variations of temperature, and yet it is never frost-bitten. 
When inflammation has fastened on the mucous membrane of 
the air passages, it makes a vast difference as to the part on which 
it fixes. The air passages commence with the larynx, and termi- 
nate with the ultimate ramifications of the bronchial tubes. If the 
disease settles at the entrance of the air passages, and forms laryn- 
gitis, the case becomes a very serious one, laryngitis being in the 
infant, and sometimes also in the adult, attended with dangerous 
and even fatal symptoms. If the trachea should happen to be the 
part on which the disease falls, the inconvenience and suffering are 
also considerable, but the danger is by no means so urgent as in the 
former case. The same thing may be said of the larger bronchial 
tubes; inflammation here is rarely attended with such violent 
symptoms as those which characterise laryngitis, and it is much 
more amenable to treatment. Out when inflammation attacks the 
minute bronchial tubes to any considerable extent, and particularly 
if it happens to be general—that is, if it affects the bronchial tubes 
in every part of the lungs—we have just grounds for alarm ; the 
disease is one of an intense character, and, unless quickly relieved, 
runs on to a fatal termination with great rapidity. 
You perceive, then, that if a patient catches cold, and gets an 
attack on the chest, it is of great importance to be able to ascertain 
what the situation and extent of the disease are, and whether the 
minute bronchial tubes are engaged or not. Now, how do you 
know this? Simply thus:—You first make a cursory examination 
of the whole chest, by applying the stethoscope over the superior, 
middle, and inferior portion of each lung, both before and behind; 
and, if you every where hear something, you conclude that the 
bronchitis is general, and not confined to any particular part. You 
next proceed to examine with greater attention these wheezing 
sounds; you apply the stethoscope, and if you find in each sepa- 
rate spot many sources of diseased sound—if you hear a ivheezing 
from a great many points close together—you may be sure that 
the morbid sound proceeds from inflammation of the minute tubes, 
for the larger ones cannot exist in the small spots over which you 
apply the stethoscope in such numbers as to give rise to so remark- 
able a plurality of sounds. Of this you may be certain, that, when 
you find a great many sounds are audible over a small space, the 
minute bronchial ramifications are engaged. 
It is the custom, with those who lecture on auscultation, to enu- 
merate many sounds as connected with alterations in the condition 
of the bronchial tubes. We hear of the mucous, the sonorous, and 
the sibilant ronchus—their varieties and intermixtures. Now I 
know, by experience, that these names are very apt to confuse and SOUNDS HEARD IN THE CHEST. 
99 
perplex the young; stethoscopist. There is no necessity for studying 
with great attention the definitions of these words, or the descrip- 
tions of the various sounds they are meant to represent: I am 
always anxious to avoid loading the memory of the student with 
names. With regard to the rales in bronchitis, all he need bear in 
mind is, that the nature of the sound produced by air passing 
through the bronchial tubes will be modified accordingly as these 
tubes are large or small, are dry or moist, or as the moisture they 
contain is thin or not. The two things of greatest importance in 
examining a case of bronchitis is to ascertain whether the minute 
bronchial ramifications are engaged, and, if the tubes contain any 
moisture, whether it is thin or viscid. 
I seldom, therefore, confuse the student by telling him whether 
the rifle is sibilant or sonorous, when asked about the nature of the 
sounds heard in a case of bronchial inflammation. All I say in 
reply is this: that the sounds are produced by the large or small 
bronchial tubes, and that they are either moist or dry. When the 
large bronchi alone are inflamed, the sounds issuing from the lung 
subjacent to the stethoscope are comparatively few in number, sel- 
dom exceeding two or three; they are likewise, when dry, of a 
grave tone, resembling the prolonged note of a violoncello, or the 
cooing of a dove; or, when moist, the bubbles are large, scattered, 
uneven. When the minute tubes are engaged, we hear, on the 
contrary, not a few, but many sounds, evidently proceeding from a 
small portion of lung; three, four, or even six or seven sounds may 
be perceived together, or circumscribed within very narrow limits. 
These sounds undergo rapid changes of tone during the same 
respiration, while every moment some of them appear to cease, to 
be replaced by new ones. The wheezing they produce is, when 
dry, sharp; but observe, it is very unusual to find every one of 
them dry : when dry sounds occur, they are generally accompanied 
by others, equally minute, but evidently moist. The moment I 
find, on applying the stethoscope, that a great many sounds are 
heard over a small spot, and that these sounds are dry and sharp, 
or are accompanied by certain modifications denoting the passage 
of air through fluid, I call the disease inflammation of the minute 
bronchial tubes, with increased secretion obstructing the free en- 
trance of air. An attention to these considerations is of great 
importance in ascertaining the nature of acute or chronic bron- 
chitis; for the danger is not only proportioned to the extent of the 
disease, but also the circumstance of the minute tubes being engaged, 
and the quantity of fluid they contain. The sound shows that not 
only the minute tubes are diseased, but also that there is a consider- 
able quantity of viscid fluid in them, preventing the entrance of air 
into the air cells, and tending to produce asphyxia. 
In the case we are at present considering, we found, on examin- 
ing the chest, that the minute bronchial tubes were extensively 
engaged, and they were obstructed by a copious secretion of mucus 
producing considerable dyspnoea. We found, however, that this 
condition had lasted for many months, and that the disease was 100 
graves’s clinical lectures. 
essentially chronic. He had no fever; his skin was cool; his tongue 
moist; appetite and digestion good ; and his pulse, which had been 
only 60 on his admission, sank to 46 after he had been in bed for 
some days. Such extreme slowness of pulse as this is a very re- 
markable circumstance, particularly in cases of pulmonary disease : 
it is seldom met with except in cases of cerebral affections. Here 
was a man breathing twenty-six times in a minute, and with a 
pulse at 46; whereas, if the pulse was proportioned to the respira- 
tion, it would have been much quicker. The relation of the num- 
ber of respirations to the beats of the artery at the wrist should be 
as one to four; thus, when we breathe fifteen times in a minute, 
the pulse should be at 60. But here we find a man breathing 
twenty-six times in a minute, and yet his pulse is only 46. We 
had another instance like this, in a patient in the chronic ward, 
whose pulse was 60, while his respirations were thirty-six in a 
minute. It seldom happens, when pulmonary disease is in the 
acute form, and respiration considerably accelerated, that there is 
not a corresponding increase in the frequency of the pulse ; but, in 
chronic cases of this description, the system becomes gradually 
accustomed to the derangement; the continued acceleration of 
breathing ceases to affect the action of the heart; the lung, which 
is obstructed by disease in the performance of its functions, con- 
trives, by working more frequently, to aerate the requisite quantity 
of blood, and, the heart adapting itself to the change of circum- 
stances, the pulse returns gradually to the natural standard. I 
have seen many cases of phthisis, in which there was accelerated 
breathing, with slow pulse, but these were always cases of a chronic 
kind. I have never observed the same phenomena co-existing when 
the disease was acute; it is a state of things which is compatible 
only with chronicity of disease, in which the system becomes 
gradually accustomed to the change, and a kind of artificial equi- 
librium is finally established. 
In this case we find that a man of tolerably good constitution, 
after exposure to cold, gets an attack of bronchitis, which becomes 
chronic and extends almost over the whole lung. He has a cous;h 
always existing—sometimes better, sometimes worse, occasionally 
aggravated. This cough is accompanied by a copious secretion of 
mucus; and this state of things continues for more than twelve 
months. Now, when bronchitis has lasted so long on persons of 
his class in life, it is very difficult to be cured ; his poverty, his 
want of proper clothing, his liability to the ordinary exciting causes 
of bronchitis from the nature of his employment, and the habitual 
disregard of self so constantly observed in persons of this descrip- 
tion, are all circumstances which forbid us to entertain any hopes 
of giving permanent relief. 
There are two points to be attended to in the treatment of this 
and every other case of chronic bronchitis: first, whether there be 
any recent attack, and consequently any fever and exacerbation of 
the local symptoms present; and, in the next place, whether the 
secretion from the bronchial mucous membrane be copious or EMETICS AND CH AL VBEATES IN BRONCHITIS. 
101 
scanty. Now, at the period of this man’s admission, there was 
some slight excitement of the pulse, but there was no fever or in- 
crease of bronchial inflammation present, and the heart’s action 
was apparently not influenced by the state of the lung. In addition 
to this, there was no urgent dyspnoea, and the secretion from the 
lungs was extremely abundant. We therefore commenced by ad- 
ministering an emetic, which was repeated for two or three days, 
and then prescribed the following mixture: mist, ferri composita, 
3 ij ; tinct. scillae, tinct. hyoscyami, aa gj ; to be taken three times 
a day in an ounce of almond emulsion. In chronic bronchitis, 
where no fever, no remarkable dyspnoea or acceleration of the 
pulse is present, and where the bronchial secretion is very copious, 
you will be able to produce very good effects by giving an emetic 
every night for two or three nights, before you begin with remedies 
calculated to arrest the supersecretion from the lung. They are 
productive of a double advantage in such cases: a large quantity 
of mucus is discharged from the stomach and lungs, expectoration 
is rendered more easy, the tongue cleans, and the appetite is im- 
proved. It was on this account we gave them in the present case, 
and, as you may have perceived, with much benefit. In no disease 
are we more apt to have a foul, loaded, and furred tongue, than in 
bronchitis. This state of the tongue, being usually accompanied 
by loss of appetite and indigestion, is frequently attributed to a bad 
stomach. Now the truth is, that in such cases the state of the 
tongue and the state of the stomach are both produced by one and 
the same cause—viz., the unnatural state of the bronchial mucous 
membrane. In the latter tissue the train of morbid actions com- 
menced, and from it was derived that source of irritation which, 
inducing disease in the bronchial mucous membrane, caused a state 
of parts rapidly propagated along that membrane to the mouth and 
tongue on the one hand, and to the stomach on the other. We 
afterwards had recourse to a tonic and astringent chalybeate—the 
mist, ferri comp.—with the view of improving the general system, 
and checking the superabundant secretion from the bronchial tubes. 
The action of a chalybeate is not merely limited to strengthening 
the tone of the stomach and general system ; it is also well calcu- 
lated to arrest the superabundant secretion from mucous surfaces 
in many chronic fluxes, and hence its utility in gleet, diarrhoea, and 
chronic bronchitis. We gave the compound iron mixture in prefer- 
ence to a simple chalybeate, because the other ingredients—namely, 
myrrh and sub-carbonate of potash—have a tendency to produce 
the same effect. I do not, however, prescribe this medicine in such 
large doses as I have frequently seen ordered, and I never give it 
alone. I order a dram or two to be taken three times a day, and I 
dilute this quantity by adding to it half an ounce or an ounce of 
almond emulsion or mint water. In this form it is a much safer 
remedy in the treatment of fluxes depending on chronic inflamma- 
tion, and its exhibition is much less likely to be followed by sinister 
accidents. I have, in the present instance, combined with it a small 
quantity of squill ; the reason of making this addition is so obvious 102 
GRAVES’s CLINICAL LECTURES. 
that it is unnecessary for me to do more than notice this fact. I 
have also added some tincture of hyoscyamus, which is an ex- 
tremely valuable sedative in the treatment of many forms of pulmo- 
nary disease. 
However well planned this treatment seemed to be, it did not 
succeed. After taking the mixture for a day or two, the man began 
to complain of tightness across his chest, and we were obliged to 
give it up. I have already stated, that in cases of this description, 
where the patient is using remedies to arrest secretion, you should 
be cautious in administering them at first, and attend carefully to 
their effects. If, after a patient has been using a chalybeate, or any 
remedy administered for similar purposes, you find that constric- 
tion of the chest and dyspnoea is increased, no matter whether the 
secretion is diminished or not, you may be sure that you are doing 
more harm than good. When the remedy acts favourably, you 
may know it by the following signs :—respiration becomes less 
frequent, and is performed with less distress, the expectoration be- 
comes more free, the sputa begin to assume the globular form, its 
quantity is diminished, and it is less tenacious and viscid in its 
consistence. When you give a stimulant, therefore, in chronic 
bronchitis, you must watch its effects with care, and if it produces 
any increase in the difficulty of respiration, or any pain or tightness 
of chest, you must omit it altogether, and pass to an expectorant of 
a less irritating character. In this case we stopped the use of the 
mistura ferri composita, and immediately ordered the patient to take 
a grain of tartar emetic in a pint of whey. This simple remedy 
succeeded in a very remarkable manner, producing on the first day 
a very considerable alleviation of symptoms. 
A man was admitted into the chronic ward a few days ago who 
cannot separate the lower from the upper jaw to the distance of 
more than two lines. What are the cases in which we find this 
immobility of the lower jaw? Most commonly in tetanus or locked- 
jaw ; but here this cannot be the case, for the man has no sign 
indicative of a tetanic affection, no rigidity of the muscles of the 
neck ; his countenance is very different from that of a tetanic pa- 
tient, and he has not been exposed to any of the ordinary exciting 
causes of that disease. But leaving all consideration of the nature 
of the disease out of the question, what is it that prevents him from 
moving his lower jaw ? It must depend on one of two causes; 
either the muscles which perform the motions of the lower jaw are 
stiff, rigid, and incapable of motion, or else there is some disease of 
the articulation which obstructs the motion of the bone. This pro- 
position is universally true of all articulations, that when they 
become impeded or completely obstructed in their motions, the 
derangement arises from some abnormal condition of the muscles, 
or of the bones and ligaments which form the joint. 
In this case we find, that, in addition to being unable to perform 
the proper motions of the lower jaw, the patient has intense pain, 
darting from the angle of the jaw towards the temple, the ear, and 
the side of the neck. This pain is of an extremely violent cha- CASES SIMULATING TIC DOULOUREUX. 
103 
racter, so as to resemble tic douloureux, and the resemblance is still 
farther increased by its being more or less intermittent. Now, on 
enquiry into the history of this case, we find that the patient had 
some time ago laboured under toothache, for which he got the last 
molar tooth but one of the upper jaw extracted, and that immedi- 
-ately afterwards he was seized with violent pain in the part, and 
found that he could no longer move his lower jaw as usual. I 
have seen many cases of this kind, in which a painful or carious 
tooth, or an injury done to the gum or jaw, has been followed by 
violent darting pain in the nerves of the face, simulating in many 
particulars tic douloureux. I remember being sent for to Middle- 
ton, near Cork, some time since, to see a young lady of delicate 
constitution, whose health was materially deranged from what was 
said to be an attack of tic douloureux. She had been under the 
care of many practitioners, and had used very large doses of the 
carbonate of iron and sulphate of quinine, and at the time I visited 
her was taking arsenic. The first thing I did on my arrival was 
to examine her teeth. On close inspection I observed that on the 
crown of one of the upper molar teeth there was a spot which ap- 
peared to be decayed, and found on enquiry that she had frequently 
suffered from pain in this spot when she drank any cold liquid. I 
had the tooth drawn and soon afterwards the pain completely ceased. 
Yet in this case the pain was not only of an intense character, pre- 
venting sleep and wearing out her strength, but it had its intermis- 
sions, and was aggravated at particular hours of the day. Another 
instance of the same kind came under my notice about twelve 
months ago. A young lady was brought to me by a medical friend 
of her’s to have my advice for an attack of tic douloureux. She 
had been attended by this gentleman with great care, and no mode 
of relief left untried, for her sufferings were intense, and she had 
constant exacerbations of pain. I asked him, were her teeth sound, 
or had she any disease of the gum or jaw ? He said not, and that 
he was sure of this, for he had examined her teeth over and over 
again. On opening her mouth, however, I thought I saw some 
appearance of unsoundness in one of her teeth, and recommended 
her to go to Mr. M’Clean and get it drawn. She did so, and the 
pain quickly disappeared. I could also give many cases in which 
an injury done to some of the branches of the dental nerve has 
given rise to symptoms closely resembling those of the tic doulour- 
eux. One of the most curious circumstances connected with such 
cases is, that the pain is always of a more or less intermittent cha- 
racter. The same thing is observed in that form of headache which 
arises from irritation of the brain, produced by spiculae of bone 
growing from the internal table of the skull. In a case which 
occurred some time back at the Meath Hospital, where several spi- 
culas, some of them more than a quarter of an inch in length, were 
pressing on the brain, the headache was of a distinctly intermittent 
character. This remarkable periodicity of exacerbation, in cases 
where the operation of the exciting cause continues still the same, 
seems to be peculiar to the nervous system. 104 
graves’s clinical lectures. 
In many cases considerable derangement of the facial nerves is 
found to follow an injury done to some branch of the dental nerve 
in drawing a tooth. When the bone has been injured by the force 
used in extracting the tooth, it frequently happens that, if the injury 
be not quickly repaired, and the parts healed up, symptoms resem- 
bling those of tic douloureux or rheumatic neuralgia will supervene, 
and give the patient a great deal of annoyance. Such was the ori- 
gin of the mischief in the case before us; the man received an injury 
of the upper jaw in drawing a tooth, which is not as yet healed, as 
you may perceive by introducing a probe between the separated 
portions of gum, when you will find it grate against the rough sur- 
face of the bone. In addition to this, there is considerable tenderness 
of the gum and swelling of the neighbouring parts, which have 
extended to the muscles, their sheaths, and finally to the articulation 
of the lower jaw. You can satisfy yourselves of this by examining 
the parts and striking the lower jaw, so as to press it suddenly up- 
wards and backwards into the glenoid cavity, just in the same way 
as you press the thigh bone against the acetabulum when you wish 
to ascertain whether there is inflammation of the hip joint. The 
motion of the lower jaw is here prevented by inflammation, ex- 
tending from the upper jaw so as to involve its ligaments and the 
neighbouring muscular sheaths. There are other causes, also, 
which may be attended with the same diminution of motion in the 
joint. Thus a man may get an attack of rheumatism in the scalp, 
which may extend to the temporal muscles and prevent him from 
being able to depress his lower jaw, and I have known cases in 
which this condition of the temporal muscle has given rise to sus- 
picions of the existence of trismus. When you examine the articu- 
lation you find nothing amiss, but when you come to press on the 
temporal muscle above the zygoma, the patient complains of pain 
and tenderness. The irritation produced by rheumatic inflamma- 
tion gives rise to a fixed rigid state of the muscle, and hence the 
patient cannot open his mouth. This form of disease I have de- 
scribed long since, in a paper published in the Dublin Hospital 
Reports. It can be relieved with great ease by applying leeches to 
the temple, and ordering the patient to rub over the part a small 
portion of mercurial ointment with extract of belladonna, two or 
three times a day. The same state of the temporal muscle is some- 
times observed as resulting from an extension of inflammation, in 
case of a wound of the scalp in its vicinity. 
In the case before us, almost every thing will depend on the 
process which nature may adopt with respect to the injury of the 
maxillary bone. If the bone throws up healthy granulations, and 
the inflammatory process ceases, the affection of the nerves, as well 
as of the muscles and joint, will quickly subside. All we can do 
under the circumstances is to apply leeches over the side of the face, 
and order the man to rub in mercurial ointment; every thing, how- 
ever, will depend on the turn the disease of the bone may take. 
I wish to make a few observations on a case of jaundice in the 
small chronic ward. I do not intend to enter into any particular JAUNDICE WITH ARTHRITIS AND URTICARIA. 
105 
enquiry concerning the causes of this disease; you are aware that 
it may depend upon many causes, upon affections of the mind, 
gastro-duodenitis, inflammation or abscess of the liver, the presence 
of gall-stones, diseases of the head of the pancreas, aneurism of the 
hepatic artery, and, what is more remarkable, in some cases may 
arise without any assignable cause whatever. In the present in- 
stance it seems to have been the result of acute hepatitis. The 
man was attacked with symptoms of inflammation of the liver, and 
about a fortnight afterwards became jaundiced. It is unnecessary 
for me to draw your attention to the history of the case, or the pre- 
sent state of the patient; all I shall do at present is to make a few 
remarks on some points of treatment. 
In the first place, the jaundice is, as you perceive, of an intense 
character; the man is as yellow as he could be. Now this I look 
upon as a favourable sign; the deeper the colour is in recent cases 
the greater is the chance of effecting a cure. There are no cases so 
untractable as those in which the tinge of yellowness is so faint 
that you would be likely to overlook it, as in the case of a man in 
the chronic ward, in whom the colouring is so slight, that it re- 
quires some attention to ascertain whether he is jaundiced or not. 
Such a care as this is always of a chronic, untractable character, 
and this is too frequently connected with a scirrhous state of the 
liver. Again, in this man’s case we cannot detect any appearance 
of bile in the evacuations : this is another good sign. When jaun- 
dice co-exists with bilious stools, the prognosis is, generally speak- 
ing, bad. A but slight tinge of yellowness of skin, and the con- 
tinued presence of bile in the stools, are two circumstances which I 
always look upon as indicative of an unmanageable and frequently 
incurable affection. It generally depends on a scirrhous state of 
the liver, or some organic derangement beyond the power of medi- 
cal treatment. Again, another good sign in jaundice is, that as long 
as the bile is absent in the stools it should be present in the urine. 
If a patient labouring under jaundice has clay-coloured stools, 
and you find on examination that his urine becomes heavily laden 
with it, it is a very favourable circumstance, for it shows that, al- 
though the usual channel for the exit of bile from the system is 
stopped up, nature has provided a remedy for the evil by establish- 
ing another emunctory. You can understand then the reason of 
the anxiety I felt at finding that this patient’s urine was becoming 
paler and diminishing in quantity, at a time when bile was not 
present in the stools. In acute cases of jaundice, you should always 
bear in mind that patients will sometimes have a complete sup- 
pression of the biliary discharge, followed by coma, without any 
symptoms of disease of the brain. Why this occurs iti some and 
not in all cases we cannot understand, but, from whatever cause it 
may arise, we find that in some instances jaundiced patients become 
stupid and lethargic, and die in a state of confirmed coma. In 
such cases there is always very great danger, and where coma has 
appeared as a prominent symptom of jaundice, you should always 
give an unfavourable prognosis. I have never seen but one patient 106 
graves’s clinical lectures. 
recover under such circumstances. On the other hand, it is equally 
curious that derangement of the urinary system is one of the most 
common symptoms of disease of the brain. You will therefore un- 
derstand the cause of my alarm, when I observed a diminution of the 
urinary secretion in this patient. As soon as I perceived this symp- 
tom, though the patient had been taking mercury, and was improv- 
ing at the time, I immediately administered a diuretic, and this 
fortunately succeeded in producing a copious flow of urine. We 
prescribed the following diuretic, which had not been taken for 
many hours when it produced a decided determination to the kid- 
neys :— 
R. Mistura amygdalarum, 3 viij. 
Nitrat. potassse, Bij. 
Tinct. digitalis, gtt. xv. 
Spiritus setheris nitrosi, 3 ij- 
of which a tablespoonful was to be taken every second hour. 
There is one practical remark to be made on this and other simi- 
lar cases. As soon as the symptoms of jaundice begin to decline, 
and bile makes its appearance in the stools, you should attend care- 
fully to the state of the patient, and note any symptom which may 
occur of an anomalous character. Now, in this patient’s case, we 
observed that a degree of restlessness was present, which terminated 
in a complete want of sleep. About the time when he began to 
manifest a degree of improvement, he became quite sleepless with- 
out any evident cause, and continued so for two or three nights; 
and I have already stated in a former lecture that, no matter when 
this symptom occurs, whether in fever or towards the termination 
of some acute disease, it always requires your attention. I there- 
fore immediately took proper steps to restore sleep; and accordingly 
we find, on enquiring this morning, that he has rested well and 
feels much better. The man had been taking mercury, and his 
bowels were free; but, not content with this, I gave him a purgative, 
consisting of infusion of senna with electuary of scammony. This 
he was directed to take early in the morning, so as to secure its 
operation before night; and about nine or ten in the evening, after 
his bowels had been freely opened, he took a full opiate, which pro- 
duced a long and refreshing sleep. 
Before I conclude, allow me to communicate a few detached 
observations on the connection which exists between jaundice and 
some other diseases—as, for example, inflammation of the joints. 
It is now many years since Dr. Cheyne and I attended a gentleman 
in Lower Mount street, who, in consequence of exposure to cold, 
was attacked with inflammation of the joints, accompanied by con- 
siderable general fever; almost every joint was attacked in succes- 
sion, and his sufferings were excessive. The disease bore the 
form I have so often described under the name of acute sweating 
arthritis—a form very obstinate and difficult to treat, and accom- 
panied after some time with great constitutional debility. When 
this gentleman had been about ten days confined to bed under 
treatment, he suddenly became jaundiced, and it was now evident URTICARIA. 
107 
that acute, but not violent, hepatitis was superadded to the original 
disease. 
In a day or two afterwards, a copious eruption of nettle rash— 
urticaria—appeared over his body and extremities. Exactly the 
same diseases appeared, and in a similar order of succession, in a 
man treated in the Meath Hospital, in June, 1832—an occurrence 
which at. the time excited some interest among the students; for 
when I observed that jaundice had supervened on arthritis, I men- 
tioned to the class that it was not at all unlikely that the jaundice 
would be soon attended by urticaria. I was induced at the time 
to make this remarkable prediction, as my mind was full of the 
subject, having been engaged, along with Mr. Porter, in attending 
a medical friend residing in Bagot street, in whom jaundice was 
soon followed by urticaria. Since my attention has been drawn to 
the connection between these three diseases, I have seen and heard 
of several other instances in which they appeared thus associated 
together. A circumstance so remarkable deserves to be studied 
with more than ordinary interest. Let us, therefore, consider what 
facts are supplied by physiology and pathology capable of throwing 
some light upon this hitherto unobserved and uncultivated subject. 
In the first place, nothing has been longer recognised by physicians, 
as an established fact, than the intimate sympathy which exists, 
both in health and disease, between the digestive organs and the 
skin. Now, acute hepatitis always produces more or less derange- 
ment of the stomach and alimentary canal, and we may therefore 
consider its connection with urticaria in the same way that we are 
in the habit of viewing the cases, so frequently observed, in which 
certain sorts of fish have produced serious symptoms of indigestion 
followed by nettle rash. The association between these two dis- 
eases is rendered more remarkable by the fact, that, when fish taken 
as food exerts a poisonous effect on the system, it frequently pro- 
duces not merely violent stomach and bowel complaint, but also 
inflammation of the joints and rheumatic pains. If I can establish 
this, you will allow that the connection between arthritis, disease 
of the digestive organs, and urticaria, can no longer be considered 
as fortuitous and depending on the accidental concurrence of causes 
having no determinate relation, but must be looked on as owing to 
and arising from the operation of some fixed law which regulates 
and originates this development of morbid actions in, if not a fre- 
quent, at least an uniform mode of succession. 
The Otaheitan eel (puhhe pirre rowte) produces, when eaten, a 
most copious scarlet eruption of the skin—most probably urticaria 
—and occasions sudden tumefaction of the abdomen, together with 
swelling of the extremities, hands, and feet; the pain felt in the 
limbs is so excruciating that the patient becomes quite frantic. I 
may remark here that this, and many other species of fish which 
act as poisons on the system, give rise very speedily to paralysis of 
the extremities. You will find, in the Edinburgh Medical and 
Surgical Journal, vol. iv. p. 396, in an excellent review of Dr. 
Chisholm’s work on the poison of fish, an account of the effects 108 
graves’s clinical lectures. 
produced by eating the tnurcena conger, the following passage. 
“ In the course of the following night, they were all seized with 
violent griping and cholera, together with a peculiar sensation in 
the lower extremities, attended with violent convulsive twitches, 
faintings, <fcc. They all perceived a brassy taste in the mouth, and 
a rawness of the oesophagus as if it had been excoriated. These 
symptoms continued to afflict the negroes for a fortnight, and then 
terminated in paralysis of the lower extremities. After suffering 
for several months, they recovered with difficulty.” 
Are we not here forcibly reminded of what I said in a former 
lecture concerning the connection between enteric disease and 
paraplegia ? 
Werlhoff, as cited by my friend Dr. Autenrieth in a book1 of 
extraordinary ability and research, gave a case where the gadus 
aeglesinus, asellus, produced a violent affection of the stomach and 
bowels, together with urticaria. Chisholm relates the same of the 
flesh of the dolphin. Urticaria, diarrhoea, dysentery, paraplegia, 
are said by the same author to be frequently observed in conse- 
quence of eating the flesh of the gray snapper. Forster relates a 
similar train of accidents produced by eating the sparus pargus 
(porgee). In short, I could bring forward citation after citation in 
proof of the truth above advanced; but I have done, for enough 
has been already said to establish the point in question. 
Having established the fact that disease of the digestive organs 
is often intimately associated with urticaria, it remains to prove 
that a similar connection exists between hepatitis—the cause of the 
derangement in the digestive organs (in the case before us)—and 
arthritis. Every one has observed how frequently inflammation 
of the joints becomes in its course complicated with inflammatory 
affections of internal viscera. In general, those viscera whose 
component tissues are most similar to the articular, are the organs 
affected. Hence the heart and pericardium are so often attacked 
in the course of rheumatic fevers. It sometimes happens, however, 
although less frequently, that the internal organ attacked has little 
analogy in point of tissue with the joints. Thus, in rheumatism 
and in gout, the stomach, the bowels, the lungs, or the liver, may 
become engaged ; and of these, none, perhaps, so frequently as the 
liver. We need not be surprised at this, when we consider how 
intimately the digestive function is connected with arthritic inflam- 
mation, which is indeed generally preceded or accompanied by 
well-marked symptoms of hepatic and stomach complaints. Indeed, 
almost all medicines that afford relief in arthritis are attended with 
well-marked symptoms of their having acted upon the secretions of 
the alimentary canal and liver. Thus, colchicum seldom dimi- 
nishes the pain and inflammation of the joints, until it produces 
copious bilious evacuations. 
1 Ueber das Gift der Fische. Tubingen, 1833. BED SORES. 
109 
LECTURE X. 
On bed sores in fever, and their treatment—Instances of fever spreading by contagion 
—Attacking a person whose mouth was affected by mercury—Observations on the 
use of tartar emetic in fever—An account of the manner in which it is usually em- 
ployed—New views upon this subject—Practice first introduced by Dr. Graves of 
giving tartar emetic, combined with opium, in the advanced stages of fever—Success- 
ful eases—Treatment of fever with profuse sweating in the commencement—Mr. 
Cookson’s case—Mr. Stephenson’s case—Mr. Knott’s case. 
I beg leave to draw your attention to-day to some points con- 
nected with the treatment of fever. The number of fever cases we 
have had of late, is much greater than for some years; and to those 
who are anxious to acquire a knowledge of the phenomena and 
character of one of the most interesting and important of human 
maladies, our wards furnish at present very ample opportunities. 
I trust every gentleman who listens to me will avail himself of such 
advantages, and not permit opportunities of acquiring valuable in- 
formation to pass away unprofitably. It is my duty to speak of 
the particular modes of treatment adapted to fever cases, to inform 
you how each symptom may be most successfully combated, and to 
lay down rules for your guidance in each particular emergency; 
it will be your business to collect and arrange the detached mate- 
rials, and form your general principles with respect to the manage- 
ment of this very important disease. It has never been my wish 
to speak generally of the nature or treatment of fever; time will 
not permit me, nor do I wish to encroach on the province of those 
who lecture on the practice of physic; my object is merely to note 
symptoms as they rise, to speak of their nature and treatment, to 
confine myself to detached observations, and, as far as lies in my 
power, to contribute facts to those who write or lecture on prac- 
tical medicine. 
A woman has been admitted lately, who had been labouring 
under fever for a considerable time before she came into the hos- 
pital. This poor creature seems to have been in very miserable 
circumstances during her illness; her bedding must have been 
totally neglected, and no attention paid to cleanliness, for on her 
admission, though nearly free from fever, she was covered with 
bed sores to a frightful extent. Almost every point which had 
been subjected to pressure had ulcerated, and the ulcers went on 
undermining the skin, and committing terrible devastation in the 
cellular substance. Cases like this require great care and unre- 
mitting attention; it is on the exercise of an active and untiring 
humanity that the cure will mainly depend. In the first place, 
you are to recollect that the efforts of the constitution towards the 
re-establishment of health are impeded by the irritation of the sores; 
sleep is prevented, and the patient kept in a state of continual suf- 
fering, while a constant drain from the system is kept up by the 
ulcerative discharge, adding to the amount of existing debility. 
Hence a pseudo-febrile state arises, characterised by quick pulse, 
restlessness, and want of sleep, somewhat akin to that which is 110 
graves’s clinical lectures. 
produced by scrofulous irritation. The appearance, however, of 
general excitement of the system, should never prevent the phy- 
sician from adopting every mode of strengthening the patient as 
much as possible. You will not succeed in removing this condi- 
tion by an antiphlogistic regimen; the patient requires tonics and 
narcotics, with a nutritious but not stimulating diet. If you put 
him on a low regimen, and give anti-febrile medicines, you will do 
mischief; you will increase the existing debility, and add to the 
source of febrile excitement. Your practice should be to prescribe 
a nutritious diet, wine, and the sulphate of quinine, and to treat 
the sores with stimulant applications. The local application which 
we found most beneficial in such cases, is one composed of two 
ounces of castor oil, and one of balsam of Peru, which is to be 
applied on pledgets of lint, and covered with a poultice of linseed 
meal two or three times a day. In addition to this, we direct the 
sores to be washed night and morning with a solution of chloride 
of soda, in the proportion of twenty or thirty drops of the saturated 
solution to an ounce of water. We also direct the patient to lie 
occasionally on her face, and enforce the strictest attention to clean- 
liness on the part of the nurse. Dr. Arnott’s hydrostatic bed is an 
excellent adjuvant in the treatment of this disease, but unfortunately 
the one we have is at present out of order. 
Such, then, is our mode of treatment. We order the patient 
nourishing, but not heating, food; we give wine, regulating its 
quantity according to its effects on the system, and the liking of 
the patient; we prescribe small doses of the sulphate of quinine, 
and administer an opiate at night to allay irritability, and procure 
sleep. The local treatment consists in the use of stimulant and 
detergent applications, poultices, attention to cleanliness, and change 
of position. 
With respect to the present epidemic fever, we have now seen 
so many instances of its direct communication from one point to 
another in our wards, that we are induced to believe it to be con- 
tagious. From the great number of applicants labouring under 
serious and threatening diseases, we are sometimes obliged to put 
into our fever wards, patients affected with local inflammations, 
accompanied by symptomatic inflammatory fevbr ; several of these, 
while recovering, have been attacked with symptoms of the present 
epidemic. A man was admitted last week into the fever ward with 
violent pneumonia; the right lung was extensively hepatised, and, 
in addition to this, the pleura was found to be engorged over a 
large portion of its surface. The case was one of extreme distress, 
and the state of the patient apparently hopeless; however, by 
appropriate depletion, assisted by mercury and blisters, convales- 
cence became established, and the pulmonary symptoms were 
rapidly subsiding. His system was still under the influence of 
mercury, his fever had disappeared, his dyspnoea was relieved, his 
cough, and all the other symptoms, nearly gone, when he was sud- 
denly attacked with fever, and that of the same character as pre- 
vailed among the patients in the same ward. This is, I believe, TREATMENT OF FEVER. 
Ill 
the sixth or seventh case, in which patients labouring under some 
other form of disease, have been seized with symptoms of the pre- 
sent epidemic, while lying in the same ward with fever patients. 
I have thought it necessary to make this observation, because you 
will find it asserted in medical works, and by physicians of con- 
siderable eminence, that in hospitals fever does not spread from 
one patient to another, and that where it does appear among many 
individuals in the same house, its spread is chiefly favoured by 
want of cleanliness and proper ventilation. This, however, we 
can state to be the fact, that fever will spread among patients in 
the same ward, independent of any thing connected with filth or 
foul air, for we have seen it occur in our wards, which I can 
assert are kept as clean, and as well ventilated, as any in the king- 
dom. 
There is one circumstance connected with this case worthy of 
remark, with reference to the supposed antifebrile properties of 
mercury. It has been stated that mercury exercises a prophylactic 
influence over the system, and several persons who have cultivated 
medicine with success, but particularly some army surgeons of 
high authority, have asserted that the use of mercury not only 
cures fever, but also secures against it. I am afraid that in this 
and other cases, mercury has more credit than it deserves. In 
speaking of cholera, on a former occasion, I have told you that I 
had seen persons under the influence of mercury take cholera and 
die of it; and here we find a man, whose mouth is still sore, in 
whom salivation had not ceased, getting an attack of fever at a 
time when he had just recovered from another disease. This 
shows that mercury is not to be looked upon as a prophylactic in 
cases of fever of a contagious nature. We cannot always cure or 
prevent fever with mercury; on the contrary, where fever of a par- 
ticular kind is present, it prevents the constitution from yielding 
to its influence. Thus, in a case of hectic fever, brought on by 
suppuration of the liver, it has been found impossible to bring the 
system under the influence of mercury. 
I come now to speak of a matter of great importance in the treat- 
ment of fever—I allude to the indications for exhibiting, and the 
mode of giving, tartar emetic at different periods of the continued 
fever of this country. For some time, I have been in the habit of 
employing tartar emetic with very remarkable success at various 
periods of fever, but principally towards its termination. I am 
therefore anxious to lay before you a brief statement of my expe- 
rience of this admirable remedy, and I shall take leave to illustrate 
this by a reference to several very remarkable cases in which its 
administration was followed by the most decided and satisfactory 
results. 
You are all aware that tartar emetic has been long and justly- 
valued by the profession for its manifold and energetic properties. 
Without referring to its importance in the treatment of pulmonary- 
diseases, and almost every form of local inflammation, I may 
observe, with respect to our present subject, that tartar emetic in 112 
GKAVES’S CLINICAL LECTURES. 
small portions, dissolved in a quantity of whey or water, has been 
for a considerable time a popular and successful remedy in the 
commencement of febrile symptoms. Whether it is by its action 
on the stomach and intestinal canal, or by producing diaphoresis, 
or by some peculiar influence on the nervous and circulating 
systems, that it produces its favourable effects, we cannot exactly 
say; but we know that it frequently succeeds in cutting short, or 
removing, febrile symptoms. All these matters are, however, suf- 
ficiently well known to every student, and require no comment. 
In a preceding lecture, when speaking of the best means of pro- 
curing sleep in various forms of acute disease, I alluded to the pecu- 
liar narcotic power of the preparations of antimony, and dwelt on 
the benefits derived from a combination of antimonials with those 
medicines which are strictly termed narcotics. I told you in that 
lecture that the good effects of tartar emetic in delirium tremens 
seem to be totally independent of its action on the stomach ; for we 
had witnessed those effects when it had not excited either nausea 
or vomiting. I referred also to many instances of delirium tremens, 
in which opium in every form had failed in procuring sleep, and 
where a combination of tartar emetic and laudanum had succeeded 
in tranquilising the patient, and producing sound, refreshing sleep. 
Bearing this important fact in mind, we shall proceed to an exa- 
mination of the circumstances which require the use of tartar 
emetic in fever. 
There is a peculiar stage in one form of fever, and that exceed- 
ingly dangerous and threatening, in which I have derived most 
signal benefit from the use of this remedy. A patient, suppose, gets 
an attack of fever, he has all the ordinary symptoms, as thirst, rest- 
lessness, heat of skin, quick pulse, and headache. You are called in 
about the third or fourth day, and find that he has all the symptoms 
I have mentioned still present; his face is flushed, his head aching, 
his pulse from 100 to 110, but not remarkably strong; you find, 
also, that he has been sweating profusely from the commencement 
of his illness, but without any proportionate relief to his symptoms, 
and that he is restless and watchful. You are informed that his 
perspirations are so great that his linen has to be changed frequently 
in the day, and that, notwithstanding this, the pulse has not come 
down, the headache is undiminished, and the patient has become 
more and more sleepless. Here comes a very important practical 
question, namely—How are you to treat such a case? The patient 
has no epigastric tenderness, no cough, no sign of local disease in 
either the thoracic or abdominal cavities ; he has been purged, used 
diaphoretics, and perhaps mercurials ; every attention has been 
paid to regimen, ventilation, and. cleanliness; but still he lies there 
in a state of undiminished febrile excitement, with persistent head- 
ache, quickness of pulse, and sleeplessness. 
In such a case as this you have nothing to expect from the 
sweating; it will never produce any relief. I was called some 
time back to see a young gentleman in fever, who was placed in 
similar circumstances to those which I have just detailed. It was TARTAR EMETIC IN FEVER. 
113 
•jbout the sixth day of his fever, and I found him with a pulse of 
about 110, with considerable restlessness and headache, and was 
informed that he had perspired profusely from the commencement 
of his illness. On hinting the necessity of more active treatment 
than that which had been employed, his physicians appealed to 
the perspirations as decidedly contra-indicating depletion. They 
said that the profuse sweating pointed out the impropriety of active 
measures, and that it was a symptom which would be speedily 
followed by relief. I was convinced that they had taken a wrong 
view of the case, and stated as my opinion that nothing was to be 
expected from the perspirations ; that when co-existing with a per- 
sistent febrile condition of the system, when accompanied by quick 
pulse, headache, and restlessness, perspirations always indicated the 
necessity for antiphlogistic measures, and in particular for the use 
of the lancet. 1 instanced the case of patients labouring under 
arthritis with profuse perspirations not accompanied by relief, and 
said that it was well known that such cases were most successfully 
treated by a full bleeding from the arm. I accordingly stated, that 
although the disease was of five or six days’ standing, and the 
pulse not very strong, I would advise immediate bleeding. Sixteen 
ounces of blood were therefore abstracted, with some relief to the 
patient, and without increasing his debility ; and it was then a 
question what further steps were to be taken. The young gentle- 
man had been actively purged; he had no, cough or abdominal 
tenderness ; his symptoms were headache, sweating, and sleepless- 
ness ; and to these, nervous agitation had now become superadded. 
I proposed here what surprised my colleagues very much, and this 
was, to give our patient large doses of tartar emetic. They said 
the practice was very strange, but consented to give it a trial, on 
laying before them the reasons which induced me to prescribe it. I 
said that in such cases the tartar emetic, forming as it were a part of 
the antiphlogistic treatment which commenced with general bleed- 
ing, would have a tendency to cut short instead of increasing the 
perspiration, by reducing the inflammatory state of the system on 
which it depended. The reasoning seemed rather paradoxical—ne- 
vertheless it turned out to be correct. I ordered the tartar emetic to 
be taken in the quantity and mode in which it is generally pre- 
scribed in acute pneumonia; that is to say, six grains of tartar 
emetic combined with a little mucilage and cinnamon water in an 
eight ounce mixture, to be taken in the course of twenty-four hours. 
After taking five or six grains, the sweating began to diminish ; on 
the second day he scarcely perspired any, and his headache was 
greatly relieved; he began to improve rapidly in every respect, 
sleep returned, nervous agitation ceased, and convalescence became 
soon established. 
The next case in which I employed tartar emetic with signal 
benefit was one of a very insidious character, as many of them are 
at present; they exhibit no prominent or alarming symptoms, and 
yet continue to run on day after day without any tendency to crisis. 
The gentleman who was the subject of this case got an attack of 114 
graves’s clinical lectures. 
fever unaccompanied by any remarkable peculiarity, except that 
he was very nervous, and alarmed about his situation. His fever 
went on day after day without any decided symptom; he had no 
distressing headache, no cough, little or no abdominal tenderness; 
there was no vomiting or diarrhoea; and his pulse was not much 
above the natural standard. He had been leeched over the stomach 
at the suggestion of some medical friends, but this was done rather 
by the way of precaution than for the purpose of combating any 
actual disease. About the eighth or ninth day the pulse began to 
rise ; he complained of headache, and became restless and watchful. 
On the eleventh day the headache had greatly increased, he was in 
a state of great nervous excitement, and had not closed an eye for 
the two preceding days and nights. This state of insomnia and 
nervous agitation was immediately followed by violent paroxysms 
of delirium; his eyes, never closed in sleep, wandered from object 
to object with unmeaning restlessness ; his limbs were in a state 
of constant jactitation, and he raved incessantly: his voice being 
occasionally loud and menacing, at other times low and muttering. 
His friends became exceedingly alarmed, and every remedy which 
art could suggest was tried :—his head was shaved, and leeched 
until they could leech no longer ; cold lotions were kept constantly 
applied with unremitting diligence, and he was purged freely and 
repeatedly. At this period, that is to say, about the eleventh day 
of the fever, I was requested by this gentleman’s medical friends to 
visit him. On examining the patient, I found that he was con- 
stantly making violent efforts to rise from his bed, and that he had 
a great deal of the expression of countenance which belongs to a 
maniacal patient. Under these circumstances, I advised the use of 
large doses of tartar emetic, in the mode already detailed, except 
that, in this case, in consequence of the violence of the delirium, I 
ordered the quantity prescribed for a dose to be taken every hour 
instead of every second hour. The patient took about ten or twelve 
grains during the course of the night, and next day his delirium 
had almost completely subsided. Under the use of the remedy he 
became quite calm, fell into a sound sleep, and began to recover 
rapidly. 
In the two preceding cases I was guided by ordinary principles, 
recognised by all physicians, and according to which the exhibition 
of tartar emetic is recommended in fever whenever there is un- 
doubted evidence of determination of blood to the head, producing 
headache, loss of sleep, and delirium. In the cases which follow, 
tartar emetic was exhibited at a period of fever, and under circum- 
stances that were, with respect to the exhibition of this remedy, not 
less novel than important. The principles which led me to this 
practice have long been established, but, nevertheless, the practice 
is entirely new, and (I say it with pride, for it has already been the 
means of saving many valuable lives) it is entirely my own. 
Shortly after the commencement of our present session, Mr. Cook- 
son, a pupil at this hospital, and remarkable for his diligent attention 
to clinical pursuits, caught fever while attending our wards, in TARTAR EMETIC IN FEVER. 
115 
which many cases of the present epidemic were then under treat- 
ment. His fever was of an insidious nature, not characterised by 
any prominent symptom, not exhibiting any local disease to combat, 
or any tendency to crisis. For the first seven or eight days, with 
the exception of headache, which was much relieved by leeching, 
he seemed to be going on very well; his skin was not remarkably 
hot; he had no great thirst, nausea, or abdominal tenderness; his 
pulse was only 85 ; and he had sweating, which was followed by 
some relief. About the eighth or ninth day the pulse rose, and he 
began to exhibit symptoms of an hysteric character. Now, in every 
case of fever, where symptoms resembling those of hysteria come 
on, you should be apprehensive of danger. I do not recollect hav- 
ing ever met with a single case of this kind which did not terminate 
in nervous symptoms of the most formidable nature. I prescribed 
at the time the usual antihysteric medicines, but without any hope 
of doing good, knowing that these symptoms were only precursory 
to something worse. I also, as a precautionary measure, had leeches 
applied to his head. The fever went on, the headache became more 
intense, he grew nervous and sleepless, and fell into a state of great 
debility. On the fourteenth day of fever his tongue was black and 
parched, his belly tympanitic; he was passing every thing under 
him unconsciously ; he had been raving for the last four days, con- 
stantly attempting to get out of bed, and had not slept a single hour 
for five days and nights. Dr. Stokes, with his usual kindness, 
gave me the benefit of his advice and assistance at this stage of Mr. 
Cookson’s illness, and we tried every remedy which experience 
could suggest. Blisters were applied to the nape of the neck, the 
head was kept cool by refrigerant lotions, the state of the belly at- 
tended to, and, as we perceived that the absence of sleep was a 
most prominent and distressing symptom, we were induced to ven- 
ture on the cautious use of opium. It was first given in the form 
of hydrarg. c. creta, with Dover’s powder, with the view of relieving 
the abdominal symptoms as well as procuring sleep. This failing 
in producing the desired effect, we gave opium in the form of ene- 
ma, knowing its great power in the delirium which follows wounds 
and other injuries. This was equally unsuccessful with the former. 
He still was perfectly sleepless. We came again in the evening, 
and, as a last resource, prescribed a full dose of black drop, and 
left him with the conviction that if this failed he had no chance of 
life. On visiting him next morning at an early hour, we were 
highly mortified to find that our prescription had been completely 
unsuccessful; he had been more restless and delirious than ever. 
Here was the state in which we found him on entering his chamber 
at eight o’clock in the morning of the fifteenth day of his fever. He 
had universal tremors and subsultus tendinum, his eye was suf- 
fused and restless, he had been lying for some days entirely on his 
back, his tongue was dry and black, his belly tympanitic, his pulse 
140, quick and thready, his delirium was chiefly exhibited in short 
broken sentences and in a subdued tone of voice; and it was now 
eight days and nights since he had slept. Here arose a question 116 
graves’s clinical lectures. 
of great practical importance. How was the nervous agitation to 
be calmed and sleep produced? Blisters to the nape of the neck, 
cold applications, and purgatives, had failed; opium in various 
forms had been tried without the slightest benefit; if sleep were 
not speedily obtained he was lost. At this emergency a mode of 
giving opium occurred to me which I had never thought of before. 
Recollect what his symptoms were at this period: quick, failing 
pulse, black, dry, tremulous tongue, great tympanitis, excessive 
prostration of strength, subsultus tendinum, extreme nervous agita- 
tion, constant muttering, low delirium, and total sleeplessness. I 
said to Dr. Stokes that I wished to try what effects might result 
from a combination of tartar emetic and opium; I mentioned that 
I had given it in cases of delirium tremens with remarkable success, 
and thought it worthy of trial under the circumstances then present. 
Dr. Stokes stated in reply, that he knew nothing with respect to 
such a combination as adapted to the case in question, that he had 
no experience to guide him, but that he would yield to my sugges- 
tion. We therefore prescribed a combination of tartar emetic and 
laudanum in the following form, which is that in which I gener- 
ally employ the remedies in the treatment of delirium tremens. R. 
Antimonii tarfarizate grana quatuor, tinct. opii. drachmam, misturae 
camphorae, 3viij. Of this mixture, a tablespoonful to be taken 
every second hour. The success of this was almost; magical. It 
is true that it vomited him; after taking the second dose he threw 
up a large quantity of bile, but it did him no harm. After the third 
or fourth dose he fell asleep, and awoke calm and refreshed; he 
began to improve rapidly, and soon recovered. 
The next case to which I shall direct your attention is that of 
Mr. Stephenson, a pupil of Mr. Parr of this hospital. This young 
gentleman, as many of you will recollect, was attacked with fever 
about the middle of January. On Thursday evening he complained 
of languor and malaise, and on the following day felt himself fe- 
verish, but without any prominent or decided symptom. At night 
he took a dose of calomel and antimonial powder, which had no 
sensible effect, and the following day complained of shivering, vio- 
lent headache, pain in the back, thirst, prostration of strength, and 
sleeplessness. He was ordered to take a combination of tartar 
emetic and nitrate of potash in camphor mixture, which produced 
a few loose stools and some diaphoresis ; but in consequence of its 
effect on the stomach, and his complaining much of thirst and epi- 
gastric tenderness, the tartar emetic was omitted, and effervescing 
draughts prescribed. Two days afterwards, the epigastric tender- 
ness still continuing, twelve leeches were applied over the pit of the 
stomach, followed by blister, which gave relief, and the bowels 
were kept open by enemata. He commenced a second time the 
use of the tartar emetic and nitrate of potash, with the addition of 
five drops of tincture of opium to each dose, but was obliged to 
give it up again in consequence of the increase in his gastric symp- 
toms. He now became exceedingly restless, and his delirium began 
to assume a very intense character. Leeches were applied behind TARTAR EMETIC IN FEVER. 
117 
the ears, his head shaved, and his temples blistered ; he had also a 
large blister over the abdomen, which gave him considerable relief, 
but the cerebral and nervous symptoms became much worse. The 
delirium went on increasing, accompanied by subsultus tendinum, 
and picking the bed-clothes ; he was perfectly sleepless ; raved in- 
cessantly, and had to be kept down in bed by force. On the 17th 
day of his fever he was in the following condition,—tongue brown 
and rather dry, no remarkable thirst or abdominal tenderness, eyes 
red and ferrety, no sleep for five nights, constant muttering and 
delirium, (which had now assumed the character of delirium tre- 
mens,) subsultus tendinum and jactitation extreme, urine and faeces 
passed under him unconsciously. I directed the combination of 
tartar emetic and laudanum to be immediately given, carefully 
watching its effects. He had only taken two doses when a degree 
of calmness set in, bringing with it relief to all his symptoms, and 
before a third dose could be administered, he fell into a profound 
sleep, from which he awoke rational and refreshed. The mixture 
was continued every four hours with increasing benefit, he slept 
long and soundly, and began to improve in every respect. On the 
second day after he had begun to use the tartar emetic, he took a 
little porter, which was changed the next day for claret and chicken 
broth. In about a week he was able to sit up in bed, and seven 
days afterwards was able to leave the hospital and go to the country 
for change of air. 
The last case to which I shall direct your attention is that of Mr. 
Knott, also a pupil of this hospital, a gentleman remarkable for his 
unremitting attention to clinical pursuits, and from whom I derived 
much valuable assistance in conducting various post-mortem exa- 
minations. This gentleman was attacked with fever about the 
latter part of January, which went on for some time without any 
particular symptom, except considerable restlessness and nervous 
excitement. He then became perfectly sleepless, complained of 
violent headache and thirst, raved, and became exceedingly irritable. 
Opium in various forms and repeated doses, either alone, or com- 
bined with musk and camphor, totally failed in producing sleep, 
and his condition became daily worse. On the 13th day he was in 
a very dangerous condition; his nervous agitation had risen to an 
alarming height, and for many days and nights he had never closed 
an eye. At this period it appeared obvious that if something were 
not done to calm nervous excitement and restore sleep, he had but 
little chance of life. Under these circumstances I proposed to my 
friend, Dr. M'Adam, who attended with me, to give tartar emetic 
and opium. After he had taken about three tablespoonfuls, he had 
a copious bilious evacuation, and immediately afterwards fell into 
a sound sleep, during which he perspired profusely, and awoke in 
about twelve hours, with every bad symptom gone. The nervous 
irritability was completely allayed; his thirst and headache relieved; 
his tongue moist and cleaning; and his reason quite restored. From 
that period every thing went on favourably, and he rapidly gained 
his health and strength. 118 
graves’s clinical lectures. 
Since the foregoing lecture was delivered, I have met with seve- 
ral cases of fever, in which I employed the tartar emetic and opium 
with the same remarkable success. A man named Christopher 
Nowland was admitted into Sir P. Dun’s Hospital, on the 3d of 
February last, labouring under fever. He had been ill ten days, had 
raving, subsultus tendinum, and appeared unable or unwilling to 
answer questions. His wife stated that he had diarrhoea for the 
preceding three days, and that he dozed occasionally, but never 
slept. He appeared exceedingly low and prostrated, and lay con- 
stantly on his back. A succession of flying blisters were ordered 
to be applied to the chest and stomach, and wine and chicken broth 
prescribed. He also got the following draught every third hour:— 
R. Mist, camphorae, 3j- 
Spirit, aetheris oleosi, 3ss. 
Spirit, ammoniae aromaticas, 3ss 
Moschi, gr. viij.—Misce. 
Under the use of these remedies he began to recover from his pros- 
tration ; but as the sleeplessness and delirium still continued, I 
ordered him to take the tartar emetic mixture in the usual way. It 
produced at first two or three full discharges from the bowels, and 
after he had taken the fourth dose he fell into a sound sleep, from 
which he awoke much better, and soon became convalescent. 
In the case of a patient named Michael Murray, who exhibited 
the same remarkable nervous irritability and sleeplessness, this re- 
medy was also employed with very striking effects. This man had 
been ill of fever for ten days before his admission into Sir Patrick 
Dun’s Hospital, and appeared so much prostrated that I ordered him 
arrowroot with beer. He raved a little on the night of his admis- 
sion, and remained without, closing an eye until morning. The 
same symptoms were observed on the following day, and his nerv- 
ous irritability became increased. On the 14th of February he had 
been five days in the hospital, and had not enjoyed a single hour’s 
sleep. I ordered the tartar emetic mixture to be given : three doses 
produced sleep : he had no other bad symptoms, and recovered com- 
pletely. 
In another very bad case of maculated fever, the same results 
were obtained. The patient, Mary Farmin, had got an attack of 
fever after a fright. She had been eight days ill at the date of her 
admission, February 25th. She had irregular pulse, sleeplessness, 
headache, and suffusion of the eyes; moaned and sighed continu- 
ally, and appeared greatly prostrated. She was blistered, had fetid 
enemata, and took the chloride of soda internally with some benefit; 
but the sleeplessness and nervous excitement continued. In this 
case, though the tartar emetic was not followed by speedy conva- 
lescence, still it produced remarkably good effects; after taking four 
doses of it she fell asleep, and did not awake until next morning. 
There are many other cases which I could adduce to prove the 
value of a combination of tartar emetic and opium in the nervous 
sleeplessness of low fever; the foregoing, however, I trust will be 
found sufficient. 119 
I forgot to observe, that all the cases I have spoken of as success- 
fully treated by means of tartar emetic combined with opium, in 
the advanced stage of the disease, were cases of maculated or spot- 
ted fever. I shall take a future opportunity of entering more fully 
into a detail of its symptoms. 
SPOTTED FEVER. 
LECTURE XI. 
General account of the spotted fever epidemic in Dublin, in 1834-5—Its most remark- 
able features—Insidious character—Further explanation of the reasoning which led 
Dr. Graves to the discovery of the utility of tartar emetic in its latter stages—Dr. 
Nolan’s remarkable case of enteritis, with collapse, cured by enormous doses of 
opium—Cases of singular proportions between the frequency of the pulse and of 
respiration—Case of acute oesophagitis. 
When I last addressed you, I spoke of a very important topic— 
the administration of tartar emetic in the advanced stages of pete- 
chial or maculated fever. A few observations descriptive of the 
present epidemic fever appear necessary. The commencement is 
frequently by no means violent, in proportion to the subsequent 
danger, and the patient often appears merely to labour under the 
symptoms of a common feverish cold, seldom preceded by violent 
rigors, but attended by a frequently recurring sense of horripilation. 
The pulse, in the very beginning, seldom exceeds 90, and in nearly 
half the cases it falls after a few days to 80, 70, or even lower. 
This slow pulse I observed in many of the pupils, and in all it was 
found to accompany a very tedious and dangerous form of fever. 
Mr. Sangster, Mr. Graves, Mr. Harris, and Mr. O’Flaherty, were 
all so affected; for none of these gentlemen had a pulse exceeding 
70 in a minute, for many days before the period of the greatest 
danger. In other epidemics similar cases have occasionally oc- 
curred, but in none near so frequently as in the present. When 
the pulse was thus tranquil, the skin was not perceptibly hotter 
than natural, although occasionally a slight degree of the color 
mordax could be detected. Patients with a slow pulse not unfre- 
quently had little to complain of at first; for the headache, general 
pains, thirst, and restlessness, generally underwent a notable dimi- 
nution, in consequence of sweating, which came on in the com- 
mencement—the appearance and the good effects of which were 
well calculated to deceive the practitioner into a belief that the 
fever had terminated. A more accurate examination, however, 
showed that this was not the case; for the tongue still continued 
much loaded, white in the centre and red at the tip, and the appa- 
rent subsidence of the fever was found to be accompanied by a 
remarkable increase of debility. As the disorder proceeded, a slight 
rash, like ill-defined or suppressed measles, became observable in 
some before the fourth day, but much oftener about the seventh. 
This maculated appearance of the skin increased rapidly, spreading 120 
graves’s clinical lectures. 
over all parts of the trunk and extremities, and in many amounted 
to a well-marked efflorescence of a dusky red colour; in others it 
was as it were suppressed, and was less obvious, but was still dis- 
cernible by an experienced eye, appearing beneath as if veiled by 
the skin. It was not totally absent in one case out of twenty, 
which occasioned me to name the disease maculated fever. So 
the patient continued, in general, until the ninth, tenth, or eleventh 
day, resting sufficiently at night, with a moderate or even a slow 
pulse, some thirst, foul tongue, little or no nausea, epigastric pain, 
or abdominal tenderness of any sort, and, in fact, without a single 
symptom calculated to excite alarm. About this period of the 
complaint, matters began to assume a more threatening aspect; 
debility manifestly increased ; the mind at times was evidently in- 
coherent, particularly after awaking from sleep, and then raving 
during the night; restlessness ; frequent attempts to get out of bed 
not unfrequently supervened in the course of a few days. The 
pulse, meantime, rose very suddenly in many, and continued to be 
frequent during the period of danger. Thus, on the tenth day, 
Mr. Syms’s pulse rose from 85 to 120, and so continued until about 
the twentieth day, when improvement commenced. The same 
sudden rising of the pulse took place on the ninth day in Mr. 
McNamara, and he died on the fourteenth day. In others, as I have 
already remarked, the pulse continued tranquil throughout. Thus, 
it was very curious to see a patient with a skin of a natural tem- 
perature, a perfectly natural pidse, tranquil respiration, clear eye, 
no headache, a soft and fallen abdomen, without the slightest ten- 
dency to epigastric tenderness ; it was very curious, I say, to see 
such a patient in a state, nevertheless, of extreme danger, passing 
both fasces and urine under him; raving, incoherent, or with a low 
muttering delirium; subsultus daily increasing until it became 
excessive ; the greatest possible degree of debility ; a dark macular 
efflorescence, and at length total sleeplessness. How many theories 
of fever were refuted by such a case ! Usually, as the disease con- 
tinued, and when the patient was in a very dangerous state—but 
seldom or never before that—the intestines began to be inflated, and 
the belly gradually became tympanitic ; a circumstance of bad 
omen, and which was often the precursor of hiccup. When the 
symptoms did not yield to the efforts of nature or of art, the con- 
gestion of the intestinal mucous membrane, indicated by these 
symptoms, was soon followed by indubitable evidence of cerebral 
congestion—such as restlessness, suffusion of the adnata, and con- 
traction of the pupils ; this last was the most fatal of all symptoms. 
In two or three cases—as, for instance, that of Mr. Cookson—the 
cerebral congestion produced repeated fits of convulsions on the 
thirteenth day, and yet he recovered. The same happened in a 
young woman in Sir P. Dun’s Hospital, in whom the convulsions 
occurred on the fifteenth day, and were more violent on the right 
side than on the left, producing strabismus and insensibility of the 
pupil of the affected eye. This girl lost the use of her left side on 
that day, but recovered it on the following; and eventually, though SPOTTED FEVER. 
121 
with difficulty, was completely cured. Frequent fits of convulsions, 
affecting the right side more than the left, took place on the seventh 
day in the daughter of a clergyman residing in the Liberty, and 
were followed by a stupor bordering on coma, which lasted for 
many hours. All these patients were covered with maculae. 
I am thus particular in dwelling on the symptoms manifestly 
denoting a combination of primary general nervous excitement 
with a secondary cerebral congestion ; for, on the successive deve- 
lopment of these states the treatment during the latter stages 
hinged. I wish you clearly to understand, that, after the headache 
and cerebral excitement which accompanied the very commence- 
ment of the fever had been subdued, or had ceased, after sleep and 
calm had returned, and had continued for many days, then a new 
order of things commenced—subsultus, watchfulness, muttering, 
raving, involuntary discharges, &c.—all denoted great derange- 
ment of the nervous system; but still there was no proof that this 
derangement depended on cerebral congestion. After a few, or 
after many days, however, unequivocal symptoms of the latter set 
in; the face and eyes became suffused and flushed ; the pupils 
manifested a tendency to become contracted, and occasionally con- 
vulsions took place; the patient became totally sleepless. When 
the latter and dangerous period of the fever was accompanied by 
the former nervous group of symptoms alone, they yielded to wine, 
musk, porter, and opiates; but when the symptoms indicating cere- 
bral congestion were superadded, then it was that the case assumed 
so great and striking a similarity, so far as the functions of the 
nervous system were concerned, to the well-known variety of deli- 
rium tremens accompanied by cerebral congestion,—to that variety 
of delirium tremens, in fact, which can only be successfully treated 
by the judicious but bold exhibition of tartar emetic combined with 
laudanum. It is the discovery of the utility of this practice in 
the advanced stages of spotted fevers, that I claim peculiarly as 
my own ; for there is not, in the writing of any author on the sub- 
ject, the slightest trace of such a method of treatment to be found. 
As this method has manifestly saved many, many lives, under a 
combination of circumstances apparently hopeless, I cannot avoid 
congratulating myself upon being the first to propose a practice 
which has not only diminished the rate of our hospital mortality1 
in a remarkable manner, but has been the means of saving many 
of my friends and pupils; for, without its adoption, our class at 
the Meath Hospital would have been more than decimated, whereas 
at present we have to regret the loss of but one pupil. 
One word more as to the circumstances under which this plan 
* Seventy-three fever patients—namely, forty-one males and thirty-two 
females—were treated in the clinical wards at Sir P. Dun’s Hospital during 
the months of February, March, and April. Of these, more than fifty were 
cases of maculated or spotted fever, and yet we lost but two females and 
one male. The latter was in a hopeless condition when brought in, and 
one of the former was attacked by varioloid just after the crisis of long- 
continued spotted fever. 122 
graves’s clinical lectures. 
was applicable. They were exactly the circumstances which form- 
erly would have been believed to demand the fresh application of 
leeches to the head, of cold lotions, and of blisters; for it was 
formerly argued, and justly, we have in this advanced stage of 
fever not merely debility to combat—not merely general nervous 
excitement to overcome—but we have also to contend with cerebral 
congestion. The latter is the most formidable of the whole: let 
us meet it boldly; let us leech, let us purge, &c. &c. I need not 
repeat to you the details of cases illustrating the ill effects of this 
practice. Suffice it to remark, that you might as well attempt to 
cure delirium tremens with mere leeching, purging, and blistering. 
Observe, I am now speaking of the advanced stages of fever ; for 
where cerebral congestion takes place in the beginning or the 
middle of fever, then is there no room for opium—then will the 
practitioner have recourse to the well-known remedies for active 
cerebral congestion ; viz., purging, leeches, cold lotions, ice to the 
head, &c. &c. In the preceding sketch of the present epidemic, 
many important features have been omitted. The outline is only 
complete in such parts as were required to be filled up for the pur- 
pose of illustrating the principles which directed me in devising 
and employing this new plan of treatment. I shall conclude these 
observations with a few details of Mr. Thomas O’Flaherty’s case. 
This young gentleman was seized with the usual symptoms of 
maculated fever, of an insidious character, and 1 Jt attended with 
any appearance of danger during the commencement of the dis- 
ease. His pulse never rose above 100, and before the seventeenth 
day of the fever, it had fallen to 70, at which it remained during 
the 'period of greatest danger. The only circumstance which 
excited alarm in my mind, at an early period of his illness, was a 
great degree of mental apprehension manifested in his anticipating 
an unfavourable result, together with a tendency to sleeplessness 
from the beginning. On the tenth, abdominal tympanitis was 
observed, but this was removed in two days by appropriate reme- 
dies. On the twelfth day, he was very restless, and although he 
was perfectly rational in his answers to questions, and did not com- 
plain of headache, nor had flushing of face, or heat of the integu- 
ments of the head, yet he frequently talked incoherently when left 
alone, and towards the latter part of the day began to make repeated 
attempts to get out of bed. On one occasion he succeeded, and 
walked down stairs, from the garret to the parlour. His tongue 
was brown and dry. Under these circumstances, I ordered him 
the mixture containing four grains of tartar emetic and one dram 
of laudanum, in eight ounces of camphor mixture ; of this he took 
3ij every second hour. The effects produced by this medicine 
were not very rapid, but still they were decidedly beneficial, for he 
gradually became calmer, wandered less, did not attempt to get out 
of bed, and, during the night, got some sleep. His bowels being 
confined, the mixture was now laid aside, and purgatives exhibited; 
I should have remarked that the tartar emetic mixture caused pro- 
fuse sweating. On the fifteenth day of the fever, his bowels having 123 
been acted on, lie was ordered twenty drops of Battley’s solution of 
opium at night, which produced a comfortable night’s rest, the first 
he had enjoyed since his illness. On the sixteenth, the sweating 
continued, belly was fallen, and he was quite rational, but had 
marked subsultus; he got another dose of Battley, but it produced 
no sleep; he had been allowed chicken-broth, beer, &c.; for some 
days. On the seventeenth day, the sweating had ceased, and his 
skin had become hot and dry ; great restlessness, constant mutter- 
ing, delirium, subsultus, tremors, picking the bed-clothes, involun- 
tary discharges. Porter in small quantities, chicken-broth, fetid 
injection, and twenty drops of Battley at night. On the eighteenth, 
he was reported to have had no stool from the injection, and no 
sleep whatsoever. He answered incoherently, thought his bed was 
covered with lancets, some of which he collected carefully, and re- 
served for me; belly not tumid, but obstinately confined; pulse 100. 
The whole of that day, and the following, were employed in pro- 
curing alvine evacuations, preparatory to again giving opium ; in 
the mean time, all his symtoms were aggravated, and when I 
visited him on the evening of the nineteenth day, his state was 
anxious in the extreme, as he had enjoyed no sleep for many days 
and nights, and was in a melancholy state of mental incoherence, 
raving, tremor, and subsultus. Here came the crisis as to treat- 
ment. I remember well the time when a patient so situated would 
have been again purged, his head would have been shaved, a few 
leeches applied to the temples, and a blister to the nape of the neck, 
while perhaps wine and musk would have been exhibited inter- 
nally. How many persons have I seen so treated by the most 
eminent physicians, and how unsuccessful was the practice! To 
have talked of giving opium under such circumstances, and when 
the marks of cerebral congestion were so evident, would have been 
regarded absurd; my experience on former occasions, however, 
determined me to give opium, and, as the danger was imminent, I 
gave it boldly. To the eight ounce mixture, with four grains of 
tartar emetic, we added one dram and a half of laudanum; of this 
he took one ounce every second hour, from eight in the evening 
until he had taken five doses. This produced copious sweating; 
the skin became cooler, he raved less, but still no sleep; at four on 
the following morning, his pulse became 70. and respirations tran- 
quil ; he got twenty drops of Battley, and at half past five in the 
morning, twenty-five drops more. He had now taken, within a 
short time, about one dram of laudanum, and forty-five drops of 
Battley, combined with nearly three grains of tartar emetic. He 
was tranquil, but did not close his eyes, and muttered occasionally; 
subsultus less. His pupils now became more and more contracted, 
his eyes less expressive and duller, and when I came at eight in the 
morning, he was evidently deeply narcotised, although not yet 
asleep. I thought that all was lost; but still, observing the respira- 
tion to be tranquil, and the pulse regular, I indulged a faint hope 
that sleep might still supervene. His eyes now became still more 
inexpressive, the lids gradually closed, his breathing became pro- 
SPOTTED FEVER. 124 
graves’s clinical lectures. 
longed and deep, and at half past eight he was buried in a profound 
and tranquil sleep, which continued for nine hours, when he awoke, 
spoke rationally, said he had no pain in the head, took some drink, 
and fell asleep again. Next morning not a single symptom of fever 
remained. 
I need scarcely observe, that the proportions of the two powerful 
medicines which compose this mixture must vary according to the 
circumstances of the disease, and the age of the patient. In young 
persons of tender age, the opium must be given in smaller quan- 
tities. 
There is one circumstance connected with this epidemic, but 
which I have also frequently witnessed in other sporadic and epi- 
demic fevers, to which I wish forcibly to draw your attention ; it 
is the existence of tenderness generally over the body, and which 
causes the patient to shrink from the pressure of the finger, applied 
to any part of the integuments. This tenderness arises from an 
irritated state of the nervous system generally, and is usually 
accompanied by severe dorsal or lumbar pain, indicating spinal 
congestion. Now, in a practical point of view, this tenderness 
requires attention; for if it be overlooked, and if the physician 
applies pressure, in such cases only, to the epigastrium, he will be 
deceived into the belief that the tenderness he there discovers is 
confined to that part, and indie,ates the application of leeches to the 
pit of the stomach. 
You may observe that I have not yet spoken of the liquor of the 
chloride of soda, a remedy you have seen me order with such re- 
markable advantage in almost all the cases of spotted fever. It is 
my intention to devote an entire lecture to a consideration of the 
nature and properties of this medicine, so successful in the hands of 
myself and my colleague, Dr. Stokes. 
Having spoken so much of the salutary effects of opium in cer- 
tain stages of fever, it may not be irrelevant to our subject to intro- 
duce to your notice a remarkable case of violent enteric inflamma- 
tion, attended, as such cases always are when exceedingly intense, 
with cholera-like collapse in the very onset of the disease. This 
case was saved by means of thirteen or fourteen grains of opium, 
given in the course of twenty-four hours, a plan of treatment 
which I first proposed, and which has since been very generally 
adopted. 
I shall take the liberty of reading to you the following letter, 
from my friend Dr. Nolan. 
My Dear Doctor,—The following is an abstract of my notes 
upon the case of my servant Horan :— 
On Monday evening, 27th February last, he casually complained 
of pains in his bowels; they had not been freed on that day, and 
supposing it an instance of mere indigestion, I ordered him five 
grains of calomel, and a draught of castor oil. For that night I 
heard no more of him, but early on the following morning I was 
hastily summoned by one of his fellow-servants, who reported that ENTERITIS CURED BY OPIUM. 
125 
he was dying. I found him labouring under severe but intermit- 
ting pain of the belly, particularly about the umbilicus, violent and 
frequent cramps, especially in the lower extremities, and occasional 
vomiting. The surface was perfectly cold ; features sunken ; eyes 
surrounded by a dark areola; voice subdued to a whisper; pulse 
140, small and feeble; abdomen tender, though not at all tumid. 
He told me he passed the night in great torture, and that the bowels 
were still unmoved. I immediately ordered ten grains of calomel, 
to be followed in two hours by an oil and turpentine draught, a 
turpentine enema, bathing, (fee. 
Three hours subsequently—temperature restored; cramps less 
violent; vomiting less frequent, but bowels obstinate; face and 
pulse equally unpromising as before; abdominal pain increased. 
Was this incipient inflammation? and what is the cure for inflam- 
mation? Bleeding? Well, I did bleed; but scarcely had four 
ounces been taken, when I was very glad to tie up the arm; the 
prostration alarmed me. Something, at all events, ought to be 
done, and I ordered a sinapism to the abdomen, a repetition of the 
enema (for I confess I have not much confidence in frequent or 
powerful purgatives), a powder, composed of calomel two grains, 
opium quarter of a grain, to be taken every fifteen minutes. 
Towards evening, I thought my patient rallied a little; his coun- 
tenance was better; pulse firmer; his abdominal pain not increased, 
and he vomited but once; the injection brought away with it a 
little mucus, but no more. Repetat haustus terebinth. Repetat 
quoque enema. During the night, there was just a trace of fecu- 
lent matter, but vomiting returned, and I found him in the morning 
(the second of his illness) suffering an increase of pain ; the abdo- 
men, too, was now not only extremely tender, but decidedly 
swollen ; the pulse remained quick and weak as ever. I could not 
discover that he passed water. Would you not call this inflamma- 
tion? But would you bleed for it? I did, unfortunately, to as 
great an extent as I could, which was about eight ounces, and the 
cadaverous look, the cold clammy surface, in short, the absolute 
col lapse which succeeded, and continued for hours, gave me strong 
reason to regret it. It produced no impression upon the pain. 
I had read with great interest the invaluable observations of your- 
self and Dr. Stokes, as well as the publications of Armstrong, 
Griffin, Gooch, (fee., wherein the applicability of opium, to certain 
modifications of abdominal inflammation, is forcibly demonstrated, 
and I thought my patient precisely in the condition in which you 
would probably have had recourse to that powerful agent. I there- 
fore commenced exhibiting half a grain of opium, and two of 
calomel, every half hour. After the second hour, I substituted for 
the calomel three grains of carbonate of ammonia, which, with the 
opium as before, I continued during the day and the whole night. 
In the morning (the third) I had the satisfaction of ascertaining 
that the pain and swelling had considerably subsided, and that the 
bowels had been twice opened ; his countenance now spoke pro- 
misingly, and pulse began to fall. I, however, persevered in my 126 
graves’s clinical lectures. 
plan of treatment for the day, and, indeed, for the two following 
nights and days, (gradually increasing the interval between each 
dose, however,) until all trace of pain and obstruction had disap- 
peared. The bowels continued to act from time to time, although 
I never ventured upon another purgative; the dejections were at 
first largely mixed with blood and mucus, but soon assumed every 
character of health. Of the sequel (may be the consequence) of 
this interesting case, you most kindly undertook the management, 
and I shall add nothing to this meagre statement of facts, which 
Mr. O’Donnell, (of Keane’s, in Suffolk street,) to whose humanity 
and care I am deeply indebted, witnessed as well as myself. I 
shall leave you to speculate upon the propriety of bleeding at all, 
under such circumstances. I shall also leave you to decide whether 
the increase of inflammation, which certainly occurred when I first 
gave up the opium plan (on the first night) for the sake of inter- 
posing a purgative, was to be attributed to the change or not. 
May not the case throw some light on the abuse or use of purgatives? 
But I am doing more than I intended, and more than is useful. 
I remain, my dear doctor, 
Yours most truly, 
J. Nolan. 
April 19, 1835.—10, College Green. 
Let me now return to a subject concerning which I spoke lately, 
viz. the pulse. In the case of a young man named St. Leger, who 
was lately a patient at Sir P. Dun’s Hospital, the variation of the 
pulse in different positions of the body was very remarkable. He 
was just recovering from fever, and exhibited a state of the pulse 
which is not unfrequently observed under similar circumstances. 
During his convalescence the pulse went on declining in frequency, 
until it sank to thirty-six in the minute. When I made him sit up 
in bed, his pulse began to rise rapidly, and, in the space of a 
minute, was at sixty-four. When he stood up it became much 
quicker, but grew so weak and indistinct, that it could not be felt 
at the wrist. On applying a stethoscope over the region of the 
heart, I found that its pulsations amount to 112 in the minute. 
Here is a very remarkable difference of pulse depending entirely 
on change of position. With respect to the number of respirations 
in this young man, I found that when lying down they were only 
fourteen, but when he stood up they were thirty. This is a very 
curious fact, and one which I have not before observed. 
In this case, the pulse was very little more than in the propor- 
tion of two and a half to one, as compared with respiration, 
whereas it ought to be as four to one. We had another case at 
the hospital, in which the pulse was 84, and the respiration 42 in 
the same time in a minute ; and a third case, in which the pulse 
was 120, while the respiration was only twelve. I have myself seen 
one case in which the pulse was 60, and the respiration 50. 
This variation in the relations which the pulse and respiration 
bear to each other, is principally observed in fever and pulmonary INFLAMMATION OF THE (ESOPHAGUS. 
127 
disease. I am at present attending a lady in fever, whose pulse 
was 120, and respiration 26, until within the last twenty-four 
hours, since which respiration has increased to 40, but the pulse 
has sunk to 86. Now, is this lady’s state improved? Would you 
prefer having her in her present or past condition ? For my part, 
I will say that in such a case I would rather have the pulse than 
the respiration accelerated. A quickening of the breathing in fever, 
without any particular lesion of the thoracic viscera, is always a 
proof that the muscular powers of organic life have been injured ; 
that the diaphragm and respiratory muscles are impeded in their 
functions ; and that the case is of a dangerous character.1 
I do not know any point on which accurate observations are 
more wanting than on the proportion between the pulse and respi- 
ration in various states of the system, and in various diseases. 
Facts upon this subject might be easily collected, and would pro- 
bably lead to curious and instructive results. This would form an 
excellent subject for a monograph, and might be investigated by 
any student who possesses attention and perseverance, and has 
extensive opportunities for observation. Having touched upon the 
change in the frequency of the pulse produced by alteration of 
position, I may here remark that subsequent observations have 
confirmed the validity of the diagnostic mark which I was the first 
to draw from this circumstance in distinguishing functional from 
organic disease of the heart. The general proposition may now 
be considered as established, that in a debilitated person, when a 
sudden change of position makes little or no difference in the fre- 
quency of the pulse, we may conclude that the heart, or at least 
its left ventricle, is increased in size and strength. 
The following case of acute inflammation of the oesophagus is 
particularly worthy of your attention, on account of the extreme 
rarity of the disease, and because its symptoms have, for that reason, 
been either erroneously or imperfectly described by authors. 
My friend Dr. Mackintosh, in his Elements of Pathology (vol. i. 
p. 228), observes, “ That of all the structures in the human body, 
the oesophagus is perhaps the least liable to disease. In general it 
is difficult to detect inflammation of the oesophagus till ulceration 
and constriction take place. I have seen only one case of universal 
inflammation of this tube not caused by poison,” &c. 
It is no wonder, therefore, that the description Dr. Mackintosh 
gives of the oesophagitis is very imperfect. The same may be said 
of that given by others. The best description of the disease is 
that given by J. P. Frank in his Epitome. If I recollect right, 
Abercrombie has recorded one well-marked case of oesophagitis. 
Strange enough, this disease is not spoken of at all in that excellent 
work, the Cyclopaedia of Practical Medicine. 
The inflammation in the following instance was evidently the 
result of cold, and occurring in a healthy habit, it ran through its 
course in a few days. The case is in the gentleman’s own words, 
1 The lady referred to died. 128 
graves’s clinical lectures. 
for when the disease was cured I requested him to give me a short 
account of it in writing. 
“ February 24th, 1835.—For some days I felt as if I had caught 
cold, with something like sore throat. I felt as if the root of the 
tongue at the left side was sore. By degrees this extended down- 
wards ; a ring about the lowest part of the throat became painful 
on swallowing. The pain was most sensible at the left side. 
“ 26th.—I took a bit of bread before dinner, and, on attempting 
to swallow it, perceived great pain from the commencement of the 
throat, proceeding downwards towards the chest, as if the bread 
was then impeded by something, and from thence it seemed to pro- 
ceed with increased pain to the back between the shoulders. I felt 
no want of appetite at dinner, but the attempt to swallow caused 
considerable pain. The night was passed in a state of great rest- 
lessness and with headache, violent pain sometimes seizing me on 
some little change of position, as it does in lumbago. The pain then 
seemed to affect the whole chest, and, extending to the back, caused 
a hot, burning sensation directly between the shoulders. 
“27th.—On attempting to swallow, I felt such pain as to force 
me to cry out as if the entire passage from the throat to the stomach 
was inflamed, and that every thing, whether fluid or liquid, had to 
force its way painfully through the passage. In swallowing it 
seemed doubtful whether the food could proceed.” 
So far the details were furnished by the patient himself. In ad- 
dition I may remark that, on the 28th, the inflammation had evi- 
dently begun to diminish, and that in the course of a few days 
more it had entirely disappeared. The treatment was restricted to 
abstinence and antimonial diaphoretics. There was no redness to 
be seen in that part of the throat which is visible when the mouth 
is opened. 
LECTURE XII. 
Persesquinitrate of iron in chronic diarrhoea—Blueness of the fingers and toes in fever 
—Some account of the yellow fever which prevailed in Dublin in 1827—Newly ob- 
served affection of the thyroid gland in females—Its connection with palpitation ; 
with fits of hysteria—Erysipelas—Remarks on the formation of acidity of the stomach 
in indigestion—Psoriasis—Treatment by arsenic. 
Having lately used, with very considerable success, a preparation 
introduced by Dr. Christison, namely, the persesquinitrate of iron, 
I shall make a few observations here on its properties and use. 
The combination of iron with nitric acid forms a remedy pos- 
sessing tonic, and, at the same time, astringent powers, and hence 
peculiarly well adapted for the treatment of certain forms of chronic 
diarrhoea and dysentery. You will bq consulted by females of a 
delicate and weakly habit, who frequently exhibit symptoms of CHRONIC DIARRHOEA. 
129 
lietvous derangement, such as palpitations, sleeplessness, and 
headache, who are easily excited or alarmed, have a tendency to 
emaciation and paleness, and have little or no appetite. Combined 
with these general symptoms, you find that they have been labour- 
ing under diarrhoea for weeks, and even months, and that this, 
with the other causes of debility, has rendered their condition ex- 
ceedingly uncomfortable. You will also be informed by the patient, 
that she has tried many remedies without benefit, and that she is 
extremely anxious to have something done to give relief; and hence 
it is a matter of importance to be acquainted with any remedy 
which may be likely to prove serviceable in such emergencies. 
It would appear that this form of diarrhoea does not depend on 
an inflammatory condition of the stomach and intestinal canal, for 
the indications of inflammation are absent, such as pain, tenderness 
on pressure, thirst, redness of tongue, and severe or continued 
griping. It would rather seem to be connected with congestion of 
the mucous membrane of the digestive tube of a passive nature, 
and resembling the scrofulous; it is also of an unmanageable cha- 
racter, and very seldom amenable to the ordinary modes of treat- 
ment. The common astringent remedies totally fail ; chalk 
mixture, kino, rhatany root, and catechu, are useless, and in such 
cases it has been observed that opium is generally injurious. If 
you prescribe opium it certainly checks the disease for a time, but 
this temporary relief is accompanied by debility, malaise, restless- 
ness, and many other uneasy symptoms, and the diarrhoea soon 
returns, and is as bad as ever. The medicine which I have found 
most effectual in such cases, is the persesquinitrate of iron, in the 
form recommended by Dr. Christ.ison. With it I have succeeded, 
within the two last months, in curing two cases which had been 
exceedingly obstinate and of very considerable duration, the dis- 
ease having in one case resisted all the efforts of medical skill for 
seven months, and in the other for two years. Seven or eight 
drops of the liq. ferri persesquinitratis, increased gradually to twelve 
or fifteen in the course of the day, was the quantity prescribed in 
both cases. In the course of four days a slight diminution of the 
diarrhoea was perceived, in a fortnight the patient felt much better, 
and in a month or five weeks it had disappeared altogether. This 
took place without being followed by any bad effects; there was 
no swelling of the stomach, no tympanitis, no tormina, no restless- 
ness or nervous derangement; the patients recovered their health 
and strength, and the cure was at once safe and permanent. 
The effect of this remedy admits of an explanation on either of 
two grounds. You are aware that nitric acid exercises a very 
powerful influence over many morbid discharges. In chronic 
diarrhoea or dysentery, and in a certain form of diabetes, it is one 
of the most efficient and appropriate medicines which can be pre- 
scribed. We can therefore understand its peculiar adaptation to 
the case of which I have spoken. The nature of the complaint 
requires a tonic as well as an astringent; and you all know that 
nitric acid is used as a tonic in many cases attended with debility 
19—e . gr 9 130 
graves’s clinical lectures. 
and emaciation. With respect to iron, its mode of action is equally 
intelligible. Many of the salts of iron exert a very remarkable 
influence on the conditions of mucous membranes. The sulphate, 
tartrate, and many other preparations, are prescribed with great 
advantage in chronic fluxes from mucous membrane; hence the 
benefit so frequently derived from the use of Griffiths’ myrrh mix- 
ture in the treatment of chronic bronchitis characterised by a 
supersecretion from the bronchial membrane, unaccompanied by 
fever. You perceive, then, both the medicines which enter into 
the composition of persesquinitrate of iron are well calculated to 
check morbid discharges and strengthen the tone of the system. 
The only objection to this remedy is, that it is apt to spoil : if kept 
longer than a week it is decomposed, and hence you should always 
take care to have it quite fresh when you prescribe it, in order to 
secure its full operation. 
I have lately had occasion to observe the good effects resulting 
from a combination of nitric acid with vegetable astringents, in a 
little girl three years of age, in whose case I was consulted by Mr. 
Wallace of Townsend street. She was of a strumous habit; her 
appearance was that of a delicate but not very sickly child, and, in 
spite of the long continuance of the complaint, she was active and 
lively, although her appetite was small. Four or five times during 
the day, and six or seven during the night, she was seized with a slight 
griping pain, and a sudden desire to evacuate the bowels. Each eva- 
cuation was scanty, and consisting of muco-fmcal matter. A great 
variety of the usual remedies had been tried—alterative doses of mer- 
cury, purgatives, astringents, opiates, &c. I prescribed the following 
mixture, which had the happiest effect, and performed a speedy cure : 
R, Decocti haematoxyli (P. D.), g iv. 
Vini rubri Lusitanici, gj. 
Acidi,nitrici dilut. gtt. x. 
Tinctarae opii. gtt. v. 
M. sumat. coch. j. medium, quater in die. 
You will recollect that nitric acid, when given in large doses, often 
produces diarrhoea, as in the common combination of one dram of 
dilute acid with a pint of decoction of sarsaparilla. 
A man in the fever ward, who has had fever in a very severe 
form, has latterly presented a tendency to have the circulation de- 
ranged in a very peculiar manner in certain parts of his body. 
Soon after his admission the tip of the nose became of a bluish- 
black colour, and within the last two days his toes began to assume 
a similar hue. This is a very curious symptom, and demands a 
few observations. Here we find a small portion of the skin of the 
nose becomes injected, the blood stagnates in the capillaries, the 
parts assume a blue colour, and a kind of morbid desiccation takes 
place in the cuticle and a thin layer of the skin is thrown off, 
which is succeeded by the rapid formation of fresh cutaneous sub- 
stance. In the toes the disease is also superficial: it does not 
engage the whole depth of the skin, or reach the subcutaneous 
cellular substance, and it is surrounded by a margin of a vivid red BLUENESS OP THE FINGERS AND TOES IN FEVER. 
131 
colour at the line of demarcation. In both places the parts are 
tender to the touch, but there is no swelling. It is therefore a 
superficial disease, not likely to be followed by the death of the 
parts affected, and differing in this respect from that form of gan- 
grene in old persons which commences with a somewhat similar 
discoloration of the skin. 
Now, whence arose the blueness in this case ? It is difficult to 
give a satisfactory answer to this question, but we may arrive at 
something like a solution by examining the circumstances under 
'Which the superficial parts of the body undergo similar changes of 
colour. If you tie a thread round the first joint of the finger, you 
will observe that very soon after the circulation has been impeded, 
the top of the finger will become blue, and, in the same proportion, 
painful. Here we produce artificially a state of the top of the 
finger bearing a very remarkable analogy, so far as pain and change 
of hue are concerned, to the state of the nose and toes in this 
patient. Again, we find that without any artificial obstruction the 
influence of certain physical agents will generate in the vessels of 
various parts of the body a state of circulation closely resembling 
that which is the result of the impediment produced by art. Thus, 
sharp cold, as you all know, will produce blueness and a painful 
state of the integuments of the nose, fingers, and other parts of the 
body. I remember a very curious case of this kind which con- 
tinued for a very considerable time; the patient was for several 
weeks in the Meath Hospital. He was a groom or helper in a livery 
stable, and being obliged to have his hands almost constantly in 
cold water at an inclement season of the year, the capillaries of the 
tips of the fingers in both his hands became so deranged in their 
condition, that they did not recover their proper degree of vitality 
and tone for many months. When he permitted his hands to hang 
for any length of time, or when they were exposed to the ordinary 
winter temperature of the air, the pain and blueness increased to a 
considerable degree, but if he held them up or plunged them into 
tepid water, the pain ceased, and the blueness became much dimi- 
nished, or even went away altogether. 
These considerations will furnish a key towards understanding 
the cause of the blueness in this case. With respect to the treat- 
ment, 1 may observe, that in such cases we have seen the best 
effects from artificially depleting that portion of the vascular system 
in which the local congestion and pain are seated. If a ligature 
were tied round your finger, and you wished to relieve the pain 
and reduce the congestion, without removing the artificial cause 
of the obstruction, you would apply leeches to the part, and thus 
give relief. It was on this principle that I was induced to apply 
leeches to those parts in which a change of colour and an impair- 
ment of sensibility appeared to be connected with some obstruction 
in the capillary system. You will recollect that this man’s toes 
were better after being leeched, and so far the practice appears to 
be borne out by the result of experience. You should not in such 
cases be led away by jthe theory of our ancestors, who referred this 132 
graves’s clinical lectures. 
condition of parts to vascular debility. A vast deal has been said 
and written with respect to the state of the capillaries in disease; 
some say. that to restore the healthy action of a part we must de- 
bilitate ; others, that we must excite the capillaries. This point 
has engaged the talents of Dr. Thomson, Dr. W. Philip, and 
several other writers, but it still remains undecided, nor do I think 
it can ever be settled. For my own part, I. am satisfied with being 
able to discover the means of relieving disease, and give myself 
very little trouble about theoretical questions, which seem, under 
existing circumstances, to be placed beyond the reach of human 
intellect. In the case before us, the modes which were most suc- 
cessfully employed were leeches, emollient poultices, and fomenting 
the parts with tepid water. 
We do not often witness this blueness of the integuments in the 
fevers of Dublin ; during the epidemic of 1827, however, it was a 
matter of frequent occurrence. That epidemic was also very re- 
markable in many other points of view; it was, if I may so express 
myself, a bad gastro-typhus. It was a fever in which the chief 
seats of congestion and disease were the stomach and small intes- 
tine ; at the commencement the re-action of the system was exceed- 
ingly violent, but this subsided very quickly, and was followed by 
a stage of awful prostration. The chief interest, however, attached 
to it, arose from the circumstance of its forming a very striking 
link of connection between the ordinary gastric fever of Ireland 
and the yellow fever of warm countries. The phenomena which 
characterised this epidemic convinced me, and every one who wit- 
nessed it, that the common gastro-typhus of this country, and the 
yellow fever of America, Gibraltar, and other places, differ only in 
degree and not in nature. The disease set in with all the usual 
symptoms—violent heat of skin, a quick small pulse, sweating, rest- 
lessness, thirst, nausea, and abdominal tenderness; this state of 
things went on for two or three days, and then the patients became 
suddenly and universally jaundiced. The symptoms now began 
to assume a greater degree of malignity; vomiting came on; a large 
quantity of dark-coloured substance, resembling coffee grounds, 
was thrown up, and the ease most commonly had a fatal termina- 
tion. Here, you perceive, we had yellow fever with black vomits 
1 examined the bodies of about twenty-five persons who died in 
this hospital, and found that the intestinal canal presented an exact 
fac-simile of the morbid appearances described by Jackson, Ban- 
croft, and various other writers on yellow fever. 
In that fever I had frequent opportunities of observing the change 
in the capillaries of the part, which accompanied the appearance of 
blueness of the nose. To a person who saw the patient with his 
nose of the natural hue this morning, and found it quite blue on 
the next, the change appeared strange and unaccountable ; but, as 
I spent a great portion of my time in the wards, I had an opportu- 
nity of marking the transition, and detecting the modifications 
which preceded blueness. The part about to become blue became 
altered in a very singular manner. It first became elevated in its 133 
temperature, but at the same time it grew paler. I cannot explain 
this. Increased heat would seem to prove the existence of increased 
vascularity—fading of colour would seem to prove decrease of vas- 
cularity. Notwithstanding this, these apparently incompatible states 
co-existed; the parts were blanched, and at the same time felt hot 
to the touch. Where the nose was about to become blue, it first 
assumed a yellowish white colour, and looked very like a wax nose ; 
in the course of six or eight hours this appearance subsided, and it 
became red; and after a short time this colour was replaced by a 
purple or dark blue tinge. The same order of phenomena took 
place with respect to the toes, and in a few cases the disease ap- 
peared in the fingers. Such cases were ordinarily accompanied by 
so bad a state of febrile symptoms, that the patients seldom reco- 
vered; indeed, they died so soon after its supervention, that we had 
no opportunities of observing what course it would take, or how it 
would terminate. The appearance which patients labouring under 
this affection exhibited, was very extraordinary; they were all 
deeply jaundiced, and the deep yellow of the face made a singularly 
hideous contrast with the indigo blue of the nose.1 
With respect to the vomiting a substance resembling coffee 
grounds, so frequently observed in this epidemic, I may state that 
it appeared to be identical in its nature with the black vomit of 
yellow fever. You are aware that the matter rejected under such 
circumstances is produced by an oozing of blood from the surface 
of the stomach and duodenum. A quantity of blood is poured out 
from the diseased surface of the mucous membrane of the stomach; 
this remains in the stomach for some time, and coagulates; the 
secretions of that organ act on it, and change it to a black colour, 
in which state it is thrown up. This is the case in yellow fever, 
and such also was the origin of the black vomit in the fever of 1827. 
I may observe, that in that epidemic, as well as in the present, a 
close enquiry into the history of numerous cases has convinced me 
that the gastro-typhus of this country, as well as the yellow fever 
of warmer latitudes, may arise spontaneously, and be propagated 
by contagion. This, I believe, is a fact which every physician who 
has seen much of fever has not the slightest doubt of. We have 
all repeatedly seen instances of persons catching cold while the 
system was in a relaxed or debilitated state; we have seen this 
cold followed by violent feverish symptoms, and we have observed 
these symptoms pass gradually into fever of a typhus character, 
and capable of being propagated by contagion. So many examples 
of this have now occurred, that there can be no doubt that fever 
may arise spontaneously—that it may become in this way sporadic, 
and finally epidemic. At certain periods, it appears to be a matter 
of very little consequence, with regard to the mass of society in 
general, how many sporadic cases of this description may occur; 
YELLOW FEVER. 
1 The remarkable epidemic fever of 1827 was described in a monograph 
printed by me and Dr. Stokes for the use of the students of the Meath 
Hospital. 134 
graves’s clinical lectures. 
but at other periods, and under a certain state of atmosphere, the 
disease becomes extensively diffused, and assumes the character of 
an epidemic. Here each individual case proves a centre of con- 
tagion, from which the disease spreads on every side. On the other 
hand, fever may originate spontaneously, assume a typhoid charac- 
ter, and yet produce no contagion. Recollecting these circum- 
stances, you will be able to reconcile the conflicting opinions of 
those who have argued so hotly respecting the nature of yellow 
fever; some asserting that it is always contagious—others, never. 
The fact is, that both are right and both wrong; fever may origin- 
ate spontaneously and without contagion, but it may also be pro- 
duced by contagion, and it may, under one class of circumstances, 
run through its course without being communicated to others; 
whereas, under a different state of things, each case becomes a 
centre from which the disease spreads on every side. In the pre- 
sent epidemic of maculated or spotted fever, the contagious nature 
of the disease was strongly exemplified—for more than twenty of 
the students, who were in the habit of visiting the fever wards in 
the Meath Hospital, were attacked with spotted fever in the course 
of two months. Although the disease was very violent in many, 
and serious in all, Dr. Stokes and I lost but one of these students; 
we had every reason, therefore, to congratulate ourselves on the 
success of the treatment we employed. I shall return to this sub- 
ject hereafter. 
—I have lately seen three cases of violent and long-continued 
palpitations in females, in each of which the same peculiarity pre- 
sented itself—viz., enlargement of the thyroid gland; the size of 
this gland, at all times considerably greater than natural, was subject 
to remarkable variations in every one of these patients. When the 
palpitations were violent, the gland used notably to swell and 
become distended, having all the appearance of being increased in 
size, in consequence of an interstitial and sudden effusion of fluid 
into its substance. The swelling immediately began to subside as 
the violence of the paroxysm of palpitation decreased, and during 
the intervals the size of the gland remained stationary. Its increase 
of size, and the variations to which it was liable, had attracted 
forcibly the attention both of the patients and of their friends. 
There was not the slightest evidence of any thing like inflamma- 
tion of the gland. One of these ladies, residing in the neighbour- 
hood of Black Rock, was seen by Dr. Harvey and Dr. William 
Stokes; another of them, the wife of a clergyman in the county of 
Wicklow, was seen by Dr. Marsh; and the third lives in Grafton 
street. The palpitations have in all lasted considerably more than 
a year, and with such violence as to be at times exceedingly dis- 
tressing ; and yet there seems no certain grounds for concluding 
that organic disease of the heart exists. In one, the beating of the 
heart could be heard during the paroxysm at some distance from 
the bed—a phenomenon I had never before witnessed, and which 
strongly excited my attention and curiosity. She herself, her friends, 
and Dr. Harvey, all testified the frequency of this occurrence, and AFFECTION OF THE THYROID GLAND. 
135 
said that the sound was at times much louder than when I exa- 
mined the patient, and yet I could distinctly hear the heart beating 
when my ear was distant at least four feet from her chest! It was 
the first or dull sound which was thus audible. This fact is well 
worthy of notice, and when duly considered appears to favour the 
explanation, lately given by Magendie, of the causes of the sounds 
produced during the heart’s action ; for none of those previously 
proposed seem to me capable of accounting for a sound so loud and 
so distinct. But to return to our subject. The sudden manner in 
which the thyroid, in the above three females, used to increase and 
again diminish in size, and the connection of this with the state of 
the heart’s action, are circumstances which may be considered as 
indicating that the thyroid is slightly analogous in structure to the 
tissues properly called erectile. It is well known that no part of 
the body is so subject to increase in size as the thyroid gland, and 
not unfrequently this increase has been observed to be remarkably 
rapid, constituting the different varieties of bronchocele or goitre. 
The enlargement of the thyroid, of which I am now speaking, 
seems to be essentially different from goitre in not attaining a size 
at all equal to that observed in the latter disease. Indeed, this en- 
largement deserves rather the name of hypertrophy, and is at once 
distinguishable from bronchocele by its becoming stationary, just 
at that period of its development when the growth of the latter 
usually begins to be accelerated. In fact, although the tumour is 
very observable when the attention is directed to it, yet it never 
amounts to actual deformity. The well-known connection which 
exists between the uterine functions of the female and the develop- 
ment of the thyroid observed at puberty, renders this affection 
worthy of attention, particularly when we find it is so closely 
related by sympathy to those palpitations of the heart which are of 
so frequent occurrence in hysterical and nervous females. 
Another fact well worthy of notice is that females liable to attacks 
of palpitation almost invariably complain of a sense of fulness, re- 
ferred to the throat, and exactly corresponding to the situation of 
the thyroid. This sensation only continues while the paroxysm of 
palpitation lasts, and frequently is so urgent as forcibly to attract 
the patient’s notice, who now complains of its inducing a sense of 
suffocation. Here the interesting question occurs, whether this feel- 
ing of something that impedes the respiration at the bottom of the 
throat, during the hysterical fit, and which has been included under 
the general term globus hystericus—the question arises, I say, 
whether this feeling is always of purely nervous origin. To me it 
appears probable that it is often induced by the pressure arising 
from a sudden enlargement of the thyroid, which enlargement sub- 
sides as soon as the fit is over. Of this I am certain, that the lump 
in the throat, of which such females complain, is often exactly re- 
ferred to the situation of the thyroid ; and, indeed, I have been told 
by other practitioners, upon the accuracy of whose observations I 
can rely, that this swelling in the throat of females during the hys- 
teric paroxysm has more than once excited their wonder. It is 136 
graves’s clinical lectures. 
obvious that if palpitations depending on functional disease of the 
heart are capable of exciting this swollen state of the thyroid, we 
may expect to observe the tumefaction of this gland also where the 
palpitation depends on organic disease of the heart, as in the fol- 
lowing case detailed to me by a friend. 
A lady, aged twenty, became affected with some symptoms which 
were supposed to be hysterical. This occurred more than two 
years ago; her health previously had been good. After she had 
been in this nervous state about three months, it was observed that 
her pulse had become singularly rapid. This rapidity existed with- 
out any apparent cause, and was constant, the pulse being never 
under 120, and often much higher. She next complained of weak- 
ness on exertion, and began to look pale and thin. Thus she con- 
tinued for a year, but during this time she manifestly lost ground 
on the whole, the rapidity of the heart’s action having never ceased. 
It was now observed that the eyes assumed a singular appearance, 
for the eyeballs were apparently enlarged, so that when she slept, 
or tried to shut her eyes, the lids were incapable of closing. 
When the eyes were open, the white sclerotic could be seen, to a 
breadth of several lines, all round the cornea. In a few months, 
the action of the heart continuing with unceasing violence, a tu- 
mour, of a horseshoe shape, appeared on the front of the throat and 
exactly in the situation of the thyroid gland. This was at first soft, 
but soon attained a greater hardness, though still elastic. From 
the time it was first observed, it has increased little, if at all, in size, 
and is now about thrice the natural bulk of the fully developed 
gland in a female after the age of puberty. It is somewhat larger 
on the right side than on the left. A circumstance well worthy of 
notice has been observed in this young lady’s case, and which may 
serve to throw some light on the nature of this thyroid tumefaction. 
The circumstance I allude to is, that from an early period of the 
disease a remarkable disproportion was found to exist between the 
beats of the radial and of the carotid arteries, the pulsations of the 
former being comparatively feeble, while those of the latter were 
violent, causing a most evident throbbing of the neck, and accom- 
panied by a loud rustling sound. In about fourteen months the 
heart presented all the signs of Laennec’s passive aneurism; the 
tumour in the neck is subject to remarkable variations in size, 
sometimes diminishing nearly one half. None of her family have 
had goitres, nor was she ever in any of the usual localities of the 
disease. 
Some time ago, you will recollect, we had a case of erysipelas in 
a young woman, which came on towards the termination of fever; 
a similar occurrence has taken place in a patient in the male fever 
ward. A man who has been for some time labouring under fever, 
got, about two days since, an attack of erysipelas of the scalp, 
spreading downwards over the neck and shoulders. The man had 
been ill of fever of a nervous type, and unaccompanied by any de- 
cided marks of visceral congestion ; his condition was to a certain 
extent modified by previous habits of intemperance, but still his ERYSIPELAS. 
137 
strength was not much prostrated, nor did he appear to be in a very 
dangerous state. About the fourth week of his illness he gets an 
attack of erysipelas of the scalp, which runs downwards over the 
neck and shoulders, and threatens very dangerous if not fatal con- 
sequences. How were we to treat this case? The man’s consti- 
tution, habits, and the period of his fever, contra-indicated depletion 
in any form, and the only thing which we could expect benefit 
from, was the use of sulphate of quinine, which we had prescribed 
in two former cases of this kind with good effects. We gave it 
here, also, in the form of an enema, for the state of the man’s sto- 
mach was such as to preclude the possibility of giving it by the 
mouth without hazard. An enema, composed of five grains of qui- 
nine, five drops of laudanum, and two or three ounces of mucilage 
of starch, was injected three times a day. I cannot as yet state 
what the result of this case may be, but the disease is certainly not 
progressing, and the man says he feels better to-day, so that there 
are grounds to hope for a favourable termination. 
Internally I have given the man magnesia with camphor mixture, 
on an empirical principle. It has been stated by some of the older 
writers, that when erysipelas occurs in a weak habit, or supervenes 
on other diseases, that there is an acescent condition of the stomach, 
and that it is on this condition the erysipelatous tendency chiefly 
depends. I have with this view been induced to try the exhibition 
of small doses of magnesia; I have ordered a mixture composed of 
six ounces of camphor mixture with a dram of magnesia, of which 
the patient is to take an ounce every second hour. 
I may take this opportunity of observing that, since I published 
some remarks in the Dublin Medical Journal, upon the occasional 
symmetrical march of erysipelas at both sides of the median line, I 
have seen other examples of this symmetry. One occurred very 
lately in Sir P. Dun’s Hospital, in a woman in whom the point of 
departure for the disease was the face. From this, the erysipelas 
spread over the scalp, and then advanced downwards over the 
neck and shoulders. During its daily progress, I pointed out to 
the students how precisely its outline at one side of the median line 
corresponded with that at the other. This coincidence was the 
more singular, for the boundary of the advancing erysipelas was at 
each side very irregular in form. I think, therefore, that more 
accurate observations on this subject will cause a change of opinion 
in the mind of a learned reviewer in Johnson’s Medico-Chirurgical 
Review. 
There is another case, in which I gave magnesia to a man la- 
bouring under a particular species of indigestion. He had been for 
a long time suffering from chronic rheumatism, and this was com- 
bined with dyspepsia, characterised by a tendency to supersecretion 
of acid in the stomach, with gastrodynia and sour eructations. In 
addition to anti-rheumatic medicines, and enemata to keep the 
bowels open, we prescribed the subnitrate of bismuth with magnesia, 
for the purpose of relieving pain and acidity. In gastrodynia, with 
increased secretion of acid from the stomach, one of the best reme* 138 
CLINICAL LECTURES. 
dies we possess is the subnitrate of bismuth, with which I am in 
the habit of combining morphia, or, as in the present case, mag- 
nesia. I ordered ten grains of magnesia, twenty of powdered gum 
arabic, and six of the subnitrate of bismuth, to be taken two or 
three times a day, according to circumstances : this powder was to 
be followed by a tablespoonful of water, containing one sixteenth of 
a grain of muriate of morphia. In such cases, if milk does not 
disagree with the patient, you may pour the powder into a quantity 
of boiled milk ; allow it to cool, and then stir it with a spoon, and 
make the patient swallow it. The gum arabic is used for its de- 
mulcent properties, and because it enables the patient to swallow 
the powder with more facility; and the fluid in which you mix the 
powder, whether it be water or milk, is to be used warm in order 
to dissolve the gum more speedily. This is a very good combina- 
tion, and I have seen many cases of dyspepsia, with acid eructations, 
which had resisted bismuth, prussic acid, or morphia, given singly, 
yield to it. 
I need not state to you the reasons why magnesia and other 
antacid remedies are given in such cases, but it may be necessary 
to mention briefly the principle on which opiates are prescribed. 
Dr. Elliotson has shown, that many of the morbid states of the 
stomach depend on deranged nervous energy, and that in such 
cases the most efficient means we can use are narcotics. As to 
the subnitrate of bismuth, its mode of action is not very obvious ; 
but we know that the metallic salts possess great influence over 
various nervous diseases, as well as over morbid secretions. Wit- 
ness the effects of carbonate of iron, oxide of zinc, the preparations 
of arsenic and antimony, and several others. On this account we 
prescribed the subnitrate, hoping to derive some benefit from its use, 
as well with respect to checking the sour eructations, as to relieving 
the gastrodynia. It may be well to make a few observations in 
explanation of the manner in which tonics and narcotics act in 
diseases of the stomach. Formerly physiologists were of opinion, 
that in weakly stomachs the act of digestion was accompanied by 
the formation of acid and flatulence, because the food being imper- 
fectly acted on was allowed to undergo the process of fermentation, 
a process which gave rise to the acid and the wind in the stomach. 
In compliance with this view, physicians endeavoured to procure 
relief in these cases by prescribing a regimen little likely to undergo 
a fermentation capable of causing a production of either air or acid; 
and they endeavoured to neutralise the bad effects of these, when 
produced by means of the administration of alkaline medicines. 
They used, however, to be astonished at observing that many arti- 
cles of food, which outside the body never formed any acid during 
fermentation, (or more properly putrefaction,) occasioned, never- 
theless, when eaten, as much acidity in the stomach as any other 
aliments. 
Tt was remarked also by practical men, that although present re- 
lief was obtained by means of alkalies, yet their constant exhibition 
seemed rather to increase than diminish the tendency of the forma- PSORIASIS. 
139 
tion of acid in the stomach. This fact could not be explained in the 
then state of physiology. In the year 1821, I read an essay on this 
subject before the Association of the King and Queen’s College of 
Physicians, in whose transactions it was subsequently published. In 
this essay I pointed out the true source of the acidity and flatulence 
observed in dyspepsia, and proved, contrary to the received opinions, 
that it was the result of a morbid secretion. In fact. I showed that 
the stomach has the power, when in health, of secreting acids and 
air, both essentially necessary for the solution of the alimentary 
mass; and I proved that in dyspepsia this power is morbidly de- 
ranged, in such a manner as to give rise to a supersecretion of acids 
and air. This view of the subject was soon recognised to be cor- 
rect, and, in consequence new methods of treating dyspepsia were 
proposed. Among the proposals for obviating acidity, that of Dr. 
Elliotson, who recommended prussic acids and other narcotics 
capable of acting upon the nerves of the stomach, (through the 
influence of which secretion is effected,) was found to be the most 
successful, and has been sanctioned by the most extensive expe- 
rience. 
Before I conclude, I shall call your attention to the case of Ellen 
Farrow, who has been for a considerable time labouring under ex- 
tensively diffused psoriasis. She was admitted about the beginning 
of last November, and we are now come to the 10th of December ; 
so that she has been a patient here for nearly six weeks. Her dis- 
ease is of better than two years’ standing, and the eruption covered 
almost every part of the surface of the upper and lower extremities, 
the trunk remaining unaffected. The patient, you perceive, is a 
fine healthy country girl, and though the complaint has lasted so 
long, her system does not seem to be in the slightest degree im- 
paired ; appetite, digestion, and sleep are perfectly good. Now, on 
examining her soon after her admission, you will recollect that I 
told you that the duration of the disease, the absence of constitu- 
tional irritation, and of irritation in the parts affected by psoriasis, 
all contra-indicated a mode of treatment which frequently proves 
highly useful, namely, the antiphlogistic. If called to a case in 
which the disease was recent, and attended with heat of skin, red- 
ness and itching, I would bleed, leech the affected parts, and put 
the patient on a spare diet. Even in some cases of a chronic cha- 
racter, this treatment may be employed with great advantage. 
Here, however, the state of the patient was such as not to require 
antiphlogistics, and accordingly we put her on the use of Fowler’s 
arsenical solution. By the way, when you give this remedy in 
private practice, where patients or their friends are very curious in 
scanning your prescription, you may, in order to prevent alarm, or 
have the action of the medicine interfered with, write on your pre- 
scription—“ Liquor mineralis Fowleri.” 
I mention this case of Farren’s chiefly for the purpose of showing 
the extent to which the arsenical solution may be carried. Mind, 
I do not mean to boast of the quantities of medicine my patients 
swallow. Some persons appear to think that there is something 140 
graves’s clinical lectures. 
very brilliant in prescribing enormous doses: I should, however, 
be very sorry to make such experiments. Arsenic is a very power- 
ful remedy, and its effect on diseases of the skin can be amply 
secured by moderate doses; where these fail, it is very often from 
not continuing the use of the remedy for a sufficient length of time. 
Latterly this girl has been taking ten drops of Fowler’s solution 
three times a day, and, as she is getting well, I do not intend to 
increase the dose. We began with three drops three times a day : 
after a few days this was increased to five, and then to seven drops 
three times daily. She then began to take ten drops three times a 
day; but after a few days having got an attack of shivering, fol- 
lowed by symptoms of feverish excitement and herpes labialis, we 
stopped the arsenic for five days, and then began to give it again 
in small doses, which were gradually increased until we came to 
the quantity she is taking at present. Whenever you have a pa- 
tient under the use of arsenic, you must never omit making daily 
enquiries as to the state of the head and stomach : if the patient 
complains of gastrodynia or nausea, if there be pain or giddiness of 
head, or if, these being absent, a state of feverishness or general 
nervous excitement supervene, it is a proof that the remedy has 
been pushed sufficiently far, and under such circumstances you 
should suspend or give up its employment. In this case, being 
unwilling to give up the use of arsenic, as it appeared to be curing 
the patient, I merely suspended it for a few days, and then had 
recourse to it again. In order, however, to prevent it from acting 
unfavourably on the stomach, I have latterly prescribed it in the 
following form:— 
R. Liq. arsenicalis, M. x. 
Aquae dislillatae, 3 j- 
Tinct. opii, M. x. 
Spirit, lavandulae, compos. 3 ss.—ft. haust. 
This appears to agree very well with the stomach ; and as she is 
improving very rapidly, I intend to continue it for some time with- 
out increasing the dose. 
The only other point worthy of remark in this case is, that we 
observed in it a phenomenon connected with the state of the skin, 
such as usually occurs when a patient is using sulphur or sulphur- 
eous waters for the cure of chronic cutaneous affections. After they 
have been taking these remedies for some time, they experience a 
slight exacerbation of symptoms, and complain that the eruption is 
growing worse. This, however, should never induce you to give 
up the remedy without further trial; for this temporary aggravation 
generally precedes the disappearance of the disease. 
We dismissed a case of dysentery lately from our wards, con- 
cerning which I promised to make a few observations. During the 
months of August and September last, we had in Dublin several 
cases bearing a decided analogy to the dysentery of Cullen. There 
were fever, griping, tenesmus, a constant inclination to go to stool 
without being able to pass any thing but a little mucus and blood, 
and occasionally scybala. In this form of disease, some authors DYSENTERY. 
141 
are inclined to attribute all the bad symptoms to the presence of 
these scybala, which are small hard lumps of faecal matter, evi- 
dently formed in the sacculi of the great intestine. You will find 
others asserting that this cannot be the case; for in many dysen- 
teries there are no scybala at all, and that, even when they do occur, 
they have no connection with the disease. The latter take no ac- 
count of scybala, while the former state that the diseased condition 
of the intestine depends upon the irritation produced by them, and 
that you never can expect to cure the disease without getting rid of 
them by active purgatives. For my part, I believe that there are 
certain dysenteric states of the great intestine, in which the main 
cause of the disease arises from the lodgment of quantities of hard, 
unhealthy, and long retained fascal matter ; but in cases of epi- 
demic dysentery, I do not think that scybala have any thing to do 
with the formation of the disease, or the aggravation of its symp- 
toms. 
Ill the present case, the affection appears to have been pure rectile 
dysentery, depending almost exclusively on inflammation of the rec- 
tum, not extending to the sigmoid flexure of the colon, and certainly 
never as far as its arch. The symptoms present were fever, in- 
creased heat of skin and quickness of pulse, with a feeling of heat 
and pain in the situation of the rectum ; for the first day the dis- 
charges consisted of mucus and blood, combined with fascal matter, 
but after this the mucus and blood were voided alone with great 
griping and tenesmus, and the patient was obliged to get up to the 
night chair thirty times in the course of twenty-four hours. There 
was, however, no symptom indicating that any portion of the intes- 
tine beyond the rectum was affected. Now, what was the con- 
sequence of this state of things? The inflammation of the rectum 
gave rise to constant spasm of that organ ; the colon partook more or 
less in its spasmodic action, and hence every attempt to pass the 
stools was resisted. Here, however, the faeces lay in a portion of 
the intestine free from inflammation; they could not produce any 
aggravation of the symptoms, and the scybala were to be looked 
on as the consequence and not the cause of the disease. Now, whe- 
ther purgatives were given by injection, or by the mouth, they 
would have done no good in such a case as this ; we might have 
copious faecal discharges, but without the slightest diminution of the 
local symptoms, I do not mean to say that there are not dysente- 
ries in which purgatives are highly useful, but in the case before us, 
where the disease was limited to the rectum, I did not think that 
any benefit could be derived from them. I confined my attention, 
therefore, entirely to local means directed to the part inflamed, ap- 
plied leeches to the anus, gave narcotic and emollient enemata, and 
after I had in this way relieved pain and irritation, I combined with 
the enemata, first, a small quantity of the acetate of lead, with the 
view of restoring the tone of the relaxed mucous membrane, and 
afterwards changed it for the sulphate of zinc. Under this treat- 
ment the case went on very favourably, and we have been able to 
dismiss the man in a very short space of time, 142 
graves’s clinical lectures. 
LECTURE XIII. 
Case of long continued nervous fever; remarks on—Pleuro-pneumonia—Cases of 
latent pleurisy ; of pneumonia—phthisis; latent ulceration of the bowels in—Diar- 
rhoea of phthisis—Observations on the stammering of paralytic persons—Its expla- 
nation—Very remarkable case of stuttering cured by chronic laryngitis—Treatment 
of hoarseness—Velpeau’s new method of treating sore throat. 
Permit me to make one or two observations on a case of which 
I have already spoken, and which, as I expected, has terminated 
fatally. A man, named Lynam, has been lying ill for a long time 
in the large fever ward ; I wrote at the top of his card “ Nervous 
Fever,” and remarked to the class, that his disease was pure fever 
of a nervous type, unaccompanied by any symptoms indicating 
decided local inflammation. You will recollect that his symptoms 
were heat of skin, quick, weak, compressible pulse, thirst, watch- 
fulness, and low muttering delirium, unattended by any apprecia- 
ble sign of visceral disease, or any symptoms denoting a putrescent 
state of the fluids. It was not congestive or putrid, or gastro- 
enteric, or petechial fever; neither could it be called a cerebral 
fever; it was only by separating from it the idea of each of these 
species, and by studying its negative characters, that you could 
arrive at something like an accurate conception of the type of the 
disease. It was, as I have already stated, nervous fever, modified 
by the patient’s previous habits of long continued intemperance. 
When a patient, addicted to intemperate habits, gets an attack of 
fever from cold, fatigue, or exposure to contagion, you will gene- 
rally find the disease will exhibit a compound or mixed character, 
the phenomena of fever being combined with those of delirium 
tremens. And so it was in this case ; the man had general tremors, 
with persistent watchfulness, and muttering delirium. 
His treatment consisted in the employment of medicines calcu- 
lated to soothe the nervous system, and I kept a constant watch 
over the state of the principal viscera. About a week after he came 
under my care, and about five weeks from the commencement of 
his fever (for he was nearly a month ill before he came to the hos- 
pital), he was attacked with erysipelatous inflammation of the face 
and scalp. The disease commenced on the face, and, traveling 
upwards, very rapidly attacked the whole scalp and back of the 
neck, its progress being accompanied by great aggravation of 
symptoms. At that time I remarked to the class that I did not en- 
tertain any apprehensions of a metastasis of the erysipelas, that 1 
had no fears of the supervention of inflammation of the brain, and 
its train of alarming consequences ; but that no good was portended 
by this attack of cutaneous inflammation, and no relief of the in- 
ternal parts could be expected from it, for every symptom appeared 
aggravated from the moment that the erysipelas commenced. 1 
pointed out the total inadmissibility of any thing like vigorous or 
antiphlogistic treatment, in a case where the disease had appeared 
in an individual of broken constitution, labouring under a combi- 
nation of delirium tremens with low fever ; and said that even the NERVOUS FEVER. 
143 
remedy which we had found most successful in similar cases, 
namely, sulphate of quinine and opium, offered but a feeble hope 
of arresting the malady. It failed, as we expected, and the man 
died yesterday, worn out by long suffering and exhaustion. Eigh- 
teen hours after death we made a most careful examination of all 
the viscera of the three great cavities ; not a single organ exhibited 
the least mark of inflammation ; we could not find any where even 
the slightest trace of local congestion. The man had all his viscera 
in an apparently sound and normal condition, and died of pure 
nervous fever. 
Some persons look upon the existence of fever independent of 
topical affections as purely imaginary, and deem those, who have 
recorded such forms of disease, as too ignorant, or too lazy, to 
make the necessary pathological investigations. I have not time 
at present to enter into this subject, but of nothing am I more con- 
vinced, than that fever may exist without any appreciable local 
lesion, that it may affect every organ and every tissue of the body 
alike, and yet that the most accurate symptomatologist cannot lay 
his finger on any one single part and say, here is local inflamma- 
tion of a decided character. I have met with many instances con- 
firmatory of this fact in hospital practice. I recollect a case which 
occurred some time ago at this hospital, which was equally remark- 
able for its extraordinary duration, as for the total absence of any 
thing like visceral lesion. The patient was admitted into the small 
fever ward, labouring under an attack of nervous fever; he had 
thirst, hot skin, pulse from 110 to 120, occasional delirium and 
watchfulness, and these symptoms went on week after week, and 
month after month, unaccompanied during the whole course of the 
disease by any phenomena indicating the existence of local inflam- 
mation. His treatment was purely expectant and temporising ; we 
had no cerebral, abdominal, or thoracic lesion to combat; there 
was no organ in which the febrile derangement could be said to 
have fixed itself exclusively, no threatening disorganisation calling 
for the prompt employment of new and energetic means. At last, 
after the fever had continued for very nearly three months, the man 
complaining all the time of more or less thirst, hot skin, watchful- 
ness, and headache, with occasional delirium, the disease termi- 
nated in a well marked crisis, accompanied by sweating. He fell 
asleep, began to perspire, awoke with a pulse nearly reduced to 
the natural standard, and perfectly recovered. I may observe that 
I have never seen fever last so long as this, nor have I ever observed 
a perfect crisis in any case after the forty-second day. Some time 
ago I attended the brother of a gentleman now present, who had 
a long and very severe attack of fever; though he never had a 
remission during his illness, and was in very urgent danger, he got 
a perfect crisis with profuse perspiration on the forty-second day, 
and is now in the enjoyment of excellent health. 
You perceive then, that the case of Lynam presents some cir- 
cumstances worthy of notice. His fever went on to its termination 
without any symptoms of inflammation in any viscus, and his actual 144 
GKAVES’s CLINICAL LECTURES. 
condition, as carefully ascertained by an accurate post-mortem exj 
animation, affords a useful lesson to the pathologist. His case is 
also interesting as showing how previous habits will modify in a 
remarkable degree the character of fever; for in him you have 
seen fever combined with the phenomena of delirium tremens, a 
state of things which it was natural to expect in a man of extremely 
intemperate habits. The termination of the erysipelas without 
any sign of disorganisation within the cranium is also worthy of 
notice. In such cases you have it frequently followed by inflam- 
mation of the brain and its membranes, and an exudation of pus 
on the surface of one or both the hemispheres ; but here you per- 
ceive that there has been no extension of the disease, or nothing 
that should have induced us to give up the plan of treatment we 
adopted, and direct our therapeutic means to the head. 
Let me now direct your attention to another topic. You have 
seen that a principal feature in the character of the present pneu- 
monia is its complication with pleuritis ; we have had several cases 
of inflammation of the lungs, combined with inflammation of their 
investing membranes, but I do not recollect that we have had a 
single case of pure pleuritis, or pure pneumonia. In the patient 
who lies at present in the chronic ward, labouring under pleuro- 
pneumonia, the inflammation occupied the superior part of the 
right lung in the first instance, and this is rather remarkable, as 
pneumonia generally commences in the lower part of the lung. 
Here, however, the pneumonia and pleuritis were located above, 
each being in point of extent nearly of the same dimensions, the 
portion of inflamed lung corresponding in its area to the portion 
of pleura engaged in the disease. Soon after his admission we 
found that the inflammation was making further progress, but its 
spreading was attended with this remarkable peculiarity, that while 
the pleuritic inflammation in the superior part of the right side of 
the chest became limited and ceased to extend itself, the pneumonic 
inflammation commenced traveling downwards and backwards, so 
that after two or three days we had pleuro-pneumonia in the upper 
part of the lung, and further down in the lower and back part of 
the lung it was merely pneumonia unaccompanied by pleuritis. 
This is an occurrence which I have frequently witnessed, that when 
pleuritis and pneumonia co-exist, the latter will spread, often in 
spite of all our efforts, while the former remains stationary. I wish 
to impress this fact on your minds, that pleuritis never exhibits 
such a tendency to extend itself gradually, day after day, as pneu* 
monia; if the pleura becomes inflamed, the extent to which it is 
likely to be engaged will be determined in twenty-four hours; 
whereas, in cases of pneumonia, the disease, though limited at the 
commencement to one or two small insulated spots, will frequently 
begin to extend in every direction from these points, until in the 
course of a few days it involves a large portion of the lung. In 
other cases, many days are required before the spreading of pneu- 
monia ceases. 
This case is of considerable interest to the stethoscopic student, PLEURO-PNEUMONIA. 
145 
as exhibiting in a very satisfactory manner all the physical signs of 
pneumonia, as well in its pure state as where it is complicated with 
pleuritis. It is unnecessary for me to enter into any detail of the 
symptoms or of the physical signs, but I invite you to study them 
as well worthy of your attention. 
A patient has recently died, who came into hospital labouring 
under a disease which generally proves fatal, namely, double 
pleuro-pneumonia. He had violent pleuritis and pneumonia in 
both sides of the chest under these peculiar circumstances; that in 
the left side the pneumonia was situated above and anteriorly, in 
the right side below and posteriorly; so that the lungs were affected 
nearly at the opposite ends of their transverse diameters. On his 
admission, he appeared extremely low and weak, and it was 
obvious that the case must terminate fatally. His respiration was 
extremely quick and laboured ; he had great oppression about the 
chest, constant anxiety, incessant harassing cough, quick weak 
pulse, and a countenance expressive of intense suffering. On exa- 
mining the chest with the stethoscope, we found that both lungs 
were extensively solidified; and this, combined with his age, and 
the manifest sinking of the powers of life, prevented us from indulg- 
ing in any hope of being able to arrest, much less to remove, his 
complaint. He was a poor creature, moving in the very lowest 
class of life, ill fed, without sufficient clothing, most wretchedly 
lodged, and constantly exposed to cold and hardships. He had 
been employed in breaking stones on a road at fourpence per day, 
and out of this miserable pittance endeavoured to maintain a family. 
From repeated exposure to inclement weather, he got a violent 
attack of pleuro-pneumonia, which, being neglected at the com- 
mencement, assumed an intractable character, and when he came 
into hospital, the disease had been of several weeks’ standing, his 
system reduced to the lowest state, and no sign whatever of reaction. 
In estimating the danger of a patient labouring under pneumonia, 
I have told you that it is not so much in proportion to the extent of 
lung engaged, as to the quickness of respiration, and the presence 
or absence of symptoms of asphyxia. You will see one man in 
pneumonia, having nearly the whole right or left lung inflamed 
and solidified, breathing easily with the other lung, and apparently 
suffering but little inconvenience; while you will find others, with 
a smaller amount of disease, exhibiting symptoms of distress border- 
ing on asphyxia. I attended a young gentleman, eighteen months 
ago, who had complete carnification of the left lung, and pleuritic 
effusion on the same side, pushing the heart so far out of its place, 
that it could be felt pulsating under the right mamma. His illness 
lasted for nearly four months; yet the fluid was afterwards com- 
pletely absorbed, the lung gradually assumed its natural condition, 
and he recovered perfectly. About six months ago, I was again 
called to see him, and found that after exposure to cold he had got 
a violent attack of pneumonia in the right lung, which had run on 
to hepatisation, and on examining him by the stethoscope and per- 
cussion, I found that almost the whole of the lung was solidified. 146 
giiaves’s clinical lectures. 
In this case, there never was any thing like an approach to 
asphyxia; indeed, the distress of breathing was extremely slight, 
and he recovered completely in two months. This was rather a 
singular case; the patient one year getting violent pleuritis, fol- 
lowed by extensive effusion, forcibly compressing the lung so as to 
render it quite useless, and pushing the heart out of its place: and 
the next year getting an attack of pneumonia in the other lung, 
ending in solidification of nearly the whole organ, and yet recover- 
ing completely from both. I need not say that there could have 
been no scrofulous taint in this gentleman’s constitution, for if there 
had, the chances were that he would have sunk under either of 
these attacks. He lives at Crumlin; and in both instances his 
attending physician was Dr. Adams, of Stephen’s Green. 
In such a case as this, the utility of the stethoscope was obvious; 
by its means we not only learned the nature and extent of the dis- 
ease we had to combat, but also the exact situation where topical 
applications, such as leeches, blisters, setons, &c., should be applied 
with greatest advantage. I had lately an opportunity of witnessing 
an extremely interesting case of perfectly latent pleurisy. It was 
seen in the first instance by my friend and pupil, Mr. B. Guinness. 
A fine young gentleman, catching cold, contracted some slight fever, 
apparently catarrhal, which altogether subsided in five or six days, 
but he remained very weak. I saw him on the tenth day ; a very 
slight cough remained, his breathing was regular, and he felt no 
want of breath; he had had no pain in the side from the com- 
mencement ; he was weak and rather sleepless; otherwise he could 
specify no complaint. I do not know what induced me to percuss 
his chest—perhaps it was the force of habit; be this as it may, per- 
cussion led me to the discovery of extensive pleuritic effusion on 
the right side. He recovered perfectly under the use of proper 
remedies. 
Let me now direct your attention for a few moments to the case 
of M. Murphy, who died on Saturday last. This man, aged sixty, 
was admitted on the first of November. He had been ill for nine 
months before his admission, and stated that his illness originated 
in exposure to cold. It commenced with cough, oppression of 
chest, dyspnoea, and haemoptysis. During the first month, the 
haemoptysis recurred frequently, and, as he thought, generally with 
more or less relief; but during the latter period of his illness, it was 
entirely absent. On his admission, he had well marked hectic 
fever, with copious puriform expectoration, and appeared very 
much emaciated. The right clavicle sounded pretty clear, but 
under the left clavicle there was well marked dulness, with a full 
mpcous rstle approaching to gargouillement and pectoriloquy. The 
two latter symptoms became much more decided in about a week 
after his admission, and l accordingly marked on his card “Phthisis 
Senilis.” The only other circumstance connected with the history 
of his case which deserves attention, was, that he laboured under 
constant costiveness, which continued up to the period of his death, 
his bowels never yielding except when he used purgative medicines. PL EURO-PNEUMONIA. 
147 
it is unnecessary for me to enter into a detail of the remedies 
employed to alleviate his symptoms—the only duty which remains 
for the physician under such circumstances ; I shall therefore con- 
tent myself with noticing the phenomena observed on dissection, 
with one or two particulars which seem to demand a brief observa- 
tion. You will recollect that this man exhibited, for several weeks 
before his death, unequivocal signs of a large cavity in the left lung, 
and that latterly the right lung also had become dull on percussion, 
and that the stethoscopic phenomena indicated the formation of a 
new cavity at its upper portion. Here are the lungs ; the left, you 
perceive, is larger than the right, and exhibits a marked depression 
at its upper portion, where the phthisical cavity is situated. You 
perceive, also, that the pleura investing it is very much thickened, 
and very rough on its surface; this appearance was in consequence 
of its intimate and universal adhesion to the corresponding pleura 
costalis, from which it was separated with considerable difficulty. 
You perceive that the right lung is rather smaller than the left; the 
left, being rendered more extensively solid by disease, has become 
incapable of collapsing after death to the same extent. We shall 
now make a section of the lung, to show the extent of the cavity. 
Here is the cavity; you perceive that it is nearly large enough to 
contain a small orange, and that its walls are lined with a firm semi- 
cartilaginous membrane. At the upper and internal part there is a 
small opening, which seems to be the commencement of a fistulous 
passage, a very common occurrence in cases of senilis phthisis ; I 
shall introduce a probe and lay it open. Here is the track of this 
fistulous opening, and you perceive it terminates in one of the large 
ramifications of the left bronchus. You may perceive, also, that 
the section I have made displays masses of small granular tubercles 
in the upper and anterior portion of the lung, quite different in size 
and appearance from the large tubercles seen in the child and adult. 
I shall now make a section of the right lung. It is much more 
natural in its feel and appearance than the left, but still in all 
chronic cases of phthisis we seldom have the disease limited to a 
single lung. Here you perceive are a few patches of granular 
tubercles, looking as if they were infiltrated into the substance of 
the lung, and not surrounded as the large tubercles of the adult and 
child are, by vascular condensed pulmonary tissue. Here, you see, 
I have cut into a small cavity ; from its contents and appearance, 
you can judge that it is of comparatively recent formation ; it has 
no semi-cartilaginous lining, and is of very inconsiderable size. 
You perceive, also, that it communicates freely with a pretty large 
sized bronchial tube, and contains a quantity of muco-purulent 
secretion. 
With respect to the state of the viscera of the abdomen, 1 may 
observe, that with the exception of some portions of the intestinal 
tube, which I am about to show you, they presented nothing very 
remarkable. The liver and kidneys were found to be of the natural 
size, somewhat indurated, and very friable, and the spleen exhibited 
several small tubercular spots on its surface. Here are the stomach 148 
graves’s clinical lectures. 
and duodenum, which you perceive retain their normal appearance; 
and the same remark is to be made of the colon and rectum. In 
the cascum, however, which you see here, and here also in the 
ilium, there are several ulcerated patches of an oval form, and cor- 
responding to the situation of the glands of Peyer. In some places 
you perceive the ulcers have destroyed not only the mucous mem- 
brane, but also the muscular coat of the intestine, and have very 
nearly produced perforation. 
A most important inference may be drawn from this fact. Here 
we have several ulcers, destroying the mucous coat of the intestine, 
and eating their way through its muscular tissue, so that the only 
barrier left to prevent an effusion of the intestinal contents into the 
cavity of the peritoneum, is a thin layer of serous membrane. Yet, 
during the whole time he remained in the hospital, his bowels were 
so obstinately costive, that we were obliged to give him purgative 
medicine every second or third day, to procure an evacuation. 
You would suppose, a priori, that a man, in whom ulceration of 
the bowels existed, would sutfer considerably from pain, griping, 
and tympanitis, and that he would labour under the diarrhoea so 
frequently observed in the advanced stage of phthisis. Our prede- 
cessors entertained a notion that the diarrhoea of phthisis is a species 
of internal sweating ; they observed, that when the patient ceased 
perspiring from the skin, he was generally attacked with a watery 
diarrhoea, and hence they termed the diarrhoea colliquative. After- 
wards it was found, on numerous examinations, that where this 
diarrhoea had existed, there was in most cases ulceration of the 
bowels ; hence pathologists began to believe that this ulceration 
had a great deal to do with the intestinal symptoms observed 
towards the termination of phthisis, referring to it the abdominal 
pain and tenderness, the unmanageable character of the diarrhoea, 
and the aggravation of the hectic symptoms. 
Now it strikes me that this mode of accounting for these symp- 
toms was, perhaps, too hastily adopted. No doubt uleeration of the 
bowels may produce all the symptoms detailed; but, on the other 
hand, it may exist to a very remarkable extent, and yet produce no 
symptoms by which it could be recognised. Here was a patient 
who never had the slightest tendency to diarrhoea, who never com- 
plained of pain, griping, flatulence, or abdominal tenderness; on 
the contrary, his bowels were not merely slow, but even confirmedly 
costive, and he always felt more or less relief from the use of pur- 
gative medicine. None of us ever suspected that any thing like 
ulceration existed; we gave him a full dose of castor oil every 
second day, which produced one rather scanty evacuation, and yet 
when we come to examine his intestines, we find numerous patches 
of ulceration. This case is calculated to make a deep impression 
on every reflecting mind ; in a practical point of view, it is of great 
importance. If the scrofulous disease had in this case been entirely 
limited to the bowels, and had not touched the lung, the great pro- 
bability is, that it would have been almost wholly "latent t that the 
man would have taken no notice of it, would have thought himself LOSS OP VOICE. 
149 
well, and eaten, drunk, and worked as usual; that the disease 
would have gone on stealthily committing its ravages, and that 
one of the first symptoms of danger would have been the occur- 
rence of perforation, followed by universal and fatal peritonitis. 
The question would then be as to the cause of death. The patho- 
logist would open the body, and find at once that the cause of the 
whole mischief was ulceration of the intestines; but he would be 
mortified to think that the work of destruction had gone on silently 
and unobserved, and that it could not be recognised until a new 
disease appeared, under which the patient sank. I have read of 
more than one case in which a person killed by accident was found 
to have large ulcerated patches in the ilium, and yet had not been 
known during life to complain of any intestinal symptoms. In 
one case, a strong and apparently healthy Lascar, who had eaten 
heartily an hour before he was killed, and whose digestion was, 
according to his friends’ account, unaffected by any morbid de- 
rangement, presented, on examination, a number of deep ulcers in 
the ilium, which would in all probability have ended in perforation 
and peritonitis in the course of a few days. 
At the conclusion of this lecture I intend to speak of hoarseness 
and chronic laryngitis, and shall most probably return to this inte- 
resting topic again. At present I shall detain you for a few moments 
with a brief outline of a case of total loss of voice, which I have 
recently witnessed, and which is in itself so singular that I make 
no apology for giving it. 
Before I mention this case, allow me to observe that loss of speech 
arises sometimes from lesions of apparently a very trifling charac- 
ter. A person may totally lose his speech without any previously 
existing or premonitory symptoms indicative of nervous lesion— 
without having experienced any sensation of pain or vertigo, any 
noise in the ears, any indications of determination to the head—in 
fact, without any thing to show that the aphonia was connected 
with any particular state of the brain. Thus, a barrister, whom I 
attended with Dr. Beatty, was walking up and down the hall of the 
Four Courts, waiting for a cause to come on, and chatting with one 
friend and another; as the hall was rather crowded and hot, he 
went out into the area of the courts for the sake of the air, and had 
not remained there more than ten minutes when an old friend from 
the country came up and spoke to him. He was pleased to see his 
friend, and wished to enquire about his family, when he found, to 
his great surprise, that he could not utter a single audible sound; 
he had completely lost his voice. He recovered the use of his 
tongue in about three weeks, but not completely, for some slowness 
of speech remained. When the loss of speech was first perceived, 
his friend brought him home in a carriage ; and during the day he 
had several attacks of vertigo, and afterwards hemiplegia. For 
several hours, however, before distortion of the face or any of the 
usual symptoms of paralysis had commenced, the only existing 
symptom was loss of speech. This gentleman died of apoplexy 
in about two months. 150 
graves’s clinical lectures. 
In many cases of paralysis you will find that, although the pa- 
tients have lost the power of utterance, yet the motions of the 
tongue appear to be nowise deranged. In the majority of cases it 
can be shortened, elongated, raised, depressed, or moved from side 
to side, with as much apparent facility as in a state of health ; and 
yet the voice is in some instances very much impaired—in others, 
totally lost. In such cases it would appear that the defect lies in 
the glottis, which forms and modulates the voice, and not in the 
tongue or lips, which divide and articulate it. Indeed, this is evi- 
dent to any one who observes the interrupted and spasmodic 
efforts which paralytic persons make when speaking; they are, in 
fact, all stutterers. 
But to return to the case to which I have alluded. A young 
gentleman of delicate constitution, and who is now about sixteen 
years of age, continued to enjoy tolerably good health up to his 
sixth year. When about six years of age, he went to bed one night 
in health and without any unusual symptom, but on getting up in 
the morning it was observed that he had lost his speech, and was 
unable to articulate a single word. His family became alarmed, 
and sent for a physician immediately; the boy got some internal 
medicine and a stimulant gargle, and recovered his speech in a few 
days, without the occurrence of any symptom of laryngeal inflam- 
mation or cerebral disease. But what was remarkable in the case 
was this: the boy, who up to this period had spoken well and dis- 
tinctly, now got a terrible stutter. This resisted all kinds of treat- 
ment, and for ten years he continued to stammer in the most 
distressing way, and was so annoyed by it himself that, when a 
boy, he used to stamp on the ground with vexation whenever he 
failed in uttering what he wished to express. In the month of May 
last he got an attack of chronic laryngitis of a scrofulous character, 
and evidently the precursor of phthisis. Indeed, he is at present 
labouring under phthisis; Dr. Stokes and I have examined him, 
and we feel convinced that tubercular deposition is going on in the 
lungs. But what is most curious in the case is this : after he got 
the laryngitis, a very peculiar change took place; the laryngeal 
inflammation modified the tone of his voice so as to make it a little 
husky, but the stammering has completely ceased. 
You are aware that stammering has been explained as depending 
on spasm of the muscles which are employed in modifying the 
column of air as it rushes through the narrow aperture of the 
glottis. At certain times, and. under a variety of circumstances, 
those fine muscular organs become spasmodically affected, the vocal 
chords no longer undergo the same steady and exact tension and 
relaxation, and speech becomes interrupted in consequence of fre- 
quently recurring closure of the glottis. With respect to this dis- 
ease, I would beg leave to refer you to a very excellent chapter in 
Dr. Arnott’s work on the Elements of Physic, vol. i. p. 644. 
In the case to which I have referred, inflammation taking place 
in the mucous membrane covering these delicate muscular fibres, 
you can conceive that either the thickening of the mucous mem- HOARSENESS AND LOSS OF VOICE. 
151 
brane, or the alteration in the state of its vitality, may have so 
modified the disposition of the parts, that they become incapable or 
indisposed to undergo those rapid contractions necessary to produce 
stammering, by inducing closure of the glottis at the moment that 
its aperture ought to remain open. The case itself, however, is an 
extremely curious one, and I do not believe that there is any similar 
one on record. Every thing which bears on the cure of so import- 
ant a disease as stammering, even though it be accidental, and not 
the result of medical care and ingenuity, is of great value, inas- 
much as it tends to place the causes of the disease in a clearer light. 
In this point of view I look upon the case as one of very great 
interest. 
I shall conclude this lecture with a few detached observations on 
hoarseness, or loss of voice, from sore throat or slight laryngeal 
inflammation—a form of disease which is now very prevalent. 
A form of hoarseness is frequently observed in growing boys or 
girls, which assumes a very chronic character, and often res is s for 
a long time almost every form of treatment. A boy gets cold, fol- 
lowed by sore throat and feverish symptoms, which may last for a 
few days, and then disappear under the use of aperient medicines, 
or perhaps without any interference on the part of the parents or 
the physician. The feverishness and soreness of throat subside, 
but the hoarseness remains, and the boy can speak only in whispers. 
This condition may last for weeks, and even months, without any 
other symptom whatever ; the patient has no cough or difliculty of 
breathing; his appetite is good, sleep and digestion natural, and 
there is no appearance of emaciation. The only thing amiss with 
him is the impairment of voice, and this continues so long that it 
gives rise to a considerable degree of anxiety on the part of his 
parents. When you examine the fauces, you find no appearance 
of inflammation in the mucous membrane, and there is no super- 
ficial or deep-seated tenderness in the region of the larynx. How 
are you to treat this form of disease? It depends on a relaxed and 
weakened state of the chordae vocales, and perhaps the muscles of 
the larynx—the result of inflammation of an exceedingly chronic 
character—and will not be benefited by leeches, or antiphlogistics, 
or low diet. The best thing you can do in such a case is to have 
recourse to the use of strong stimulant gargles. You begin with 
a dram of the tincture of capsicum in six ounces of decoction of 
bark, which is to be used five or six times a day. After some time 
you can increase the quantity of tincture of capsicum, but you 
never need go farther than half an ounce in a six ounce mixture. 
In the next place, you will have recourse to frictions over the region 
of the larynx and external fauces with croton oil, which is much 
better adapted for such cases than tartar emetic ointment. The 
eruption produced by tartar emetic ointment is productive of a great 
deal of annoyance, and when the pustules break they prevent the 
boy from wearing his neckcloth. All the purposes of a counter- 
irritant are quite as well fulfilled by croton oil, and with much less 
inconvenience. The best form for using it is the following:— 152 
graves’s clinical lectures. 
li. Liniment: camphorae comp. 3j- 
Olei crotonis tiglii, M. xx. 
Of this mixture a small quantity—say a couple of drams—should 
be poured into a saucer, and rubbed over the fore part of the neck 
night and morning, until a full crop of pimples appears. When 
these have dried up and desquamated, it should be again applied, 
and in this way a mild and manageable, but very effectual, degree 
of counter-irritation can be kept up for any length of time. In 
addition to these measures (should the disease continue), 1 would 
strongly recommend small doses of iodine, and change of air. I 
have been induced to give iodine in such cases from observing that 
inflammation of a chronic character seems to have many points of 
resemblance to that which arises from scrofula. The last thing 
which I have to observe on this form of hoarseness is, that you 
should, particularly in the beginning, insist on the observance of 
strict silence—a point which is said to be exceedingly hard to be 
attained where the patient happens to be a female. In some cases 
all these means fail, and then something more energetic must be 
attempted. The inhalation of the vapour arising from tincture of 
iodine and tincture of conium, added to hot water in a proper appa- 
ratus, has proved useful to some; but in all obstinate cases the 
sheet-anchor is mercury exhibited internally, and by means of in- 
haling the fumes of hydrargyrum cum creta. In general, it is 
necessary to continue the mercurials until the mouth is slightly 
touched, when the hoarseness will be found to yield. It is obvious 
that, before we employ mercury in a case of chronic hoarseness, we 
must feel well assured that we have not to deal with a hoarseness 
arising from a phthisical tendency, for in this case mercury would 
prove injurious to the constitution. In such cases the stethoscope 
and percussion often afford valuable assistance, by showing that 
although the patient has had a hoarseness and cough for weeks, or 
even months, yet there are no symptoms of tubercular development 
in the lungs. The cough is only the result of laryngeal inflamma- 
tion or irritation; the submaxillary glands and the amygdalae are 
often slightly enlarged, the fauces are red, and the back of the pha- 
rynx is covered with irregular superficial excoriations. Connected 
with the subject of sore throat is the discovery, lately announced 
by Velpeau, of the use of alum in powder in acute cynanche ton- 
sillaris. He states that this powder, applied by means of the finger 
to the fauces and inflamed parts, exercises a wonderful effect. The 
symptoms, says Velpeau, are stopped as if by enchantment, the 
fever diminishes, the redness and tumefaction of the inflamed parts 
subside, the appetite returns, and convalescence is speedily esta- 
blished. This application is successful at any period before suppu- 
ration has been established. Alum has long since been applied in 
substance to the throat, in cases of angina maligna, and in chronic 
sore throat; but, before Velpeau, no practitioner ever dreamed of 
making use of alum as a local application during the first stages of 
acute cynanche tonsillaris. By the way, this use of alum is calcu- AMAUROSIS. 
153 
lated to throw some light on the good effects which this substance 
exerts, when taken in large doses, in cases of violent pain in the 
stomach arising from indigestion, recommended by Dr. Griffin, of 
Limerick. 
LECTURE XIY. 
There is at present in the hospital, a man whose case has been 
marked imperfect or (to use a better phrase) incomplete amaurosis. 
He has been complaining at different times during the past year, 
and for the last six months his vision has been very weak, with the 
exception of occasional intermissions. He can perceive objects 
tolerably well with the right eye, but scarcely at all with the left, 
and in both vision is more or less dim and imperfect. 
On examining this man’s eyes, you cannot discover in either of 
them the slightest perceptible defect as an optical instrument. The 
deficiency of vision, therefore, does not depend on opacity of the 
cornea, on disease of the lens or its capsule, or on any affection of 
the aqueous or vitreous humours; it is simply an impairment of 
the vitality of the organ, connected with functional disease of the 
retina. Having thus satisfied ourselves as to the seat and nature 
of the disease, we come next to enquire into its cause and origin. 
From a careful examination of the man’s state of health, we can 
have no doubt on our minds as to whether the amaurosis in this 
case has been produced by derangement of the stomach or not. 
You are all aware that the celebrated Richter has long since 
shown, that functional disease of the retina is often connected with 
a deranged state of the alimentary canal, and that it may be treated 
successfully with emetics and purgatives. Here, however, we 
have no evidence of the existence of congestion or derangement of 
the stomach and bowels. The man’s appetite is good, his bowels 
regular, and his health robust. But when we come to examine the 
head, we find evidence of cerebral congestion sufficient to account 
for the functional lesion of the optic nerve. Our patient has been 
a long time complaining, at different periods, of a sense of fulness 
in the head, and is subject to attacks of vertigo while walking, 
causing him to stumble occasionally, and labour under frequent 
apprehensions of falling, down in the street. He prefers walking 
along the middle of the street to either side, and says that he is 
always worse when he attempts to walk along the flagway. This 
is an ordinary symptom observed among persons who have a ten- 
dency to vertigo; they are frequently made worse by the operation 
of causes in themselves apparently inconsequential, and the nature 
of which we cannot well understand. You are aware that, in 
many persons, the act of looking for any length of time at objects 
moving rapidly in a straight line, and still more in a circle, has a 154 
graves’s clinical lectures. 
tendency to produce giddiness. Thus, looking out of the window 
of a steam-carriage on the objects apparently moving backwards 
with great velocity, or looking over a bridge at the current of a 
rapid river, or gazing at a person whirled round in a gyrating 
swing, is very apt to give rise to vertigo. Again, persons labour- 
ing under a morbid sensibility of the brain, very often become 
giddy from looking at a succession of objects moving with much 
less rapidity. Hence you will find such persons made giddy by 
walking through a crowded city, and having a number of persons 
pass by them on the flagway, and they seek for an opportunity of 
getting into the middle of the street, to avoid meeting so many 
objects. I knew a person who could never pass by a line of railing 
with any degree of comfort; if he happened to look at them as he 
moved by, he became almost immediately vertiginous. Giddiness 
is also generally produced by looking down from a great height, in 
a vertical direction, or by looking- upwards, provided the object be 
immediately overhead, and at a great distance. Under these cir- 
cumstances, most persons experience a feeling of vertigo, no matter 
what their position may be at the time. There seems to be little 
doubt that the sensation of giddiness does not depend merely on 
the distance or position of the object looked at. It would appear 
that, in general, some continuous communication must exist be- 
tween that object and the spectator. Thus we feel giddy when we 
look down from a precipice at something below, or when standing 
beneath the dome of St. Peter’s or St. Paul’s we regard with atten- 
tion the vaulted structure above; but we do not feel giddy when 
we look down from a balloon, or look upwards at the moon or stars 
near the zenith. It has not been sufficiently remarked by writers, 
that persons subject to vertigo are often almost as much affected by 
looking upwards as by looking downwards. Persons who are in- 
clined to vertigo, will also become giddy by directing the eye with 
a fixed attention for any length of time to the one object,—such as 
continuing to look in a straight line, or endeavouring to direct the 
course of their movements along a plank or narrow pathway. 
These circumstances are all very difficult to explain, and I bring 
them forward merely as illustrating the fact of this man’s prefer- 
ence for walking in the middle of the street. 
In this man, as you may have perceived, we had several circum- 
stances calculated to direct our attention to the state of the brain as 
connected with the impairment of vision; besides vertigo, and a 
tendency to stumble in walking, he had flashes of light before his 
eyes, and other luminous hallucinations, with tinnitus aurium on 
one side. With respect to the flashes of light before the eyes, I 
may observe, that they may be produced by the operation of 
various causes; a blow or pressure on the eye will cause them; 
they may arise also from a particular state of the arteries which 
supply the optic nerve, and thus at each pulsation of the heart a 
flash of light is seen. This morbid sensibility of the retina, which, 
under such circumstances, appears to be itself the source of light, 
is very often a symptom which ushers in the extinction of the AMAURuSIS. 
155 
visual power. It is a very general remark, that hypersensibility of 
an organ is but too often the prelude to total loss of its functions. 
Thus we frequently have a morbidly sensitive state of the eye be- 
fore it becomes incurably amaurotic, a morbid sensibility of the ear 
ushering in loss of hearing, and unnatural excitement of the sense 
of touch preceding paralysis. But in this case we have not only 
an irritable condition of the retina, but also an affection of the 
pupil; the iris is sluggish in its motions, and this symptom occur- 
ring at this particular period, combined with the vertigo, luminous 
hallucinations, and gradual but steady progress of the disease, give 
us some reasons to apprehend that it will end in complete amaurosis. 
Seeing, however, that the symptoms have originated in a congested 
state of the brain, it is our duty, as far as possible, to check its pro- 
gress. This is to be done by cupping over the nape of the neck, 
leeching the temples and behind the ears, and acting on the bowels 
by brisk purgatives. With the same view, I intend to insert a seton 
in the nape of his neck, and to administer the nitrate of silver in- 
ternally, combined with a small quantity of aloes, a remedy which 
is possessed of some valuable properties in the treatment of chronic 
congestion of the brain, whether tending to produce amaurosis or 
headache. 
With respect to the causes of amaurosis, I may observe, that they 
depend either on disease of the brain, as congestion, inflammation, 
the presence of tumours of various kinds, or on injuries of the retina 
itself, or of the supra and infra orbital branches of the fifth nerve, 
or on affections of the alimentary canal. All these matters, how- 
ever, have been so well detailed, particularly in the excellent 
article on amaurosis, by Dr. Jacob, in the Cyclopaedia of Practical 
Medicine, to which I refer you, that I shall pass over them at pre- 
sent, and close my notice of this case with a few desultory remarks. 
I believe I mentioned in a former lecture, that I had seen a very 
curious case of amaurosis, in which the cause of the disease seemed 
to be connected with an impression made by cold on the facial 
branches of the fifth nerve. I have already taught the class, that 
paralysis of any part of the body may arise from an impression 
made not only on its own nerves, but also on the peripheral ex- 
tremities of the nerves of another and even a distant part. I have 
also remarked that the fifth nerve is connected with the nerves of 
all the senses, but in particular with the optic, and hence we can 
explain why injuries of its supra and infra-orbital branches may 
bring on amaurosis. In the case to which I refer, the patient was 
exposed, while travelling outside on a stage-coach, to a keen north- 
easterly wind, and, when he arrived in Dublin, his lips were very 
much chapped, and the skin of his face bore evident marks of the 
cold, and drying powers of the wind. Soon afterwards, he began 
to complain of dimness of vision, and a thin gauze veil seemed to 
be extended between him and every object he looked at. After 
five or six days, when he applied to me, I found a considerable 
degree of amaurosis present, and at the distance of a few feet he 
was unable to recognise the countenance of a friend. He had no 156 
GRAVEs’s CLINICAL LECTURES. 
headache, vertigo, or tinnitus aurium; in fact, nothing to indicate 
cerebral congestion, and his appetite was good, sleep undisturbed, 
bowels regular. He had never thought himself, nor did a medical 
gentleman, to whom he had applied, ever suspect, that the impres- 
sion of cold on the face had produced the amaurosis, and he said 
that he had been advised to get himself leeched and cupped over 
the back of the neck. On examining into the cause of his disease, 
and having found that he had been exposed to severe cold, it 
occurred to me that the amaurosis might be connected with the 
impression made by cold on the superficial branches of the fifth 
nerve, and, on more accurate investigation, I found that there were 
some grounds for this opinion. I was further confirmed in this 
view of the subject by the details of a case communicated to me by 
my friend, Dr. Montgomery, in which the patient evidently got 
paralysis of the portio dura from exposure of one side of the face to 
cold. Of course this paralysis was attended with distortion of 
countenance, in consequence of many of the muscles of the face 
depending on the portio dura for their supply of nervous energy. 
But what was particularly remarkable in this case, was, that vision 
on the affected side of the face became dim and indistinct. Now, 
can this be explained? Yes, very easily. You all know that the 
branches of the portio dura have an extensive communication with 
the supra and infra orbital branches of the fifth. Now, the para- 
lysis which commenced in the portio dura, gradually extended to 
the branches of the fifth, and through them to the optic nerve, 
with which the fifth is intimately connected, and hence it was the 
retina became finally deranged in its function, and dimness was 
produced. 
There is one circumstance more to which, as I am on the subject 
of amaurosis, I shall briefly call your attention. You will recollect 
the case of a boy whom we have had very recently under treatment 
for amaurosis, and may perhaps remember that one of the remark- 
able points in his case was this :—when he looked straight forward 
he did not see any thing in the direction to which his eyes were 
turned, but he could see the objects that were considerably below, 
or to either side of, the axis of vision. There are two or three cir- 
cumstances under which a person cannot see an object by looking 
directly at it, and I wish to state these circumstances. In the first 
place, it may happen that an opaque spot may be situated on the 
centre of the cornea and directly in the axis of vision, as we some- 
times see in cases of scrofulous ulceration, followed by permanent 
opacity of the cornea. Now, in this case it is plain that the person 
cannot see objects placed directly before him and in the axis of 
vision. The second case is one where the patient cannot see ob- 
jects directly before him, but can distinguish them tolerably well at 
a certain angle of obliquity, the cornea being perfectly clear and 
uninjured in its texture. Now, this may arise from an opacity of 
the lens, limited to its centre, and not generally diffused through 
its substance. The lens is a compound body, the structure of which 
was, until very lately, but little known. When the lens or its cap- AMAUROSIS. 
157 
sule is affected with opacity, this opacity is not always equally 
diffused, but sometimes occupies the central portions of these 
organs, while the circumferential portions retain their transparency. 
Hence, when a person under such circumstances wishes to see an 
object, it is necessary that the rays of light should fall obliquely in 
order to reach the retina. A third case is, where, although the 
cornea and crystalline lens are in the natural state, still the patient 
sees objects a little removed from the axis of vision much better 
than those which are in it, as in the case to which I have just 
alluded, where the patient could scarcely distinguish any object 
placed directly before him, but see tolerably well objects at either 
side of, or below, the direct line. The reason of this appears to be, 
that when a person so circumstanced looks directly at an object, 
the picture of the object falls on a part of the retina not obedient to 
the stimulus of light. In the process of ordinary vision the parts 
around the axis, and corresponding to the field of vision, have the 
picture of the object looked at painted on them, and vividly and 
strongly illuminated. The central portion of the retina bears on it 
the picture of the object which the mind attends to, for it is sur- 
prising how indistinct and how little attended to any object seen 
obliquely is. Now, where disease has rendered this central portion 
of the retina insensible to light, then the attention is immediately 
turned, with a greater degree of intensity, to the sensations 
derived from the surrounding portions, and the patient is enabled, 
so long as this portion retains its sensibility, to enjoy the sight of 
objects placed obliquely and not in the axis of vision. Even in 
healthy eyes the non-central portions of the retina may be rendered 
available in particular cases. This has been proved by Brewster, 
Herschel, and others. In looking, for instance, at a star of the 
smallest magnitude, it vanishes from the sight and is lost when 
looked at directly, but, if you turn a little from it, it will still catch 
the eye and be visible, because the image of the star will now fall 
on a part of the retina which is generally in darkness, and which 
is more sensible from being unaccustomed to the glare of light. 
Hence in many cases of amaurosis it is not unusual to find that the 
patient retains the power of vision so far as regards objects placed 
at an oblique angle with the axis of the eye after direct vision has 
been all but extinguished. This is all I have to say at present 
with respect to amaurosis. 
As there is no other case presenting peculiarities to which I 
might call your attention, I shall beg leave to occupy your time for 
the remaining part of our lecture hour with a detail of the circum- 
stances under which I have been led to employ the acetate of lead 
in Asiatic cholera, and to communicate briefly the mode of its ad- 
ministration and the results which attended its use. You are aware 
that during this epidemic, which commenced its fearful career in 
Dublin in the spring of 1832. the modes of treatment principally 
relied on were, bleeding in violent spasmodic cases, emetics of ipe- 
cacuanha and mustard, the application of heat externally, and 
internally stimulants, but, above all, calomel, not in small but in 158 
graves’s clinical lectures. 
large and frequently repeated doses, either alone or combined with 
opium. I need not tell you that the mercurial treatment came to 
us sanctioned by high authority: it was a remedy to which the 
experience of Indian practitioners had given a high character, but 
in our hands, I must say, it proved of very little value. Be this as 
it may, I must say that I had reason to be dissatisfied with this 
mode of treatment; I had tried it myself, and had seen it tried in 
every way which ingenuity or experience could suggest, but I had 
seen it fail in almost every instance. 
About the middle of last summer the epidemic began to spread 
fearfully among those who had hitherto been exempt from its at- 
tacks ; many persons in respectable life were seized, and my private 
practice afforded numerous opportunities of becoming practically 
acquainted with the disease. In several cases to which I was called 
in, the malady had not advanced to the stage of collapse, the symp- 
toms of cholera, properly so called, had merely commenced, the 
intensity of the disease was still far away, and a fair chance was 
afforded for the operation of therapeutic agents. In most instances 
I tried calomel and all the ordinary remedies with profitless results; 
my treatment proved too often ineffectual; and some persons, whose 
lives I highly valued, perished in spite of all my efforts, leaving me 
grieved for their loss, and mortified by my own want of success. I 
found that I could no longer place any confidence in calomel, and 
determined, in my own mind, to give up a remedy which had so 
signally failed ; it was, however, a question of deep anxiety to me 
what I should select instead, or to what article in the Materia Me- 
dica I should have recourse, where so many had proved utterly 
valueless. 
About this period I happened to be called on to attend a case of 
obstinate diarrhoea with ray friend Dr. Hunt. The case was an 
extremely harrassing one, and had resisted all the ordinary reme- 
dies. I advised the use of acetate of lead and opium in full doses; 
this was given, and I had the satisfaction of finding that the diar- 
rhoea soon yielded. Before this period I had received a letter from 
that able practitioner and excellent man, Dr. Bardsley, of Man- 
chester, directing my attention to the use of acetate of lead in large 
doses in that form of diarrhoea which occurs towards the termina- 
tion of long fevers, that is to say, the diarrhoea which precedes and 
accompanies inflammation of the glands of the small intestines. I 
had subsequently, at Sir P. Dun’s Hospital, several opportunities of 
witnessing the truth of Dr. Bardsley’s remarks. I saw that, in many 
cases during the course of fever, where the patient was low and 
prostrated, symptoms of intestinal congestion came on, followed by 
diarrhoea, which many persons thought would end in ulceration of 
the glands of Peyer ; and I found that in such cases the acetate of 
lead was the only remedy that could be relied on. I observed, too, 
that, contrary to the prevailing opinion on the subject, it could be 
given in large doses with perfect safety. You are aware that Dr. 
Bardsley has shown that it may be given to children in very con- 
siderable doses without any bad effects, and that in adults he has ACETATE OF LEAD IN CHOLERA. 
159 
pushed this remedy to the extent of twenty or thirty grains in the 
day, without any unfavourable consequences. 
With these impressions I came to the resolution of trying the 
acetate of lead in the next case of cholera which offered a chance of 
deriving benefit from any kind of treatment. It is known that there 
are some cases in which the disease at once assumes so frightful a ma- 
lignity, that the patient is lost from the very moment of his seizure. 
This hopeless and intractable malignity is not peculiar to cholera; 
it is seen in fever, scarlatina, croup, measles, and hydrocephalus; 
in fact, there are certain forms of all diseases in which the best 
directed efforts of medical skill not only fail in curing the disease, 
but even in retarding its progress. But there are cases of cholera 
where the patient is not struck down at once, where the disease is 
not developed at once in all its awful intensity, and where time, 
brief though the space may be, is allowed for the play of therapeutic 
agencies. It is in such cases the acetate of lead may be given with 
some prospect of success, and it is by such cases alone, and not by 
those which are necessarily fatal ab initio, that its value is to be 
tested. 
Before we proceed further, I may observe, that the principle on 
which the calomel treatment was employed in cholera arose from 
almost constantly observing that there was a total deficiency of bile 
in the stools. Soon after the supervention of an attack, the alvine 
discharges were observed to be white and without the slightest 
tinge of bile; and on this very remarkable symptom practitioners 
dwell almost exclusively, thinking that the patient’s only chance 
lay in restoring the secretion of the liver. Now it is obvious that 
the absence of bile in the stools is no more a cause of the disease 
than is the deficiency of urea in the kidneys or of serum in the 
blood. Viewing the disease in this light, it would be just as rea- 
sonable to give a diuretic to restore the secretion of the kidneys, as 
to give calomel to produce a flow of bile. The liver ceases to se- 
crete, not only in consequence of the injury done to its vitality by 
the proximate cause of cholera, whatever that may be, but also 
from a mechanical cause, namely, from a diminution in its supply 
of blood. It may appear strange that when the same given num- 
ber of vessels go to the liver and come from it at all times, that 
the quantity of blood circulating in it should be greater at one time 
than another. I have not time at present to enter fully into this 
subject; but it is a fact admitting of sufficient proof, that the quan- 
tity of blood circulating in any organ is very much modified by 
the state of its capillaries. The quantity of blood also which goes 
to a gland varies according to the peculiar state of that glandj 
being greater during its period of active secretion than when it is 
at rest. But in a case of cholera, where the capillary vessels of the 
intestinal canal from the stomach and the rectum are actively en- 
gaged in taking up the serum from the whole mass of blood, and 
pouring it into the cavity of the digestive tube, there is an enor- 
mous drainage from the system, and there must be, consequently, a 
deficiency of blood somewhere. Now it would appear that a quan- 160 
GRAVES’S CLINICAL LECTURES. 
tity of blood, sufficient for the purposes of secretion, is abstracted, 
not only from the biliary, but also from the urinary system; and 
hence it appears just as reasonable to give diuretics to restore the 
urinary secretion, as to give calomel to excite the secretion of the 
liver. It would be, a priori, as original a mode of treatment, and 
be equally as successful. I have therefore no hesitation in saying, 
that the calomel treatment has no claim to merit on the ground of 
theory, and. as far as I have observed of it in this country, it seems 
to be of no practical value in the treatment of cholera. 
With regard to the quantity of acetate of lead which may be 
given in this disease, and the mode of administering it, a few words 
are necessary. I have already stated that, when I first tried it, I 
prescribed it in large doses, fortified by the authority of Dr. Bards- 
ley, and by my own experience, of its utility in many cases of 
diarrhoea. It appears that, before I recommended the acetate of 
lead, it had been used at the Cholera Hospital in Grangegorman 
lane. Of this I was not aware, until a book was subsequently pub- 
lished by Dr. Cranfield, which I afterwards reviewed in the Dublin 
Medical and Chemical Journal, and I feel that on that occasion I 
did fair and impartial justice to its merits. I certainly did not 
know that the acetate of lead had been given at the Grangegorman 
Hospital; for, in the very able report of cholera, as observed at that 
institution, published by one of its officers, Mr. M‘Cov, the treat- 
ment relied upon appears to have been the mercurial, and not a 
word was said of acetate of lead. It had certainly been used there 
by one physician; but it was given in smaller doses, insufficient to 
produce decided effects, and no stress had been laid on its value as 
a remedy in cholera by the practitioners attached to the hospital. 
Be this as it may, acetate of lead was not known to the medical 
men of Dublin, and to the practising apothecaries, before I recom- 
mended it. It had been frequently employed in the form of injec- 
tion by them, but no one had given it in large doses by the mouth, 
or introduced it to the particular notice of the profession. I believe 
I can fairly claim the merit, such as it is, of being the first to give 
it in large and effectual doses. The mode in which I prescribed, 
was this:—A scruple of the acetate of lead, combined with a grain 
of opium, was divided into twelve pills, and of these one was given 
every half hour, until the rice water discharges from the stomach 
and rectum began to diminish. In all cases where medicine pro- 
mised any chance of relief, this remedy was attended with the very 
best effects. It gradually checked the serous discharges from the 
bowels, and stopped the vomiting. I need not say of what import- 
ance this is; as long as these exhausting discharges continue, as 
long as the serum of the entire body continues to be drained off by 
the intestinal exhalants, what hope can we entertain? What 
benefit can be expected from calomel and stimulants, when every 
function of the digestive mucous membrane seems to be totally 
extinguished, except that of exhalation, and while profuse dis- 
charges, occurring every five or ten minutes, are reducing the 
patient to a state of alarming prostration ? Knowing the inevitable ACETATE OF LEAD IN CHOLERA. 
161 
fatality of all cases where these discharges went on unchecked, I 
was happy in having discovered a remedy which seemed to possess 
more power in arresting them than any yet devised, and this im- 
pression was confirmed by the results of subsequent experience. 
That the acetate of lead will succeed where all other aslringents 
fail, was proved by the case of Mr. Parr, of this hospital. Having 
got an attack of threatening diarrhoea, at a time when cholera was 
prevailing in Dublin, this gentleman used various kinds of astrin- 
gents. and took so large a quantity of opiates that he became quite 
narcotised, but without any relief to his symptoms. When I saw 
him, he was as bad as ever, and was beginning to exhibit appear- 
ances of collapse. I advised the use of pills, composed of acetate 
of lead and opium, in the proportions already mentioned, and had 
the satisfaction of finding that before night the diarrhma had ceased. 
The pills are to be used one every half hour while the diarrhma 
remains unchecked, but as it begins to diminish, the intervals be- 
tween each pill may be prolonged, and in this way the patient may 
be gradually prepared for leaving off the remedy altogether. I 
have frequently given in this way as much as forty grains of 
acetate of lead in twenty-four hours, with great advantage to the 
patient, and without any bad consequences ensuing. 
It is unnecessary for me to say any more on this subject; if I 
chose to mention names, I could bring forward the names of many 
medical men in Dublin whose lives, I am happy to state, were 
saved by the use of this remedy. I may, however, observe, that 
this mode of treatment has now become universal here, and that it 
has almost completely superseded the use of calomel and opium. I 
will confess that this fact is a source of high gratification to me, 
and I point also with pleasure to the fact, that since it became ex- 
tensively known (as it did during the last invasion of the epidemic), 
the profession has gained more credit than before, and the number 
of cures has been proportionally greater. 
I have referred to this subject also for another reason. I feel it 
a duty which I owe myself, to defend myself against a series of 
attacks which were made on me, and to vindicate my claims, not 
to having been the first to administer acetate of lead, for it had 
been given previously by Dupuytren, and at the Grangegorman 
Cholera Hospital, but to having been the first to prescribe it in 
large and sufficient doses, to render it an available and useful 
remedy, and to introduce it to the general notice of the profession. 
The credit to which I lay claim, rests solely on these grounds. I 
have been attacked on more than one occasion in the public papers, 
and gentlemen subscribing themselves Honestas, Candidus, and 
Verax, (per antiphrasin, I suppose, for they have shown neither 
honesty, candour, nor truth,) have attempted to rob me of the merit 
of what they sneeringly called the lead treatment. I am not in the 
habit of noticing attacks in the daily or weekly papers, but I have 
thought it necessary to say so much in the way of explanation, 
lest any of my friends or pupils should misinterpret my silence. 
The following case of remarkable mobility of the sternum was 162 
graves’s clinical lectures. 
observed by Dr. Stokes and myself. A medical student, nineteen 
years of age, and of a sanguineous temperament, who had often 
been attacked by violent pectoral inflammation, particularly a few 
years ago. but who had since become comparatively healthy and 
robust, applied to me for advice concerning a pain in his chest. 
This happened after lecture in Sir P. Dun’s Hospital, in the pre- 
sence of several of the students and Dr. Law, who saw with asto- 
nishment this young man open his shirt, and with his hand push 
the sternum deep inwards towards the spine, so as to convert the 
anterior part of the chest into an extensive and by no means 
shallow cavity, at the bottom of which was the sternum. The 
rapidity which this was effected, and the unnatural appearance the 
chest then presented, excited a most disagreeable feeling of alarm 
in the minds of the spectators, for we could not avoid dreading that 
he was inflicting on himself some serious injury. 
The portion of the chest which yielded in this singular manner 
to pressure, comprised the sternum from within two inches of its 
superior edge, and seemed below this point to be limited laterally 
by the lines answering to the junctions of the cartilaginous with 
the osseous portions of the ribs, so that the whole space capable of 
being pressed inwards was nearly triangular in shape, and was 
very extensive. The sternum was so tender to the touch, that, in 
applying the pressure, he was obliged to press at some distance at 
each side of this bone. When the pressure was carried to the 
farthest point, the sternum was pushed in, as nearly as we could 
guess, about two inches, and the action of the heart, as well as that 
of the subjacent lung, appeared to be notably diminished, and, in 
consequence of this, the pulse was weakened. This young man 
was subject not only to constant pain in the sternum, but likewise 
to frequently recurring violent palpitations of the heart. His chest 
was sufficiently ample and well formed, but he had lately become 
round shouldered, in consequence of his seeking relief from pain 
by stooping forward. No other portion of his osseous system ex- 
hibited the least trace of softening. The only affection which I 
can call to mind the least resembling this, is the softening which 
sometimes affects the female pelvis, giving rise to great distortion, 
and which softening is accompanied, during the months or even 
years of its formation, by severe pelvic pains. 
LECTURE XV. 
Case of phlebitis—Remarks on the symptoms and treatment of this disease—Pathology 
of phlegmasia dolens—Its treatment—Case of cancrum oris—Fatal termination—Re- 
medies employed—Case of ague cake—Observations on the different varieties of ague 
—True ague, or intermitting fever—Ague produced by inflammation of internal 
organs—Nervous ague—Hysterical ague—Treatment of ague cake. 
Among the cases at present under treatment in our wards, that 
of Mary M‘Q,uade particularly demands your attention. This poor 
woman was admitted a few days since labouring under an attack PHLEBITIS. 
163 
of fever, accompanied by considerable prostration, anxiety, and rest- 
lessness ; in addition to these symptoms, she has a local affection 
of a very important nature; the right leg, as far as the knee, is 
swelled to twice its natural size, and a large erysipelatous blotch 
occupies the fore part of the foot, extending over the ankles on each 
side. The thigh also is increased in size as far as its upper third, 
so that the tumefaction embraces more than two thirds of the whole 
extremity. There is a considerable degree of tension present, 
and the limb, particularly along the internal surface of the leg, is 
extremely tender, the soreness being so great over the course 
of the veins and lymphatics, that she could not bear the slightest 
touch. 
Here we had a swelling of the lower extremity depending on an 
inflammatory condition of the part, and the question is, in what 
tissue did it commence, and what are its characteristic features 7 
Before we discuss this question, it may be proper to observe here 
that the disease had its origin from cold. When a patient is ex- 
posed to cold under unfavourable circumstances, local inflammation 
is generally the consequence, and it depends on a variety of causes 
of what description the inflammation will be, and on what parti- 
cular part it will fall. Where the lower extremities are the parts 
chiefly exposed, inflammation of the cellular membrane of the leg 
is apt to ensue, or it may attack the veins, as in the case before us, 
constituting phlebitis, or the lymphatics may be primarily and al- 
most exclusively engaged. In a few cases inflammation attacks 
the arteries of the limb, as in a case which has been published by 
Dr. Stokes and myself in the Dublin Hospital Reports, where a per- 
son, after exposure of the lower extremities to cold, got an attack of 
arteritis, terminating in mortification of the limb and death. Expo- 
sure of the lower extremities to cold gives rise to phlebitis much 
oftener than to arteritis* Dr. Stokes and I have published a striking 
case where inflammation of the veins of the leg was produced by 
this cause. You will find this case referred to by Dr. Lee, in the 
excellent article, Phlegmasia Dolens, in the Cyclopaedia of Prac- 
tical Medicine. You perceive, then, that painful swelling of the 
lower extremities originating in cold, may consist either in the 
whole cellular membrane being engaged, or it may arise from in- 
flammation of the lymphatics of the veins, or of the arteries. Now 
when inflammation attacks in the first instance the subcutaneous 
tissue of the lower extremities, it frequently in its progress involves 
the lymphatic and venous tissues, the arterial very seldom, for the 
arteries lie deep, and have no connection with the subcutaneous 
cellular membrane. There is, however, nothing more common 
than that inflammation commencing in this way should terminate 
in phlebitis, and disease of the lymphatics. This appears to be 
the nature of phlegmasia dolens, that peculiar inflammation which 
generally attacks one, and seldom both, of the lower extremities, 
which is most commonly observed in females, and which is cha- 
racterised by swelling not pitting on pressure, by excessive cuta- 
neous tenderness, and by a remarkable whiteness of the skin of the 164 
graves’s clinical lectures. 
affected limb, accompanied by increased heat, and more or less 
lesion of the locomotive function. These are the principal symp- 
toms which characterise phlegmasia dolens. The inflammatory 
condition of the limb causes an exudation of fluid into the cellular 
membrane, consisting partly of serum and partly of lymph ; this 
produces swelling which is of a firm and rather unyielding cha- 
racter, not pitting on pressure like that which results from anasarca. 
After some time the inflammation extends to the neighbouring tis- 
sues, and attacks the veins and lymphatics, a circumstance which 
has led many persons, among others Dr. Lee, to believe that phleg- 
masia dolens arises primarily from phlebitis. This, however, is 
not borne out by the fact, nor is it true that it consists in inflamma- 
tion of the lymphatics, as others have suggested; it may engage both 
the lymphatic and venous tissues, but it differs in many points from 
pure phlebitis, or true inflammation of the lymphatics. 
In the case before us, it would appear that the inflammation 
commenced primarily in the veins, and by a careful examination 
you will be able to discover some essential points of difference be- 
tween the disease and phlegmasia dolens. There is a good de&l 
of soreness present in this case, but the exquisite neuralgic tender- 
ness of phlegmasia dolens is wanting. Again, the shining appear- 
ance of phlegmasia dolens is absent, and the colour differs greatly 
from the dead whiteness observed in that disease. The tenderness 
also is here more localised, being chiefly complained of on the 
inside of the limb, and along the course of the veins and lymph- 
atics. On the other hand, it may be observed that these affections 
have many symptoms in common, and you may have remarked 
that here, as in phlegmasia dolens, the locomotive power of the 
limb is considerably diminished. This, however, has been reme- 
died, to a certain extent, by the curative means employed, and the 
patient is now able to raise up the whole limb, and bend the leg on 
the thigh. Now, whence arises this loss of power so often wit- 
nessed in cases of phlegmasia dolens, and phlebitis, and inflamma- 
tion of the subcutaneous cellular tissue of the lower extremities ? 
I am inclined to think it depends on a morbid impression made on 
the ultimate ramifications of the sentient nerves, which is propa- 
gated along the larger trunk to the spinal cord, and from thence by 
a reflex course is brought to bear and react on the muscular nerves 
of the limb. In my remarks on paraplegia, I have spoken of this 
matter at large, and given several instances of loss of power in a 
limb, produced by impressions made on the extremities of its cuta- 
neous nerves; and such appears to be the lesion of the locomotive 
power observed so frequently in cases of phlebitis and phlegmasia 
dolens. In many cases of paralysis, we find the first stage of the 
disease attended with an increased sensibility of the nerves of the 
part affected, tending to show that the primary source of the disease 
consists in an impression made on the sentient extremities of the 
nerves; and there is nothing more common in such cases than to 
find the loss of the motor power accompanied by deranged sensa- 
tion. In phlegmasia dolens and phlebitis, we have great cutaneous 165 
tenderness, and this is very rapidly followed by more or less dimi- 
nution of the muscular power of the limb. 
I shall now refer briefly to the curative means employed in 
this case, observing that it has this in common with many cases 
of phlegmasia dolens, viz., the inflammation has engaged in suc- 
cession the cellular membrane, veins, and lymphatics. When the 
lymphatics are attacked with inflammation, they become swelled, 
and have a knotty cord-like feel, and this condition is most com- 
monly attended with the appearance of erysipelatous patches on 
various parts of the limb, over the place where a number of 
lymphatics are simultaneously engaged. This appears to be the 
case in the present instance, and it explains the occurrence of the 
erysipelatous blush which covers the instep and ankle. I need not 
tell you that the appearance of erysipelas over any part of a limb 
so circumstanced, strongly demands our attention, as it might be 
an indication of the seat of an injury which may have given rise to 
the disease. In this case, however, it was the product of the 
disease, and had no connection with its origin. The treatment of 
a case of this description cannot be conducted on strict antiphlo- 
gistic principles. The fever which accompanies venous inflamma- 
tion is of a low typhoidal character, and prostration sets in at a 
very early period. The intimate connection of the venous system 
with the whole economy, the peculiar character of the inflammation 
affecting venous tissue, and the rapid prostration of strength which 
ensues, are all circumstances which contra-indicate general deple- 
tion. On the other hand, the best effects have been obtained by 
active local bleeding, and this appears to be so much the more ne- 
cessary in cases of phlebitis, as the inflammation is apt to run very 
quickly into the suppurative stage. I therefore ordered forty leeches 
to be applied along the inside of the affected limb, directing the 
nurse to encourage the bleeding by warm fomentations. In addi- 
tion to this, two ounces of mercurial ointment, combined with two 
drams of the extract of belladonna, were spread on large pieces of 
lint, and applied over the limb after the leech bites had ceased to 
bleed. That mercurial ointment thus applied has a tendency to 
subdue inflammation of a low erysipelatory character, has been 
shown by Mr. M‘Dowel in an excellent paper published in a late 
number of the Dublin Medical and Chemical Journal. To this 
we added the extract of belladonna, because the local inflammation 
was attended with hypersensibility of the limb, a condition over 
which belladonna is known to possess a remarkable influence. Dr. 
Lee, I should observe, does not appear aware of the great utility of 
narcotics in the painful swelling of the extremities after fever, or in 
true phlegmasia dolens. In both these diseases, together with 
active local depletion by means of the frequent application of leeches, 
we should employ anodyne ointments, and, above all, large doses 
of opium internally. Some patients in phlegmasia dolens, if the 
bowels be regulated, will bear and derive benefit from four, five, or 
even six grains of opium in the day ; I speak of the second stage of 
the disease. The same observation applies with regard to wine, 
PHLEGMASIA DOLENS. 166 
graves’s clinical lectures. 
and to sulphate of quinine. It is obvious that phlegmasia dolens 
consists of something besides mere inflammation ; the pain is alto- 
gether different from that attending ordinary phlegmasia; it more 
resembles a general neuralgia of the extremities of the subcutaneous 
nerves. The internal treatment consisted in giving a few grains 
of hydrarg. cum creta three times a day, to keep up a free state of 
the bowels, and with the view of gently affecting the system. 
These means are very likely to be attended with success. The 
woman at present is much better, and the inflammation is sensibly 
declining. I shall not however anticipate the result, and for the 
present shall only call your attention to the case. 
You may perhaps ask me to account for the great tumefaction of 
the limb observed in this case. It has been supposed by some per- 
sons that the whole swelling depends on the obstruction of the 
veins ; but if inflammation was entirely limited to the veins, the 
swelling could not be so extensive, It is true that if you produce 
artificial obstruction of any of the great veins, by placing a ligature 
on it, you\ cause, for the time, very considerable oedema of the 
limb. The obstruction to the passage of blood through an inflamed 
vein will necessarily give rise to a certain degree of swelling, but I 
am inclined to think that this is not the only source of the tumefac- 
tion ; it would appear that in addition to phlebitis we have the 
inflammatory process communicated to the neighbouring parts ; the 
cellular tissue and probably the lymphatics become engaged, there 
is a copious effusion of serum and lymph, and to this the general 
increase in size of the limb is to be chiefly attributed. 
With respect to the termination of phlebitis, I may remark that 
it generally ends in adhesion of the sides of the vein and oblitera- 
tion of its cavity, so that when the patient recovers, the affected 
vein feels like a piece of whipcord lying under the skin. We had 
some patients here who had obliteration of this kind, and in one of 
them who died afterwards of fever, I found some of the smaller 
subcutaneous veins had become totally impervious through their 
whole extent, and resembled hard cords. This is all I have at 
present to say with respect to phlebitis, observing that the diseases 
which are most analogous to it are phlegmasia dolens, and a parti- 
cular morbid enlargement of the lower extremity, which has been 
described by Dr. Tweedie, and by Dr. Stokes and myself in the 
Meath Hospital Reports. 
A child about four or five years old, who has been for some time 
in the fever ward, has been recently attacked with a very formi- 
dable disease, cancrum oris. Like most patients labouring under 
this malady, she had been previously debilitated by the occurrence 
of fever, for a child in good health seldom, indeed, I may say never, 
gets an attack of this kind. A preceding febrile condition of the 
system, and a depraved habit of body, must have existed in every 
case where cancrum oris occurs. The disease itself is nothing 
more than mere local inflammation setting in under unfavourable 
circumstances, and during a morbid state of the system, and hence 
the local inflammation rapidly assumes the gangrenous character. 167 
In children, many forms of general disease are apt to bring on a 
state of the system in which inflammation of any part has a strong 
tendency to run into gangrene, and this is to be borne in mind 
with reference to the present case, for cancrum oris has nothing 
peculiar in it except its situation. 
It is not my intention at present to enter into any particular de- 
scription of this disease, it has been well described by many surgical 
writers, and you will find a very valuable essay on the subject 
published by Dr. Cuming in the fifth volume of the Dublin Hospital 
Reports. There is also a very excellent article on cancrum oris 
in the London Cyclopaedia of Practical Medicine, to which I beg 
leave to refer you. It may, however, be necessary to allude briefly 
to some points connected with its treatment. In the first place, I 
may observe, with reference to the general principles of treatment, 
that you should not be misled by the name of the disease, or think 
that because there is a gangrenous condition present, you should 
rely exclusively on detergent and antiseptic remedies. This is a 
common but pernicious error—it is the error of prescribing for 
names and not diseases, the easy but dangerous practice of unre- 
flecting empiricism, by which the reputation of medicine has been 
so often damaged. He who commences the treatment of cancrum 
oris with the internal and external use of antiseptics, is acting on 
false principles ; his practice may have the sanction of time, but it 
has not the support of observation and experience. In the early 
stage of the disease, when the cheek is of a deep red colour, tense, 
prominent, and shining, I do not know of any means which tend 
so directly to diminish the amount of inflammation, and check the 
progress of gangrene, as the application of leeches, few in number, 
but frequently repeated. This is the mode of treatment which I 
have found to be most effectual, and which, from my experience of 
the disease, I can recommend as the most likely to prove beneficial, 
when, unfortunately, the ordinary resources of medicine are too 
often ineffectual. 
CANCRUM ORIS. 
With respect to internal remedies, Dr. Cuming lays great stress 
on the utility and value of purgative medicines. They may be 
certainly necessary, and as the little patients very often swallow the 
sanious discharge from the ulcer, more or less derangement of the 
intestinal canal must accompany the disease. But along with pur- 
gatives I would strongly recommend the use of sulphate of quinine, 
either in the form of enema, or, if the child can be got to swallow 
it, made up into a syrup, and its solution favoured by the addition 
of a little sulphuric acid. With regard to the external applications, 
you have a choice of many remedies, each of which you will find 
recommended by authors, but none of which can be exclusively 
relied on in any case. The balsam of Peru with castor oil forms a 
good application, or you may blend it with honey, as we did in 
this case—one ounce of the balsam to two ounces of honey. You 
may also employ washes composed of solutions of nitric or muriatic 
acids, or of the chlorides of soda or lime. 
In the present instance the sore has, in spite of all our efforts, eat 168 
graves’s clinical lectures. 
its way from the internal to the external surface of the cheek. On 
Saturday, the centre of the cheek was characterised by the appear- 
ance of a bluish-black spot, indicating the occurrence of sphacelus. 
In the meantime it was curious to observe how little constitutional 
disiurbance was yet produced ; the child, notwithstanding the ma- 
nifest existence of extensive sphacelation of the cheek, continued 
for several days to have a tolerable appetite, and to sleep well, being 
nearly free from fever, and complaining but little ; as the mortifi- 
cation progressed, destroying rapidly the external parts of the 
cheek, &c., matters soon altered, and the poor little patient sunk 
exhausted and suffering. 
Let us now direct your attention to the case of a sailor who has 
recently been discharged. This boy was one of the crew of a vessel 
which returned lately from the West Indies, and was exposed to 
great hardship during his voyage. Boys in his situation suffer an 
enormous quantity of fatigue and rough treatment; they are the 
drudges of all on board, and it is impossible to conceive what pri- 
vations they endure. When the vessels arrive in unhealthy cli- 
mates they are generally the first who fall victims to the prevailing 
malady, and such was the case of this lad, who got yellow fever 
immediately after his arrival at the West Indies. From this he 
recovered, but on his way home was attacked with irregular inter- 
mittent, which lasted for a considerable time. He had no treatment, 
and the disease subsided spontaneously, leaving him extremely 
weak and emaciated. He was, however, obliged to work as usual 
on his passage, and he arrived in Dublin about three weeks since, 
debilitated, thin, and with a countenance expressive of long-con- 
tinued suffering. He had on his admission that peculiar hue of 
skin which often follows tedious intermittents, and which those 
who have once seen will always recognise with facility. This 
colour is to be distinguished from the hue of slight jaundice—it is 
what has been termed a clay colour. In the present instance it was 
mixed with a faint tinge of jaundice, and on examining the stools 
we found that they contained scarcely any bile. He had no fever; 
his pulse was rather slow and regular; he complained of lassitude; 
his urine was deeply tinged with bile ; and his belly tumefied. On 
examining him, we found that the abdominal tumefaction did not 
depend on the presence of fluid in the peritoneum: it was produced 
by enlargement of the liver and spleen, intestinal congestion, and 
tympanitis. 
Here was a case of what has been vulgarly termed ague cake ; 
that species of congestion and enlargement of the liver and spleen 
which is apt to accompany the paroxysms of an intermittent, and 
in some cases to remain after the disease has subsided. You are 
aware that some persons, during the paroxysm of an intermittent, 
will complain of pain in the right hypochondrium, but more fre- 
quently in the left, and on examination the liver or spleen is found 
increased in size, If you take the trouble of reading the experi- 
ments which have been made with the view of illustrating the 
functions of the liver and spleen, you will have a good idea of the AGUE CAKE. 
169 
facility with which enlargement of these organs, but particularly of 
the latter, may take place. The spleen undergoes very remarkable 
changes, even in its natural state, during*the process of digestion, 
and there is a great difference between its size when an animal is 
fasting, and its size when an animal has taken food. Indeed, it is 
surprising how rapidly it will become filled with blood, and how 
quick the transition is from a state of collapse to a state of con- 
gestion. It is easy, therefore, to conceive how the spleen may, 
during the paroxysms of an intermittent, particularly in the cold or 
congestive stage, become manifestly enlarged. The increase of 
size, however, never occurs to such an extent in the liver; unlike 
the spleen, its magnitude remains nearly the same, and its volume 
does not vary like that of the spleen with the time of day or the 
period of digestion. It is obvious, therefore, d priori, that the 
spleen should be more frequently the seat of congestion than the 
liver, and that its enlargement should be more distinct and palpable. 
But it is not in the liver or spleen alone that congestion occurs 
during an aguish paroxysm, it may take place in any organ ; and 
this, in a practical point of view, is worthy of being borne in mind. 
Thus, in a case which I attended, the patient got intermittent of a 
tertian type ; during each paroxysm he had some distress about 
the chest and slight cough, but these symptoms disappeared during 
the intervals. As the disease, however, went on, the fits of cough- 
ing and dyspncea increased, and the sulphate of quinine failed in 
arresting the paroxysms. The pulmonary congestion became gra- 
dually more marked and permanent, and no longer disappeared 
during the intervals ; finally, inflammation of the lung took place, 
and the patient died with extensive hepatisation. This happened 
about twelve years ago, when the old notion of connecting the cold 
stage of ague with debility was universally prevalent, and before 
the practice of bleeding for the relief of visceral engorgement had 
been introduced. Subsequently, the practice of bleeding in the 
cold stage, as introduced by Dr. M‘Intosh, was tried on an exten- 
sive scale in the Meath Hospital, and it is a practice which I can 
strongly recommend in those cases where there is recurring inflam- 
mation of some internal organ. It is not a mode of treatment appli- 
cable to all cases, and in mild cases unaccompanied by excessive 
congestion of any viscus, it is totally unnecessary; but where an 
important organ is threatened, it is a valuable remedy, and has on 
some occasions cut short the paroxysms altogether, or rendered 
them much milder and more manageable. 
Sometimes ague is accompanied by symptoms of congestion and 
inflammation of some internal organ during the paroxysms; and 
yet, by giving sulphate of quinine, you will succeed in arresting 
the intermittent and the visceral disease at the same time. I recol- 
lect the case of a boy who was under treatment here for ague, and 
who, during the paroxysms, had severe bronchitis with dyspnoea. 
The cough did not leave him even during the intervals, but it was 
much milder; I was, however, doubtful whether the case would 
admit of the exhibition of sulphate of quinine, from the violence 170 
graves’s clinical lectures. 
of the pulmonary symptoms during the fits. I determined, after 
some time, to try the quinine, and I found that it stopped both the 
intermittent and the bronchitis. It is to be observed, however, that 
in this case the bronchitis was of a chronic character; and I believe 
that in all cases of ague accompanied by visceral derangement, 
where quinine succeeds in curing the disease, the inflammation is 
either of a trifling description, or is one of a chronic nature. Where 
the visceral derangement is great, quinine will not succeed, and 
hence it is of great importance, in the treatment of ague, that you 
should carefully attend to the state of the internal organs. 
There are several forms of disease which simulate intermittent 
in a very remarkable manner; and, as this may lead to very danger- 
ous errors, it is necessary on all occasions to make a strict enquiry 
into the origin and history of the complaint. Some forms of hectic 
assume the intermittent character, and have been frequently mis- 
taken for ordinary ague. Of this I had lately a very striking 
instance in the case of a lady, who came from the county of Lime- 
rick to consult me for what was stated to be an attack of irregular 
intermittent. She had been confined in August; had been feverish 
after her accouchement—the consequence, she believed, of exposure 
to cold—and got a slight cough. This continued, but without any 
expectoration, for two or three weeks, and then she was attacked 
with fever of an intermittent character, and exhibiting a well- 
marked tertian type. She began to take quinine, but this aggra- 
vated the cough very much without having any effect on the 
paroxysms. Various other remedies were also tried, but their only 
effect was to render the paroxysms more frequent and irregular. 
The moment I saw her I was convinced that she was labouring 
under some visceral disease. I examined her chest, and found dul- 
ness under the right clavicle with tubercular crepitus. Her cough 
had been dry until she came to Dublin, but now it became suddenly 
moist, and a distinct gargouillement could be heard. The apparent 
intermittent was nothing more than phthisical hectic; and Dr. 
Stokes, who was also called in, came to the same conclusion. I 
recollect having observed something of the same kind in a case 
which I attended some time ago with Dr. Marsh. The patient had 
well-marked intermittent, and we treated him for it; but the sul- 
phate of quinine, and the other remedies which we employed, had 
only the effect of converting the fever into remittent. On a sudden, 
the gentleman, without having made any complaint of pain in the 
side, or any thing indicative of derangement of the liver, became 
suddenly jaundiced, and sank rapidly. On dissection, we found 
seventeen or eighteen small circumscribed abscesses in the sub- 
stance of the liver. The intermittent hectic here depended on 
interstitial inflammation of the liver—a disease which is generally 
of a latent and incurable character. 
I need not refer here to certain forms of fever which accompany 
disease of the brain and of the urinary system, and which are 
remarkable for their intermittent character. There is, however, 
one form of anomalous intermittent, of which it may be necessary AGUE CAKE. 
171 
So say something: I allude to that species of ague which seems to 
be exclusively confined to females of a nervous habit—at least I 
have never met with it in any others. Persons of this description, 
after an accouchement or some acute disease, or in consequence of 
violent mental emotions, will sometimes get into a peculiar state of 
health, in which they are liable to recurring periodic attacks of 
fever. Some time since, Dr. Stokes called me to see a lady who, 
shortly after her confinement, had got an attack of well-marked 
tertian. She had, at the regular time, severe rigors, followed by 
acceleration of pulse, heat of skin, and profuse sweating. When 
the paroxysm was over, she felt tolerably well, but still there was 
much excitement of pulse, and the intermissions were any thing 
but perfect. Sulphate of quinine had been tried by the accoucheur 
in attendance, but had failed. On examining the case, I found 
that the lady was of a decidedly nervous and hysteric habit, and 
advised the use of nervous and antispasmodic medicines. A mix- 
ture containing musk, camphor, and ammoniated tincture of vale- 
rian, was prescribed, and the intermittent symptoms rapidly dis- 
appeared. 
But to return to the case of this boy. How are we to treat this 
ague cake? The disease has not as yet proceeded so far as to 
produce ascites, but if permitted to run on it would soon cause 
effusion into the peritoneal cavity. In a case of this kind a great 
deal will depend on whether there is any fever present or not. If 
there is no remarkable excitement of pulse or heat of skin, general 
antiphlogistic means will be unnecessary, for any local tenderness 
or irritation can be relieved by local bleeding. In the case before 
us, there was a slight degree of tenderness, and we applied leeches 
once with benefit; but we did not apply them over the abdomen— 
they were applied to the anus, because it is well known that leeches 
applied in this situation have a remarkably good effect in removing 
intestinal congestion, and consequently in relieving hepatic engorge- 
ment. Those who have remarked the relief which a flow of blood 
from piles gives in cases of hepatic engorgement with dyspepsia, 
will recognise the value of depletion of this kind, and will imitate 
the natural mode of relief by art. Hence the use of leeches applied 
to the anus in cases of intestinal congestion and hepatic or splenic 
engorgement. There is no necessity here for applying a great 
number of leeches—three or four every second day will be quite 
sufficient, and we have found this number answer every necessary 
purpose. In addition to local bleeding and attention to diet, I or- 
dered this lad to take a few grains of blue pill once a day, not with 
the intention of affecting his system, but merely with the view of 
keeping up the free action of the bowels. I continued the mercury 
only as long as the tenderness of the liver remained; for experience 
has shown, that in those cases of ague cake where there is merely 
enlargement of the liver without tenderness, mercury is a bad 
remedy. 
In cases of this kind, where the stage of active congestion is 
past—where there is no fever—where the tenderness is removed. 172 
graves’s clinical lectures. 
and nothing but the increased size of the liver remains—how are 
you to accomplish a cure ?—first, by inserting one or two setons 
over the liver; and, secondly, by the use of iodine and tonics. 
The use of setons in cases of this description is well known, and 
needs no comment. I recollect the case of a lady, who, after seve- 
ral attacks of jaundice, got chronic enlargement of the liver. The 
right lobe of the liver, which was the portion chiefly affected, 
extended down towards the crest of the ilium, and was excessively 
indurated. This state had occurred after the patient had used 
mercury and been copiously salivated. Two setons were inserted 
over the region of the liver, and these produced rapid diminution 
of the enlargement, and a perfect cure. 
With respect to tonics, I may observe that they prove extremely 
useful in chronic enlargements of the liver and spleen. We are in 
the habit of using, in this hospital, a combination somewhat similar 
to the celebrated Bengal spleen powder; it consists of vegetable 
and mineral tonics, combined with a vegetable purgative—as, for 
instance, aloes—and we have seen the best results from its use. 
With respect to iodine, it is a valuable adjuvant in such cases, par- 
ticularly where the system has been much deranged, and where 
mercury would be likely to run down the patient. Here iodine 
gives vigour to the constitution, and tends in a very remarkable 
manner to promote the absorption of the morbid products, on which 
the enlargement chiefly depends. 
LECTURE XVI. 
It is my intention in this day’s lecture to refer briefly to some 
cases worthy of your attention ; I shall not dwell long on them, as 
I wish merely to point them out that you may observe them more 
accurately. 
In the first place, there is a man, named Verp, in the fever ward, 
whose case I beg you will study with attention. He applied for 
admission here some time ago, labouring under violent and general 
bronchitis, accompanied with high inflammatory fever; we took 
him in at the time, as his case was one of the most urgent danger, 
hut were obliged, by the crowded state of the hospital, to put him 
into the large fever ward. It is unnecessary for me to detail the 
treatment employed, as you have all witnessed it. By the most 
energetic measure's, we succeeded in arresting the disease, but his 
convalescence was rendered tedious in consequence of his having 
been suddenly affected by a small quantity of mercury. His mouth 
became very sore, his breath fetid, his gums spongy, the inside of 
his lips covered with lymph, and his system exhibited all the marks 
of mercurial irritation; but, under the care of Mr. Grady, a gradual 
but decided improvement in his condition was going on, and he NERVOUS FEVERS. 
173 
was advancing rapidly in convalescence, when, unlucky for him- 
self, he was persuaded to leave the hospital for the sake of voting 
at the city of Dublin election. In doing this, he was necessarily 
much fatigued, and was exposed to cold on returning from the 
heated booth. Now, mark the consequences of this indiscretion. 
This man just arrived at the period of convalescence from a severe 
and dangerous inflammatory fever, and greatly debilitated both by 
the disease and the venesections and other remedies necessarily em- 
ployed, improvidently exposes himself while his frame was still 
emaciated and weak, and while his mouth was still sore in conse- 
quence of severe mercurial salivation ; in this condition he exposes 
himself to the operation of mental excitement, great bodily fatigue, 
and cold—and what have been the consequences ? Why, that a 
new attack of fever immediately struck him to the ground with a 
heavy hand, and, after an absence of ten days, he returned to the 
hospital on the 24th of January, complaining of rigors, and other 
symptoms indicative of commencing fever. We saw him next 
morning, that is, before this new fever had lasted twenty-four 
hours, and we found him affected in a most remarkable manner; 
we found him labouring under a number of severe symptoms, 
which would have led the most experienced, if asked to guess how 
long his fever had already lasted, into the commission of a gross 
error, for he would answer that it must be at least the eleventh day. 
It is, indeed, very rare to find fever at once commencing with 
symptoms such as we observed on the first day in Vero. Great 
prostration of strength, hot skin, dry tongue, pulse 108, nervous 
agitation, restlessness, together with subsultus tendinum, were 
present from the commencement. The subsultus was very re- 
markable, and increased to such a degree, even on the second day, 
that Mr. Grady found it very difficult to count the pulse at the 
wrist; and yet, though his muscular system was thus irregularly 
excited, and its nervous influence deranged, he had not even a ten- 
dency to delirium, and he slept soundly; neither had he the least 
headache. 
I called your attention to this circumstance at the bedside of this 
patient, and I endeavoured to impress strongly on your minds how 
forcibly this case opposes the doctrines of those who attribute all 
the nervous disturbance of every part of the system, and, among 
the rest, subsultus, to congestion or to inflammation of the brain. 
When the subsultus had attained a degree of violence in Yero’s 
case, such as we seldom witness, we remarked, nevertheless, that 
he slept well, had a clear eye, without the least approach to suffu- 
sion, and that he was free from headache, heat of scalp, or throb- 
bing of the temporal arteries. Neither were we able to detect the 
slightest indication of inflammation, or even of congestion, in the 
chest or abdomen. The breathing was indeed quickened, but only 
in proportion to the acceleration of the pulse, and there was no 
cough or thoracic pain or uneasiness. The belly was fallen, soft, 
and quite free from tenderness; and there were no griping pains, 
flatulence, nausea, or diarrhoea, and yet the patient was evidently 174 
graves’s clinical lectures. 
very dangerously ill. Agitated with subsultus, he was in a con* 
stant state of restlessness when awake; his skin was hot, his 
tongue dry, and his weakness was sudden and excessive; in short, 
he was labouring under intense nervous fever< This is a rare 
form of disease, and one the very existence of which most modern 
pathologists have been in the habit of denying; but, as I told you 
in a former lecture, I have seen several examples of it. 
I may remark that, in the present epidemic fever, the termination 
of the disease by a well-marked crisis never occurs. Now, in the 
epidemic fever of which I have spoken in a former lecture, and 
which committed such devastations in 1837, a crisis was observa- 
ble in the majority of the cases, and was almost always preceded 
by rigors and a hot fit, attended for a few hours with marked 
exacerbation of the symptoms, and followed by a most profuse, 
warm, general perspiration, bringing: perfect relief, and often so 
excessive that the steam of it could be seen issuing forth in vapour 
through the blankets in which the patient lay wrapped. In the 
beginning of the epidemic, the critical rigor often took place on the 
fifth day, and oftener on the seventh, but, as the disease continued, 
these short fevers, which, by the by, always left the patient very 
liable to relapse, entirely disappeared; and when the epidemic 
reached its acme, the crisis rarely took place so early as on the 
eleventh day, and most general on the fourteenth or seventeenth 
day. 
You perceive, that in judging of the truth of the doctrines held 
by the ancients, concerning the existence of critical days in fevers, 
an observer of the present epidemic might be led into error, and 
might, by generalising too hastily, arrive at the false conclusion, 
that this doctrine of critical days is totally destitute of foundation. 
But to return to our patient Vero. It is not very difficult to ex- 
plain why, in him, the moment fever was excited it assumed the 
nervous type. He had been debilitated by severe inflammatory 
fever and by active antiphlogistic treatment, and, above all, his 
nervous system had been severely tried by an unexpected mercu- 
rial salivation, brought on by an unusually small quantity of 
calomel. 
You are aware that various nervous symptoms attended with 
irregular muscular action, and simulating chorea, or paralysis 
agitans, are frequently the result of metallic salts, whether lead or 
mercury. For this reason, I look upon the previous mercurialisa- 
tion as the chief cause of the nervous type of Yero’s fever. In 
spite of all our efforts, he died exhausted on the tenth day. 
Let me now refer you briefly to the case of Catherine M‘Donnel. 
This girl is labouring under an attack of chorea of considerable 
standing, and is at present about fourteen years of age. I mention 
this because it is not improbable that the appearance of the cata- 
menia, which frequently come on about this period, may have 
some influence on the future progress of her complaint. She states 
that her disease commenced about seven years ago, and that ever 
since she has been subject to its attacks at various times. Her CHOREA. 
175 
health is somewhat impaired, but not, however, to such a degree 
as to prevent her from following her usual avocations. Her pre- 
sent attack commenced about three weeks ago. 
It is unnecessary for me to enter into any description of the con- 
vulsive motions of the limbs, and other symptoms which characterise 
chorea ; neither is it my intention to enter into the general history 
of the disease; you will find an admirable account of its symptoms, 
pathology, and treatment, in Copland’s Dictionary. I shall merely 
remark, with reference to this case, that there is no headache, and 
an accurate examination has failed in detecting any symptoms of 
determination to the head. Neither have we derangement of mus- 
cular motion during sleep; the girl’s sleep is tranquil and regular. 
There is no evidence of gastric derangement present. She relishes 
her food, and, what is rather singular, her appetite is better during 
the attacks than during the intervals. Her tongue is clean and 
moist, but her bowels are inclined to constipation. It is of import- 
ance to bear in mind here, that her symptoms do not appear to 
have any connection with cerebral or gastric derangement. She 
has no headache, flushing of the face, noise in the ears, or throb- 
bing of the temporal arteries, and there is nothing but constipation 
to show that the digestive organs are out of order. I dwell on 
these two circumstances particularly, because some persons have 
attributed chorea to cerebral irritation, and others to indigestion 
and gastric derangement exclusively. I am quite ready to grant 
that it may be produced occasionally by either of these two causes, 
and that the presence of either will tend to aggravate it, but am 
inclined to look on chorea as chiefly a nervous disease, and to be 
cured chiefly by nervous medicines. Dr. Copland’s remarks upon 
this question are excellent, and deserve to be attentively studied. 
For my own part, I think that in this, as in many chronic diseases 
where indigestion exists, it is often a consequence, not a cause, and 
is produced by debility of the vital powers of the stomach and in- 
testines, organs which are affected by causes acting on the whole 
organisation. Thus a too rapid growth, premature or unnatural 
sexual indulgence, confinement, want of exercise, of rest, care and 
anxiety, &c., may each occasion a weak state of every organ of the 
body, including debility of the stomach. In a girl of this age, who 
labours under constipation, it is always proper to commence with 
the use of purgatives, and I have accordingly ordered her some 
pills, composed of aloes and capsicum ; but I would not persevere 
in the purgative plan any longer than was necessary for removing 
constipation. What I mainly depend on for removing the disease 
is tonics, one of the best of which is the carbonate of iron, in doses 
of half a dram four times a day. There is at present a controversy 
between Dr. Billing and Dr. Johnston, with respect to the doses of 
carbonate of iron to be employed in this disease; and it is asserted, 
that in cases where doses of half a dram, three or four times a day, 
will not succeed, a cure may be effected by giving three, four, or 
even five drams, frequently in the day. With regard to this sub- 
ject, I must confess that I am for moderate doses, and I think, in 176 
graves’s clinical lectures. 
general, as much good may be accomplished by half a dram or a 
dram, three or four times a day, as by much larger doses. I have 
accordingly ordered this girl to lake half a dram four times a day, 
and will persevere in the use of the remedy until we have given it 
a fair trial. The carbonate of iron tends, in general, rather to pro- 
duce a relaxed than a constipated state of the bowels, and conse- 
quently is peculiarly well adapted to chronic cases of debility. The 
mistura ferri aromatica, in moderate doses, is another excellent 
formula. When we have to deal with constitutional weakness, 
which has arisen gradually, and continued long, we must trust 
more to the operation of general physical influences than to medi- 
cine, and in graduating the doses of tonics, we must remember that 
it is impossible in such cases suddenly to strengthen ; we must 
therefore rely upon the gradual operation of tonics, given for a long 
continuance, and in moderate doses. This rule should never be 
lost sight of in the treatment of chronic diseases ; important as it 
is, most practitioners seem little influenced by it, or perhaps they 
are altogether ignorant of it, otherwise we should not see them 
using concentrated and powerful tonics in such large and repeated 
doses in chorea. Another general rule as to the use of tonics in 
chronic diseases—usually you will be more successful with mild 
and diluted than with powerful and concentrated medicines. 
Thus, for example, cinchona in powder is often preferable to sul- 
phate of quinine in chronic diseases. 
There is a very curious case of paralysis agitans at present in 
the female chronic ward, which claims a few remarks. You must 
have all remarked the patient Ellen Davis, a young woman about 
twenty-five years of age. She has a most peculiar expression of 
countenance, and, as her disease is rather a rare one, I beg that any 
gentleman who has not seen it will take the opportunity of paying 
her a visit. According to the account which she gives of herself, 
the disease appears to have originated in a sudden and violent 
mental emotion. The poor girl, like most of the lower class of 
country people, happened to be a firm believer in the existence of 
ghosts and such like nonentities, and this superstition has formed 
the source or exciting cause of the disease in question. She was, 
unfortunately for herself, located In a very uncomfortable situation, 
her house being close to a road between two churchyards, a com- 
plete thoroughfare for ghosts, and where figures of a very question- 
able description had been frequently seen by many of her neigh- 
bours. Some of her acquaintances, who were aware of the frightful 
notions she entertained about personages of this kind, resolved to 
amuse themselves at her expense, and played off a practical joke of 
a very cruel nature. A churn-dash was procured, to which a sheet 
was appended, so as to form no unapt representation of a sheeted 
headless corpse, and this was dandled between two trees by means 
of a rope. The poor girl, who happened to be going to bed at the 
time, was utterly appalled by the sight of what she conceived to be 
one of these ghosts sweeping through the air, and immediately 
dropped down in a state of total insensibility. The fright deranged Paralysis agitans. 
m 
her nervous functions in an extraordinary degree, she became veD 
tiginous, lost the use of her limbs on one side, and took to bed, from 
which she states she did not get up for three months. 
The history of this case is of course extremely uncertain. In 
Chronic cases, and among patients in her class of life, you can sel- 
dom expect to get an accurate or satisfactory account, It is quite 
clear that she had hemiplegia, but whether it arose from the fright 
or not we cannot exactly say. The symptoms of hemiplegia after 
some time began to decline, and she gradually regained the power 
of walking. This, however, is but feeble, and though it is now 
seven years since the occurrence of the attack, the muscular power 
of the limbs is very slight. She had also during the progress of her 
complaint, an attack of amaurosis which she says deprived her 
entirely of sight for nearly a year, and that after this period she 
recovered the use of one eye completely, but the other still remains 
amaurotic, and she can distinguish objects with it very imperfectly. 
At present she affords a very remarkable specimen of paralysis 
agitans. She cannot walk slowly, and when she has commenced 
walking she cannot stop without considerable difficulty. The 
muscles of the extremities, face, and tongue are very little under 
her control, and are in a state of almost perpetual motion. The 
muscles of the eyelids and eyeballs are also similarly affected, and 
this gives to her countenance a strange and peculiar expression. 
You will find an excellent description of this disease in Dr. Elliot- 
son’s lectures; a very interesting case is also detailed in Dr. Wm. 
Stokes’s lectures, published in Renshaw’s London Medical and 
Surgical Journal. 
It would appear that in this disease the muscles are not by any 
means beyond the control of the will, but they are so influenced 
by the operation of some other unknown cause, that their motions 
are more or less imperfect and inadequate. She can walk quickly 
with tolerable ease, for in walking quickly the muscles are con- 
tracted more rapidly, and the will more strongly exercised, so that 
the obstacles to regular motion are in a great measure overcome, 
but when she walks slowly, time is given for the cause which 
produces the anomalous motions to come into play, a spasmodic 
state is established, and the muscles cease to obey the will so im- 
plicitly. I knew a gentlemen who had a very curious form of this 
paralysis agitans. When about to walk, he was obliged to have 
himself balanced, and set off by some other person, just like a piece 
of machinery. When once set agoing, and on a smooth road, he 
went on very well for a considerable time, but if interrupted by a 
hill, or by the unevenness of the ground, he was compelled to run 
backwards in a right line until stopped by some one, and so little 
control of his motions had he at this time, that if a pond or preci- 
pice lay behind him he could not prevent himself from tumbling 
over it. I have occasionally seen him under such circumstances, 
and the appearance he makes is singular and ludicrous. He goes 
backwards until he meets with a wall or some other object which 178 
graves’s clinical lectures. 
resists his further progress. This is a very curious circumstance 
as connected with the nature of the disease. 
I do not intend at present to enter into any enquiry respecting 
the nature and treatment of paralysis agitans. The prognosis of 
the disease appears to be, a priori, unfavourable, from the total 
want of any exciting cause which might be discovered and removed. 
If the disease consisted in congestion of the head or spine, or if 
there was any apparent lesion by the removal of which we could 
hope to effect some good, we might entertain a more favourable 
opinion with respect to its termination, but it unfortunately happens 
that in too many cases we can do nothing more than observe the 
curious phenomena which it presents. 
Let me now direct your attention to the case of a man named 
Murphy in the chronic ward, who came in with bronchitis accom- 
panied by anasarca. He had old bronchitic cough, copious expec- 
toration, and orthopnoea ; but he had no symptom of disease of the 
heart; his pulse was regular and rather slow, he had also albu- 
minous and scanty urine, but without any fever, thirst, or nausea. 
The recent origin and sudden appearance of the disease induced 
me to look upon it as a case of acute dropsy, and I commenced 
the treatment by antiphlogistic measures, which, as you may have 
perceived, have been followed by remarkable benefit. What I 
wish to call your attention to particularly in this case, is the state 
of the patient’s urine. On his admission, we found that his urine 
was highly albuminous; when submitted to the action of heat at 
the temperature of 170° it coagulated rapidly, and showed distinct 
traces of the presence of a large quantity of albumen. Yet under 
the use of opium in moderate doses this man’s urine became in fwo 
or three days perfectly free from every trace of albumen, and has 
continued so ever since. 
Now this case alone would be a sufficient refutation of the opi- 
nions of those who look upon albuminous urine as a pathognomic 
sign of disease of the kidneys, as described by Dr. Bright, and who 
are in the habit of marking such cases in the hospital as cases of 
“Bright’s Kidney.” It appears rather strange, as in our case, that 
a man should have “ Bright’s Kidney” to-day, and not have it the 
next day. We have had a great many instances of this kind, and 
in various cases which came under treatment in this hospital, I 
have shown that this state of the urine may depend on mere func- 
tional disease of the kidney. Indeed, nothing is more common 
than to meet albuminous urine in the dropsy which succeeds scar- 
latina. and yet most of the patients perfectly recover. I had lately 
an opportunity of examining the kidneys of a boy named William 
Young, who was admitted into Sir Patrick Dun’s Hospital on the 
sixth day from the commencement of anasarca after scarlatina. 
This boy’s urine had a specific gravity as high as 1027, and con- 
tained an enormous proportion of albumen. He died suddenly of 
convulsions the fourth day after his admission. His kidneys were 
in every respect healthy. 
One word with respect to the diuretic remedies, which in this DIABETES. 
179 
case I have employed with remarkable success. Having removed 
the acute symptoms by antiphlogistic treatment, I prescribed tjje 
following decoction :— 
R. Decocti hordei, ifcj. 
Sacchari albi, 3j. 
Nitratis potassae, 3 ij- 
Acidi nitrici diluti, 3j. 
Spiritus aetheris nitrosi, 3 j. 
Two tablespoonfuls to be taken every second hour. 
This is an excellent mixture, and well suited to the stage interme- 
diate between the acute and chronic form of dropsy, where you 
wish to excite the action of the kidneys, and are afraid of stimulat- 
ing the system generally. It has acted very favourably in the case 
before ns, having increased the urinary discharge very considerably 
without producing any constitutional excitement. 
There is a man at present in hospital labouring under diabetes; 
he furnishes one of the best examples of the disease you can 
meet, and I would recommend you to study his case with attention. 
He has got the notion that his complaint is one of no ordinary 
interest, and he comes occasionally to remain awhile in hospital and 
exhibit himself to the class. It is unnecessary for me to enter into 
any general description of this affection ; you will find a very satis- 
factory account of it in the Cyclopaedia of Practical Medicine, and 
a shorter but equally valuable one in Dr. Copland’s Dictionary. 
The most remarkable features of the disease are those connected 
with the change in the quality and quantity of the urine. With 
respect to the former, it is called mellitus when it contains a large 
proportion of sugar, and insipidus when it wants the saccharine 
taste, and presents nothing beyond a mere watery flavour. With 
regard to quantity, the change is very remarkable; the man who 
is at present in hospital passes eighteen pints in the course of 
twenty-four hours. In the normal state a man passes about two or 
three pints; this therefore must be considered as an enormous 
increase. 
When you come to examine diabetic urine chemically, you find 
its specific gravity increased. Natural urine ranges from 1017 to 
1020, diabetic from 1020 to 1050. Now in every pint of urine of 
the specific gravity of 1030, there is contained nearly an ounce and 
a half of solid animal matter. If you took a pint of this man’s 
urine, and exposed it to a temperature of 170° on an evaporating 
dish until all the watery parts were dissipated, there would remain 
at least an ounce and a quarter of solid animal matter. Now if 
you multiply this by eighteen, it will give you more than a pound 
and a quarter of solid animal matter, which this man loses in the 
course of twenty-four hours by means of the kidneys alone. I 
need not tell you that this is a very considerable loss, and hence it 
is that the man naturally calls for large quantities of food to replace 
it. And such is the nature of diabetes in general: patients labouring 
under it have the activity of the digestive organs increased in pro- 
portion to the drain from their system; and were it not for this 180 
graves’s clinical lectures. 
they would be rapidly run down by the emaciating effects of the 
We notice this extraordinary activity of the digestive 
system in other diseases.which have a tendency to produce ema- 
ciation ; thus a patient recovering from long fever will frequently 
take and digest with facility quantities of food which produce re- 
pletion in a state of health. 
In the case before us, one of the most remarkable things is the 
length of time the disease has lasted. The man has been now ill 
for more than three years; it is nearly twelve months since he was 
here before, and at that time he was just as bad as he is at present. 
He was relieved then, and went out of his own accord, and con- 
tinued since nearly in the same state we found him at his last 
admission. He states that he has been ever since passing from 
twelve to twenty pints of urine in the day. He is, however, able 
to go about as usual, eats, drinks, and sleeps well, and, with the 
exception of the kidneys, all his functions appear to be natural; 
indeed, he appears to be exceedingly active and vigilant; he exer- 
cises a system of surveillance over the patients, nurses, and ward- 
maids, exposes all their sins of omission and commission, and might 
be now and then a very useful kind of person in an hospital. 
AVith respect to the state of his skin, I may observe that it is by 
no means so dry, acrid, and harsh as we frequently find in diabetic 
patients; indeed, it feels nearly natural, and is partially covered 
with moisture at various times of the day. Some persons, looking 
almost exclusively to the condition of the skin, have taken a very 
limited view of this disease. They consider it as arising from the 
perspiration being repressed and turned inwards on the kidneys. 
This, however', is by no means satisfactory. Some of the worst 
cases I have ever seen were accompanied by colliquative sweats. A 
gentleman came from the country last June to consult me for some 
affection of the digestive system; on enquiring into his case I 
found that he was in the habit of passing very large quantities of 
urine. I took some of it to my friend, Dr. Apjohn, to analyse, and 
it was found to be of the specific gravity of 1049. Now this gentle- 
man had been subject to profuse perspirations, and used at that 
irery time to sweat copiously every dajL In the case above stairs, 
the patient’s breast and neck are frequently bedewed with perspira- 
tion. AVith respect to the opinions entertained concerning the 
nature of this disease, I beg leave to refer you to Dr. Copland’s 
Dictionary ; for my own part I can form no idea of it, except that 
it is a functional derangement of the secreting powers of the kid- 
neys. I look upon all those hypotheses which have sought to 
account for diabetes by referring it to derangement of the digestive 
organs as useless and unsatisfactory ; nor do I see why, in cases of 
disease, we are to look for all the matters secreted by the kidneys 
in the blood. It is true that there are but few of the matters se- 
creted by any glands in a state of health which may not be disco- 
vered in the blood. All or most of the proximate principles of the 
matters secreted by the salivary glands, liver, and kidneys, are to 
be found in the blood during a state of health, but in disease the DIABETES. 
181 
case is quite different. Diseased vessels or parts may assume the 
function of combining animal principles in proportions and modes 
that form results differing in their nature from any thing usually 
to be found in the system. I confess I can see no difficulty in sup- 
posing that a substance so simple as sugar is, may be formed from 
the elements of the blood, or that the vessels of the kidneys may, 
in a state of disease, take on a new action and secrete this substance 
with great rapidity. Sugar is one of those substances which are 
easily formed by nature, its elements are few and simple, and it 
may be formed with ease by beings belonging to the animal and 
vegetable kingdoms. From how many individuals of the vegetable 
class do we not procure it with facility ? How often do we meet 
it as an animal secretion ? Indeed, I have strong suspicions that 
a great many persons in society, who labour under what is merely 
considered in the light of indigestion, are affected with diabetes. 
This was the case of the gentleman whose urine was of the re- 
markably high specific gravity of 1049. He still continues to pass 
a larger quantity of water than natural, but not near so much as 
formerly ; its quality, however, has not improved so much as its 
quantity, and it still contains sugar. The state of health he enjoys 
is, with the aid of proper regimen and precautions, far from bad, 
and he is enabled to discharge effectively the numerous duties 
attached to the agency of an extensive estate in the county of 
Carlow. Dr. Marsh, who has paid much attention to this subject, 
attests the prevalence of chronic diabetes in a mild form. It is to 
be feared that many cases escape detection, because the quantity of 
water voided by the patient being but little increased, the idea of 
diabetes does not suggest itself to the mind of the physician. With 
regard to the quality of the urine, I may here remark, that diabetes 
may be divided into two sorts : the first includes those cases in 
which the quantity of urine is increased, but its specific gravity is 
less than natural; this comprises hysterical and nervous varieties 
of increased flow of water: the second, and to which indeed the 
term diabetes ought properly to be restricted, embraces those cases 
where the urine contains an animal principle either not naturally 
found in it or found in increased quantity. To this belong diabetes 
with sugar, with albumen, and with urea, viz.—diabetes mellitus, 
diabetes albuminosus, diabetes ureosus. The latter is by far less 
common than the other varieties. I have not myself met with an 
example, but it has been described by Dr. Bostock and others. The 
albuminous diabetes is often associated with dropsy, which latter 
attracts the chief attention of the physician. In some cases, however, 
the dropsical swellings are either very slight or altogether absent, 
while the urine is much increased in quantity, and highly loaded 
with albumen. A remark with respect to dropsy was suggested to me 
this morning by one of the cases in our chronic ward, and, lest I 
should pass it over hereafter, it may be as well to introduce it here. 
Dropsical effusion is in every instance produced by diseased action 
in the vascular system, and is the result of a morbidly affected 
secretion on the part of the extreme vessels. Now, like every other 182 
GRAVKS’S CLINICAL LECTURES. 
product of secretion, the effused fluid is liable to undergo great and 
sudden variations as to its quantity, variations produced by corre- 
sponding changes in the vascular or in the nervous system, which 
latter is so intimately associated with the function of secretion. 
This circumstance it is which occasions the swollen parts in ana- 
sarca to vary so continually in chronic cases of this disease, one 
part appearing more oedematous and again subsiding on the mor- 
row. Now dropsical patients are morbidly attentive to every thing 
that passes, and are constantly dwelling on all the particulars which 
relate to their swellings. In hearing their reports of themselves, 
you must not, therefore, allow yourselves to be misled, and you 
must never attribute any great importance to these local changes, 
which are too often merely temporary. But what I want to fix 
your attention on at the present is the fact, that the dropsical effu- 
sions to which internal organs are liable are subject to similar unac- 
countable changes, whether of increase or diminution, and that 
from day to day in some cases. Thus an anasarcous patient will 
complain of having spent a wretched night, on account of cough 
and difficulty of breathing. You find his face, neck, and the inte- 
guments of the chest very oedematous; and, on examining his 
chest, great dulness is found in one lung, with moist crepitus ; 
great oedema of that lung in fact exists. In a day or two after, and 
without any assignable reason, you find that the external oedema 
has much diminished, and that your patient, free from dyspnoea, has 
slept comfortably. You examine the chest, and you find a corre- 
sponding subsidence of the pulmonary infiltration. The same 
capricious increase or diminution is observed also in other secre- 
tions, as, for instance, in that of the bile. 
I have lately examined with much attention the figured large 
and solid foecal evacuations of a jaundiced gentleman, and observed 
more than once that one portion of the faecal cylinder was quite 
brown and thoroughly impregnated with bile, while the remainder 
was perfectly destitute of it, and therefore was clay coloured. 
LECTURE XVII. 
There is a patient, named Catherine Corbally, in the Chronic 
Ward, to whom I would direct your attention ; she is not seriously 
ill, but there are two circumstances connected with her case worthy 
of notice. She was an attendant in a family residing- in town, the 
mistress of which, a young- and healthy lady, was attacked with 
symptoms of fever about three days after child-birth, and died. 
Her fever was irregular in its progress, and attended with rapid 
pulse, laboured respiration, early sinking of the powers of life, and 
an eruption which was supposed to be miliary. Shortly before her 
death I was called in to see her; on examination, we found that SCARLET FEVER. 
183 
the disease was malignant scarlatina; the case was completely 
hopeless, and indeed I believe that almost every female who got 
scarlatina after childbirth this winter died, no matter what might 
be the mode of treatment employed. The true nature of the dis- 
ease, however, was not made known to the family until five or six 
days afterwards, when all the children and two maid-servants took 
it. It was also remarkable that a person residing in the house, 
who had laboured under scarlatina before, was attacked with bad 
sore-throat about the same time. I advert to this circumstance, 
because it is a fact, that, persons who have had scarlatina before, if 
closely engaged in attending bad cases of the disease, are very apt 
to get sore-throat. I know several medical men to whom this 
happened, and the same thing occurred to myself not long since, 
though I had scarlatina in the malignant form. 
Another circumstance connected with this case is, that the pa- 
tient complains of severe pain in one of her ears, accompanied with 
deafness. This occurrence is frequently observed in similar in- 
stances ; the inflammation spreads from the fauces along the Eusta- 
chian tube, until it reaches the ear, and hence we find many cases 
of scarlatina attended with more or less lesion of the function of 
hearing. It is very probable that this girl also got cold, for there 
is a considerable degree of tenderness about the external ear and 
over the mastoid process. In a recent lecture delivered at the 
Meath Hospital, I impressed on the class the necessity of making a 
careful examination of the parts where earache occurs during the 
progress of fever ; if is very often a treacherous symptom, and you 
will find in the works of Abercrombie and Itard several cases in 
which it preceded fatal disease of the brain. I do not intend 
speaking on this subject at present, but the case before us puts me 
in mind of a form of otitis which is frequently met with, and on 
which it may be necessary to say something. Otitis, like conjunc- 
tivitis and inflammation of the tonsils, is very apt to attack persons 
of a scrofulous habit, and it is sometimes of importance to be able 
to distinguish this from the acute otitis, which comes on in a 
healthy person, as the latter is found sometimes in connection with 
disease of the brain, the former hardly ever. In scrofulous otitis, 
the means of diagnosis are drawn chiefly from the constitutional 
symptoms, the appearance of the patient, the obstinacy of the dis- 
ease, and the sudden manner in which it gets better and then bad 
again. I lately saw an excellent example of acute scrofulous otitis, 
in a young lady of a decidedly strumous habit, living in Eccles 
street, and whom I attended, together with Mr. Leech, of Parlia- 
ment street. She was attacked with violent earache, accompanied 
with some otorrhoea and tenderness of the external meatus, indicat- 
ing inflammation. The pain, however, was intense, and far greater 
than the degree of inflammation seemed likely to produce ; it re- 
mitted, or nearly intromitted, corning on violently about the same 
hour every day, and continuing to occasion intense agony for a 
few. hours. Low diet, fomentations, leeches frequently applied, 
cathartics, blisters, all failed to produce relief. The disease, 184 
graves’s clinical lectures. 
finally, suddenly yielded to ten grains of sulphate of quinine, given 
daily. The difficulty in such a case consists in determining how 
long we ought to persevere in the antiphlogistic method, and when 
we ought to begin with tonics suited to the neuralgic portion of the 
disease, for, like scrofulous ophthalmia, scrofulous otitis is accom- 
panied by a degree of pain by no means proportioned to the 
violence of the inflammation. The acute healthy otitis generally 
comes on after exposure to cold ; it is attended with severe pain, 
and considerable tenderness of the parts about the ear, and runs its 
course in a comparatively short period. Now, how is this acute 
otitis in the healthy subject to be treated? Recollect the disease is 
one of a very intense character; this pain is frequently agonising, 
and the tenderness and heat of the parts about the external meatus 
are very great; recollect, too, that it may, and sometimes does, 
usher in disease of the brain, and let your treatment be, therefore, 
prompt and energetic. Purge the patient briskly, put him upon 
low diet and antimonials, and apply leeches in successive relays to 
the external ears, and over the mastoid process. In scrofulous 
otitis, on the contrary, the antiphlogistic treatment, both general and 
local, must be more cautiously applied, and must be sooner laid 
aside to be succeeded by the exhibition of tonic remedies. The 
greatest care and attention, however, is necessary before we decide 
to pass from one mode of treatment to the other, and we must be 
well convinced that we have sufficiently guarded against the 
danger of the brain becoming engaged in the inflammation, before 
we change to the tonic treatment; when we do, we must proceed at 
first cautiously, afterwards more boldly. Give the carbonate of 
iron, or the sulphate of quinine, watching its effects, and increasing 
the dose as you proceed; and in this way you will succeed in 
arresting the disease, and curing your patient. I would, however, 
strongly impress upon you the necessity of caution ; feel your way, 
be sure that there is no active inflammation present, watch the 
effect of every dose you give; by doing this, you will not, as some 
have done, run the risk of inducing fatal symptoms. In many of 
these cases, it is hard to draw a proper line of distinction at first; 
adopt, therefore, the safe practice, and, though the disease be of an 
intermittent character, defer the use of tonics until you have re- 
moved inflammation ; you only lose a little time, whereas, by 
having recourse to them at too early a period, you may do your 
patient irreparable mischief, 
I shall now speak of the case of Christopher Nolan, which I trust 
you have all watched with attention. When this man came into 
the hospital, his condition appeared to be completely desperate; he 
has, however, not only rallied, but is now convalescing rapidly. 
It is unnecessary for me to enter into a detail of his case, as I trust 
you have all observed it through its different stages; I shall only 
remark, that on his admission he was labouring under fever of the 
worst character; his body was covered with maculae ; he lay con- 
stantly on his back, and had low muttering delirium ; was unable 
or unwilling to answer questions; his breathing was oppressed; BLISTERS AND STIMULANTS IN FEVER. 
185 
his pulse rapid, small, and failing; the powers of life awfully pros- 
trated ; in fact, he was in a state of apparently threatening dissolu- 
tion. 
My first object was to rouse the sinking powers of the system, 
and with that view I adopted the following treatment. He was put 
into a comfortable bed, and heat was restored to the surface by dili- 
gently rubbing his trunk and limbs with warm flannel. 1 next 
ordered a succession of flying blisters to the neck, chest, and abdo- 
men. I may observe here, that his chest was heaving, there was a 
general wheezing audible over the whole surface, and he had that 
peculiar livid expression of countenance, and dusky hue of skin, 
which indicate an imperfect aeration of the blood. With the view 
of stimulating the oppressed action of the respiratory nerves, I had 
two blisters applied, one on each side of the neck, above the cla- 
vicle ; after remaining on for two hours, these were removed, and 
two more applied over the supra-mammary region, then over the 
heart and right side of the chest, and lastly, over the epigastrium. 
In addition to this, he was ordered to have wine and chicken broth, 
and the following draught was prescribed, to be taken regularly 
every second hour until symptoms of reaction began to appear. 
R. Misturse camphorae, 3 j. 
Liquoris anodyni Hoffmani, 3ss. 
Spiritus ammonise aromatici, 3ss. 
Moschi grana octo. 
In employing blisters in this case, my object was to stimulate 
powerfully, and in rapid succession, the integuments of the neck, 
chest, and abdomen. The practice has in such cases been attended 
with very marked effects, and in ours proved extremely valuable. 
Its efficacy seems to depend, not on the discharge of serous fluid, 
or on any revulsive action of the blisters, but on the powerful 
stimulus applied to an extensive cutaneous surface. I may observe 
here, that, during the present epidemic, blisters have been one of 
our most efficient means of cure. In several bad cases, I have 
blistered the nape of the neck, the chest, hypochondrium, and 
nearly the whole of the abdomen,- in succession, and often with 
remarkable benefit. In ordinary cases of fever, tenderness of the 
epigastrium, pain in the head, and derangement of the respiratory 
system, are best treated by the application of leeches, or even by 
the use of the lancet; but in the present epidemic, I have observed 
that patients bear bleeding very badly, though practised at the 
commencement of the disease; and the same rule applies, though 
with less force, to abstraction of blood by leeches or cupping-glasses. 
As far as my experience goes, local or general depletion should be 
resorted to with caution. I am not timid in the use of the lancet 
or leeches, but I have seen several cases of fever which terminated 
fatally, and these were chiefly cases where venesection had been 
performed at the commencement of the attack; and, with respect 
to leeching, I have found that those cases were very difficult of 
cure, in which, relying on my experience of former epidemics, I 
had leeched too freely for what I considered to be local congestion. 186 
graves’s clinical lectures. 
With respect to the general employment of blisters in fever, it is, 
I believe, a prevalent but erroneous practice to leave them on much 
longer than is necessary. I seldom let them remain on longer than 
four or five hours ; I speak here of flying blisters, which are applied 
successively to the nape of the neck, inter-scapular region, chest, 
and abdomen. Sometimes two or three hours will be sufficient. 
It is true that a blister will seldom rise in this space of time; but, 
though you have no serous discharge, the moment the skin under 
the blister becomes red, every purpose is accomplished; if the 
blister be removed, and the parts dressed with spermaceti ointment, 
it will rise in the course of a few hours. By acting in this way, 
two important advantages are obtained—you prevent the formation 
of bad sores, and obviate the risk of dysuria from the absorption of 
cantharides. It is in many cases extremely wrong to leave a 
blister on too long, and yet we see them frequently permitted to 
remain on for twelve, eighteen, and even twenty-four hours. If 
you excite the vessels of the skin by rubbing the part with a little 
proof spirit, or oil of turpentine, before the blister is applied, it will 
rise in three or four hours; if not, it can be again employed. From 
a number of experiments made at the Meath Hospital, I have ascer- 
tained that the time necessary for producing the action of a blister 
is much shorter than is generally imagined. In some cases, three 
hours; in some, even two were sufficient; and in almost every 
instance, the irritation of the cutaneous surface was effected in four 
hours. 
I have stated that in this case we gave wine and chicken broth. 
With respect to the regulation of diet, I may observe that, in the 
present epidemic, a light nutritious diet may be prescribed at an 
early period of the disease. After the fourth or sixth day, we are 
in the habit of giving chicken broth, light beer, and even small 
quantities of wine. I do not speak here of chicken tea, as it is 
termed, but of broth of good strength and flavour. There is 
another point with respect to nutriment which I would beg leave 
to impress on your attention. When you give nutriment, be care- 
ful in observing the usual periods of meals. The space of time to 
which I limit the giving of chicken broth, jelly, arrow root, and 
other mild articles of diet, is from eight o’clock in the morning to 
eight in the evening. Always make it a rule that your patient 
shall take nutriment within the space of those twelve hours during 
which he is accustomed to take his meals when in health, and 
allow him nothing but mild diluent fluids during the night. I am 
persuaded that I have seen much benefit derived from following 
this simple plan. 
A few words in conclusion, with respect to the stimulant 
draughts which we employed in this case with such remarkable 
effects. During the prevalence of those doctrines which attributed 
all fever to local inflammation, diffusible stimulants fell into neglect 
and disuse ; but, since our knowledge has been rendered more cer- 
tain and fixed, by the results of a truer pathology, we have learned 
to estimate their real value. I do not by any means exaggerate, DROPSY. 
187 
when I say that I have seen many lives saved by a combination 
similar to that employed in the present case. Where there is great 
prostration of the powers of life, oppression of the nervous func- 
tions, and low, muttering delirium, I do not know of any remedy 
which can be prescribed with more advantage. You will, of 
course, while employing medicines of this description, attend to the 
state of the bowels. 
In the mixture we have ordered, you will perceive that the prin- 
cipal ingredient is musk. Musk exercises a stimulant effect on the 
nervous system, without having any tendency to produce cerebral 
congestion or coma. Unlike those remedies which powerfully 
affect the nervous system, it does not produce intoxication or nar- 
cotism. Hence it is that musk proves such a valuable stimulant 
in cases such as I have described, where there is reason to appre- 
hend congestion of the brain. At the same time that you prescribe 
musk, you should assist its action by blisters, judiciously applied. 
They may be applied along the sides of the neck, or over the 
chest, to excite the nerves of the heart, lungs, and diaphragm; or 
you may apply them between the shoulders, and to the back of the 
neck, where your object is to act on the brain and spinal marrow. 
In cases like this, the best places for applying blisters are the neck, 
region of the heart, epigastrium, and spine. The blister should be 
small, and you should make up for their want of size by successive 
applications. 
I have only to add that the treatment adopted in this case suc- 
ceeded in again rousing the almost suspended powers of the system, 
the patient rallied, and his fever assumed a much more manage- 
able aspect. I was obliged, however, to have recourse to the tartar 
emetic mixture with opium, in order to produce sleep. This com- 
pleted his cure; from the time of its exhibition, every thing went 
on well. 
Two cases of dropsy, in the chronic ward, next claim our atten- 
tion. Both have occurred in persons who have previously enjoyed 
tolerably good health, and in both the disease seemed to be unac- 
companied by organic lesion of any important viscus. One of the 
patients, J. Austin, states that he has been ill two months before he 
came into hospital, and acknowledges that his illness was the result 
of long continued habits of inebriety. Careless and intemperate in 
his mode of life, and frequently exposed to cold and wet, he got an 
attack of bronchitis, accompanied by a sense of constriction about 
the chest, and difficulty of breathing. He was bled for this, and 
states that the bleeding relieved his dyspnoea; but about this period 
he remarked that an anasarcous swelling appeared in his face, 
neck, and chest. 
In this case we have a specimen of the ordinary history of 
dropsy in this country:—first, intemperate habits, next exposure to 
cold, followed by bronchitis or pneumonia, and then dropsy, com- 
mencing in the face, chest, and upper extremities. I have on a 
former occasion pointed out to the class the importance of observ- 
ing in what part of the body the dropsical swelling first appears, 188 
graves’s clinical lectures. 
because, by doing so, we obtain a more accurate idea of its nature, 
and are furnished with a clue towards discovering its source. Dropsy 
is generally the consequence of organic disease of some deep-seated 
viscus. When it is produced by thoracic disease, as bronchitis, 
pneumonia, or affections of the heart, it is said that the swelling 
always begins in the face, neck, trunk, and upper extremities; 
when it depends upon chronic hepatitis, disease of the spleen, 
obstruction of the system of the vena porta, or disease of the mesen- 
teric glands, the swelling commences in the abdomen, and then 
proceeds to the lower extremities ; but when it arises from mere 
debility, the consequence of hectic fever, long continued diarrhoea, 
or a cachectic state of the system, the effusion is first observed in 
the lower extremities, coming on in the evening, and again disap- 
pearing towards morning. The history of dropsical swellings, 
therefore, by informing us in what part they first appeared, is often 
sufficient to indicate the general nature of the producing cause. 
When this man came into the hospital, his cough had disappeared, 
and there was not any unequivocal symptoms of disease of the 
heart, but he had considerable dropsical swelling of the face, chest, 
and superficial parts of the abdomen; his appetite was bad, and on 
examining his urine, we found it loaded with albumen, and of the 
specific gravity of 1029. Though he had no fever or dyspnoea at 
the time, we commenced the treatment by general bleeding, because 
he was a person of rather robust constitution, and on account of his 
dropsy having originated in cold. In persons who are able to bear 
bleeding, and where the disease has commenced in an acute form, 
you may often commence the treatment of dropsy by a single bleed- 
ing with great advantage, even though there be no fever or local 
inflammation present. We next prescribed an aperient injection, 
to be followed by a vapour bath. I then, by way of trial, give him 
an electuary containing some diaphoretic medicines, and found that 
it acted well on the skin, and that sweating could be easily induced. 
This furnished me with a key to the after treatment. Whenever 
you find that sweating can be easily brought on in dropsical cases, 
you should obey the hint given by nature. You should not, under 
such circumstances, have recourse to mercury, or hydragogue pur- 
gatives, or diuretics; you are to open the passage which nature has 
pointed out, you are to encourage diaphoresis, and you may rely 
upon it that you will in this way effect an easier, safer, and more 
permanent cure than you could by any of the various modes em- 
ployed for similar purposes. We therefore gave this man a powder 
containing four grains of Dover’s powder and five of nitrate of 
potash, three times a day. The Dover’s powder is tempered by 
combining it with nitrate of potash, which is an antiphlogistic, 
and prevents the former from exercising a heating effect on the 
system. Having continued these powders for seven or eight days, 
we commenced the exhibition of opium, in doses of half a grain, 
four times a day, to be increased after a few days to half a grain 
every fourth hour. Under the use of vapour baths used daily, and 
opium to the amount of three grains in the twenty-four hours, the TREATMENT of drops!-. 
189 
man has improved wonderfully, and the dropsical swelling is fast 
subsiding. Opium has here, you may have remarked, produced 
no bad effects. The tongue is neither dry nor furred, and it has 
not any of that appearance which is observed in persons who are 
in the habit of taking opium; his appetite is unimpaired, his bowels 
regular, and his strength undiminished. 
Now why did I give opium in this case ? The more advanced 
students will perceive that I have treated it nearly in the same way 
as I treat cases of diabetes; because I have taught, and have been 
the first to teach, there seems to be an analogy between chronic 
dropsy and diabetes, and because experience has proved to me that 
this mode of treatment is most likely to be attended with success. 
I shall not dwell on this point at present, as I have already pub- 
lished a paper on it in the Dublin Medical and Chemical Journal, 
to which I refer you, merely observing here, that opium and other 
diaphoretics increase strength, remove the dropsical swelling, 
diminish the quantity of albumen in the urine, and bring on con- 
valescence without producing any bad effects on the head or diges- 
tive system. Dr. Osborne, Dr. Gregory, and Dr. Bright, have 
asserted that the presence of albumen in the urine arises from a 
particular disease of the kidney, in which the whole texture of the 
organ is altered, it becomes hypertrophied, finally harder than 
natural, and of a pale yellowish colour. On the other hand, Dr. 
Elliotson, Dr. M‘Intosh, and myself, have opposed this view of the 
question. It is true that this kind of kidney is sometimes found to 
exist with an albuminous state of the urine, but this is by no means 
invariably the case. I have seen many cases of albuminous urine 
which yielded completely to the exhibition of opium, and this surely 
could not happen if organic disease were present. And though the 
cases in which this has occurred are not very numerous, still the 
evidence is good, and it cannot be denied that such a state of the 
urinary discharge may, and does, depend on constitutional causes 
totally independent of disease of the kidneys. 1 have very little 
doubt that it is to such an origin the present case is to be referred, 
and I feel confident that we shall cure it with opium. I am 
anxious that you should attend to this case and watch the result, 
for the treatment is quite different from that employed by others. 
I say this without meaning to claim any originality ; but I may be 
permitted to say, that it is a mode differing very much from those 
generally pursued. It cannot be used in cases where fever or local 
inflammation is present; but when the local and general excite- 
ment has been subdued, or when the case is chronic and unaccom- 
panied by quick pulse, or any symptoms of visceral inflammation, 
it may be employed with safety and advantage. 
The second case is that of the patient Matthew Gray, a man of 
middle age, and rather robust constitution. On admission, he 
stated that he had been dropsical for about twelve days, and com- 
plained of cough, dyspnoea, constriction of chest, and feverish 
symptoms. His cough was hard, short, incessant, preventing 
sleep, and increased by every attempt at full inspiration. He had 190 
graves’s clinical lectures. 
general wheezing, much oppression about the chest, and scanty 
expectoration of frothy mucus. His pulse was 84, soft and rather 
weak; he complained of nausea and loss of appetite, and had 
oedema of the lower extremities. On examining the chest, I found 
it sounded clear on percussion, and that the physical signs present 
were those of bronchitis passing into the stage of supersecretion. 
In addition to this, there were symptoms of engorgement in the 
lower and posterior parts of the lung. 
Here, then, we had a case of dropsy supervening on acute bron- 
chitis. I therefore ordered him to be blooded immediately, and 
afterwards to have cupping glasses applied over the congested part 
of the lung. The local abstraction of blood was followed by re- 
markably good effects; it relieved the cough and constriction of 
chest, and diminished materially the pulmonary congestion. I 
next prescribed the following mixture, of which he was directed to 
take one tablespoonful every hour. 
R. Misturse amygdalarum, 3xij- 
Antimonii tartarizati granum, 
Nitratis potassae, 3 ij. 
Tincturae hyoscyami, 3iss. 
Tincturag digitalis, 3ss. 
A mixture like this is well adapted for such a case, it removes 
the febrile condition of the system, and, by its demulcent and seda- 
tive properties, allays the cough and bronchitic irritation at the 
same time that it determines to the kidneys. Those medicines 
which are termed demulcent, are frequently of great value in the 
treatment of bronchitis; you will often derive more benefit from 
gum Arabic, spermaceti, almond emulsion, and the like, than from 
any other class of remedies. In the present case, we combined 
them with sedatives and narcotics ; and as the remedies prescribed 
under such circumstances should be antiphlogistic, we added a 
grain of tartar emetic and two drams of nitrate of potash. I have 
already spoken of the powerful antiphlogistic properties of a com- 
bination of tartar emetic and nitre, and dwelt on the benefits derived 
from it in many forms of inflammatory disease, so that it is unne- 
cessary for me to say any thing at present on the subject. It is 
obvious to all, that the tinctures were added on account of their 
sedative and narcotic properties, tending to remove irritation and 
induce sleep, of the want of which the patient complained. But 
you may ask me why I did not order opium: simply because the 
disease was in its acute stage, and at a period when opium is apt to 
produce excitement of the system, and aggravation of the local 
symptoms. Instead of opium, I gave hyoscyamus, which neither 
increases heat, produces headache, nor checks expectoration; and 
to this was added digitalis, a narcotic possessed of considerable 
antiphlogistic properties. Of all the narcotics, digitalis may be 
given with the greatest safety in cases where antiphlogistic treat- 
ment is required. 
It is unnecessary for me to follow up this case through all its 
details. It will be sufficient to state that, by gradually changing TREATMENT OF DROPSY. 
191 
the nature of the treatment as inflammation declined, and particu- 
larly by the proper employment of powerful purgatives, I have 
succeeded in producing a rapid amendment in his symptoms. It 
may be, however, necessary to explain why I used purgatives, and 
in what way they were exhibited. In cases where extensive bron- 
chitis has given rise to pulmonary engorgement and dropsy, when 
you have relieved the acute symptoms by bleeding, leeches, or 
cupping, and other antiphlogistic means, and when there only 
remain some wheezing, oppression of the chest, and rather copious 
expectoration, you will often effect a vast deal of good by the judi- 
cious employment of powerful purgatives. You will clear the 
chest, relieve the breathing, and diminish the dropsical effusion. 
In the present instance, the patient took the following bolus :— 
R. Pulv. jalapse—rhei—scammoniee, aa, gr. v. 
Elaterii, gr. ss. 
Bitartratis potassee—sulphatis potassse, aa, 3 ss. 
Syrupi zingiberis, q. s., ut fiat bolus. 
This acted powerfully, and its operation was followed by marked 
diminution of the pulmonary engorgement and dropsical swelling. 
I have frequently endeavoured to impress upon the class the truth 
of an observation made by Dr. Paris, that in the exhibition of 
remedies, much better effects are obtained by combining several 
analogous remedies in small quantities, than by giving a single 
one in a large dose. By combining substances which are of the 
same nature, that is to say, which are individually capable of exert- 
ing the same effect on the system, we are capable of producing 
more decided effects, even though these substances be given in 
diminished quantity, than if we prescribed any one ingredient of 
the combination in a full dose. I refer to this general principle, in 
order to explain why I had recourse to so many different medi- 
cines, instead of employing a single powerful ingredient in con- 
siderable quantity. It explains why, instead of giving at once 
fifteen grains of the powder of jalap, I gave five grains of jalap, 
five of rhubarb, and five of scammony, and added to these half a 
grain of elaterium, and a small quantity of cream of tartar and sul- 
phate of potass. With respect to elaterium, I may observe that it 
has been strongly recommended in those cases of dropsy where 
there, is no irritation of the digestive system present. Its action on 
the intestinal tube is very energetic, and from the quantity of 
watery secretion which it generally brings away, it is of great 
utility in removing anasarcous swellings. 
These are the principal observations which I have to offer with 
respect to this case. I may mention, that as the patient complained 
much of restlessness, we prescribed half a grain of morphia, to be 
taken at bedtime. This succeeded in producing sleep, a most im- 
portant point in the treatment of all acute affections. We have 
now omitted the use of the more powerful remedies, and have pre- 
scribed to-day a decoction of Iceland moss with tincture of opium, 
to act as a pectoral demulcent, and he has been allowed chicken 
broth and jelly. He is going on at present in a very satisfactory 192 
graves’s clinical lectures. 
way, but it will be necessary to watch him carefully during his 
convalescence, and obviate the occurrence of a relapse. If dis- 
charged at present, and before convalescence is perfectly esta- 
blished, he would in all probability relapse, and soon become much 
worse than ever. Hence I intend to keep him here for a month or 
six weeks. As long as I have been attached to public hospitals, I 
have made it a fixed rule, in all cases where a cure was possible, 
to keep the patient until it was confirmed. Whenever I Was 
obliged, under the pressure of urgent necessity, to dismiss a case 
before healthy action was completely re-established; or whenever 
patients left the hospital prematurely of their own accord, I have 
observed that such persons, particularly if placed in the lower 
ranks of life, and subject to the numberless accidents and expo- 
sures of poverty, almost invariably returned in a far worse condi- 
tion than before. It is much better, though perhaps it does not 
make so striking an appearance in hospital returns, that a certain 
number of patients should receive all the benefits derivable from 
such institutions, than that a greater number should pass through 
them in the year, and be hurried out of them in a state of imperfect 
convalescence. This observation particularly applies to fever hos- 
pitals, and is, I fear, too little attended to in this city. Certain I 
am, that a vast number of the cases of incurable pulmonary and 
intestinal disease which are admitted annually into the Meath Hos- 
pital, have had their origin during the state of debility in which 
the patients were when dismissed from a fever hospital. Improper 
diet, imperfect clothing, bad lodging, damp rooms, are borne by the 
constitutions of the poor with comparative impunity as long as 
they are in a state of health ; but not so when they are debilitated 
by a recent attack of fever, treated or maltreated by active reme- 
dies, and dismissed from hospital in a week or ten days after the 
crisis has taken place. How injurious to persons so debilitated the 
change from the warmth and comfort of a hospital to the cold and 
desolation of a damp garret or cellar ! Add to this, that many of 
them, at the time of their discharge, still evidently bear the marks 
of mercurial action in their system, and many have their hair very 
short, in consequence of the head having been shaved during their 
illness. Hence many catch colds that affect the ears or eyes; 
hence many become deaf, and not a few get sore eyes ; while the 
number of those in whom the sequelae of the fever rapidly induce 
incurable chronic diseases is so great, that, were the balance of the 
account to be fairly struck out, it would be found fever hospitals 
do less good to the public health than is generally imagined. SCARLET FEVER. 
193 
LECTURE XVIII. 
It is my intention to-day to make a few observations on the 
scarlet fever which now prevails as a destructive epidemic in 
Dublin, and many other parts of Ireland. The history of such 
epidemics is very interesting, and tends to shed much light, not 
only upon the changes which diseases undergo, but upon the fluc- 
tuations of medical opinions and treatment. In the year 1801, in 
the months of September, October, November, and December, 
scarlet fever committed great ravages in Dublin, and continued its 
destructive progress during the spring of 1802. It ceased in sum- 
mer, but returned at intervals during the years 1803-4, when the 
disease changed its character ; and although scarlatina epidemics 
recurred very frequently during the next twenty-seven years, yet it 
was always in the simple or mild form, so that I have known 
an instance where not a single death occurred among eighty boys 
attacked in a public institution. The epidemic of 1801-2-3-4, on 
the contrary, was extremely fatal, sometimes terminating in death, as 
appears by the notes of Dr. Percival, kindly communicated to me, 
so early as the second day. It thinned many families in the 
middle and upper classes of society, and even left not a few parents 
childless. Its characters seem to have answered to the definition 
of the scarlatina maligna of authors, for a description of which I 
beg leave to refer you to the Cyclopaedia of Practical Medicine, 
where you will find an article on the subject by Dr. Tweedie. In 
making this reference, however, I do not wish to be understood as 
expressing my unqualified approbation of the article in question, 
for I must in candour confess that it falls far short of what we 
might have expected from a physician of Dr. Tweedie’s learning 
and experience. The long continuance of the period during which 
the character of scarlet fever was either so mild as to require little 
care, or so purely inflammatory as to yield readily to the judicious 
employment of an antiphlogistic treatment, led many to believe that 
the fatality of the former epidemic was chiefly, if not altogether, 
owing to the erroneous method of cure then resorted to by the 
physicians of Dublin, who counted among their numbers not a few 
disciples of the Brunonian school; indeed, this opinion was so pre- 
valent, that all those whose medical education commenced at a 
much later period, were taught to believe that the diminished mor- 
tality of scarlet fever was entirely attributable to the cooling regi- 
men, and to the timely use of the lancet and aperients, remedies 
interdicted by our predecessors. This was taught in the schools, 
and scarlet fever was every day quoted as exhibiting one of the 
most triumphant examples of the efficiency of the new doctrines. 
This I myself learned—this I taught; how erroneously will appear 
from the sequel. It was argued, that had the cases which proved 
fatal in 1801-2 been treated by copious depletion in their very 
commencement, the fatal debility would never have set in, for we all 
regarded this debility as a mere consequence of previous excessive 194 
graves’s clinical lectures. 
reaction. The experience derived from the present epidemic has 
completely refuted this reasoning, and has proved that, in spite of 
our boasted improvements, we have not been more successful in 
1834-5 than were our predecessors in 1801-2. 
Before I detail more particularly the symptoms that accompany 
the present epidemic, I wish to enter a little at large into the sub- 
ject of the changes and variations which the same disease is 
observed to undergo at different periods of time. This is a topic 
which occupied some of the master minds of antiquity, and upon 
which the greatest of modern physicians, the illustrious Sydenham, 
bestowed considerable labour. It has been too much neglected of 
late, and consequently I consider it my duty to call your attention 
to it, and I cannot do this better or more forcibly than by commu- 
nicating to you a literal translation which I have made from the 
German of my friend Dr. Autenrieth’s observations on this sub- 
ject. The task of translation is always not only difficult but 
irksome; but if, as in the present instance, I can by this means 
convey to you valuable information not before presented to my 
class, or to the public in English, I never decline the labour. What 
I am now about to read is, indeed, most important, and well 
deserves the deep attention of every practical physician. 
The third cause, connected with time and capable of modifying 
diseases, is of infinite importance, both in a theoretical and practical 
point of view, but has seldom attracted much attention. Its exist- 
ence is attested by its effects alone, for its nature remains unknown. 
I allude to the constitulio morborum stationaria, first noticed by 
Sydenham, but, since his time, nearly forgotten, or else confounded 
with the permanent influence of the seasons, or the accidental 
atmospherical changes spoken of above. All diseases, contagious 
and non-contagious, acute and chronic, (the latter, however, seldom, 
except when attended with some degree of general excitement,) 
have been observed to preserve a certain constitution or general 
character, which continues for a number of years in succession, 
with occasional interruptions, until it is displaced by another con- 
stitution of a different character. Thus, during one period, dis- 
eases are remarkable for being frequently accompanied by a sensa- 
tion of extreme weariness, sudden sinking of the strength and vital 
powers, unpreceded by any evident marks of excitement, and 
attended by a disposition to pass into true typhus. During another 
period, the tongue is in general loaded with a thick white or 
yellowish coat, and many other symptoms of derangement in the 
digestive organs, such as a bitter taste, costiveness, or diarrhoea, 
are constantly observed. 
During a third period, diseases are characterised by a remarkable 
degree of vascular excitement, an evident tendency to local deter- 
minations, a frequent formation of morbid productions ; in a word, 
by all the symptoms of inflammation. 
It is not known whether the transition from one of these periodic 
constitutions to another takes place suddenly or gradually; but the 
latter supposition appears more probable, except when the transition SCARLET FEVER. 
195 
is accompanied by unusually great atmospheric changes. The 
erysipelatous affection, which, both in England and Germany, suc- 
ceeded the gastric and accompanied the first appearance of the 
inflammatory period, seems to have been an example of the gradual 
transition, Accurate observations are still wanting to determine 
whether this periodic constitution is confined to certain parts of the 
world, or extends over the whole, and whether its different species 
follow each other in a regular order of succession. If their order of 
succession should at any time be determined, it will enable the 
physician to foretel the character and most appropriate treatment 
of future diseases. The above question cannot be answered with- 
out very great labour spent in the investigation of the history of 
diseases in all ages and all countries, and are therefore foreign to 
the present work. 
The general indications of course vary with the nature of the 
prevailing constitution; and, consequently, during one period 
stimulating remedies, during another alvine evacuations, and dur- 
ing a third venesection and the antiphlogistic plan, will constitute 
the most effectual treatment. 
This very circumstance has caused much confusion in medical 
opinions, and has occasioned the reputation and the downfal of 
many an infallible system, each of which is in its turn consigned 
to oblivion, and perhaps again revived as a novelty at some future 
period. The English boast much of the astonishing improvements 
in science, and deride the ignorance of their predecessors, regardless 
of the old proverb—“Every thing has its day.” Whenever, there- 
fore, the periodic constitution undergoes an alteration, they either 
obstinately uphold their usual plan of treatment to the manifest 
injury of their patients, or else blindly embrace some system, to 
them new, but which really rests upon ancient and established 
principles. In general, they do not fail to make use of so much 
exaggeration in support of their opinions, and thus succeed in mis- 
leading so many, that none but very well informed physicians can 
distinguish the fallacy of their arguments. 
The medical history of Great Britain affords many striking 
proofs of the truth of these assertions, and is replete with examples 
of the singular obstinacy with which the English cling to opinions 
once formed, a circumstance which has materially contributed to 
obstruct their attaining to general views and impartial conclusions. 
Even to this day, a warm contest is carried on (less, however, in 
books than in the debates of learned societies) between the senior 
and the junior parts of the profession, the former still inclining to 
Brunonianism, while the latter attribute nearly all diseases to 
inflammation. Both, indeed, appeal to experience to prove the 
justice of their principles, and seem entirely to forget that while 
the propriety of their practice, as applied to particular cases, 
remains unimpeached, the very nature of the diseases themselves 
may have been changed. A summary review of the character 
assumed by diseases during the last twenty years, both in England 
and other countries, will perhaps afford a solution of this question. 
About the end of the last, and during the three or four first years 196 
graves’s clinical lectures. 
of the present century, the proportion of nervous fevers to other 
diseases was as one to eighteen in Plymouth (Woolcombe), as one 
to sixteen in London (Willan), as one to ten in Newcastle (Clarke), 
and in Liverpool, one to five (Curry). Nor was this scourge of 
mankind less severely felt upon the continent, where typhus, and 
diseases closely allied to it, committed extensive devastations, par- 
ticularly during the epidemics of Erlangen, Jena, Kiel, Ratisbon, 
and Vienna. Cadiz and Seville were at the same period depopu- 
lated by the yellow fever, and Europe in general suffered much 
from repeated visitations of influenza. An inclination to a sudden 
sinking of the vital power, unpreceded by violent reaction, and 
unaccompanied by any marked symptoms of a gastric or inflamma- 
tory nature, constituted at that period the characteristic form of 
acute diseases, which were always preceded and attended by an 
unaccountable degree of debility. Stimulating and tonic medicines 
obtained, therefore, much celebrity, and every physician who prac- 
tised during that period, attests the injurious or even fatal effects 
which were produced by the use of venesection, and other deple- 
tory remedies. What is still more remarkable, an epidemic typhoid 
pneumonia prevailed in many parts of Germany during the years 
1800-1-2, in which the speedy production of an inflammatory 
state, by means of bark and ether, was the only method which 
afforded a chance of recovery. These facts must impress every 
impartial mind with the conviction, that the constitution of diseases 
has undergone much alteration since that period, and explain why 
physicians did not then employ copious venesection, but were 
obliged to content themselves with ordinary cold effusions, acids, 
and mercury. 
The reign of typhus appears to have ceased with the influenza of 
1804, when a new constitution began, at first more remarkable for 
the disappearance of nervous fevers and other contagious diseases, 
than for any peculiar character of its own. Catarrhal and rheu- 
matic complaints, partly attributable to the weather, prevailed for 
some time, and fevers of an intermitting type became more frequent, 
forming an evident transition from the purely typhus constitution 
to that of the vascular excitement of the following years. Some 
remnant of the typhus constitution was indeed still perceptible in the 
pectoral complaints which prevailed in London during the winter 
of 1804-5, and were attended with remarkable debility, requiring 
the greatest prudence in the use of the lancet. Venesection was 
indeed often entirely contraindicated, and Bateman states that it 
sometimes even proved fatal. The constitution, however, soon de- 
veloped itself more decidedly, became more universally diffused, 
and obliged physicians to relinquish their former plan of treatment 
and adopt other measures. Derangement of the alimentary canal 
became its prominent feature in the summer and autumn of 1804, 
and diarrhoea, terminating in dysentery, was often met with. 
This constitution suffered indeed a check from the cold of 1805, 
but it increased again during the following years, and afterwards 
became still more prevalent, manifesting itself by headache, a bitter 
taste in the mouth, a loaded yellow tongue, irregularity of the GASTRIC CONSTITUTION. 
197 
bowels, nausea, and anorexia. The utility of purgatives now be- 
came so obvious, that Hamilton’s doctrines soon obtained as much 
celebrity as had been before enjoyed by the stimulating system. 
The nervous fever at Nottingham in 1807, the dysentery at Lon- 
don in 1808, the scarlatina at Edinburgh in 1805, and the measles 
at the same place in 1808, all required the purgative plan of treat- 
ment, and calomel became the favourite cathartic. The advantage 
then derived from the use of purgative medicines is abundantly 
testified by the writers of that period. This gastric constitution 
appeared also on the continent, but its progress was less rapid there 
than in England, where the inhabitants live in a manner calculated 
to augment or even to produce a tendency to gastric diseases. 
There were likewise other circumstances which impeded the for- 
mation of this constitution on the continent. Thus in Germany, 
the purely nervous constitution had scarcely yielded to catarrhal 
and rheumatic affections, when it was again revived in that un- 
happy country by the political occurrences of 1805-6-7. Typhus 
seldom, however, assumed the character of exquisite, for the rheu- 
matic and catarrhal affections with which it was mixed partook 
somewhat of a gastric nature, as was proved by the great benefit 
derived from the exhibition of emetics and calomel. This appears 
in accordance with the fact that the gastric constitution was more 
fully developed wherever the ravages of war had not extended, 
although it still required less attention in the treatment than the 
rheumatic symptoms, then likewise prevalent. Thus the agues 
which were common at Tubingen about the end of 1806, com- 
menced in general with pain in the belly, vomiting, and irregularity 
of the bowels; a yellow furred tongue, headache, and tremors of 
the parotids, were of frequent occurrence, and in general gastric 
symptoms were by no means rare. These symptoms gradually 
gained ground, and the reputation of ipecacuanha and cathartics 
increased in the same proportion. At Ratisbon the constitution 
was remarkably gastric in the autumn of 1809, and a nervous fever 
prevailed at Weimar in 1809-10, which was accompanied by bitter 
taste in the mouth, diarrhoea, nausea, and vertigo. Active catharsis 
was injurious in this epidemic, but much benefit resulted from the 
exhibition of castor oil. The advantage derived about the same 
time in Berlin from the treatment of fevers by emetics and cooling 
purgatives, proved that they were there also complicated with gas- 
tric derangements. 
The gastric constitution had scarcely established itself, or become 
pretty generally diffused, when a new character, viz. the inflam- 
matory, appeared upon the stage, and has ever since continued, 
sometimes combining itself with the gastric to form diseases of a 
mixed character, such as erysipelas, and sometimes, when favoured 
by the seasons or local circumstances, raising itself to the rank of 
the chief performer. With its appearance, venesection, which had 
previously fallen into disrepute, became once more a favourite 
remedy, and in the course of a few years was pushed so far, par- 
ticularly in Great Britain, that Sangrado’s maxim, “ C’est une 
erreur de penser que le sang soit necessaire a la conservation de la 198 
graves’s clinical lectures. 
vie, on ne peut trop saigner un malade,” seems to have been the 
general rule of practice. The same inflammatory constitution be- 
came also general in Germany, but there it neither attained such a 
height, nor required such active treatment as in Great Britain, 
where many circumstances favoured its more perfect development; 
with us it generally yielded to the use of acids, cold applications of 
mercury, but in England it called for copious blood-letting. Even 
in 1810, diseases had become more inflammatory at Tubingen than 
they had been previously; but the change was still more perceptible 
in 1813, when the antiphlogistic treatment required the aid of small 
venesections, and nervous fevers were accompanied both by inflam- 
mation and derangement of the digestive organs. Erysipelatous 
affections were also frequent, and in many cases were of a marked 
inflammatory character. Erysipelas and true inflammatory fever, 
requiring the use of the lancet, were common at Ratisbon in 1811; 
Parrot exhibited acids, especially the acetous, with great success in 
the epidemic nervous fever which raged at Dorpat in 1812, and a 
diarrhoea of a bilious inflammatory nature prevailed at Konigsberg 
during the same year. This important change in the constitution 
became very evident in the nervous fever at Berlin in 1813, as well 
as in the formidable epidemic described by Hufeland, which ensued 
after the war, and raged in the north of Germany during that and 
the preceding year. Although but a few years before the strongest 
stimulants had been necessary to obviate the paralysis which super- 
vened even in the beginning of the disease, yet an opposite practice 
was now required, and antiphlogistic remedies were alone found 
capable of preventing the vascular excitement from terminating in 
inflammation of either the head or chest. In short, the inflamma- 
tory constitution has been prevalent in Germany ever since the 
years 1810-11, sometimes in its pure and marked form, and some- 
times complicated with gastric and rheumatic symptoms. 
This constitution became general at the very same period in 
Great Britain. Dr. Clutterbuck, of London, had indeed ascribed 
the origin of fever to inflammation of the brain, so early as 1807, 
and about the same time Dr. Steiglitz, of Hanover, had recom- 
mended the antiphlogistic treatment of scarlet fever, in preference 
to the stimulating plan then in vogue. But as the inflammatory 
was then still subordinate to the rheumatic and gastric constitutions, 
their opinions did not gain many converts. But the inflammatory 
constitution had increased so much in the autumn of 1800, and 
the winter of 1810, that even Dr. Bateman was obliged to prescribe 
venesection in fevers, a practice quite at variance with his former 
views. Erysipelatous inflammation became common in London, 
Aberdeen, and Leeds, and numerous cases of puerperal fever oc- 
curred in the latter towns, which, according to Gordon and Hey, 
never terminated favourably, except when bleeding and purgatives 
were employed with freedom. But it was not until 1813, when 
the inflammatory constitution had fully developed itself, and the 
bad consequences arising from violent determination of blood to 
the head in nervous fever could not be averted except by decisive 
measures, that venesection came into general use in Great Britain NERVOUS FEVER. 
199 
in consequence of a publication by Dr. Mills, who had prescribed 
it with much success since 1810. In the same year that truly 
estimable physician, Dr. Thompson, published his admirable 
work upon inflammation. Blackall recommended blood-letting in 
several species of dropsy, and Armstrong employed the same re- 
medy, combined with large doses of calomel, in the inflammatory 
puerperal fever which was prevalent at Sunderland. Yenesection 
became from this time as great a favourite as ever in England, not, 
however, to the exclusion of purgatives, which were indicated by 
the derangement of the stomach and bowels that accompanied the 
inflammatory constitution. Both these remedies were found ex- 
tremely beneficial in the nervous fever which was epidemic in Ire- 
land in 1813-14 ; its inflammatory character being clearly evinced 
by a hard and full pulse during its first stage, and a violent deter- 
mination of blood to the head, by which the headache and raving 
are increased, while its gastric type was not less strongly marked 
by tenderness of the epigastrium, costiveness, or else frequent and 
unnatural alvine discharges, together with a loaded tongue and 
bilious vomiting. The latter symptoms were, in Dr. Grattan’s 
opinion, of such importance, that he gave a decided preference to 
the purgative plan. The fever, which had previously been con- 
fined to Ireland, became generally diffused over the rest of Great 
Britain after the famine of 1816, and continued without intermission 
for four years. Its inflammatory character being peculiarly favoured, 
both in England and Scotland, by the habits of the inhabitants and 
the situation of these countries, venesection attained an unexampled 
degree of celebrity, notwithstanding the representations of the Irish 
physicians, who used that remedy with more moderation. It was 
soon believed that there is, literally speaking, no disease whatever 
in which the lancet ought not to be used, and as the human mind 
is ever prone to extremes, it was soon generally considered, both in 
England and Scotland, to be a well founded pathological inference, 
“there is but one species of fever, viz. the inflammatory, and con- 
sequently venesection is the only true anti-febrile remedy. Such 
is the case in England at present, and it must have been so always, 
and in every part of the world.” I flatter myself, however, that the 
preceding observations and statements of facts, drawn from au- 
thentic sources, sufficiently negative these assertions, and establish 
the real existence of a change in the constitution of diseases, not- 
withstanding what Dr. Duncan once said to me, “ that such 
changes existed only in the imagination of physicians.” 
It is now twelve years since Dr. Autenrieth, in his Account of 
the State of Medicine in Great Britain, made the foregoing inte- 
resting observations; and to me it appears that the history of the 
diseases which have since prevailed affords convincing proofs that 
the then inflammatory constitution has again subsided, and is now 
replaced by a typhous type : indeed, it cannot be denied that a very 
great difference exists not only between the present and the former 
scarlatina, but also between the fever of the present day and that 
which prevailed shortly before Dr. Autenrieth published. But this 
is too important a question for us to decide, without more reflection 200 
Graves’s CLINICAL LECTURES. 
and thought than I have been able to bestow on it, and without 
more facts than I have been able to collect. The opinion I have 
brought forward I do not wish to be received as established ; I look 
upon it as probably well founded, but as yet not proved, except so 
far as to merit further consideration and excite further discussion. 
Indeed, I have for the present been obliged, by the pressure of 
other engagements, to postpone a more accurate examination of 
this subject, and a more severe scrutiny of the facts which just 
now crowd into my memory; but I conclude with remarking, that 
the wide-spreading epidemic influenza which lately visited the 
whole of Europe, including the British Isles, was not only truly 
remarkable, both for the violence of the feverish symptoms and of 
the local congestions of the chest and heart which accompanied its 
attack, but likewise for the unexpected relation which it was found 
to bear to all measures of active depletion. I appeal to the profes- 
sion for their testimony on this matter—I ask whether all our pre- 
conceived opinions as to the a priori indications for venesection, 
leeching, and purging, were not found to be contradicted by the 
effects of these remedies in the epidemic influenza of 1833. The 
sudden manner in which the disease came on, the great heat of 
skin, acceleration of the pulse, and the intolerable violence of the 
headache—together with the oppression of the chest, cough, and 
wheezing—all encouraged us to the employment of the most active 
modes of depletion, and yet the result was but little answerable to 
our expectations, for these means were found to induce an awful 
prostration of strength, with little or no alleviation of the symp- 
toms. In some who were thus treated, recovery was protracted 
and doubtful, and the strength was not restored for several months. 
Indeed, nothing was more curious than the length of time which 
was necessary for some persons, in order to recruit their strength 
after an attack of this influenza, although that attack had not con- 
tinued more than a few days, and had been judiciously treated, 
without blood-letting or unnecessarily debilitating remedies. I 
have known some who lapsed into a cachectic state of long conti- 
nued debility from which they never recovered; for, while thus 
reduced, they fell victims to the first acute complaint which seized 
them. The influenza above referred to fully confirmed the opinion 
I had long entertained, that in acute diseases debility and exhaus- 
tion of the vital power are by no means in every case either caused 
by, or proportioned to, a state of previous excitement. This opinion 
received further support from the symptoms and phenomena exhi- 
bited by the Asiatic cholera, in which the stage of debility and 
collapse commenced, and too often closed, the scene. Why do I 
dwell upon these occurrences, and why have I so frequently referred 
to the opinion above expressed? Simply because the prevalence 
of the contrary opinion laid the foundation for the injudicious and 
exclusive application of the lancet, and of the antiphlogistic method 
generally, in Britain, and was, consequently, the cause of working 
excessive mischief. But I must have done, and must defer the 
special pathology of the scarlatina, lately epidemic, to our next 
meeting. 201 
SCARLATINA. 
LECTURE XIX. 
I have already mentioned that the disease called scarlet fever 
assumed a very benign type in Dublin soon after the year 1804, 
and continued to be seldom attended with danger until the year 
1831, when we began to perceive a notable alteration in its cha- 
racter, and remarked that the usual undisguised and inflammatory 
nature of the attack was replaced by a concealed and insidious 
form of fever, attended with great debility. We now began occa- 
sionally to hear of cases which proved unexpectedly fatal, and of 
families in which several children were carried off; still it was not 
until the year 1834 that the disease spread far and wide, assuming 
the form of a destructive epidemic. The nature of the disease did 
not appear in the least connected with the situation or aspect of 
the patient’s dwelling, for we observed it equally malignant in 
Rathmines as in Dublin, on the most elevated habitations on 
mountains as in the valley of the Liffey. It raged with similar 
violence at King’s Town, and throughout the provinces, exhibit- 
ing, so far as I have been able to learn from country practitioners, 
the same type over the whole of Ireland. The state of the weather 
seemed to exercise no influence either upon its diffusion or its 
symptoms, which continued to exhibit equal virulence, no matter 
whether it was wet or dry, warm or cold, calm or stormy. The 
contagion seemed to act as a more deadly poison on the individuals 
of some families than upon those of others, and, consequently, 
when one member of a family had died, there was always much 
reason to fear for the others when attacked. At first I thought that 
its greater severity in such cases could be traced to a strumous 
habit, but subsequent experience did not confirm this suspicion, 
for the most scrofulous family I ever saw went through the dis- 
ease without a death, whereas in some others the mortality was 
great, although not a single indication of a strumous diathesis could 
be detected. Many parents lost three of their children, some four, 
and in one instance which came to my knowledge, five very fine 
children were carried off. As usual in such epidemics, the degree 
of intensity with which different persons were attacked varied ex- 
ceedingly, some exhibiting the mildest form of scarlatina simplex, 
which required no treatment, and scarcely confinement to the room, 
while the majority were severely affected. When the disease was 
violent, it assumed one or other of the following forms :— 
First.—It at once produced not merely fever with sore throat 
and headache, but such violent congestion of the brain, and deter- 
mination to the head, as occasioned convulsions and apoplectic 
coma on the first or second day. This happened to a fine young 
woman of robust habit in Worburgh street, to whom I was called 
by my friend Dr. Brouton. She was attacked with convulsions 
on the second day, and died comatose on the third. In her the 
scarlet eruption was extremely vivid and general, a fact I notice as 
a proof that the congestion of internal organs was not caused by 202 
GRAVEs’s CLINICAL LECTURES. 
any retrocession of the eruption. In truth, as will appear hereafter, 
the worst cases had the most general and most intense cutaneous 
efflorescence. When this tendency to the head took place in so 
violent a manner at the very onset, the patient was seldom saved; 
sometimes, however, very active measures of depletion, general and 
local, relieved the brain, and the case then went on favourably. 
This happened in a young gentleman residing in upper Baggot 
street, to whom I was called by the late Mr. Nugent, of Merrion row. 
When the scarlet fever attacked a person subject to epileptic fits, 
the tendency to the head was increased by the epileptic habits, and 
the fits of convulsions at once supervened. Thus in the case of 
a gentleman, aged twenty-two, who had been for several months 
treated by Mr. Colles and me for epilepsy, the fits commenced on 
the second day of scarlatina, and continued with frightful violence 
until the fifth day, when they proved fatal. In a young lady resid- 
ing near Black Rock, to whom I was called by Dr. Wilson, pre- 
cisely the same thing occurred. She had been subject to epilepsy 
for many years, and when the scarlet fever commenced she was 
at once seized with frequently recurring fits, which, in spite of the 
most active measures, ended in fatal coma on the fifth day. 
In the second form of the disease which I noticed, the symptoms 
were exceedingly violent and intense from the beginning, and the 
disease set in with the usual symptoms of severe exanthematous 
pyrexia, remarkable in the very commencement for the violence of 
the accompanying headache and spinal pains, and for the great 
irritability of the stomach and bowels. Indeed one of the very first 
symptoms in such persons was nausea, vomiting, and bowel com- 
plaint. Large quantities of recently secreted bile were thrown up, 
and the patient passed frequent, at first semifluid and afterwards 
fluid stools, curdled green or saffron yellow, and evidently composed 
of bile suddenly effused into the intestinal canal, with a copious 
and hurried secretion of mucus from the internal membrane of 
the bowels, and mixed with some true fascal matter. It was sur- 
prising what quantities were thus thrown up, and passed from the 
bowels by some during the first day or two of the disorder; neither 
the constant repetition of the nausea and vomiting, nor the abund- 
ance of the discharge from the stomach and bowels, in the slightest 
degree mitigated either the violence of the fever or of the headache, 
or seemed to prevent the full formation of the eruption. It was 
curious to observe that this obstinate vomiting and purging was 
unaccompanied by the slightest epigastric or abdominal tenderness ; 
during its continuance the belly became fallen and soft. In fact its 
cause was situated not in the belly, but in the brain, a fact I did not 
perceive until I had had an opportunity of watching the progress of 
five or six such cases. It depended on cerebral irritation and con- 
gestion, and was in nature very similar to the irritability of stomach 
and bowels which so often accompany, and too frequently mask 
the progress of, acute hydrocephalus. As soon as I had become 
aware of the pathological relations of this vomiting and purging, I 
did not confine my endeavours to check these symptoms to mea- SCARLATINA. 
203 
sures intended to act directly on the stomach and bowels, such as 
effervescing draughts, chalk mixture, stupes, leeches to the epigas- 
trium, &c. &c., 1 changed my plan of treatment, and turned my 
attention to the state of the cerebral circulation. Having in a 
former lecture referred to this topic, and having explained to you 
the manner in which derangement of thp stomach and bowels of a 
properly gastric origin is to be distinguished from disorder of the 
digestive apparatus, originating in a sympathetic derangement of 
function, itself caused by a morbid condition of the brain, and hav- 
ing already pointed out the importance in practice of not confound- 
ing these two states, one or other of which is so common in the 
commencement of violent fevers, phlegmasia, and exanthemata, I 
shall not at present dwell any longer on this subject. The second 
form of scarlatina was likewise remarkable for the violent excitation 
manifested from the very beginning in the circulating system and 
in the production of animal heat. The pulse at once rose to above 
100, it was seldom less than 120, and in many cases, particularly 
in young people, it ranged from 140 to 150. I have never in any 
other disease witnessed so many cases of excessively rapid pulse. 
In general the pulse in this form was regular, but in two cases it 
became irregular; one was that of a gentleman living in Upper 
Mount street, whom I attended along with Dr. Marsh ; his pulse 
became intermitting and irregular on the third day, and continued 
to be more or less thus affected for about a week. This gentleman 
was attacked with subsultus, delirium, jactitation, and various ner- 
vous symptoms, at a very early period, and complained constantly 
of his throat and head. The former was violently inflamed, and 
his skin was covered with a bright red eruption. On the ninth day 
he was seized with convulsive fits of great violence, and which 
returned very frequently during the night; his case appeared 
utterly hopeless, and yet he perfectly recovered. In a young lady, 
whose case is detailed by Dr. Nolan, great irregularity and inter- 
mission of the pulse commenced about the eighth day, and con- 
tinued during the state of danger ; she also recovered. Of course 
irregularity of the pulse was in many not so much a symptom of 
disease as of approaching death, but then the state of the patient 
could not be mistaken, judging from all the other circumstances of 
the case. The acceleration of the pulse abated in all when an evi- 
dent improvement in the general condition took place, but in few 
did the pulse become quite natural for many days after a favour- 
able change, and in none did it fall to its usual standard in the 
course of twelve or twenty-four hours, as it not unfrequently does 
after the crisis of continued fevers; in fact, the scarlatina never 
ended with a well-defined crisis. As to the temperature of the 
body, I have already observed that in the cases I am now describ- 
ing it was from the first considerable, and continued elevated until 
a very short period before death. Both the pulse and the heat of 
skin, however, were very easily reduced in energy by the use of 
the lancet or by the repeated application of leeches, and it was not 
uncommon to observe that even the judicious use of these means 204 
graves’s clinical lectures. 
induced a general coldness of surface, very great sinking of the 
strength, and a faltering state of the pulse. This was remarkably 
the case in a young lady whom I attended along with Mr. Wilkin- 
son, in Black Rock, and also in one of the family whose cases are 
related by Dr. Nolan. In both, these etfects were very obstinate and 
alarming, for reaction was not restored until after the lapse of more 
than twelve hours; both finally recovered. The pulse was sharp 
but not strong, and resembled the pulse of great irritation rather 
than that of true inflammation. The most distressing symptom 
at the commencement of this form of scarlatina was the sore 
throat; the fauces were violently inflamed, and deglutition conse- 
quently much impaired, while a general soreness was felt in the 
back of the head and neck ; urgent headache was complained of by 
all, and from the second day the eyes became suffused; great rest- 
lessness, anxiety, jactitation, moaning, and interrupted raving soon 
made their appearance, and in many sleep was banished or utterly 
broken by startings and delirium before three or four days had 
elapsed. The eruption had now arrived at its height, which it did 
with great rapidity, dating from the first moment of its appearance, 
so that the skin, everywhere covered with a scarlet eruption, 
resembled in appearance the hue of a boiled lobster. In these 
violent cases the efflorescence was perfectly continuous, and never 
broken into spots or patches ; the skin appeared as if evenly dyed 
with one uniform colour ; the surface of the tongue was likewise 
much affected with the same exanthematous redness, and soon 
became foul, and afterwards dry and parched. The sudden drying 
of the tongue on the fifth or sixth day indicated in this form a rapid 
aggravation of the disease, and death in several cases was observed 
to follow this change in less than twenty-four hours, when this 
change was, as in a young gentleman Mr. Rumley and I attended 
in French street, accompanied by a sudden acceleration of the pulse 
and increase of the jactitation and delirium. In this form the brain 
and nervous system seemed to be the parts which suffered most, 
and many became insensible for several hours before death ; others 
had convulsions; when the patient survived the seventh day there 
was a fair chance of recovery, but many, too many, died on the 
fourth, fifth, or sixth days. 
After I had witnessed a few examples of this form of scarlatina,. 
I consulted with several of my friends and colleagues, and we 
determined to use the most active measures of depletion in the very 
first instance that occurred to us. A case was not long wanting. 
Dr. Marsh and I were engaged in prescribing for some children 
labouring under the epidemic, in a house in Pembroke street, where 
our attention was directed to a fine boy, six years old, and hitherto 
perfectly healthy, who was, while we were paying our visit, 
attacked with the first symptoms of the complaint; we immediately 
resolved that as soon as the stage of rigour and collapse which 
preceded the febrile action had passed, to visit him again and act 
energetically, if circumstances seemed to permit it. Accordingly we- 
came again in the course of a few hours, and found reaction already 205 
established, attended with vomiting, purging, and headache. The 
sore throat, too, was much complained of, and there was great ten- 
derness of the external fauces. We ordered relays of leeches, eight 
at a time, to the neck, for the purpose of relieving both the throat 
and brain, and we administered James’s powder and calomel inter- 
nally. On the next day the skin was burning in spite of a copious 
loss of blood from the leech-bites, the eruption vivid and already 
established, the pulse 140, and there had been little or no sleep. 
Relays of leeches were again ordered, and persevered in until con- 
siderable and lasting faintness was produced, and yet no impression 
seemed to be thereby made on the disease ; no abatement of its viru- 
lence seemed to be the result, for the raving became more incessant 
on the gecond night, and on the third day suffusion of the eye com- 
menced, and the tongue became parched. Shaving of the head, 
the most industrious application of cold to the scalp, and various 
other remedies were in vain applied; the pulse became weaker, 
the breathing quicker, the strength failed rapidly, raving and 
delirium gave place to insensibility and subsultus, and the patient 
died on the fifth day. In this case depletion was applied at once 
and most decidedly, for we blanched and weakened the boy by loss 
of blood as far as it was possible to venture, and yet the disease 
was not in the least degree checked, nor the symptoms even 
mitigated. 
A fine boy, thirteen years of age, was attacked in the county of 
Wicklow, when he was placed under the care of a very judicious 
practitioner, who did not use either venesection or leeches, but re- 
lied chiefly on the exhibition of diaphoretics, particularly antimo- 
nials. The boy died on the seventh day, having suffered much 
from delirium, subsultus, want of sleep, &c. His brother, who was 
one year older, and a very strong boy, was seized with the disease 
in Dublin, and placed immediately under my care. I had the 
advantage of Mr. Rumley’s assistance, and we determined to pre- 
vent the supervention of the cerebral symptoms if it were possible 
to do it by means of antiphlogistic treatment; we failed, and our 
patient died on the sixth day. In short, in this form of the disease, 
where the pulse, without becoming strong, at once became extremely 
rapid, bore venesection badly, and required great caution even in 
the application of leeches; the nervous symptoms only appeared 
accelerated by the system of depletion, although the heat of the 
skin suggested its employment. The derangement of the brain 
and nerves in this form depended on something more than the 
violence of the circulation, and originated in something altogether 
different from mere cerebral inflammation or congestion. What 
that something was I cannot even conjecture, but it was probably 
the result of an intense poisoning of the system by the animal 
miasma of the scarlet fever. Every tissue of the body seemed, if I 
may use the expression, equally sick, equally overwhelmed, and it 
is probable that the capillary circulation in every organ was simul- 
taneously deranged. It was not gangrene of the throat which 
proved fatal, for in this form it never occurred ; it was not inflam- 
SCARLATINA. 206 
graves’s clinical lectures. 
mation of any internal viscus, for such was not found on post-mor- 
tem examination of the fatal cases, but it was a general disease of 
every part. In many, another state of things, which required to be 
carefully distinguished from that just described, existed, and the 
disease was evidently attended with an inflammatory state of the 
constitution, requiring energetic measures. In such cases the 
symptoms were severe in the commencement, the throat very sore, 
the efflorescence, however, not quite so sudden or so perfect, and 
the pulse never near so quick, never excessively rapid, and always 
strong and distinct. Such bore bleeding and leeching well, and 
experienced from their use almost immediate alleviation of the sore- 
throat, headache, and restlessness, and were not much weakened 
by the depletion. It must be confessed that it was 
ingly difficult to determine, a priori, whether the depletory system 
ought or ought not to be tried; where doubt existed, my custom 
was to try moderate leeching, and from its effects I judged of the 
propriety of persevering. 
The disease very frequently occurred in a third form, more sin- 
gular still than the two first, and much more insidious in its com- 
mencement. This form'was evidently very common in the epidemic 
scarlet fever described by Withering, as cited by Dr. Tweedie. In 
this form the disease was ushered in by the usual symptoms of 
pyrexia, together with sore throat, slight headache, and in due time 
a very moderate and normal eruption. The symptoms continued 
moderate, the patients, after the first few days, slept tolerably well 
during the night, had no raving, and were quiet during the day. 
About the fourth or fifth day all the febrile symptoms had so far 
subsided, that a most accurate examination could detect nothing 
urgent, nothing in the slightest degree either alarming or calculated 
to excite the least anxiety in the patient’s condition. His skin be- 
came nearly of the natural standard, his thirst diminished, and the 
pulse was now scarcely accelerated; a calm nearly complete, in 
fact, seemed to have followed the first onset of the disease ; and on 
entering the room the physician might easily be deceived, as I my- 
self was more than once, into the pleasing hope that all danger was 
past, and that perfect recovery might confidently be anticipated. 
This hope was, in truth, founded on such circumstances as we can 
usually rely on; for who would prognosticate danger where his 
little patient, sitting up in bed, and perhaps eating a dry crust with 
some appetite, had a placid countenance, and had enjoyed a night 
of tranquil sleep? Regular alvine evacuations, diminution of 
thirst, sore throat, headache, and fever, together with the normal 
state of the cutaneous eruption, all conspired to confirm a favour- 
able prognosis; and so matters proceeded, the family dismissing all 
apprehension as to the result, and the physician most probably dis- 
continuing his attendance about the seventh day, in the belief that all 
danger was over, and that his interference was no longer necessary. 
Matters proceeded thus until the eighth or ninth day, when a cer- 
tain degree of restlessness was observed to occur, and in the morn- 
ing a slight return of fever might be noticed. Then it was that a SCARLATINA. 
207 
peculiar train of symptoms set in. The nostrils assumed a sore 
and irritated appearance about the edge of the alas, and a serous 
moisture began to flow from their internal cavities. Sore throat 
was again complained of, the skin became hot, great debility and 
prostration of strength came on suddenly, a painful tumefaction 
commenced in the region of the parotids and submaxillary glands. 
This tumefaction increased rapidly, becoming every day harder, 
more elevated, diffused, and exceedingly tender, but without much 
redness. In the course of a few days it surrounded the neck like a 
collar, and being attended with swelling of the face, the poor little 
patient’s countenance was sadly disfigured. In the mean time the 
discharge from the nose had increased considerably, and become 
more viscid and fetid; the internal membrane lining the nasal 
passages was affected throughout, its entire surface everywhere 
inflamed and tumefied, so that a snuffling sound was produced 
when the patient breathed through his nose ; at length the dis- 
charge increased to such a degree, that the nostrils became com- 
pletely impervious to the air in breathing. The state of the throat 
generally began to alter for the worse at the very commencement 
of this change; and a similar inflammation, attended with an ill- 
conditioned secretion of lymph and fluid, occupied the entire sur- 
face of the mouth and tongue, and at last spread deep into the 
pharynx. While this was going on, the fever freshly lit up at once 
exhibited the most decided symptoms of the worst form of typhus 
and subsultus, constant muttering, raving, anxiety, want of sleep, 
restlessness, moaning mingled with an occasional screech, remind- 
ing one of that which is so ominous in hydrocephalus. Great 
difficulty was now experienced in swallowing, and the drink was 
frequently spurted out of the mouth after a vain attempt at degluti- 
tion. Matters now proceeded rapidly from bad to worse, and at 
last, after much suffering, death closed the scene, being preceded 
for many hours by a state of extreme restlessness, during which it 
was impossible to determine whether the patient was still sensible. 
The swelling of the neck went on increasing to the last, but seldom 
exhibited any tendency to point; it continued, on the contrary, 
every where hard, or, at most, became indistinctly softened, or, to 
use a technical phrase, “boggy.” When cut into, no matter was 
found; blood, serum, and a diffused cellular slough, not separated 
from the living tissues, were observed on making the incision. 
I shall conclude these remarks on scarlatina, by reading you a 
letter I received on the subject from Mr. Ferrall. His observations 
are extremely valuable, more especially those which are made 
towards the termination of the letter, where he describes a most 
important sequela of scarlatina not hitherto mentioned by any 
writer. 
“ My Dear Sir,—In reply to your letter, I have the pleasure to 
send you a few brief notes of my experience of the scarlatina of last 
autumn and winter. 
“Of seventeen cases of which I possess notes, four occurred in 208 
graves’s clinical lectures. 
adults, three in children under four years of age, and the remainder 
at different ages between the latter and fourteen or fifteen years. 
I seldom saw the cases in the commencement. The mode of 
attack was occasionally similar to that of common sore throat, fol- 
lowed by rigors. Sometimes violent pyrexia and shiverings, with 
intolerable headache, and even delirium, preceded by other signs. 
In some few cases, the efflorescence first attracted notice, the fever 
in these instances being throughout so mild as scarcely to demand 
attention. 
“ The progress of the disease was various, but usually bore a 
relation to the character of the incipient fever. In general, the 
fever increased in intensity as the disease advanced, or as new 
parts became engaged, but this was not always the case. In two 
instances, which I saw in a state of great vital depression on the 
third or fourth day, I was assured that the early fever was very 
high, although it had passed rapidly into the typhoid state. 
“ The danger sometimes appeared to arise from the condition of 
the entire system, sometimes from that of important parts. Of two 
cases which I saw when dying, one was sinking like a person in 
typhus fever; the other, a boy thirteen years old, was moribund in 
the coma, which succeeded to violent phrenitic delirium. The 
latter case was remarkable in this, that the phrenitic state occurred 
while the eruption was in its prime, the whole body retaining its 
deep scarlet colour until a short time before his death. The dis- 
ease in this instance set in with delirium, which had been sub- 
dued, I have reason to believe, by the most active means. Death 
occurred in one instance from croup, the disease of the throat 
having passed into the trachea and bronchial tubes. In another, 
sloughing of the fauces, with low fever, carried off the patient on 
the sixth day. 
“ In several, who ultimately recovered, life was seriously endan- 
gered by local inflammatory attacks. In one instance, a girl about 
seven years old, enteritic symptoms sprang up suddenly while the 
patient was in a very weak state, and were with difficulty subdued. 
In another, a boy ten years old, acute pain in the region of the 
heart occurred when the eruption was on the decline; it was 
accompanied by short cough, palpitations, dyspnoea, rapid, though 
not irregular, pulse, and sudden accession of fever. There was no 
perceptible frottcment, but the action of the heart was violent, and 
there was acute pain on pressure. It yielded to leeching, followed 
by calomel, with James’s powder, till the gums were slightly 
touched. 
“Another patient, a girl twelve years old, narrowly escaped the 
effects of sloughing of the throat. Croup occurred in two in- 
stances, in which, notwithstanding the opinions of M. Trousseau, I 
could not doubt its origin in scarlatina. It happened, no doubt, in 
cases which had exhibited the diptheritic patches, without much 
surrounding inflammation on the tonsils, but the eruption was suf- 
ficiently marked to remove all obscurity. One child, who reco- 
vered, ejected the false membrane (which I still preserve) in a SCARLATINA. 
209 
tubular form, and presenting a cast of the trachea a little beyond 
its bifurcation. In the child before mentioned, who died, patches 
of false membrane were also ejected, but she sank exhausted, and 
the disease was afterwards discovered to have extended far into the 
bronchia] ramifications. 
“ Although the treatment was generally antiphlogistic, this plan 
was not always applicable, even in the commencement of the dis- 
ease. In all instances which I had an opportunity of observing, it 
was necessary to watch the effects of local bleeding. It was easy 
to pass the boundary of relief, and then most difficult to repair the 
loss, and meet the symptoms of exhaustion when they had actually 
set in. Wine and diffusible stimuli were often required from this 
cause alone, even when the cases had nothing of the malignant or 
typhoid character in their nature. 
“ Tepid sponging appeared in many instances preferable to cold, 
and I think the soothing effects were of longer duration. Reaction, 
and the distressing sense of burning heat, did not appear to recur so 
soon as when cold fluids were employed. Purgatives, except of the 
mildest kind, were not well borne, but cooling diuretics were clearly 
indicated, and when persevered in, had, in many cases, the apparent 
effect of anticipating the sequelas of the complaint. 
“ The ulcerations and sloughings of the throat were treated by 
nitrate of silver, alum, and the chlorides, according to their states. 
But none of these applications were to be depended on, when the 
colour of the fauces was intensely red, unless a few leeches had 
been previously applied. In one gentleman, twenty-eight years of 
age, free leeching, externally, (to the number of forty,) failed in 
removing the sense of suffocation or enabling him to swallow. A 
few leeches applied to the inside of the nostrils was followed by 
copious bleeding and immediate relief. The latter expedient was 
indicated by the tumid state of the velum and pituitary membrane, 
the stertorous breathing, and complete occlusion of the nares. 
“Its mode of spreading in families was uncertain. It sometimes 
attacked children within a few days of each other; at other times, 
a fortnight has elapsed before I was again requested to see a new 
patient. Some children escaped the disease altogether. 
“Among the sequelse which I had occasion to see, diarrhoea 
occurred in two or three instances, chronic bronchitis in one, and 
anasarca in four. The urine was slightly albuminous in two of 
the latter cases before the face and limbs began to swell; in the 
other two it exhibited this character when the disease was formed, 
but I did not see them previously. The treatment of the anasarca 
was antiphlogistic and diuretic, and succeeded in restoring three to 
perfect health; the fourth still remains an invalid, but not from this 
cause; the apex of the right lung affords evidence of tubercular 
disease. 
“ I have now to mention a peculiar affection of the neck, which 
I have not before seen in connection with scarlatina, but of which 
four cases have occurred during my observation of the epidemic in 
question. 210 
graves’s clinical lectures. 
“ Case I.—About the beginning of August, 1834,1 was requested 
by my friend Dr. Davy to see a young girl, ten years old, in Upper 
Baggot street. Her convalescence was tedious, some degree of 
fever still existing at the end of six weeks from the commencement, 
of the attack. But her principal complaint was severe pain of the 
right side of the neck, close to the head, and extending as high as 
the vertex on the least motion of the part. She could not raise the 
head from the pillow without putting a hand at each side for its 
support, and when taken out of bed, instinctively sought a resting- 
place for the chin. The face was awry, its vertical diameter pass- 
ing from above downwards, and from right to left. Posteriorly, 
the upper cervical vertebras were curved, the convexity of the 
curve being situated a little to the left of the middle line; there 
was considerable swelling of the soft parts covering the bones. 
Pressure here was intolerable, and the least attempt to rotate the 
head occasioned severe pain. Deglutition was now tolerably easy, 
but there had been considerable difficulty of swallowiug during the 
early period of the complaint. There was here obviously a carious 
state of the articulation of the atlas and dentata, and we did not 
expect to remove the curvature. Perfect rest was, however, en- 
joined, and the usual remedies employed with a view to arrest the 
further progress of the disease. She gradually recovered her 
health, and is now lively and well grown, but the curvature is per- 
manent. 
“Case II.—Early in August, 1834, Mary Inglesby, of Russell 
place, set. 7, was sent to me by Mr. Long, of Summer Hill. She 
was confined to bed in scarlatina for a fortnight. At the end of 
this time she was taken out of bed, and then the head was observed 
to be turned to one side. It was now five weeks altogether from 
the beginning of the disease, and the parts were still in the same 
state. The face was awry. She complained of pain in the con- 
cavity of the curve and that side of the head, and could not bear 
the slightest motion or shock. Leeches were prescribed, and 
calomel given afterwards in doses of a grain, three times a day, till 
the gums were touched. As soon as this effect was produced, the 
pain subsided, and the head gradually acquired its natural position. 
Her recovery was complete. 
“Case III.—A younger brother of Mary Inglesby was subse- 
quently under the care of Mr. Long for scarlatina. The same state 
of the head and neck wbre detected on the thirteenth day, and treated 
by Mr. Long on the same plan as that adopted in the former case. 
The pain disappeared as soon as the mouth was made sore, and 
the position of the head became natural. He is now in good health. 
“ Case IV.—I met Mr. Edgar, of Arran Quay, in February last, 
in the case of a young gentleman about six years old, whose conva- 
lescence from scarlatina was tedious, and in whom the difficulty of 
swallowing persisted after the redness of the fauces was removed. 
On taking him out of bed, it was remarked that he was quite 
unable to keep the head erect. The symptoms were similar to 
those of the two last cases, but in a milder degree. A few leeches TREATMENT OP FEVER. 
211 
were applied, and evaporating lotions instantly used to the part, on 
account of considerable local heat. The leeching was repeated in 
a day or two, but as the symptoms yielded rapidly, and as he had 
some tendency to diarrhoea, calomel was not employed. In about 
a fortnight, the natural position of the fead and neck was restored. 
“ I can offer no better explanation of the occurrence of this affec- 
tion, during the progress of scarlatina, than by supposing that the 
inflammation of the fauces, and back of the pharynx, was propa- 
gated to the covering of the spine, and thence more or less deeply 
to the adjoining parts. In all those cases there had been marked 
and prolonged difficulty of deglutition as a symptom of the disease ; 
and it is to this circumstance I am desirous of calling attention, as 
affording an index for a careful review of the condition of the 
spine during the period of convalescence. Should a child be 
observed to lie more on one side than the other, and evince an un- 
willingness to be disturbed, it would be an additional reason for 
suspecting a tendency to this complaint. 
“ Believe me, dear sir, 
“ Yours, very truly, 
“Joseph M. Ferrall. 
“ Rutland square, west, May 30th, 1835.” 
LECTURE XX. 
I shall speak to-day of some prescriptions which I am in the 
habit of using in the treatment of fever. In the treatment of fever 
it is frequently of importance to gain time, and periods will occur 
in every long fever, in which there may be no direct indication for 
the exhibition of any powerful remedy; at the same time, such is 
the ignorance of non-medical persons, and the anxiety of the pa- 
tient’s friends is so intense, that they cannot imagine how it is 
possible for an attentive physician to let twelve hours pass away 
without doing something. The mere circumstance of seeing the 
fever going on, is sufficient proof to them of the necessity of making 
renewed efforts for its removal. This, however, is very excusable. 
If any of you happened to be ill, I dare say you could scarcely 
bear to pass many hours without taking something which you 
supposed might prove either immediately or remotely useful. Con- 
sequently, we could not treat fever in a satisfactory manner without 
medicines of what may be termed an expectant character, and cal- 
culated to fill up the spaces intervening between those periods when 
active treatment is necessary. You are not to suppose that in 
ordering such medicines you are acting a dishonest part, and prac- 
tising a deception unworthy of your profession ; on the contrary, 
your conduct is perfectly just and proper: and though you were 
convinced that no medicine is required, still it will he necessary to 212 
graves’s clinical lectures. 
prescribe something, if you do not wish to lose the confidence of 
the patient and his friends. Again, if at a period when you say 
that no medicine is necessary, and when the patient has passed 
twenty-four hours or two days without taking any thing, an unex- 
pected turn in his disorder should take place, people will be very 
apt to say, either that you did not know what to do, or that you 
took no steps to obviate the threatened change, and that one or two 
days were completely lost. Conduct like this has frequently brought 
down a great deal of censure on medical men. It may be said that 
these are mere prejudices, and above the dignity of a man of firm 
and consistent character; but when prejudices are intimately blend- 
ed with human nature, and constitute, as it were, a part of it, it is 
much better in many cases to submit to them, particularly when 
compliance does not involve a sacrifice of principle. In cases of 
acute disease of any considerable duration, and especially in private 
practice, there are periods when medicines of an expectant and 
temporising character must be employed, and hence the introduc- 
tion of a class of remedies extensively used in fever and other com- 
plaints, and generally denominated palliatives. These are remedies 
which have a general tendency to assuage thirst, act as diluents, 
gently promote the secretions of the skin, intestinal canal, or kid- 
neys, and which are known to possess at least the negative quality 
of doing no harm. They are most commonly prescribed in com- 
bination with a considerable quantity of fluid, and hence are admi- 
nistered either in the form of draught or mixture. The medicine 
in most general use among the physicians of Dublin is one which 
was introduced by Dr. Cheyne. It is prepared by dissolving a 
dram of carbonate of ammonia in three ounces and a half of water, 
with as much lemon juice as will saturate it; the mixture is then 
sweetened with syrup of orange peel, and given in doses of two 
tablespoon fills every third or fourth hour. In this way a solution 
of the citrate of ammonia is formed which possesses the properties 
of a mild anti-febrile, and gently stimulant diaphoretic. 
Now it cannot be denied that this mixture answers the purposes 
of an expectant remedy, calculated to pass away the time, and do 
no injury; but it appears to labour under one considerable disad- 
vantage, it is not agreeable to the taste. If you taste the citrate or 
acetate of ammonia, you will find that its flavour is by no means 
pleasant, and I need not tell you that in cases where there is no ac- 
tual indication to be fulfilled, it is of importance to have something 
that will not be disagreeable to the patient. Feeling, therefore, the 
necessity of altering this prescription, I have lately introduced ano- 
ther, which I am happy to find has been extensively adopted, and 
which is formed by substituting the carbonate of soda for the car- 
bonate of ammonia. The mode in which I generally employ it is 
the following:—carbonate of soda, a dram; water, four ounces ; 
lemon juice, a sufficient quantity to saturate the alkali; syrup of 
orange peel, half an ounce ; tincture of orange peel, two drams. 
A little more than an ounce of lemon juice will be sufficient to 
saturate this quantity of carbonate of soda, whereas it would take RETENTION OF URINE. 
213 
from two and a half to three ounces to saturate the same quantity 
of carbonate of ammonia. If you wish to have a weaker solution, 
and I believe it is the better way, you can dissolve a dram of car- 
bonate of soda in five ounces of water instead of four. Nothing 
can be more agreeable in flavour than this mixture. The citrate 
of soda which is formed, does not, it is true, exert any active influence 
on the animal economy, but it partakes in the properties of neutral 
salts, determines gently to the kidneys, tends to keep up a soluble 
state of the bowels, and forms a most grateful and refreshing bever- 
age, The syrup of orange peel gives the mixture an extremely 
pleasant flavour, and this is further heightened by the agreeable 
aromatic bitter of the tincture. Since I commenced using it, I have 
found it to answer all the necessary purposes extremely well, and I 
can recommend it to you with confidence. 
I shall now speak of the principles which guided me in pre- 
scribing for a young woman in the chronic ward, named Catharine 
Roach. I am anxious to make a few observations also on her 
case, as it belongs to that anomalous and frequently unmanageable 
class of female complaints, which puzzle the practitioner so much, 
and which he is so often called on to treat. The most prominent 
feature in the case of this young woman, who is of stout make, 
considerable embonpoint, and rather healthy appearance, is reten- 
tion of urine. Retention of urine occurs much more frequently in 
young and tolerably healthy females than in males at the same 
period of life. It is very rare to meet with retention of urine in 
males under thirty, except in cases of fever, or disease of the 
urinary passages; in a healthy person, and who is going about in 
the usual way, it is never observed. This, however, is not the 
case with females; young females, apparently in good health, and 
going about as usual, not unfrequently suffer from retention of 
urine. 
The history of this girl’s case is briefly as follows. About twelve 
months ago she was treated in Mercer’s Hospital for fever, during 
which she laboured under retention of urine ; this disappeared with 
the return of convalescence, but after some time it again attacked 
her, and has appeared at intervals ever since, being sometimes 
absent for weeks, and sometimes only for a few days. You per- 
ceive, then, it is quite evident from the history of the disease, from 
the circumstance of its being unaccompanied by any local inflam- 
mation or change in the part affected, and from its occurring during 
the course of fever in which the brain, spinal marrow, and other 
parts of the nervous system were engaged, that the retention of urine 
must here depend solely on a nervous cause. It is in fact a species 
of temporary paralysis of the bladder, arising from the nervous 
influence by which the motions of that organ are regulated, being 
subjected to occasional disturbance. This affection of the bladder 
is of frequent occurrence among hysterical females, and is some- 
times met with in persons who appear to have no other disease. Tt 
is also very apt to continue for a long time; I have seen it last for 
months, and require the daily use of the catheter. 214 
graves’s clinical lectures. 
In this case the origin of the disease did not appear to have any 
connection with the discharge of the uterine functions, the cata- 
menia were regular, and there was nothing connected with the 
state of the uterus on which it could be suposed to depend. But 
on enquiring carefully into the history of her complaint, we found 
that ever since she had laboured under fever, she had experienced 
a train of symptoms indicating that the derangement of the nervous 
system which then occurred had never completely subsided: she 
complained of pain in the head and loins, want of appetite, con- 
stipation, and tympanitis, symptoms which all indicated that a con- 
siderable degree of nervous derangement still existed—in other 
words, that the affection of the nervous system which accompanied 
her fever had now become as it were chronic, and, with the chro- 
nicity, had assumed the intermittent character of nervous diseases. 
I shall now explain briefly the mode in which I treated this case, 
and the reasons which induced me to prescribe the remedies em- 
ployed. In the first place, it was necessary to remove and obviate 
constipation. My object here was not merely to keep the bowels 
open, but also to give such medicines as would agree with the sto- 
mach and lessen the tendency to tympanitis. Now if, in addition 
to these purposes, I could accomplish another very important object, 
namely, to strengthen the tone of the nervous system, and effect an 
alteration in its mode of action, I considered that I should fulfil all 
the required general indications. I therefore ordered an electuary, 
which I have been much in the habit of using in similar cases, and 
from which I have often derived remarkable advantage. 
R. Electuarii sennae, 3hj- 
Bitartratis potassae 
Sulphuris loti 
Carbonatis ferri 
aa 3ss. 
Syrupi zingiberis, q. s. 
Ut fiat electuarium. Sit dosis cochleare minimum ter quotidie. 
I am sure every gentleman present understands the principles on 
which each ingredient of the foregoing combination was prescribed. 
The electuary of senna, or, as it is usually termed, the lenitive elec- 
tuary, by its mild but extensive operation on the digestive tube, 
forms an excellent basis for a combination like this. The carbonate 
of iron was ordered, because it was obvious that the young woman 
laboured under considerable derangement of the nervous system, 
requiring the salutary influence of a tonic calculated to strengthen 
the nerves, and thus gradually restore them to their healthy and 
normal action. Besides, we know that in cases where persons 
labour under a relaxed and debilitated state of the digestive organs, 
giving rise to tympanitis, constipation, and want of appetite, the 
carbonate of iron, by giving additional vital energy to the intestinal 
tube, tends not only to restore appetite, but also to check tympanitis 
and promote defecation. You perceive, then, what my motives 
were in giving the carbonate of iron; but as, in such cases, there is 
always more or less irritation and excitement of the nerves, it will 
be necessary to temper the action of the carbonate of iron, lest, by RETENTION OF URINE. 
215 
proving too stimulating, it may do more harm than good. I com- 
bined, therefore, with it a neutral salt of aperient and cooling pro- 
perties, the supertartrate of potash. It might be objected here, that 
an error was committed in prescribing remedies which are che- 
mically incompatible, and that so far the combination was imper- 
fect ; but it may be observed, that the supertartrate of potash is 
soluble with difficulty; and, besides, even supposing that decom- 
position actually does take place, and that we have a tartrate of 
iron and a carbonate of potash formed, still we know that the 
tartrate of iron is an excellent chalybeate, and experience teaches 
us that the new combination forms an active and valuable remedy. 
To these ingredients we added sulphur, to act on the skin and the 
mucous surfaces of the lungs and digestive tube. You will re- 
collect that this girl had frequent attacks of tympanitis, which con- 
sists in an effusion of air into the intestines, produced by a fre- 
quently recurring congested state of the bowels. Now, strange as 
it may appear, sulphur, though apt to induce a secretion of sulphu- 
retted hydrogen from the intestinal mucous membrane, and thus 
give rise to flatulence, exercises by its gently stimulating and 
alterative effects a remarkable influence over morbid secretions of 
air from the bowels, and so far the homoeopathic doctrines seem to 
be borne out. It certainly appears singular that sulphur, which is 
a stimulant, and which generally increases the gaseous secretions 
of the digestive canai, should have a tendency to remove conges- 
tion and diminish flatulence ; but I appeal to experience and 
analogy for the truth of this opinion, and refer to its use in another 
form of disease where congestion and flatulence is always present, 
namely, in cases of haemorrhoids. So much for the reasons which 
led me to prescribe this combination. 
In ordering this electuary you should give directions (and this is 
a point never to be neglected in treating female complaints) to the 
patient to attend carefully to the effect of the remedy. If a tea- 
spoonful three times a day is sufficient to keep up a gentle but full 
action of the bowels, there will be no necessity of changing- the 
dose ; but if this is not enough, it should be increased, or it may be 
quickened by the addition of a small quantity of jalap or electuary 
of scammony. This, however, should be done cautiously, because 
in such cases your object is not to purge briskly, but merely to 
maintain a soluble state of the bowels. When the use of this 
electuary has been persevered in for some time, and when the 
patient takes it regularly, and knows the exact quantity necessary 
to produce one or two loose evacuations in the day, it is surprising 
how favourably it will act. It regulates the bowels, invigorates the 
tone of the intestinal mucous membrane, increases the appetite, im- 
proves the strength, and restores the healthy action of the nervous 
system. In the case before us it has proved eminently serviceable. 
So far with respect to our attempts to act on the system generally; 
a few words now with respect to the local treatment, In the first 
place, with the view of strengthening the tone of the bladder, and 
promoting the expulsion of urine, we gave fifteen drops of the 216 
graves’s clinical lectures. 
muriated tincture of iron (liquor muriatis ferri p. d.), in an ounce 
of camphor mixture three times a day. The reason for prescribing 
the muriated tincture of iron is so obvious, and it has been so fre- 
quently employed for similar purposes, that it is unnecessary to say 
any thing in the way of explanation. In addition to this, I ordered 
a large vessel of cold water to be poured over her back and loins 
every day. This practice has often proved very beneficial to 
nervous females; it has in many cases restored the power of the 
bladder and improved the functions of the uterus ; it also exercises 
a remarkable influence over the digestive system, and, like sea 
bathing, is an excellent remedy for constipation. In order to ensure 
its full effect, you should order the patient to place her feet in warm 
water, and have the cold water poured from a considerable height. 
Like many other remedies of a similar kind, it is difficult to explain 
its action, but experience has shown that it is extremely valuable. 
We next prescribed such remedies as contribute to promote the se- 
cretion and evacuation of the urine, and, lastly, we have given a 
combination of tonics and stimulants. To-day I have ordered the 
following draught, to be taken twice daily :— 
R. Decocti foliorum buchu, 3 j- 
Tincturse ejusdem, 3 ss. 
Spiritus aetheris nitrosi, 3 ss. 
Tincturse cantharidis, M.ij. 
Fiat haustus. 
I need not tell yon, gentlemen, what the properties of buchu are: 
it is gently stimulant, sudorific and diuretic; it acts as a tonic on 
the urinary system, and in chronic affections of the bladder has 
proved extremely useful. Of the sweet spirit of nitre it is unneces- 
sary for me to say any thing, but a few remarks on the action of 
cantharides may not be improper. Being convinced that in this 
case the retention depended chiefly on temporary paralysis of those 
muscular fibres by means of which the bladder is enabled to 
evacuate its contents, it became necessary not only to act on the 
general system, but also on the parts affected, and we know from 
experience that cantharides exert a stimulant effect on the whole 
urinary apparatus. The tincture of cantharides, however, should 
be given with caution, and only in small doses, as it is apt to 
stimulate too powerfully if prescribed in large quantities. I should, 
however, have no objection that it increased in this case the pain 
which the patient experiences in passing water, as it is necessary to 
have some symptoms present indicating its action on the bladder. 
A small quantity, however, is generally sufficient in all cases of 
this description, and I have seen very good effects from doses of two 
drops three times a day. 
While I am on this subject, permit me to speak briefly on an op- 
posite state of the bladder, which is frequently observed in very 
young persons. A boy, perfectly healthy, but of a nervous tem- 
perament, studious, and extremely anxious about his lessons, is- 
subject from his infancy to pass his water under him in bed. He 
is, suppose, arrived at the age of six or seven years, and has no TREATMENT OF FEVER. 
217 
disease ; but still this habit sticks to him, and cannot be removed. 
The irritability of his disposition has been increased by injudicious 
correction ; he has been taken up at night and whipped ; he has 
been ridiculed during the day; his infirmity has been made known 
to his companions, who call him nicknames; and in this way the 
habit has been rather confirmed than removed. Now you may 
happen to be consulted about such a case, and be asked whether it 
can be relieved or not. The matter appears, perhaps, trifling and 
ridiculous, but you may get more credit by curing a bad habit of 
this kind, than by removing an acute disease. Now what are you 
to do ? In the first place, you must remove the boy entirely from 
all companions of his own age, who are acquainted with his bodily 
infirmity. In the next place, you must not allow him to be cor- 
rected or reproached, and you must adopt every moral means to 
diminish general irritability. The boy should not be too much 
confined ; he should not be allowed to apply too closely to his 
lessons ; and he should have generous diet, good air, and sea 
bathing. On these general principles I have cured several very 
obstinate cases with the use of infusion of buchu, with tincture of 
cantharides, in small doses. With respect to the use of cantharides, 
it struck me that the same medicine which would have the pro- 
perties of stimulating in large doses, might, when given in small 
quantities, have the property of increasing the tone of the bladder, 
and perhaps altering its mode of action ; nor in this expectation 
have I been disappointed. In a number of the Dublin Medical 
and Chemical Journal, I have spoken of a remedy which appears 
to be adapted to such cases, namely, the Lycopodium clavatum, 
which grows on the Dublin mountains, and which is said to have 
stimulant and diuretic properties analogous to those of the Diosma 
crenata and Arbutus uva ursi. It appears to be a remedy well 
adapted to cases where there is a chronic irritability of the bladder; 
and it is stated by some German writers, that it has produced very 
good effects in many chronic catarrhal affections of the bladder. I 
have not, however, time to speak of its properties at present, and 
beg leave to refer you to the paper in which I have spoken of it, 
which you will find in one of the late numbers of the Dublin 
Medical and Chemical Journal. 
A woman, named Anne Scarlet, was admitted on Saturday, con- 
cerning whose case it may be necessary to make a few observations. 
She states that she has been ill for the last eight days, and that her 
illness originated in cold, preceded by rigors, and followed by 
feverish symptoms. The general pyrexia had subsided at the period 
of her admission ; but she had some symptoms worthy of attention. 
Her pulse was 72, and regular ; her skin rather cool, and her 
bowels natural ; but she complained of acute pain in the left side, 
which, she said, came now and then, catching her breath, and pre- 
venting her from taking a full inspiration. This pain was so 
intense, and seemed to affect respiration so considerably, that, look- 
ing to its situation and its effects, you would at first sight be in- 
clined to think that it arose either from pleurisy or pericarditis. 218 
graves’s clinical lectures. 
On examining the chest, however, by the stethescope and percus- 
sion, we found the sound was clear and normal: there were no 
rales present, and the respiratory murmur was heard distinctly over 
the whole lung. In fact, auscultation showed that the cause of 
the pain was not connected with pleuritis, pneumonia, or peri- 
carditis. What then was it? A variety of pleurodynia, well 
worthy of your attention, as being connected in her case with re- 
tention of the milk and engorgement of the left mamma. At the 
time she was attacked with cold, she happened to be only a few 
days after childbirth : the feverishness which ensued obliged her to 
give up nursing, and in this way a sudden and unnatural check 
was put upon the secretion of milk. When an occurrence of this 
kind takes place, and proper means are not taken to obviate the 
mischief, a high degree of local irritation is the consequence, pro- 
ducing inflammation of one or both the mammae, which, if not 
treated well and energetically, will certainly end in mammary 
abscess. 
What I wish to draw your attention to, however, at present, is 
this—that inflammation of the mamma, arising from retention of 
milk, is very apt to be attended wiih pleurodynia in one or more 
parts of the chest. The flow of milk to the breasts, three or four 
days after delivery, is very often accompanied by flying pleurodynia, 
and the formation of mammary inflammation, from the arrest of the 
lacteal secretion, is also very frequently attended with fixed pains 
of a pleuritic character. 
The treatment adopted in this case was very simple. In the first 
place, you endeavour to check the determination of fluid to the 
breast; and for this purpose you exhibit a purgative of an hydra- 
gogue kind, calculated to act briskly on the bowels. We gave a 
combination of infusion of senna, sulphate of magnesia, tincture of 
senna, and electuary of scammony, which acted six or seven times 
on the bowels, and tended materially to relieve, by derivation, the 
mammary congestion. In the next place, we directed our attention 
to the breast, and endeavoured to remove the milk, by the use of 
the syringe employed for that purpose. The milk may be removed 
from the breast by means of the syringe, or by sucking with a 
breast-bottle, and where the tenderness of the part is so great that 
neither of these modes can be employed, the next best means is 
diligent fomentation. This produces a constant oozing from the 
breast, and if the fomentation employed be made with a decoction 
of poppy heads, it has considerable effect in abating pain and in- 
flammation. We also applied leeches in this case, not with the 
view of removing the pleurodynia, but with the intention of remov- 
ing its cause, mammary inflammation. By the use of means 
directed to the breast, you will find that we can remove all symp- 
toms of pleurodynia, and that the pain and difficulty of breathing 
will soon disappear. This is a simple case, but it is one of frequent 
occurrence, and it requires some tact and management for its suc- 
cessful treatment. 
To-morrow I shall speak on some other matters connected with TREATMENT OF FEVER. 
219 
the treatment of fever, and shall give some extracts from a pam- 
phlet on the medical effects of the chlorides of lime and soda, pub- 
lished some time ago by the Archbishop of Cashel, an erudite 
scholar, an accurate chemist, and an excellent man. You have 
frequently, since the commencement of the present epidemic, seen 
me use the chloride of soda in the treatment of fever with the best 
effects. Indeed, we have much cause to congratulate ourselves on 
the happy results of our fever treatment. Since the commence- 
ment of the session, there has been a vast number of cases in the 
hospital, some mild, but many very doubtful and dangerous ; yet 
we have not, as yet, lost a single patient. This is a circumstance 
well calculated to excite agreeable reflections. It is also pleasant 
to recollect how plain and simple our mode of treatment has been. 
You have probably observed that, in the treatment of all the cases 
that came before me, I have not prescribed altogether a dozen 
grains of calomel ; that I have very seldom ordered any kind of 
purgative medicine; that I have been sparing in the use of leeches 
and cupping, and that I have not ordered a single patient to be 
blooded. This I am sure will appear strange to the various sects 
of pathologists and theorists whom I have seen, like so many waves 
succeeding each other, and whose doctrines were equally doomed 
to break on the solid and immovable shore of truth. I recollect 
how each doctrine arose, and made converts, and influenced prac- 
tice ; how each had its day, and then sank into that obscurity and 
neglect to which vain and profitless speculations are always 
destined. I recollect when it was the custom to commence the 
treatment of fever, by prescribing ten grains of calomel, to be fol- 
lowed by a bolus containing fifteen grains of jalap, or by a large 
draught composed of infusion of senna, epsom salts, and electuary 
of scammony. I remember the time when it was the fashion to 
bleed every case of fever which came into hospital, no matter what 
the stage of the disease might be. or what the condition of the 
patient was, at the time of admission. I recollect, too, when the 
prostration and weakness which accompanies local inflammation, 
particularly of the digestive system, used to be treated with wine 
and stimulants. In fact, so great was the difference of opinion 
among medical authorities, and so discordant was the practice 
employed, that an able and honest man declared, in a pamphlet 
published about sixteen years ago, that the treatment of fever was 
nothing but a farce, and that as many would recover under one 
form of treatment as under another; or. in other words, that as many 
persons were killed by one form of treatment as by another. This 
appalling announcement of the truth met the public eye, and it was 
further confirmed by observing that the poor, particularly those 
located in remote country districts, who had little or no medical 
attendance, died in much fewer numbers than the rich, who lived 
in towns or in their vicinity, and who had every attention paid 
them which professional skill could devise. Various explanations 
of this dreadful fact were given ; and among the hallucinations of 
the day was the statement, that a poor wretched being, who lived 220 
graves’s clinical lectures. 
on bad food, who ate nothing but potatoes and milk, or probably 
salt, and who was addicted to habits of intoxication, was better 
calculated to bear fever than the man who lived well and led a 
regular life. The truth, however, is, that the rich were killed by 
the nimia diligenti medicorum, and the poor, who had nothing to 
look to (to use a quaint expression of Dr. Rutty) but the providence 
of God, escaped. It is certainly an undeniable fact, that those who 
had plenty of medical attention, and took a great quantity of medi- 
cine, frequently died; while those who had no attendance, and 
took scarcely any thing but water, generally recovered. Any 
observant practical physician, who is in the habit of treating fever, 
knows that there is no single principle on which it can be treated 
successfully. Every epidemic is peculiar and distinct in its nature, 
and each consequently requires a distinct and peculiar mode of 
treatment. Hence the necessity of studying fever unbiased by 
any preconceived notions, and independent of the trammels of dog- 
matism. With a person who observes in this way, who studies the 
disease as it is, and not as it is described; whose practice is regu- 
lated, not by the doctrines of the schools, but by the results of in- 
vestigation, carefully weighed and considered ; with such a person, 
the treatment of fever will be simple and successful, and I believe 
that there is no disease in which success so much depends on treat- 
ment as fever. It is difficult to explain how it came to pass that a 
contrary opinion could be promulgated in Dublin. Something 
must be attributed to the neglect or incapacity of those whose duty 
it was to teach the truth. The chief cause may, however, be 
traced to the activity and zeal which inspired some, not only to up- 
hold their own branch of the profession, but to decry, I had almost 
said to defame, that which they were pleased to call pure medicine. 
With characteristic inconsistence, however, these gentlemen, who 
declared that the treatment of fever was at best useless, readily 
engaged in its management in private practice, and while they pro- 
fessed openly their disbelief in the efficacy of any medicines, they 
busily employed themselves in prescribing pills and draughts with- 
out number for their own fever patients. That they thought their 
treatment of some value, might be gathered from their acceptance, 
their invariable acceptance of pecuniary remuneration from the 
sufferers’ grateful friends, who little dreamed the while that the 
hands which, with automatic movement, so readily grasped their 
fees, belonged to persons who held, nay, who maintained, the 
opinion that the treatment of fever was all a farce. Posterity will 
scarcely give credence to this fact, and will probably refuse to be- 
lieve that such an opinion could have been advanced in what we 
are pleased to call an enlightened age, and an enlightened city. 
They will scarcely think I speak the truth in assuring them that a 
spirit of medical intolerance existed to such a degree at the time of 
the discovery of the stethoscope, that whoever in Dublin actively 
occupied himself in verifying the researches of the immortal 
Laennec—whoever availed himself of the new resources invented 
by this great physician, was sure to become an object, not merely DOUBLE PNEUMONIA. 
221 
of dislike, but of animadversion and ridicule, on the part of those 
who ought to have exerted their influence in endeavouring to ad- 
vance, and not retard, the progress of science. Happily for the 
character of the country, their endeavours have been frustrated, 
and the cause of truth has triumphed. Happily for the students 
and their future patients, those teachers are now most followed, 
who best explain, and most diligently illustrate, the phenomena 
observed by means of mediate auscultation. 
LECTURE XXI. 
I shall refer briefly to some points connected with the case of an 
old man in the chronic ward, who died lately of inflammation of the 
lung. At the period of his admission, he had been ill for some 
time; both sides of the chest, but particularly the left, sounded 
dull on percussion; he had extensive bronchial respiration and 
crachet rouille, in fact, it was a very bad case of double pneumonia, 
a disease which at his time of life is very seldom cured. We did 
all we could to arrest the progress of the disease ; we cupped him 
over the left side, gave him mercury so as to affect his system, and 
applied blisters to both sides of the chest, anteriorly and posteriorly. 
These were the only active measures which remained for us to 
employ; from the man’s age, the weakness of his pulse, and the 
duration of the disease, we could not venture on general bleeding; 
we could only attack the disease with local depletion, mercury, 
and counter-irritation. All these remedies were applied with great 
diligence, but unfortunately proved incapable of checking the dis- 
ease. His cough continued, respiration became more difficult, and 
though his mouth became affected, the dulness on percussion in- 
creased day after day ; and though the patient was removed into a 
warmer room, and every attention paid to his comfort, it was evi- 
dent that he was getting gradually worse. About a fortnight after 
his admission, his expectoration assumed the purulent character, 
and it was obvious that the lung had passed from the stage of hepa- 
tisation into that of interstitial suppuration. He took the decoction 
of polygala, with Iceland moss and syrup of white poppies, but 
without any relief to his symptoms ; the disease increased, and he 
died on the nineteenth, sixteen days from the date of his admission. 
On examining the lung, the ordinary phenomena of pneumonic 
inflammation were discovered ; parts of the lung were in the state 
of gray hepatisation, others were infiltrated with pus, and broke 
down easily under the finger. We found, too, that he had not only 
pneumonia, but also extensive pleuritis and pericarditis. The 
pleurisy had probably commenced about eight or nine days before 
his death ; the pericarditis was of an origin somewhat more recent. 
You may ask why I did not recognise these affections before 222 
graves’s clinical lectures. 
death. The reason is twofold. The man was in a very weak 
and hopeless condition, and both sides of his chest were sore from 
the blisters ; these are circumstances under which I have strong 
objections to torment a patient with examinations, and therefore I 
made none in this case. The other reason is, that in a patient who 
has been greatly reduced by some acute disease, new inflammations 
are apt to spring up with great rapidity, and with still greater 
latency. I remember a very remarkable case of the same descrip- 
tion which occurred at the Meath Hospital, where the patient had 
a very extensive inflammation of the pleura with exudation of 
lymph and effusion of a considerable quantity of fluid, and yet not 
one of these symptoms were recognised during life. This man, 
you will recollect, never complained of pain in the side, nor had he 
orthopncea, irregularity of pulse, lividity of countenance, or any of 
those symptoms which are looked upon as indicative of pericardial 
inflammation, yet on dissection we find the pleura extensively en- 
gaged, lymph exuded on its surface, and a small quantity of sero- 
purulent effusion in its cavity; and on examining the heart, we 
find the pericardium covered internally with an extensive gelati- 
nous layer, consisting of lymph and puriform fluid intimately 
mixed together. You perceive, then, in this case, a confirmation 
of what I have so often insisted on, that pleuritis may occasionally 
run through its course, unaccompanied by pain in the side, and 
that inflammation of the pericardium may exist without orthopnoea, 
irregularity of pulse, lividity of countenance, or fainting, symptoms 
formerly believed to be more or less manifest in every case of peri- 
carditis. The pathology of pericarditis has been investigated but 
lately with the care it deserves : the labours of our French brethren 
have been mainly instrumental in producing its present degree of 
advancement. In England some valuable observations have been 
contributed by Dr. Eiliotson and others, but they have been more 
than rivaled by the contributions to the diagnosis of this disease, 
which have appeared in the Dublin Journal of Medicine and 
Surgery. The French, indeed, have afforded the strongest evi- 
dence of the high value they attach to the essay of Dr. Stokes on 
the subject of pericarditis, by the transference of his entire article 
to the pages of the Archives Generates de Medecine. A most 
masterly paper, by Mr. Mayne, in the twentieth number of the 
Dublin Journal, ought to be consulted by every one anxious to 
make himself master of this important subject. Indeed I have no 
hesitation in asserting that Mr. Mayne’s paper will be found capable 
of bearing a comparison with any thing yet written on the symp- 
toms of pericarditis ; compare it, for instance, gentlemen, with the 
article Pericarditis, by Dr. Hope, in the Cyclopcedia of Practical 
Medicine, and you will at once perceive the very great inferiority 
of the latter ; compare it and Dr. Stokes’s paper with the reports of 
clinical lectures delivered in London on cases of pericarditis, and 
you will agree with me in thinking that the writings of our coun- 
trymen yield not in merit to those of the metropolitan professors. 
Gentlemen, I speak not in the spirit of vanity; I do not bring these ABSCESS OF THE HEART. 
223 
matters forward in order to flatter and augment a feeling of medi- 
cal nationality; far be it from me to extol beyond their deserts the 
merits of Irish writers, still farther from me the wish to depreciate 
the labours of English authors. Let us emulate our neighbours in 
the spirit of honest rivalry, and not imitate the example of some 
London lecturers and Scottish reviewers, who—but I have done, 
fearing that the narrow-minded prejudices of an editor in Edin- 
burgh, or of a few teachers in London, should induce me to forget 
the favourable, the too flattering reception, which every thing of 
merit issuing from the press of Ireland has met with from the 
medical periodicals of England. 
To return to our subject. Pericarditis is a disease of quite as 
frequent occurrence as pleurisy, and often, as in the present in- 
stance, associated with the latter; on the whole, I do not consider 
pericarditis as more dangerous or more difficult to cure than pleu- 
ritic inflammation, neither does its existence seem less easily ascer- 
tained. Some cases, it is true, are extremely insidious in their 
nature, but the same may be said of cerebritis, pneumonia, and all 
other phlegmasim ; usually, however, a careful and attentive physi- 
cian will at once detect the existence of pericardial inflammation. 
When he finds that a patient has been exposed to causes capable of 
exciting fever, that he has been liable to gout or rheumatism, or has 
been actually attacked with either, then will his attention be directed 
to the heart; if he perceives that its action is either unusually vio- 
lent or irregular, or if he observes that uneasiness and oppression 
of chest are complained of to a degree not to be accounted for by 
any pulmonary lesions present; if he finds that his patient has the 
appearance of a person labouring under some serious disease, and 
that none such exists in the lungs themselves, then will he be 
called on to examine the region of the heart with the greatest accu- 
racy. One of the most common symptoms of pericarditis is tender- 
ness in the intercostal spaces over or near the heart. This is not 
perceived in many cases until pressure is made with the fingers. 
Tenderness occurs in many who do not complain of pain or stitch 
in this portion of the chest; when the latter co-exists with tender- 
ness, the presumption in favour of the presence of pericarditis is 
still greater. The pain and uneasiness about the heart, are, as Dr. 
Elliotson remarks, generally increased by pressing in the left hypo- 
chondrium upwards towards the diaphragm. I must refer you to 
Dr. Stokes’s and Mr. Mayne’s papers for any analysis of the physi- 
cal signs derived from percussion and auscultation, and also for an 
explanation of the reasons why the general symptoms are subject 
to such striking variations in this disease. In some you have, 
soon after its commencement, lividity, orthopnoea, and tendency to 
fainting, combined with irregularity of pulse ; in others the disease 
runs its whole course, whether it terminates fatally or in health, 
without any of these symptoms ; in fact, no disease is more incon- 
stant in its characters, and none more requires the aid of investiga- 
tion by means of physical signs, which, if well conducted, seldom 
fails to clear up all doubts. Of one thing I am certain, that inflam- 224 
graves’s clinical lectures. 
mation of the pericardium in a person of tolerably good constitution 
may be generally arrested in its progress by bleeding, frequent 
leeching, and scruple doses of calomel. It is mere trifling on such 
occasions to have recourse to tartar emetic, digitalis, or the common 
antiphlogistic remedies. Instantly use every effort to produce the 
full action of mercury on the system. Apply the ointment to the 
axillas ; smear it over the inside of the thighs ; make your patient 
respire the vapour of hydrargyrum cum creta as often in the day 
as he can bear the process, and be assured that you are pursuing 
the proper course. Well has it been observed by Dr. Elliotson, 
when speaking of a fatal case of pericarditis,—“ The only chance 
I had to save the life of this person would have been to have pushed 
the mercury further. I am quite sure that more lives are saved in 
inflammatory diseases by carrying mercury to a great extent, than 
by merely having recourse to it for the simple production of pty- 
alism.” It is the want of decision in the practice of the French 
physicians—it is to their want of confidence in mercury, that we 
must attribute the greater mortality of pericarditis in Paris than in 
Dublin; for most of our patients recover, most of theirs die. Of 
course, gentlemen, the most unfavourable of all cases is where 
pericarditis attacks a person debilitated by previous sickness, such 
as fever, dropsy, <fcc. Here the disease runs a very rapid, and too 
often a fatal, course, and cannot be controlled. One practical 
remark, and I have done. Before effusion takes place into the 
pericardial sac never apply a blister ; after it has occurred, repeated 
and severe blistering over and about the region of the heart is one 
of our best remedies. 
Two years ago I had an opportunity of studying a case which 
subsequently proved to be an example of inflammation of the mus- 
cular substance of the ventricles, ending in suppuration and the 
formation of a large abscess in the ventricular parietes. This is a 
very rare occurrence, for the simple reason, that inflammation of 
the substance of the heart generally proves fatal before pus is 
formed. A very robust gentleman, aged fifty-five, from the neigh- 
bourhood of Wicklow, came to Dublin for the benefit of advice. 
He had complained of cough for many months, together with dysp- 
noea and palpitation of the heart; latterly, he had become anasar- 
cous, and suffered much from distress and pain referred to the 
region of the heart. This pain formed the chief subject of his 
complaint, and darted over the chest. On examination, I imme- 
diately detected hypertrophy and dilatation of both ventricles, and 
I announced the existence of valvular disease, inasmuch as a loud 
and extensive bruit de souffiet existed, together with a remarkable 
frem.issement cataire, and a very irregular pulse. This opinion 
was delivered in the presence of Dr. Sherwood and Mr. Hethering- 
ton. Our patient returned to the country, where he continued to 
complain of pain in the heart that was at times excruciating. He 
died suddenly at the end of a few weeks. The results of the post- 
mortem examination were kindly communicated to me by Dr. 
Sherwood. Considerable dropsical effusion into both pleural ABSCESS OP THE HEART. 
225 
cavities ; heart exceedingly enlarged. “ On slitting open the peri- 
cardium, I found (says Dr. Sherwood) that the heart adhered to its 
entire surface by means of bands of coagulable lymph, which were 
easily broken down except at the apex of the heart, where they 
were very strong and firm. In attempting to break them, more 
than two ounces of purulent matter escaped into the cavity of the 
pericardium, which caused me to institute a very close examination 
of the parts, in order to discover whence the pus came. I found a 
small rent in the apex of the heart, immediately below the floor of 
the left ventricle, exactly in the situation of the firm adhesions before 
spoken of. On enlarging this opening, I discovered a cavity in the 
substance of the heart, with a regularly-defined wall, capable of 
containing more than two ounces of fluid. The walls of both ven- 
tricles were enormously thickened ; all the valves were more or 
less affected ; but the chief disease lay in the semi-lunar valves of 
the aorta, which were nearly altogether ossified.” 
This case was extremely remarkable, and exhibits an example 
not merely of the dropsy and dyspnoea which so usually attend 
hypertrophy and valvular disease of the heart, but also of a combi- 
nation of chronic pericarditis and chronic inflammation of the mus- 
cular substance of the ventricles, ending in the very rare termina- 
tion, abscess. 
Having made these observations, I shall next call your attention 
to the disease of Francis Thorpe, which is important both in itself 
and from the circumstance of such cases being frequently met with. 
This lad, who was much exposed to the weather, being an outside 
servant, was attacked about six months ago with cold, followed by 
hoarseness and sore throat, with cough, then slight, but at present 
rather troublesome. A certain degree of rawness about the fauces 
was observed soon after the attack, and latterly the submaxillary 
glands have become slightly enlarged. On looking into the throat, 
the velum and fauces appear redder than natural, the amygdalee 
are swollen, and the mucous membrane covering the back and sides 
of the pharynx is dry, and covered with irregular superficial exco- 
riations. The hoarseness still continues, and he can only speak in 
whispers. His general health, however, does not seem in any de- 
gree impaired; he has no fever, his appetite is good, and his sleep 
natural. 
This case, however, is one which demands particular attention. 
A boy is attacked with cold, he gets slight local inflammation of the 
fauces and larynx; this produces cough and hoarseness, which go 
on for months rather increasing than diminishing, and his symp- 
toms finally assume a chronic and intractable character. Still he 
does not fall away in flesh, has no symptom of hectic, and, on 
examining his chest, you cannot find any evidence of the existence 
of tubercles. In making the prognosis in such a case, you should 
always act with great caution. Though an examination of the 
chest should detect no distinct sign of tubercles, and a review of 
the state of the constitution should satisfy you that there was no 
fever, night sweats, or wasting of flesh, yet the obstinacy and per- 226 
graves’s clinical lectures. 
sistence of the inflammatory condition of the larynx and fauces 
would seem to show that the affection, though not decidedly of the 
scrofulous character, was still very analogous to it, and might end 
in phthisis. You should not be so sanguine as to anticipate a cer- 
tain cure, because the cough and laryngeal symptoms are unac- 
companied by fever, or by stethoscopic phenomena indicating the 
approach of phthisis. The disease, by fixing itself in the larynx, 
and keeping up a constant irritation in the neighbourhood of the 
lungs, would probably, after some time, (if exacerbated by fresh 
colds, and confirmed by neglect,) give rise to tubercular develop- 
ment. 
Allow me to allude here briefly to a form of chronic laryngeal 
inflammation which has been described under the name of phthisis 
laryngea. Of this disease there are two varieties. In one case 
the hoarseness and sore throat follow the development of tubercles 
in the lung ; in the other, they precede it. Consumptive persons 
very frequently get, shortly after the occurrence of scrofulous 
inflammation of the lungs, sore throat, hoarseness, and laryngeal 
cough. But this is different from the hoarseness and cough which 
precede phthisis. In the former, the laryngeal symptoms are 
secondary, and form only a part of the general disease; in the 
latter, they constitute the first link in the chain of morbid action. 
The former take place only in a constitution decidedly scrofulous; 
the latter occur most commonly in constitutions which have been 
impaired by various debilitating causes, and thereby rendered 
analogous to, or identical with, the scrofulous. One disease, how- 
ever, explains the other, for it is clear that if a certain state of the 
constitution is capable of occasioning scrofulous inflammation of 
the lungs and tubercular development in the pulmonary tissue, in 
the first instance, and laryngeal disease in the second, it is clear, I 
say, that the order of succession may be very easily inverted, and 
that, in such a constitution, the accidental circumstance of a cold 
falling on the larynx may determine the appearance of disease in 
that part long before the lungs become engaged. Hence, whenever 
you are called on to treat a case of chronic laryngitis, where the 
disease has lasted for any length of time, and where the patient’s 
system has been impaired by any debilitating cause, or where you 
have any reason to suspect that he is of a strumous diathesis, your 
prognosis should be always guarded. 
You should not, however, give up the case at once, particularly 
if an examination of the chest assures you that there is no scrofu- 
lous deposition going on in the lung. In the first place, endeavour 
to remove the inflammation of the throat, if possible; by doing this, 
you will accomplish a vast deal; and in the next you should direct 
all your efforts towards improving the state of the constitution, for 
in this way you make the greatest progress in checking the ten- 
dency of the individual to scrofula. If there be much tenderness 
of the larynx on pressure, as you can easily ascertain by placing 
your finger and thumb on each side of the thyroid cartilage, press- 
ing the larynx backwards, and moving it from side to side, you CHRONIC LARYNGITIS. 
227 
should commence with the local detraction of blood. A small 
number of leeches should be applied to the throat every second or 
third night, and this should be continued for a week or a fortnight. 
If there be no tenderness of any amount, and the patient can bear 
pressure freely, there is no necessity of applying leeches. Your 
means must then be confined to those remedies which act imme- 
diately on the diseased mucous surface, and for this purpose, one 
of the best applications is a solution of nitrate of silver, ten grains 
to the ounce, or a solution of the sulphate of copper, in the same 
proportions. The best mode of applying it is to take a probang, 
or a small piece of sponge, fastened to the end of a quill, dip it in 
the solution, and having slightly squeezed it to prevent the fluid 
from dropping, touch the excoriated and red parts of the fauces as 
far as you can conveniently go, rather by pressing the sponge 
gently against the inflamed mucous membrane than by rubbing. 
It will be essentially necessary to touch every portion of the dis- 
eased surface of the pharynx, for if any part be omitted, it will 
have the effect of keeping up the disease. You perceive the object 
here is to change the action of the mucous membrane. By acting 
powerfully in this way on the mucous membrane covering the 
pharynx, fauces, and entrance of the larynx, you will often succeed 
in bringing on a healthy action, which spreads to the parts in the 
vicinity. Of this we have an illustration, afforded by the results 
of treatment in chronic diseases of the skin, where local applica- 
tions to a particular part not only cure that part, but also extend 
their influence to a considerable distance on every side. It is the 
same with respect to irritation or inflammation of the lower part of 
the digestive tube ; the use of astringent injections, which can only 
affect the lower part of the rectum, is often found of essential ser- 
vice in relieving dysenteric affections of the colon. 
In addition to the use of the nitrate of silver, we have employed 
a remedy in this boy’s case which has been found beneficial in 
several instances where no sign of pulmonary irritation is present 
—I allude to the use of iodine inhalations. This was also intended 
to make a still further change in the condition of the diseased 
mucous membrane. It is made by putting from five to ten drops 
of the tincture of iodine with half a dram of tincture of conium, 
and four ounces of hot water, into an inhaler, and making the patient 
draw the vapour into his throat for about ten minutes, every night 
and morning. This form of inhalation proved extremely service- 
able in the case of a gentleman who has attended my lectures this 
winter. About the commencement of November, while in a deli- 
cate state of health, he was attacked with cold, and got sore throat, 
followed by slight huskiness of voice, and hard, incessant, laryngeal 
cough. These symptoms continued during December and the 
greater part of January, and were not completely removed until 
the beginning of February. He had considerable rawness of the 
back and sides of the fauces and larynx; we observed that the 
mucous membrane of those parts had a strong tendency to become 
excoriated, for whenever an exacerbation of his symptoms occurred, 228 
graves’s clinical lectures. 
and that his cough in the morning was harder than usual, small 
portions of the detached pellicles of lymph, exuded by the mucous 
membrane, came away at each fit of coughing, and his sputa were 
tinged with blood. There was another symptom in this case, 
which you will very frequently meet with in similar instances, 
namely, a remarkable feeling of chilliness in the integuments of 
the fore part of the neck and external fauces. This he was in the 
habit of remarking, and could always foretell the occurrence of an 
exacerbation of his laryngeal symptoms, by the increased feeling 
of cold in the cutaneous surface over the diseased parts. In this 
case, a great deal of good was effected by the inhalation of iodine 
with conium. The mode in which this gentleman employed it, 
was by dissolving from six to nine grains of the extract of conium 
in hot water, and then adding the tincture of iodine. Instead of 
the common inhaler, which contains but a small quantity of fluid, 
and in which the inhalation becomes cold in a very short time, he 
employed for the purpose a high old fashioned teapot, which con- 
tained a large quantity of fluid, and could be used for a much 
longer period. Under the use of this, with counter irritation, and 
the internal use of iodine with sarsaparilla, the laryngitis disap- 
peared ; it returned, however, about a month afterwards on fresh 
exposure, but was speedily removed by the use of the nitrate of 
silver solution. 
Another thing which we have prescribed for this boy, and which 
proves an excellent adjuvant in the treatment of such cases, is 
counter irritation by croton oil frictions. To an ounce of com- 
pound camphor liniment, add twenty or thirty drops of croton 
oil; and of this lotion about one or two drams are to be rubbed 
over the parts, night and morning, until the eruption appears. Two 
rubbings are generally sufficient to produce a copious eruption of 
papulae about the size of a pin’s head, and having exactly the ap- 
pearance of a disease at present very rare—the eczema mercuriale. 
We have not, however, been able to effect any remarkable 
improvement in this boy’s symptoms, by the means to which I 
have just now alluded; and the question is, what other remedies 
have we left, from which we could hope to derive any advantage? 
The boy has no fever or emaciation, his appetite is good, his sleep 
regular, and the stethoscope informs us that there are no symptoms 
of tubercular development; we are therefore, I think, authorised in 
attempting to arrest the disease by the only means of which we 
have a choice under such circumstances. It is my intention to 
attempt its removal by mercury, and I have therefore ordered him 
to take, three times a day, half a grain of calomel, three grains of 
blue pill, with a grain of the extract of conium; and, instead of 
iodine, we have directed him to inhale the vapour of hydrargyrum 
cum creta twice or three times daily. If, however, we find that 
this does not produce speedy improvement of his symptoms, we 
shall stop it immediately, as the use of mercury in such cases is 
generally a perilous experiment. I shall also take care to pay 
attention to the general state of his health, as this is a matter of PRURIGO. 
229 
great importance in cases of chronic disease. I had almost for- 
gotten to observe, that in such cases the use of the decoction of 
sarsaparilla with nitric acid has been found extremely beneficial. 
There is one point in the treatment of chronic laryngitis which you 
should never forget—and that is, to make the patients refrain as 
much as possible from speaking. Unless they do this, you will find 
it very difficult to effect a cure. A person with an inflamed larynx, 
who exercises his voice as usual, acts as foolishly as a man who 
reads with inflamed eyes, or walks with a sprained ankle. The 
only thing I have to add with respect to the treatment of this dis- 
ease is, that the patient should be kept as much as possible in an 
equal temperature, and hence it will be necessary, in many in- 
stances, to confine him to the house, or at least to prevent him from 
exposing himself to a cold and damp atmosphere. When he reco- 
vers, he should use cold gargles and cold lotion to the throat, in 
order to render the parts less susceptible of cold. 
Allow me now to direct your attention to two cases of prurigo 
which have been recently admitted. The first is that of Jane Cas- 
sady, a woman advanced in life, but of tolerably good constitution, 
considering her age, station, and circumstances. About three months 
before admission, a rash appeared over her arms, legs, and body, 
which was preceded and accompanied by pain of the stomach, head, 
and limbs, with recurring rigors. As far as we can learn from her 
description, this appears to have been urticaria; of this, however, 
we cannot by any means be certain ; and besides, it is of little con- 
sequence, as prurigo may come on without it. She is at present 
labouring under prurigo senilis, not thickly disseminated, but still 
a source of constant annoyance to her from the intolerable itching 
it produces. Several of the papulae have formed dark red crusts, 
but this is in consequence of their bleeding from being scratched. 
This affection has been so well described by writers on cutaneous 
diseases, and is so easily recognised, that I shall not take up your 
time in detailing its characters; a few circumstances connected 
with treatment, however, should be mentioned as deserving your 
notice. In the first place, I may observe that prurigo is a most 
harassing complaint, and, if not checked, has a tendency to under- 
mine the constitution by disturbing the patient’s rest. The warmth 
of the bed-clothes, by increasing the vascularity of the skin, occa- 
sions an aggravation of the symptoms; the patient passes a mise- 
rable and restless night, and rises in the morning quite unrefreshed. 
This, in process of time, gives rise to a kind of febrile condition of 
the system; the mouth and fauces become dry; the appetite is 
impaired; the secretions deranged, and debility and emaciation 
gradually produced. It is a disease which has broken many a 
constitution, which, previous to its accession, was to all appearance 
unimpaired and healthy. 
Prurigo has been confounded with common itch, but if you exa- 
mine the parts it occupies you will easily distinguish them. It is 
most likely to be confounded with the small vesicular itch, where 
the vesicular papulae (this is the most expressive term I can think 230 
graves’s clinical lectures. 
of) are extremely minute. There is a papular itch, and there is 
also one which is intermediate between the vesicular and the papu- 
lar; it is with the latter that prurigo is most apt to be confounded. 
The difference between them, however, may be recognised by 
observing the parts of the body on which they appear. Itch gene- 
rally attacks the extremities, and particularly the inside of the joints, 
and the spaces between the fingers. Prurigo, however, does not 
occupy the same situations. If you examine this woman, you will 
not be able to find any trace of the eruption about the joints or 
between the fingers—and this circumstance is of itself sufficient to 
make the distinction, for itch would not have lasted for three 
months without attacking these parts. I may also observe, that 
prurigo senilis is generally accompanied by derangement of some 
of the important secretions of the body, but particularly of the 
urine. Its appearance is in many instances preceded by a scanty 
flow of urine, and it is frequently accompanied by the deposition of 
a copious whitish sediment, which is the lithate of ammonia. This 
observation is worthy of attention, because it furnishes us with a 
hint towards the treatment, of which we may sometimes avail our- 
selves with great benefit to the patient. You will, in such cases, 
often effect a great deal by the use of diuretic medicines—as cream 
of tartar with decoction of juniper berries and squill; or with the 
more stimulant diuretics—as turpentine and cantharides. It will 
be also good to vary these remedies according to the circumstances 
of the case, and they should be always given in combination with 
medicines calculated to act beneficially on the digestive organs. In 
this case, we have given decoction of sarsaparilla with nitric acid 
for the last two days; before this we gave cream of tartar with 
powdered bark. These are some of the best medicines which can 
be used internally in the treatment of prurigo senilis. It is, how- 
ever, a very obstinate disease, and you will be often obliged to try 
many internal and external remedies before you can hit on one that 
will prove serviceable. Cooling diuretic aperients, aperients com- 
bined with tonics, and the decoction of sarsaparilla with nitric acid, 
—these are the chief infernal remedies ; as to external ones, they 
are extremely numerous. In the present case we have, in the first 
place, directed the patient’s body to be washed with a lather of soap 
and warm water every night and morning. The water for this 
purpose should be used as hot as the patient can bear it, and a very 
soft brush or sponge should be employed. In prurigo, a vast deal 
of good has been done by merely washing the itchy parts with soap 
and warm water; how it acts I cannot say, but I have seen a great 
deal of advantage derived from a long-continued perseverance in 
its use. After this you may have recourse to more powerful appli- 
cations—such, for instance, as sponging the parts at bed-time with 
hot whiskey and laudanum, a pint of the former to a dram of the 
latter. Here you have the stimulant effect of the whiskey, the 
narcotic of the laudanum, and the peculiar action of heat on the 
skin, all combined, and calculated therefore to make a very decided 
impression. How this effect of heat is produced I cannot tell, but PRURIGO. 
231 
we all know that, whether applied in a moist or dry form, it exer- 
cises a powerful influence over the vascularity and nervous vitality 
of the skin. Neither can I tell you what description of cases are 
most likely to benefit by it: some cases of prurigo senilis are much 
relieved by warm applications, others are not; you should, how- 
ever, always make a trial. 
There was one application used in this woman’s case, to which 
I shall briefly call your attention. A dram of acetate of lead was 
dissolved in two ounces of wine vinegar mixed with the same 
quantity of water, and this was rubbed up with olive oil so as to 
form a liniment. Mr. Nalty, who mixed up the ingredients, says 
that three ounces of olive oil were absorbed. You are aware that 
oil conducts itself, with respect to the metallic oxides, as it does 
with the alkalies. This formed a liniment, which, when allowed 
to stand, separates; but its ingredients are at once mixable by 
shaking the bottle. From its use the woman has derived great 
relief, and lean recommend it to you as one of the best applications 
in prurigo. 
Before I conclude this lecture, I shall allude briefly to the very 
interesting case of Sarah O’Neil. This young woman was ad- 
mitted on the 17th of February, having been attacked, on the 10th, 
with fever of the ordinary type. On the day after her admission, 
she complained of want of sleep, and pain of the forehead and 
temples; but she had no raving, tinnitus aurium, intolerance of 
light, or other symptoms of inflammation of the brain. She had 
been confined about a fortnight before she came in, and complained 
that her breasts were very troublesome to her. Her belly was soft 
and fallen, quite free from tenderness or soreness, and she stated 
that her bowels were free. Her tongue was furred, her pulse 130, 
the lochia suppressed for the last two days. Things went on tole- 
rably well for four or five days, when her belly became tympanitic, 
and she began to complain of pain on pressure. The action of the 
heart now became more violent; her pulse rose to 140, and blood 
began to appear in her stools. On the 24th of February—that is 
to say, about the fourteenth day of her illness—her pulse was 150; 
she passed a large quantity of blood from the bowels, and the tym- 
panitis subsided. 
In cases of fever accompanied by tympanitis and signs of intes- 
tinal congestion, hemorrhage from the bowels, particularly when it 
occurs on one of the critical days, should not be interfered with. 
It is in this way that nature very frequently brings about relief of 
the congestion and irritation of the. gastro-intestinal mucous mem- 
brane, just as she relieves congestion of the head by bleeding from 
the nose. In the case of a lady whom I attended along with Mr. 
Palmer, some time ago, at Drumcondra, the occurrence of intestinal 
hemorrhage was followed by the most marked effects; her belly 
became soft, the tympanitis disappeared, and all her febrile symp- 
toms were speedily removed. The appearance of blood, therefore, 
at such periods and under such circumstances, is to be looked on 
as a favourable occurrence; nor should it be interfered with in any 232 
graves’s clinical lectures. 
way until, from its continuance or its quantity, it appears likely to 
produce debilitating1 effects. In the present case, however, this 
hemorrhage will require to be very carefully watched. The 
woman’s system is in that state which is favourable to profuse 
fluxes of blood, for it is not long since her accouchement, and she 
has had suppression of the lochia. She has had but little fever for 
the last two or three days, but the action of the heart still continues 
extremely violent, and her pulse is still rising. Respiration, too, 
has been considerably accelerated ; and, where this occurs, you 
have always reason to apprehend danger. I have accordingly en- 
deavoured to moderate the hemorrhage by the use of acetate of 
lead and opium. A draught composed of two grains of acetate of 
lead, eight minims of tincture of opium, and fifteen minims of wine 
vinegar in six drams of water, has been prescribed to be taken as 
occasion requires. A large blister has been applied, so as to cover 
the epigastrium and sternum, and she has been allowed port wine 
and chicken broth. Where a patient, debilitated by previous fever, 
has been attacked with hemorrhage, you should be careful in sup- 
porting the system by small quantities of wine, and light nutritious 
food ; for there is always more or less danger to be apprehended of 
a sinking of the powers of life. In cases of this kind the cautious 
use of acetate of lead, with opium and wine, are the only means on 
which we can rely with any confidence. 
I regret that time will not permit me to make any further observ- 
ations on this very interesting case; I shall, however, resume its 
consideration at our next meeting. 
END OF THE FIRST SERIES. CLINICAL LECTURES. 
SECOND SERIES. 1836-r. 
LECTURE 1. 
Introduction—Connection between diseases of different organs ; between arthritis, jaun- 
dice, and urticaria; between periostitis, produced by abuse of mercury, and hyper- 
trophy of the liver—Details of cases illustrating this connection—Its explanation— 
Hypertrophy of the liver produced by scrofula—Enlargement and inflammation of the 
liver after scarlatina—Importance of recognising this disease. 
Although it is customary to state, at the commencement of a 
course of clinical lectures, the mode of instruction the teacher 
intends to pursue, it is not my intention to dwell on the plan of 
communicating medical information adopted in this hospital, or the 
facilities, advantages, and inducements which it affords. I have 
spoken so often on the subject, and my opinions have been so long 
before the public, that I do not feel it necessary to enter into details 
on the present occasion. It is extremely satisfactory to me to find 
that the mode of clinical instruction which I introduced at this 
hospital in 1822, has been adopted in most of the Dublin hospitals, 
and in many of the medical institutions of Great Britain. It is now 
several years since I delivered an introductory lecture at the old 
Meath Hospital on the Coombe, setting forth the insufficiency of 
the clinical instruction imparted to the students in Dublin at that 
period, and proved, to the satisfaction of my auditors, that the 
German mode was infinitely superior. The lecture I then de- 
livered was subsequently published in the London Medical Gazette.1 
This mode I soon afterwards introduced at this hospital, and it is a 
source of extreme gratification to me to find it adopted and ap- 
proved of by so many medical teachers of established reputation. 
It is recommended at once by its simplicity, and by its admirable 
fitness for fulfilling the purposes which it is intended to accomplish. 
A card is suspended over each patient’s bed, on which is recorded 
the date of his admission, the history of his case, and the daily 
1 See Medical Gazette, vol. x. p. 401. 234 
graves’s clinical lectures. 
treatment, dietetic as well as medical. These cards remain in the 
wards until the patient leaves the hospital, and in this way any 
gentleman who wishes to observe the progress and termination of 
any particular case, can easily make himself master of its principal 
features, and the different remedial agents employed for its allevia- 
tion or removal. I shall not dwell any longer on this subject, as 
my object at present is to excite you to a diligent cultivation of the 
many and valuable opportunities which this institution affords. Qo 
round the wards, and observe the numerous and varied forms of 
disease they present. You will find in them many examples of 
morbid affections, interesting alike to the student and the practi- 
tioner, and capable of affording practical lessons of inestimable 
value. He must be sadly deficient in zeal, attention, and every 
other quality necessary to constitute the accomplished and success- 
ful physician, who does not feel himself excited to study by what 
is there presented to his observation. 
Did time permit, I should be glad to furnish you with an outline 
of the most interesting cases which have been under treatment in 
our wards for the last three months, in order to give you some idea 
of the prevailing forms of disease, and their most remarkable mo- 
difications ; and in this way to prepare you for studying with more 
advantage the cases that may come under your notice during the 
ensuing session. We have had some cases of extreme interest 
during the months of August, September, and October ; but I fear 
even a brief review of these would occupy more time than I could 
conveniently devote to the subject, and would interfere with mat- 
ters of paramount importance. I have, however, kept records of 
these cases, and shall feel most happy to show them to any gentle- 
man who may be anxious to peruse them. Before I proceed to 
make any observations on the cases at present in our wards, I 
shall give a statement of the most remarkable results obtained in 
the chronic wards, and the most important pathological observa- 
tions made in the fever wards during the last three months. This 
will occupy but two or three lectures, and in the interim 1 shall 
each day direct your attention to any thing of importance which 
occurs in the wards. It is my intention at present to limit myself 
to the illustration of some points connected with pathology, and to 
dwell merely on those prominent features of disease which bear a 
special reference to practical medicine ; I shall afterwards give some 
lectures on fever. I shall not enter into any disquisition as to the 
origin and cause of fever; for these matters you must consult your 
books : all you can expect from me is to endeavour to impart to 
you some useful hints on the treatment of fever. 
In order to acquire a correct and available knowledge of human 
pathology, and to extend the range and confirm the accuracy of 
diagnosis, it is of the utmost importance to observe attentively the 
connection between the diseases of certain organs or systems of the 
body. You are aware that some organs, when labouring under 
disease, are apt, after the disease has continued some time, to im- 
plicate other organs, giving rise to various deranged conditions, DISEASES OF DIFFERENT ORGANS. 
235 
Which are developed, sometimes simultaneously, but in general con- 
secutively, and in sequence. I have already pointed out several 
diseased actions thus associated together, each forming a link in 
the morbid chain. Now it is of the greatest importance to study 
each link, and ascertain the nature of its connection, so as to have 
a distinct conception of the whole; Last session I directed the 
attention of my class to a train of morbid phenomena sometimes 
observed co-existing with arthritic inflammation. A person labour- 
ing under inflammation of the joints gets an attack of hepatitis, 
accompanied by jaundice, and this is followed by urticaria. I have 
observed this sequence of disease in eight or nine cases. The first 
was in a gentleman residing in Lower Mount street, whom I at- 
tended with Dr. Cheyne. This gentleman, in consequence of 
exposure to cold, was attacked with arthritic inflammation and 
fever. After he had been about ten days illj he became suddenly 
jaundiced, and in a day or two afterwards a copious eruption of 
urticaria appeared over his body and limbs. Exactly the same 
train of phenomena, and in a similar order of succession, were 
observed in a man treated in the Meath hospital in 1832. A short 
time before this I had been attending a medical friend in Baggot 
street, who had been affected in the same way ; and I mentioned to 
the class, as soon as I perceived the man was jaundiced, that he 
would most probably get urticaria. I made a similar prediction in 
a case which occurred recently in our wards, and it was verified 
by the event. Now this is not a mere fortuitous occurrence ; the 
various symptoms must be connected in the relation of cause and 
effect. It is interesting to bear this in mind, and it is besides of 
considerable importance to the practising physician ; it enables him 
to predict the appearance and form of disease, and inspires his 
patient with confidence in his opinions and judgment. 
There is another sequence of disease not unfrequently observed, 
but of which the connection has not been hitherto noticed by any 
Writer, as far as I can ascertain; About two years since, Mr. 
Crampton and I were consulted by an English gentleman, who 
had been ill for a considerable time. The history of his case from 
the commencement was this :—Three years previously he had 
venereal—used and abused mercury—was exposed to cold, and got 
periostitis. He now got into a bad state of health, used mercury 
a second obtained some relief, and then relapsed again ; 
finally, after having used mercury three or four times, he was at- 
tacked with mercurial cachexy, became weak and emaciated ; the 
periostitis degenerated into ostitis, producing superficial caries and 
nodes of a bad character; he had exfoliation of the bones of the 
cranium, and rupia, and was reduced to a most miserable state; 
Under our care the symptoms gradually disappeared ; he recovered 
to all appearance, and even got fat. He then caught cold, and 
relapsed again. At last his liver became engaged ; he was attacked 
with hypertrophy of the liver, ascites, and jaundice, and died soon 
afterwards. Here, then, we have venereal, abuse of mercury, 
periostitic inflammation, abuse of mercury followed by exacerbation 236 
graves’s clinical lectures. 
of the periostitis, and the establishment of mercurial cachexy, and 
the history of the case is wound up with hypertrophy of the liver. 
This was the first case in which I had observed this concatenation 
of diseases; since that period I have seen a similar train of morbid 
phenomena, twice in private practice and once in hospital. First 
we have abuse of mercury, then periostitic inflammation and mercu- 
rial cachexy, and the scene is closed by morbid enlargement of the 
liver. Now I do not look upon this sequence as merely fortuitous. 
The diseased actions are, I think, related as cause and effect, and 
each successive condition is consequent on the previous one. It 
may not be amiss to mention here some curious circumstances 
observed in the case to which I have just alluded. While this 
gentleman’s liver was enlarging, there was no tenderness of the 
right hypochondrium on pressure. I have observed the same 
absence of tenderness in all the cases of this description which I 
have witnessed. The gentleman could bear pressure over the 
hepatic region without any inconvenience, and yet the liver was so 
enormously increased in size, that its inferior margin extended almost 
down to the pelvis. What is equally remarkable, he had no fever, 
and the tongue was perfectly clean and moist during the whole 
course of the hepatic affection. In my observations on a case in 
the fever ward, I remarked a few days since that some persons 
were too hasty in drawing inferences from the state of the tongue 
as to the existence of affections of the digestive organs. I shall not 
touch on this point, however, at present, and shall merely observe 
that this gentleman’s tongue was perfectly clean and moist, notwith- 
standing the morbid condition and rapid growth of the liver. 
Another curious circumstance was, that during the hepatic affec- 
tion, digestion appeared to go on very well, at least so far as the 
formation and due expulsion of faeces are concerned. The alvine 
evacuations were regular, and the matter discharged presented the 
form and consistence of that which is passed by a person in good 
health. But there was a peculiarity in it to which my attention 
was first directed by the patient, who was an intelligent and ob- 
servant person. The cylinder of faecal matter was composed of 
parts differing in colour and appearance: two or three inches con- 
sisted of pale clay coloured substance ; and immediately after this 
another portion of about the same length was observed, presenting 
the ordinary bilious or brown colour of natural excrement; and 
then again another mass of clay-coloured matter, without any ob- 
vious trace of bile. This appearance I have now frequently wit- 
nessed ; and the inference to be drawn from it is this—that in such 
forms of hepatic disease the functions of the liver are performed, as 
it were, intermittently; it secretes bile during a certain period of 
the digestive process, then stops, and then secretes again. 
This peculiarity is noticed in many diseases of the liver ; and it 
is important to remark, in attempting to explain the rationale of 
these hepatic affections, that in no disease of the liver is this symp- 
tom more frequently observed than in the scrofulous. Scrofulous 
disease of the liver is that state in which there is an increase of 237 
size in the organ, with induration and imperfect secretion, but with- 
out any remarkable tenderness. This condition in children is 
accompanied with irritability of the digestive organs, fretfulness, 
emaciation, loss of sleep, and impaired nutrition. The little patient 
becomes what is termed “pot-bellied,” and labours under thirst, 
debility, and febrile excitement. This has been frequently called 
remittent fever, and disease of the mesenteric glands, but in my 
opinion unjustly. It is only a form of general cachexy connected 
with the scrofulous diathesis, affecting secretion and nutrition in 
general, and the digestive and biliary systems in particular. It 
would be quite wrong to imagine that, in this form of disease, the 
liver is the cause of the whole train of morbid phenomena; it is 
merely affected in common with other organs, and forms only an 
individual feature in the group of symptoms. 
Now in this form of scrofulous cachexy, where you have diar- 
rhcea, emaciation, fever, thirst, and restlessness, the liver is fre- 
quently affected in the manner already described ; and in the loose 
stools of such a child you will find one part bilious, another part 
clay-coloured ; they will be yellow to-day, and pale the next, ac- 
cordingly as the liver secretes bile or suspends its functions. But 
in this instance, I repeat that the liver is only one of many organs 
affected by the same general cachexy. Could we ascertain the 
derangements of other secreting organs with the same facility, it is 
very probable we should find similar evidences of the morbid 
influence which pervades the whole system. 
This view of the question shows that you are not to expect to 
succeed in removing the disease by the use of calomel or any other 
mercurial preparation. Many of those persons whose practice is 
little better than routine, when called to treat a case of this descrip- 
tion, first examine or enquire as to the nature of the alvine evacua- 
tions, and fixing on the single symptom of deficiency of bile, imme- 
diately prescribe calomel, to be repeated or continued until the 
secretion of the liver is established ; but they forget that this state 
of the biliary system depends on the general state of health, and 
that the absence of bile is the consequence, and not the cause of the 
disease. Almost all the organs of the body are affected ; and though 
calomel may restore the secretion of the liver for a time, it cannot 
bring back the organ to its natural state, or cure the disease. The 
malady is to be remedied in a different way: the secretions (and 
that of the liver among the rest) are to be improved by change of 
air, by an appropriate diet, by exercise, tepid or cold bathing, and 
the use of those remedies which are adapted to modify or correct 
that state of the system on which the general derangement depends. 
An observation of such cases has led me. to a train of reflection 
respecting the occurrence of the same order of symptoms in per- 
sons who have been injured by the abuse of mercury. Many 
persons who get venereal employ mercury injudiciously, and fall 
into what has been termed the mercurial cachexy, in which there 
is a general unhealthy state of the organs. A patient who has 
fallen into this state very closely resembles a scrofulous person, and 
HYPERTROPHY OP THE LIVER. 238 
GRAVEs’s CLINICAL, LECTURES. 
is apt to labour under the same emaciation, impaired nutrition, irri- 
tability, feverishness, and the same sort of cutaneous, glandular, and 
periostitic affections. The chronic mercurial cachexy is very like 
the scrofulous, and attacks very nearly the same organs and tissues. 
Hence the difficulty of curing affections of the liver and other 
organs, when they are the result of this depraved habit. This is 
the key to the explanation of those horrible ravages which we fre- 
quently witness in cases of venereal disease complicated with mer- 
curial cachexy—a state of constitution which is closely allied to 
the scrofulous. You will frequently meet with this consecutive 
affection of the liver in cases of morbus coxae, where the patient 
has been labouring for years under ulceration of the joint. The 
growth of the rest of the body appears checked, the patient is 
stunted and emaciated, while the liver increases rapidly in size. It 
was from observing the occurrence of liver disease in persons 
labouring under the scrofulous cachexy, that my attention was 
first turned to its occurrence in persons broken down by long or 
injudicious courses of mercury. 
One word as to the curability of hepatic affections of this kind. I 
believe that it is always an unpromising form of disease ; but per- 
sons of originally good constitutions, and under the age of thirty, 
will generally escape, if treated judiciously, and with proper care 
and attention. Some months ago I attended, with Dr. Marsh, a 
young gentleman labouring under this affection, as a consequence 
of the abuse of mercury. We found him greatly emaciated, and 
labouring under considerable enlargement of the liver, with com- 
mencing ascites. He had also great determination of blood to the 
abdomen, diarrhoea, and hemorrhoids. By strict attention to his 
bowels, a well regulated diet, change of air, and the use of taraxa- 
cum, coniurn, and hydriodate of potash, he was ultimately cured, 
after an illness of nearly two years, during which the liver had 
grown to an enormous size. I may state that he is at present in 
good health, and that the liver is nearly reduced to its natural 
dimensions. It may be proper to add, that this gentleman’s age is 
about four and twenty. 
I observed one circumstance in the progress of this case which is 
worth noting. He was suddenly attacked with a papular form of 
purpura, accompanied by much tingling and itchiness, and answer- 
ing to the description given of purpura urticans. This peculiar 
eruption was very troublesome at night, and formed several suc- 
cessful crops, which altogether lasted a month. It occupied the 
extremities, upper and lower, and was very abundant on the latter. 
This gentleman wore a bandage to relieve a varicose state of the 
veins of the left leg. Now the eruption never appeared in the 
parts subjected to the pressure of the bandage, although it was very 
thick immediately below and above those parts. 
In persons below thirty the liver may become enlarged to a very 
considerable extent, and yet return again to its natural size under 
proper treatment. I could point out several persons in Dublin in 
whom the liver had been so much enlarged that I thought their ENLARGEMENT OP THE LIVER. 
239 
cases hopeless, and yet they have recovered, and are at present in 
the enjoyment of good health. The process by which the organ 
returns to its natural state and dimensions is generally slow; in 
two or three cases it occupied a space of time varying from one to 
two years. I attended a gentleman some time ago with Mr. Carmi- 
chael ; and from the history of the case, as well as the symptoms 
present, we were induced to look upon it as incurable; and yet the 
patient has completely recovered. Mr. Macnamara and I attended 
a lady who had a very remarkable enlargement of the liver, but in 
the course of a year the viscus diminished so much in size, as to 
be very little above the normal dimensions. This is a matter of no 
common interest, for cases of this description have been generally 
looked upon as beyond the reach of medical aid. You should 
therefore be very careful in your prognosis of such cases, and not 
give them up at once as incurable. 
I may observe, in conclusion, that it is entirely as the result of 
the cachectic habit that this enlargement of the liver is observed. I 
have assumed this principle as the basis of my argument, and I 
think it is founded in fact and truth. It is also curious to observe, 
that the same cachectic state which gives rise to emaciation and de- 
cay of the body, generally occasions hypertrophy of some particular 
organs. What we most commonly observe in such conditions is, 
general wasting of the system, accompanied by increased morbid 
nutrition in certain organs. This appears to be the general law. 
You perceive that in the explanation I have given, I have supposed 
that enlarged liver is the result of a general cachectic state of the 
system, and it is of importance to recollect that this state may be 
brought on by the injudicious exhibition of mercury, or by carrying 
mercurialisation further than the constitution will bear. In this 
instance we are compelled to allow that our practice may furnish 
weapons to be turned against us by the disciples of homoeopathy. 
It cannot however be denied, that the immoderate use of mercury 
has been productive of liver disease. The late Mr. Hewson pointed 
out this to the attention of those who visited the Lock Hospital 
while under his care. At this period it was the custom to salivate 
every patient, and keep him under the full mercurial influence for 
a month or two ; and it frequently happened that, just as the mer- 
curial course was finished, the patient got disease and enlargement 
of the liver. Were I inclined to theorise, I might perhaps offer 
some fanciful hypothesis in explanation of this occurrence, and 
might trace some connection between the stimulant effects of mer- 
cury on the liver, and the subsequent hypertrophy. I shall, how- 
ever, content myself at present with noticing the fact, and leave 
the explanation to my juniors, who always explain matters, accord- 
ing to my observation, much more readily than their seniors. 
There are also other diseased states of the system, in which we 
have enlargement and morbid alteration of the liver. I can point 
out to you four different states of the system in which hypertrophy 
and disease of the liver forms one of the results of the general affec- 
tion of the system. The next of those to which I shall direct your 240 
GRAVES’S CLINICAL LECTURES. 
attention is scarlatina. Those who have attended the wards during 
the past month have seen examples of this. We have observed 
during the same week two patients labouring under scarlatina, who 
got disease of the liver and jaundice. One of the patients, a little 
boy, was attacked with the disease in an extremely violent form, 
accompanied with high fever, and a very remarkable eruption. In 
a few hours after the exanthema appeared, the entire cutaneous 
surface was dyed of a brilliant red; in fact, the skin looked as if it 
had been painted over, and there was not a single spot free. In 
cases of this kind the violence of the cutaneous inflammation is 
sufficient to kill, without any other unfavourable complication; and 
the patient seldom lives more thank three or four days. You 
observed in this case that the whole epidermis peeled off. But 
what I wish to direct your attention to is, that this boy after two 
days had evident symptoms of disease and enlargement of the liver. 
A young man, in the same ward, had also an attack of scarlatina, 
but in a milder form. On the third day he likewise got inflamma- 
tion of the liver, but was cured by general and local antiphlogistic 
treatment. You are aware that scarlatina is one of those diseases 
in which a train of unfavourable sequelae are apt to remain after 
the removal of the original complaint. Persons, after recovering 
from the exanthematous fever, will sometimes get into a bad state 
of health, and instead of convalescing, become restless and feverish 
towards evening—have an irritable jerking pulse, hot skin, derange- 
ment of the digestive organs, diminished urinary secretion, and 
finally become dropsical. Now, from observing the supervention 
of hepatic disease in such cases, both in hospital and private prac- 
tice, my attention has been directed to the liver ; and I never omit 
making an examination of that organ when called to treat those 
symptoms which are looked upon as the sequelas of scarlatina. In 
many of these patients I have found the liver in the state of inflam- 
mation of rather a chronic character, and without any of that 
remarkable pain or tenderness which characterises acute hepatitis. 
But still it was inflamed, as proved by the benefit derived from local 
antiphlogistic means; and, moreover, its condition appeared to retard 
and prevent convalescence. Not long since, a friend of mine, a 
very intelligent practitioner, who was attending a case of this de- 
scription, and had tried a variety of remedies without any benefit, 
was very much surprised when I drew down the bed-clothes and 
showed him that the liver was diseased. He had not thought of 
the existence of any thing like an hepatic affection, and was very 
much surprised that his treatment had proved so ineffectual. By 
the use of leeches to the right hypochondrium, the employment of 
mercury, and a proper regulation of diet, the patient was soon re- 
lieved, and the fever, thirst, and anasarca, quickly disappeared. In 
cases of this kind the hepatic affection is the result of the general in- 
flammatory diathesis superinduced by scarlatina. You are all aware 
that nothing is more common, after scarlatina, than inflammation 
of various organs. Thus some persons are attacked with pleuritis, 
some with pneumonia, others with inflammation of the liver. Many CHRONIC HEPATITIS. 
241 
persons continue in a valetudinary state after the eruption has de- 
clined ; they do not convalesce according to our expectations ; the 
pulse remains rather quicker than natural; the bowels are deranged; 
the appetite bad; thirst urgent, and urine scanty. In many of these 
cases you will find that there is a species of chronic hepatitis going 
on, which keeps up the feverishness and retards convalescence. 
This is a point of great importance, to which I am the more anxious 
to draw your attention, because even the latest writers on scarla- 
tina have either entirely omitted, or very insufficiently noticed it. 
LECTURE II. 
Connection between disease of the liver and disease of the heart—Chronic hepatitis, 
from this source, curable in young persons—Enlargement of the spleen connected 
with superficial ulceration of the legs—Erysipelas and gangrene, sometimes of a 
pseudo-inflammatory character—Treatment of this form of disease. 
At my last lecture I endeavoured to point out some remarkable 
connections of diseased action observed in certain morbid states of 
the economy. I shall pursue the subject a little further to-day, as I 
look upon it as extremely important in a practical point of view. 
There is another organ whose morbid affections frequently impli- 
cate the liver: I allude here to the heart. I have already spoken 
of certain cachectic states, in which the liver becomes enlarged and 
hypertrophied as the result of the general derangement of the sys- 
tem. In the present case the hypertrophy and disease of the liver 
originates in a morbid condition of the heart; this is a very frequent 
cause of hepatic derangement. You have an example of it at 
present in the chronic ward, in the case of a poor man labouring 
under bronchitis of long standing, with disease of the heart, dropsy, 
and enlargement of the liver. In cases of this description, it is a 
matter of some difficulty to determine in what organ the morbid 
sequence commences; for where many diseases co-exist, it is not 
easy to ascertain how they are related to each other as cause and 
effect. I have, however, had several opportunities of observing the 
progress of the disease from the commencement, and the manner in 
which the different organs become successively implicated. 
Some time ago there occurred a remarkable example of this form 
of hepatic affection in a relative of mine, aged fourteen, who, in 
consequence of exposure to cold, was attacked with rheumatic in- 
flammation of the joints, of a very intense character. Owing to a 
want of proper care, the disease was allowed to go on unchecked, 
and metastasis to the pericardium took place. I happened to be 
out of town at the time, and he had no advice or assistance for 
nearly twenty-four hours. Pericarditis of a violent character be- 
came developed, and it was only by the most energetic treatment 
that he escaped with his life. He had pericarditis with effusion, 242 
GRAVEs’s CLINICAL LECTURES. 
and all the physical signs and symptoms of carditis. After the 
acute symptoms were removed, the signs of adhesion of the peri- 
cardium, hypertrophy, and partial valvular disease, continued; and 
for a long time the heart’s action was invariably accompanied by a 
loud bruit de sovfflet. These affections were followed by dyspnoea 
and increased action of the heart. But this was not all: he next 
got inflammation of the testicle, and finally chronic hepatitis with 
enlargement. The liver grew to a very considerable size; it con- 
tinued to enlarge for about seven months; and, altogether, he 
laboured under a chronic form of hepatitis for more than a year. 
At last the disease yielded to treatment, and he recovered com- 
pletely. 
This, you will say, was a fortunate termination ; but in young 
persons the powers of nature often act in a very remarkable manner 
in remedying or removing disease, and cures are sometimes effected 
in such patients which it would be quite absurd to expect in per- 
sons advanced in life. After having laboured under a long train 
of diseases, and having continued an invalid for nearly five years, 
this young gentleman at last, owing to his youth and favourable 
constitution, surmounted all his maladies, and is at present as strong 
and healthy as any person I am acquainted with. In this instance 
the chronic hepatitis was the result of the pericarditis, which 
formed the first link in the chain ; and for the space of a year this 
young gentleman continued to labour under an affection of the 
liver—the result of disease commencing in the heart. This is a 
morbid sequence very frequently observed. You have pericarditis, 
accompanied with inflammation of the lining membrane of the 
heart, partial disease of the valves, hypertrophy of the muscular 
substance, and then enlargement and induration of the liver. This 
is a very common complication, and deserves your most particular 
attention. When you see a patient whose appearance indicates 
disease of the heart—who has swelling of the face, dyspnoea, livid- 
ity of the lips, and turgescence of the cutaneous vessels; in fact, 
that peculiar expression of countenance which at once informs the 
practised observer that the patient is labouring under disease of the 
heart—you should not neglect to enquire after the condition of the 
liver, for in such cases it is very frequently in a state of chronic 
disease. I pointed out this circumstance some time since, in the 
case of a late surgeon, Mr. M., and directed the attention of the 
medical gentlemen, engaged in the treatment of the case, to the 
liver, in which no one had suspected the existence of disease. 
Recollect, therefore, that in many cases of disease of the heart you 
will also, on examination, find disease of the liver, produced, as 
far as I can judge, in the majority of instances, by disease of the 
heart; at least, I think I have never seen any case in which the 
hepatic affection had the initiative, and seemed to have brought on 
the organic affection of the heart. In Mr. M.’s case, and several 
others which I had an opportunity of watching from the com- 
mencement, I have no doubt that the disease of the liver was 
secondary, and that the morbid sequence commenced with the 243 
CHRONIC HEPATITIS. 
heart. I am quite convinced that disease of the liver may give 
rise to functional derangement of the heart; for whatever impairs 
secretion and deranges digestion will give rise to palpitations, ten- 
dency to syncope, and other phenomena of functional disease of 
the heart; but I have never seen any example of organic disease 
of the heart as the result of disease of the liver. 
It is of some importance to be aware of this complication; for, 
in treating the disease of the heart, you must also attend to the 
hepatic affection, because it has a tendency to aggravate and con- 
firm the cardiac symptoms. This affection, however, is not to 
be looked upon as acute, or even sub-acute, hepatitis. There is 
scarcely any pain of the side or tenderness present, and the patient 
is not always jaundiced; it appears to be scarcely any thing more 
than congestion, causing hypertrophy and chronic morbid growth. 
I shall not, however, speak too positively on the subject, as the 
difference between hypertrophy and inflammation of a low and 
obscure character cannot be easily determined.1 
There is another disease in which derangement of the liver is a 
common symptom, and I bring it forward chiefly for the purpose of 
rendering the subject under discussion more complete, as it is an 
occurrence well known to practitioners, and sufficiently dwelt on in 
medical books. I allude to that affection of the liver which is ob- 
served in cases of intermittent fever. Ague frequently produces a 
powerful determination to the internal organs, particularly the liver 
and spleen; and if treated badly, or unsuccessfully, is apt to bring 
on disease of the liver. The organ becomes congested, hyper- 
trophied, and indurated, and presents a condition somewhat analo- 
gous to that which supervenes on disease of the heart, or results 
from the cachectic state of constitution produced by mercury or 
scrofula. 
The next form of organic derangement which I shall briefly 
touch on is that of the spleen. It is of advantage to place cognate 
affections beside each other, for the purpose of comparison ; by 
doing so, we frequently derive many instructive and useful analo- 
gies. Besides, we have had a remarkable case of enlargement of 
the spleen in our wards at the same time we had the cases of hepatic 
disease to which I have alluded. I may observe, that the circum- 
stances under which enlargement of the spleen takes place differ, 
in many points, from those which determine hypertrophy of the 
liver. We have but few examples of inflammation of the spleen, 
while the cases in which enlargement and congestion of that organ 
take place are numerous. From the peculiarities of its anatomical 
structure, the spleen is very apt to become suddenly enlarged. Like 
1 I am glad to find that this subject has been taken up by so able an 
observer as Dr. Bright, who, in the third number of Guy’s Hospital Reports, 
p. 605, has made some excellent remarks on the influence of heart disease 
in producing congestion of the liver. In Dr. Elliotson’s Human Physiology, 
Part I, p. 103, there are some observations which throw much light on the 
intimate relation existing between the circulation within the chest and the 
liver. 244 
GRAVES’S CLINICAL LECTURES. 
the liver, it may become indurated and hypertrophied from inter- 
mittent, or from some general disease affecting the system, and thus 
lead to a train of secondary phenomena—the most remarkable of 
which is dropsy. But there is one peculiar symptom attending 
enlargement of the spleen, which I have frequently pointed out to 
the attention of the class, as observed at least in two thirds of the 
cases, and of which we had an excellent specimen in the patient 
under treatment in the chronic ward. The history of this symptom 
is the more curious, as showing a remarkable uniformity in the 
phenomena of a particular disease at very distant periods of time. 
This is seen by comparing the most recent descriptions of Indian 
splenitis, as given in an able analysis of Voight’s work on the 
Spleen, published in a late number of the British and Foreign 
Medical Review, and the description of enlargement and disease of 
the spleen given by Aretgeus. The ancients, it is true, cannot be 
now considered as authorities to be followed either in pathology or 
practice; for they were ignorant of many of the most important 
facts connected with the healthy and diseased states of the human 
body. In consequence of their inaccurate anatomical notions, they 
were unable to appreciate or describe many of those details which 
now enrich the domain of pathological anatomy: their writings, 
however, are invaluable in many respects, as containing admirable 
descriptions of diseases which still continue to infest the human 
body, and as recording certain groups of symptoms which are still 
associated. A comparison of their descriptions with those of mo- 
dern times cannot fail to be extremely curious, and may even prove 
highly instructive; for if we find that certain internal affections 
have, from the most remote antiquity up to the present period, been 
generally accompanied by peculiar derangements of distant parts, 
we are authorised in considering this connection to be something 
more than accidental, and consequently we may be led to discover 
relations between organs generally believed to be quite unconnected 
with each other. Thus, some years, I had three patients in suc- 
cession under my care, who laboured under chronic enlargement 
of the spleen, who were all affected with a similar sort of cachexy, 
and had all the same affection of the skin—namely, superficial 
ulceration of the legs. This coincidence forcibly arrested my atten- 
tion ; and I was still more struck with the observation, on finding 
that Aretaeus had noticed this very circumstance in his admirable 
description of splenitis. “ If (says he) the spleen does not suppu- 
rate, but becomes chronically enlarged, then the patients lose their 
appetite, and become cachectic, swollen, and of an unnatural colour, 
while the surface of the body manifests a disposition to ulcerate, 
particularly on the legs: the ulcers are hollow, round, livid, sanious, 
and difficult to heal.” This description agrees precisely with the 
cases to which I have already referred, and it coincides, in a very 
remarkable manner, with the account lately given by Dr. Yoight, 
of chronic disease of the spleen, as it occurs in India. He observes, 
that the cachexy connected with the splenalgia Bengalensis fre- 
quently manifests itself by a tendency to ulceration; the disposition 245 
to which is so great, that leech-bites and blisters occasionally give 
rise to foul or phagedenic ulcers, which, under certain circum- 
stances—as where the patient has used mercury, and is residing in 
a swampy district—will sometimes run on to a fatal termination. 
It is also curious, that the predisposing causes of the different varie- 
ties of chronic enlargement of the spleen, as given by Yoight, are 
exactly the same as those detailed by Aretseus; and both writers 
correspond in their statements as to the age and habits of life of 
persons most liable to this disease, as well as the nature of the 
locality and the season of the year most favourable to its produc- 
tion. This agreement between authors separated from each other 
by so many centuries, and who describe the disease as it occurred 
in distinct regions and among different races of mankind, is ex- 
tremely curious, and exhibits a very remarkable example of the 
identity of the morbid phenomena produced by the same causes. 
So far of the pathological states of particular organs which arise 
in certain conditions of the system, and most generally form a ter- 
minating link in the chain of diseased action. You will perceive 
that my observations are chiefly limited to a detail of the most 
important pathological observations made in our wards during the 
preceding three months. After we have made a brief review of 
what has occurred during this period, we shall take up the con- 
sideration of the cases at present under treatment. 
The next disease which came under our notice so often as to 
deserve a separate notice, was erysipelas. There were some points 
of interest connected with the history of the erysipelas which pre- 
vailed in this hospital during the months of August, September, 
and October. In the space of somewhat more than two months, 
we had about twenty cases of this disease; and, indeed, the morbific 
cause appears to be still lingering in our wards, though less fre- 
quently manifesting itself, for we have had only one case within 
the last ten days. Before, however, I proceed to notice the pheno- 
mena of the disease, as observed here, I shall make a few observa- 
tions connected with the treatment of this affection in general. I 
am anxious to direct your attention to this point, because the history 
of this epidemic has furnished some useful lessons, and has shown 
how much the treatment of any disease will depend on its epidemic 
character and existing peculiarities. The disease was treated here 
in every instance, and through all its stages, with wine, quinine, 
and opium; and, with the exception of a single case, this treatment 
has proved uniformly successful. Erysipelas, you are aware, is 
generally looked upon as an inflammatory disease, and its treatment 
is always more or less antiphlogistic, particularly during the early 
stage. At this period it is customary to treat it with general bleed- 
ing, leeching, scarifications, purgatives, mercury, and tartar emetic; 
and I will allow that many cases should be treated in this manner. 
But the gentlemen who have attended this hospital within the last 
three months have witnessed a form of erysipelas which required, 
from the beginning, an exactly opposite line of treatment. In the 
management of the cases which fell under our observation, no one 
ERYSIPELAS. 246 
GRAVES’S CLtNICAL LECTURES. 
in his senses would think of using general or local depletion, pur- 
gatives, or tartar emetic. The moment the disease appeared, we 
were obliged to attack it with tonics, narcotics, and stimulants. 
You perceive, then, that in erysipelas there are two very distinct 
extremes, between which there are many intermediate shades and 
varieties. It is well to bear this in mind. When you are called to 
treat a case of erysipelas, you should recollect that it is a disease 
capable of exhibiting a great variety of forms, amenable to no fixed 
line of treatment, and requiring for its management all the saga- 
city and skill of an accomplished practitioner. I have seen many 
instances in which this affection appeared in a distinct and well- 
marked inflammatory form; and I have treated cases with vene- 
section, leeching, purgatives, and tartar emetic, and found these 
means admirably well fitted to remove the disease. Here, on the 
contrary, wine, opium, and sulphate of quinine, were the only 
remedies on which we could rely with any degree of confidence. 
On the other hand, you will meet with intermediate cases in which 
these different modes of practice should be employed, either at dis- 
tinct stages of the complaint and at a considerable interval, or should 
succeed each other by a rapid transition. Erysipelas, I must again 
repeat, should not be treated from its name. Many persons have 
maintained that, when gangrene supervenes on inflammatory affec- 
tions—and, among the rest, on erysipelas—it is the result of an 
excessive degree of inflammation, and that it might be successfully 
combated by judicious depletion. This, however, is by no means 
generally true; and it is of importance that, in forming proper 
notions of the pathology and treatment of erysipelas, you should 
dismiss from your minds ail preconceived opinions, and be regu- 
lated solely by the impressions derived from correct observation and 
facts. What I wish to impress upon your minds is, that gangrene 
may and does occur in cases of erysipelas quite independently of 
excessive inflammatory action, and requiring a plan of practice 
quite different from the antiphlogistic. I do not assert that gan- 
grene does not arise, in many instances, from the violence of 
erysipelatous inflammation, and that in such cases it is to be met by 
prompt and decided antiphlogistic treatment, but I think your views 
of the pathology of this disease will be both imperfect and false, if 
you look upon the gangrene which frequently supervenes in ery- 
sipelas as the result of immoderate inflammatory action. The 
following case, which is one of extreme interest, will, I think, bear 
me out in my assertion. 
Mrs. B., a lady of middle age, was attacked with feverish symp- 
toms on the 24th of last March, Notwithstanding the diligent 
employment of antiphlogistic treatment by Mr. Barker, the pyrexia 
increased; in the course of a few days her throat became sore, and 
shortly afterwards erysipelas appeared on the face. Her case as- 
sumed a very dangerous aspect; she continued seriously ill for 
some days, and was saved with difficulty. On the 1st of April, Mr. 
Carmichael advised the diligent application of fomentations, with 
the view of relieving the local symptoms; and her son, a young ERYSIPELAS. 
247 
man of eighteen, of temperate habits, florid complexion, muscular 
frame, and who had always enjoyed a vigorous state of health, 
undertook the duty of applying the fomentations with much zeal 
and assiduity. Towards evening, he thought, but without reason, 
that her case was hopeless, and fell into a violent paroxysm of grief, 
from which he was induced to rouse himself for the purpose of 
resuming his occupation of applying the fomentations. While thus 
engaged, he got, to use his own expression, “a whiff of sickening 
air from the bed-clothes,” and immediately felt unwell. This was 
on the 1st of April. On the 2d, he was feverish and complained 
of headache, for which he got aperient medicine, and was leeched. 
On the 3d, there was no improvement, and he had passed the night 
without any sleep. On the 4th, Mr. Carmichael considered it 
necessary to leech the temples again, and to continue the exhibition 
of antiphlogistic and aperient medicines. He now began to com- 
plain of severe pain in the right shoulder, which at first appeared 
to be of a rheumatic nature. He became more and more restless* 
and on the 7th of April was reported to have slept none for the 
three preceding nights. A very perceptible fulness was now ob- 
served under the right clavicle, extending down over the pectoral 
muscle; the parts were tender to the touch, but not red. Mr. 
Carmichael now examined the hand and arm of the same side with 
much attention, for the purpose of ascertaining whether any wound 
or injury had existed, for the symptoms seemed to resemble closely 
those produced by poisoned wounds. None, however, could be de- 
tected. The restlessness now increased to an extraordinary height; 
during the following night the patient changed from one bed to 
another at least one hundred times, and the servants were inces- 
santly employed in making and adjusting three beds, from one of 
which he wandered to another, impelled by an intolerable feeling 
of anxiety and uneasiness. During this period his bowels were 
free, his urine copious; and though his fever was considerable, it 
was by no means proportioned to the nervous excitement, nor was 
it accompanied by delirium or pain in the head. The swollen parts 
of the trunk were leeched freely twice, and diligently fomented,- 
and continued to present the same appearance until the 10th, when 
a red patch appeared near the shoulder, subsequently spreading into 
a vividly red erysipelatous blush, which occupied the skin covering 
the pectoral muscle and right axillary region. I saw him for the 
first time on the 11th. His pulse was 120, and by no means defi-- 
cient in strength ; skin hot, but covered with perspiration; he did 
not complain of headache, but was quite sleepless and excessively 
uneasy. His muscular strength was apparently not much reduced; 
and, indeed, until a few hours before his death, he was able to turn 
in bed with ease. His tongue was dry in the centre, and furred* 
but moist at the edges. The erysipelas was now spreading rapidly 
towards the left side, and down the front of the abdomen. An 
attempt was made, but in vain, to arrest its progress by the appli- 
cation of nitrate of silver to the skin around its margin—an opera- 
tion which was performed with great care by Mr. Carmichael. 248 
GRAVES’S CLINICAL LECTURES. 
Mercurial ointment was next applied to the inflamed surface; and, 
although the erysipelas continued to spread, we were led to enter- 
tain some hopes of our patient—having succeeded, by means of 
tartar emetic followed by opium, in procuring for him much, and, 
as he said, refreshing sleep. On the morning of the 13th, however, 
a black colour of the corium was observed in the situation of one 
of the bullae on his left side. This alarmed us, and in a few hours 
afterwards our suspicions were confirmed by the appearances of 
dark maculae in many parts of the erysipelatous surface. These 
livid patches spread very rapidly, and were in some places accom- 
panied by effusion beneath the cuticle, but in others they appeared 
to consist in a mere change of colour in the external surface of the 
erysipelatous corium, without any detachment of the epidermis. 
The patient took abundant nourishment, and got wine and cordials, 
but without any favourable effect. The scrotum now became en- 
gaged, and speedily assumed a gangrenous appearance. In some 
places the epidermis separated, and the gangrenous surface of the 
corium secreted sanies in large quantity, but in many parts no 
detachment of the cuticle took place. On the 14th, nearly the 
whole of the right side of the abdomen and the scrotum were 
superficially gangrenous, and the belly became tympanitic. During 
this time, apparently healthy faeces were discharged in considerable 
quantity; the skin was covered with perspiration; the urine was 
copious and natural; and we had here, what is worthy of notice, 
apparently healthy secretions from the bowels, liver, skin, and kid- 
neys, co-existing with extensive gangrene of the surface. His 
tongue, however, continued dry and furred; his restlessness una- 
bated ; and the sleep previously procured by means of opium now 
ceased, although that medicine was repeated in the same doses. 
His pulse also began to sink, but he remained quite sensible and 
free from delirium until immediately before his death, which took 
place on the evening of the 15th. During the latter days of his 
illness, he had sweated copiously, and there was nothing remark- 
able in the odour of the perspiration. I may also observe, that the 
pulse likewise furnished but very fallacious indications ; for I can 
assert, with truth, that six hours before his death, though soft and 
compressible, it still possessed a steadiness and a volume by no 
means calculated to impart a suspicion of his approaching dissolu- 
tion. His strength was also such as would lead to an erroneous 
conception of his real danger; for, as I have before observed, he 
was able to turn in bed shortly before death. This observation is 
borne out by other cases, in which persons with extensive gangre- 
nous erysipelas, and in imminent danger, have been known to be 
capable of walking about. 
The evidently contagious nature of the erysipelas in this instance, 
and the youth and previous good health of the patient, render this 
case sufficiently remarkable. It is likewise worthy of notice, as 
proved by the circumstances, that the gangrene did not originate 
in the excessive violence of the cutaneous inflammation ; for it did 
not appear in those portions of the skin which were primarily and ERYSIPELAS. 
249 
most violently affected. On the contrary, we observed that the 
parts which became gangrenous had been paler and less tense 
than those which did not assume that condition, and that the por- 
tions of the skin which died were those which had become engaged 
at the latter stage of the disease. This is of importance ; for, com- 
bined with other facts, it forms an obvious refutation of the opinion 
not long since maintained, that gangrene and sphacelus are in all 
inflammations the result of immoderate inflammatory action, and 
consequently to be averted by antiphlogistic treatment only. In 
many instances this opinion, and the treatment founded on it, are, 
no doubt, judicious; but that there are cases in which the gan- 
grenous tendency supervenes on inflammation—or, in other words, 
is superadded to the inflammatory process, but independent of its 
intensity—no one will deny who candidly weighs the details of the 
case which I have just related, and recollects that the conclusions 
deducible from them have of late received too frequent a confirma- 
tion, from the rapidly fatal progress of putrid sore throat—a form 
of cynanche which has reappeared in Ireland, after having almost 
disappeared for upwards of twenty years. In both cases the disease 
appears to be infectious, and in both the gangrene seems to be quite 
independent of the intensity of the inflammation. 
This is a question so important, in a practical point of view, that 
I shall make no apology for detaining you, as I am anxious to im- 
press upon the minds of my younger auditors that there are certain 
forms of disease, termed inflammatory, in which the ordinary treat- 
ment by depletion is quite inadmissible. I shall, at my next lecture, 
enter upon the treatment of fever, and endeavour to communicate 
such observations as a review of our cases for the last three months 
has afforded. And here I beg leave to return my thanks to the 
gentlemen who have furnished the cases, and to express the grati- 
fication I have felt in finding that so many of the pupils have 
recorded their facts in such a clear and satisfactory manner. 
LECTURE III. 
Erysipelas in an epidemic form—Symmetrical spread of erysipelas on the body— 
Maculated fever, and Irish typhus—Dr. Lombard’s remarks—Improved treatment of 
fever—Choice of a proper nurse and assistants—Air of the sick chamber—Neces- 
sity of attending to diet and nourishment. 
I shall now resume the subject of erysipelas, which I alluded to 
in a cursory manner at our last meeting. You will recollect I 
mentioned that we had a kind of epidemic erysipelas in our fever 
wards during the months of August, September, and October ; this 
has now almost disappeared, for we have had but one case during 
the present month. The disease generally attacked the head, com- 
mencing in the scalp, or about the nose and cheeks; but in some 250 
graves’s clinical lectures. 
cases it appeared first on the nape of the neck, particularly in those 
patients who had been blistered in that situation during the course 
of fever. The fever which now prevails seldom abates in less than 
fourteen or seventeen days; and it was generally about the termi- 
nation of the febrile excitement, and while convalescence was going 
on, that the erysipelas appeared. Usually, on the fourth or fifth 
day of convalescence, a change was observed in the patient, and 
the erysipelatous attack commenced, being ushered in by a feeling 
of weakness and uneasiness, or an indistinct rigor, followed by 
quick pulse, headache, some increase of thirst, and in most cases 
by a marked change in the tongue, which became dry and parched. 
The inflammation was of a superficial character, expending itself 
almost exclusively on the external surface of the corium, and not 
affecting to any extent the subcutaneous cellular tissue. 
You are aware that erysipelas becomes obstinate, complicated, 
and dangerous, in proportion as the inflammation spreads inwards. 
In such cases its characters are less distinctly marked, and it makes 
a near approach to a very formidable disease—diffuse inflammation 
of the cellular substance. The affection of which I am now speak- 
ing was generally simple, and in most cases limited to the super- 
ficial apparatus of the corium. It was characterised by the ordinary 
phenomena of true erysipelas, namely, redness, heat, a burning 
sensation, and slight elevation of the affected parts. There was 
seldom any remarkable degreee of (Edema, except in some cases 
where it attacked the eyelids ; and we had no instance of abscesses 
forming under the skin. It was attended with a considerable 
degree of constitutional disturbance, and the fever generally con- 
tinued for four or five days. On looking over the cases of this 
affection, which have been recorded by the gentlemen who had 
charge of the patients, I find that in most instances the fever ter- 
minated on the sixth day. In many cases a peculiarity was ob- 
served, to which I have alluded on a former occasion, namely, the 
spread of the erysipelatous redness in a perfectly symmetrical 
manner. I believe I was the first who directed attention to the fact, 
that when erysipelas commences at any point of the mesial line of 
the body, it is very apt to spread in a symmetrical manner. Thus, 
in the present instance, the inflammation commenced in the majority 
of cases about the nose, and then extended in a perfectly symme- 
trical manner over the forehead and down the neck; or when it 
appeared first on the nape of the neck, it traveled down between the 
shoulders with a very remarkable symmetry of extent and outline. 
Sometimes this precise correspondence did not exist; but I can 
assert that in more than two thirds of the cases it was extremely 
well marked. It appears, then, that this occurrence is not so very 
rare as my friend Dr. Johnson supposes. When I first noticed the 
fact of the occasionally symmetrical spread of erysipelas, he said it 
was an observation of very little importance, and that it was to be 
looked upon as a matter of mere curiosity, a phenomenon which a 
man would not see twice in the course of his life. I have, how- 
ever, shown it to many of the students half a dozen times during 
the last two months. ERYSIPELAS. 
251 
The treatment of this affection, which was abundantly simple, 
and the same in every instance, was entirely regulated by the cir- 
cumstances under which the erysipelatous attack occurred. No 
local treatment was employed, nor was any required. It was not 
necessary to apply leeches, cold lotions, fomentations, or mercurial 
ointments. The cutaneous inflammation was not either very ex- 
tensive or intense; and the constitutions of the patients did not 
admit of any kind of depletion. The internal treatment was de- 
termined on, more from a consideration of the circumstances under 
which the disease had appeared, than from an accurate analysis of 
the symptoms, or from any preconceived opinions of the nature of 
the complaint. In the practice of your profession you will be fre- 
quently called upon to treat affections, in which you will have to 
consider not only the existing symptoms, but also the circumstances 
under which they have originated ; and in many instances you will 
find that your treatment will be determined more by the latter than 
the former. Here we had a number of patients labouring under 
erysipelas, at a period when the system was reduced by fever, and 
the powers of life at a very low ebb. No one could think of using 
antiphlogistic or depletory measures under such circumstances. 
Recollecting that our patients had just emerged from a dangerous 
disease, we adopted a very different mode of treatment; and in all 
cases, except where the patient’s strength was unbroken, the fever 
high, and the local symptoms of an intense character, we had re- 
course at once to tonics, narcotics, and stimulants; We first gave 
an emollient injection, and then administered sulphate of quinine 
in the form of enema, to the amount of from five to ten grains, 
blended with mucilage of starch. This was administered twice a 
day, and the patient was directed to take small quantities of wine 
and light nourishment. 
Many of the pupils at the time were surprised at this mode of 
treatment. From the dry state of the tongue, the occasional de- 
lirium, the restlessness, and the headache present, they were in- 
clined to think that the patients would be injured rather than served, 
by dietetic and medicinal stimulants of this description. I had, 
however, witnessed cases of a similar description, and had observed 
the tongue become clean and moist, the skin soft and cool, the 
thirst, fever and restlessness subside, and the local symptoms dis- 
appear, under the use of wine. In this instance, also, the value of 
our mode of treatment was borne out by the result; for, with the 
exception of a single case, all our patients recovered. In one in- 
stance the disease assumed a malignant form, and carried off the 
patient in a few hours. She was a young girl of apparently 
vigorous constitution, and who had got tolerably well through a 
dangerous maculated fever; towards the middle of the fever she 
had exhibited symptoms of cerebral excitement, for which we 
deemed it necessary to blister the scalp. At the time when the 
erysipelatous attack came on, she had been for several days ill, and 
was in that low state in which the skin has a great tendency to be- 
come ecchymosed, and form bad sores. This tendency I have ob- 252 
graves’s clinical lectures. 
served in many instances of low fever, and it is a condition which 
is always pregnant with danger. The occurrence of ecchymosis, 
excoriation, and superficial gangrene, in such cases, is not so much 
the result of pressure, as of the general debility, and the impaired 
condition of the fluids and solids of the body. It was in this state 
of the system, and with her scalp still suffering under the inflam- 
mation produced by the blister, that this poor girl was attacked with 
erysipelas of the face. Unfortunately, at the time the erysipelas 
attacked the sound skin of the head, the blistered surface was at- 
tacked with gangrene; and two dangerous local affections became 
thus suddenly conjoined. Under this unfavourable complication 
her constitution sank with great rapidity, and she died in twenty- 
four hours from the commencement of the attack. 
I shall now, in pursuance of my intention, proceed to speak of 
the treatment of fever. I may observe here, that we are now at a 
point of time possessing no common interest for the reflection of 
medical observers. It is now nearly two years since my attention 
was first arrested by the appearance of maculated fever, of which 
the first examples were observed in some hospital patients from the 
neighbourhood of Kingstown. This form of fever has lasted ever 
since, prevailing universally, as if it had banished all other forms 
of fever, and being almost the only type noticed in our wards. 
Within the last four days, however, a change appears to have taken 
place. Scarcely any cases of maculated fever have been admitted 
within the last fortnight, and the majority of fever patients at pre- 
sent under treatment are free from the cutaneous eruption so fre- 
quently observed during the last two years. The cases which we 
have recently admitted present no spots, or maculae, and have been 
termed, perhaps improperly, simple typhoid fever. And here per- 
mit me to observe, that it would be very wrong to conclude, from 
this circumstance, that our recent cases are of a more favourable 
description than those which preceded them; the disease, it is true, 
appears to have lost a character which is always looked upon as 
bad and unfavourable, but it may be just as dangerous a modifica- 
tion of lever as the eruptive typhus. During the predominance of 
the latter form, all cases without maculae were in general simple 
and free from danger ; but it is probable that this is not the case at 
present. There are two cases of this non-maculated typhus in the 
female ward, which are of an extremely doubtful character, and in 
which it would be difficult to predict the result. Indeed, were I to 
make any prognosis, I should say that the chances, if not against 
them, are at least very fairly balanced. 
Now, gentlemen, as it appears we have come to a change, and 
that we may have to treat a new modification of fever, it behoves 
us to be extremely vigilant. I invite you to watch and study, with 
the closest attention, the cases of fever which come before you. 
Let us, in the first place, endeavour to ascertain whether we have 
seen the close ol one epidemic, and are now at the commencement 
of another. The number ol cases of simple typhoid fever have, 
you perceive, increased in a very remarkable manner, and the FEVER 
253 
number of cases of eruptive typhus have become remarkably scarce. 
Bat there is another and a more important reason why we should 
study these cases with all due diligence and attention. They may 
be the first examples of a new epidemic, and every new epidemic, 
as it has its peculiar characters, so has it its peculiar treatment. 
We cannot follow the same track which we have pursued for the 
last two years—we cannot apply our remedies with the confidence 
of experience—we must now strike into a new path, and for some 
time our practice must be tentative and experimental. It was only 
after a good deal of experimental observation that we were able to 
arrive at a plan of treatment adapted to meet the exigencies of the 
maculated form of fever: and it is very probable that this new fever 
may prove at first extremely difficult to manage ; and it may be 
some time before the diminished rate of mortality will show that 
we have at length discovered its true character, and the remedies 
best calculated to arrest its progress.1 
Let me now direct your attention to some practical points con- 
nected with the treatment of the maculated fever which has pre- 
vailed for the last two years, and which has spread to a very con- 
siderable extent in this city and its environs, attacking alike the 
upper, middle, and lower classes of society. It is not my intention 
to enter into a detailed history of the origin and progress of this 
fever, its varieties, symptoms, and pathological phenomena; my 
purpose is to furnish you with a brief but comprehensive outline of 
its treatment, and of the remedies which have been found most 
successful in its removal, as well as the most appropriate time and 
mode of their application. But as many of the students are un- 
acquainted with this form of fever, I shall premise by observing 
that it is the same fever which has been frequently observed in this 
country, and of which a full account has been given in the Report 
published by Dr. Cheyne and Dr. Barker. You will also find a 
sketch of its principal characters in one of my lectures, published 
in the 172d No. of the London Medical and Surgical Journal for 
May 1835. It is generally insidious in its first, attack, and the 
symptoms are by no means proportioned to the subsequent danger. 
From the third or fourth to the seventh day, generally about the 
latter period, an eruption of dark red spots appears on the skin in 
various parts of the body. Towards the latter stage, this fever is 
characterised by great nervous derangement, either with or without 
symptoms of cerebral congestion. It rarely lasts less than fourteen 
or seventeen days, and very seldom terminates by a well-defined 
crisis. It has spread extensively through this country, and has 
been observed at Liverpool, Glasgow, Birmingham, Manchester, 
Edinburgh, and London. In this country it has been for many 
years the prevailing type, and, although its spread as an epidemic 
may have been checked, and its course interrupted, by the occur- 
rence of other diseases, it is always found in this country, and pre- 
1 Since this lecture was delivered, many cases of typhus without maculae 
have been admitted, but the maculated form of fever still continues very 
common. 254 
graves’s clinical lectures. 
vails in a distinct form. It may originate spontaneously, or from 
contagion. From what I have seen of it, I have no doubt of its 
double origin. I am also inclined to think that it never attacks the 
same individual more than once, and that when a man has had the 
true maculated fever, he never gets it again. In this point, as well 
as in the eruption, it bears a close analogy to the exanthemata. It 
is so much more common in Ireland than in any other country of 
Europe, that my friend, Dr. Lombard, of Geneva, calls it the Irish 
typhus. Whether it be from the moisture of our climate, or from 
the poverty and wretchedness of the people, I know not; but it is 
a fact that typhus is more prevalent in this country than in any 
other European nation. This may be easily seen by comparing 
the proportion of fever patients treated in the hospitals of the 
various capital cities, with the number treated in the same way in 
Dublin. Dr. Lombard also states, that the British towns which 
have most intercourse with this country, have more of this fever 
than those which are more remote, or have less intercourse with 
us. Thus there is more maculated fever seen in Liverpool and 
Glasgow, than in Edinburgh, Birmingham, or London. He looks 
upon it as a fever peculiarly Irish, originating in this country as 
an endemic, from causes the nature of which are not well under- 
stood ; and that when it appears in English or Scotish towns, it is 
the result of contagion imported from Ireland. You will find some 
very interesting observations on this subject in his papers, publish- 
ed in the 28th number of the Dublin Medical Journal. 
In the fever of which I speak, there is nothing which would lead 
to the conclusion that the disease arose from inflammation. Many 
persons have regarded fever as produced by inflammatory affections 
of some organ or system of the body, and have asserted that it is in 
every instance preceded and accompanied by some form of local in- 
flammation. One class of pathologists have placed the seat of this 
inflammation in the brain, another and a more numerous class in 
the digestive system ; and all have believed that inflammatory action, 
whether limited to one or more organs, is the cause of fever. No 
opinion can be more unfounded, so far as typhus is concerned. 
Local congestion and inflammations may and do frequently arise 
in fever, but they are merely superadded to it, and form no part of 
its essence. I have now witnessed many cases in which fever ran 
through its course to a fatal termination without any distinct evi- 
dence of local inflammation or even congestion ; and I have 
dissected numerous cases of fever in which there was not any ap- 
preciable trace of inflammatory action in the organs of the three 
great cavities. 
Having made these general observations, I may observe, in addi- 
tion, that in the whole range of human maladies there is no disease 
of such surpassing interest and importance as fever; and I cannot 
dwell too much on the necessity of your applying most attentively 
to the study of its pathology and treatment. If you compare the 
mortality from fever with that resulting from any other disease in 
this country, you will be struck with the overwhelming fatality of FEVER 
255 
this affection, and will readily admit the inestimable value of a 
thorough knowledge of its nature and treatment. Recollect, too, 
that fever is a disease which numbers among its victims persons 
chiefly in the prime of life, and during the most active and useful 
stage of existence,—fathers and mothers, persons who are the orna- 
ment or the stay and support of their families, the intellectual, the 
industrious, the efficient,—those whose lives are most valuable to 
their friends and to society. This gives an additional interest to 
the study of fever, and should stimulate you to endeavour to arrive 
at a correct knowledge of its nature and treatment. And here let 
me observe, that there is nothing more untrue than the assertion, 
that the treatment of fever is a matter of indifference. It has been 
the custom to look upon every plan of treating fever as idle and 
absurd, and until very lately there were many persons in this 
country who believed that patients recovered, not from having had 
the advantage of treatment, but from goodness of constitution or 
some favourable accident; and it was usual with such persons to 
appeal to the experience of Dr. Rutty, who, in recording the history 
of the epidemics of his own time, observes, that the mortality was 
greatest among those who were best attended to, and that those 
who were left to God’s providence, and got nothing but cold water, 
recovered. And, indeed, I must admit that the treatment of some 
of the cases of fever which I witnessed when a student, would 
seem to justify the quaint and sarcastic observation of Dr. Rutty. 
At that period, whether it was from bad treatment, or from what 
has been termed the nimia diligentia medici, it is a fact that the 
maximum of mortality was among the rich, and that those who 
were most attended to died most speedily. In the epidemics of 
1816, 1817, 1818, and 1S19, it was found by accurate computa- 
tion, that the rate of mortality was much higher among the rich 
than among the poor. This was a startling fact, and a thousand 
different explanations of it were given at the time ; but I am in- 
clined to think that the true explanation was, that the poor did not 
get so much medicine, and that in them the vis medicatrix had 
more fair play. I could appeal to the practice of those times in 
proof of this opinion, and as we go along I shall have an opportu- 
nity of alluding to this part of the subject again, and contrasting 
the practice of the present day with that which was generally 
followed thirty years ago. If you look to Dr. Cheyne and Dr. 
Barker’s Synopsis of the plan of treatment employed by the physi- 
cians of those days, you will be prepared, from a mere inspection 
of it, to admit, that it was at least as hard to escape the physician 
as the disease. Since that period our practice has greatly im- 
proved, and things are much changed ; the preponderance of fatal 
cases is now to be found among the poor, and the mortality among 
the rich, or those who have proper medical advice from the com- 
mencement, is not one third of that which is found among the in- 
digent, who are generally neglected at the commencement of the 
disease. I am therefore fully prepared to deny that, in the present 
state of medical knowledge, our practice is a matter of indifference; 256 
graves’s clinical lectures. 
on the contrary, there is no disease in which diligent attention and 
skilful treatment are more frequently successful than in fever, nor 
is there any affection of equal importance in which our therapeutic 
means are more efficient and valuable. 
Now, when called on to treat a case of fever, there are several 
things which require your attention. In the first place, you should 
examine the state of the family arrangements. This is a matter 
which men are apt to overlook or treat as a matter of indifference, 
but in my mind it is of no ordinary importance, and should always 
be attended to. You should never, if possible, undertake the treat- 
ment of a case of fever where the friends or relations of the patient 
supply the place of a regular fever nurse. The mistaken tender- 
ness of relatives, and their want of due firmness, presence of mind, 
and experience, will frequently counteract your exertions and mar 
your best efforts. Affection and sorrow cloud the judgment, and 
hence it is that very few medical men ever undertake the treatment 
of dangerous illness in the members of their own families. The 
sympathy which a nurse should have for her patient should be 
grounded on a general anxiety to serve, and a strict sense of duty, 
as well as a laudable desire of increasing her own reputation ; it 
is, in fact, a sympathy analogous to that which a physician should 
have. Again, it will not do to have a nurse who has been usually 
employed in other diseases; your assistant must be a regular fever 
nurse, and the man who undertakes the treatment of a long and 
dangerous case of fever without such an assistant, will often have 
cause to regret. T could mention to you many cases illustrative of 
the truth of this assertion. I could tell you, that where I have per- 
mitted the continuance of the services of one of the family, or of a 
common nurse, I have been almost invariably annoyed and disap- 
pointed. I now make it a general rule to refuse attending any dan- 
gerous and protracted case of fever without a properly qualified 
nurse. 
In the next place, when treating a case of bad typhus, do not 
think that it will be sufficient to see your patient once a day. But 
you will say, perhaps, that our hospital patients here do very well, 
and yet they are visited only once in the twenty-four hours. True 
—but then we have experienced nurses to look after them at all 
hours; we have the valuable surveillance of our apothecary, Mr. 
Parr; we have the attendance of the resident pupils, and of the 
gentlemen who take charge of the cases. You see, then, that they 
do not depend on a solitary visit. How often has Mr. Parr, the 
resident pupil, found it necessary to change the treatment adopted 
at the morning visit? How often have the remedies of which we 
had only given a hint in the morning, been actually and energetic- 
ally employed before the close of the day; and how often have 
lives been saved by the valuable attentions to which I have just 
alluded? No one should attend a case of fever without having 
proper medical assistants. My practice, in general, is to visit my 
fever patients two or three times a day; and, when I have a bad or 
a dangerous case to manage, I always have a competent medical FEVER. 
257 
assistant to stay by the patient and watch every change of his 
malady. I do not know how they manage this matter elsewhere, 
but in this city we have so many zealous intelligent students, so 
many young medical friends, and so many well-educated apothe- 
caries, that we are never at a loss for an assistant. This fact is, I 
think, a sufficient answer to the objections put forward by Dr. 
Johnson, in the last number of the Medico-Chirurgical Review. 
He says that tartar emetic is a two-edged sword—an agent power- 
ful alike for good or evil, and in the administration of which no 
ordinary circumspection is demanded. All this I am willing to 
admit; there is no remedy capable of producing more mischief 
when abused, but when properly watched it is, I am confident, the 
means of saving many valuable lives. He says, also, that Dr. 
Graves cannot give that share of attention to his patients which 
the employment of such a remedy demands. He is quite mistaken 
on this point. I am never at a loss for some skilful person to re- 
main with the patient, watch the operation of each dose, and modify 
or change it according to circumstances. The want of proper 
assistants may be an objection to the administration of tartar emetic, 
but this objection does not hold good with respect to Dublin. 
One or two more observations of a general nature. Some per- 
sons have such a terror of foul air, in cases of fever, that you will 
find all the windows in the house thrown open, not even excepting 
those of the patient’s bed-chamber, and wherever you turn you are 
sure to meet with a current of air. Now, this is an unnecessary 
practice, likely to entail disease on the family and local inflamma- 
tion on the patient. The bed-room of a patient labouring under 
fever should be well aired, but without what is termed thorough 
air; and it should, if possible, be a quiet back room, away from 
the street. In the next place, it should be sufficiently large to hold 
two bedsteads conveniently; and you should order the attendants 
to have two well aired beds in readiness, from one of which the 
patient should be changed to the other every twelve or twenty-four 
hours. You can scarcely have an idea of the comfort this affords 
to a person in fever. The room can be kept properly ventilated by 
a fire‘ and the temperature can be regulated by a thermometer. 
Some persons are in the habit of constantly sprinkling the room 
with vinegar—others with the chlorides. I do not know that it is 
necessary, and I think the use of chlorine is doubtful, if not im- 
proper, and may prove injurious to the patient. 
Having made these few general observations on the steps to be 
taken by those who enter on the treatment of typhus, I shall now 
proceed to speak of diet and medicines. In a disease like fever, 
which lasts frequently for fourteen, twenty-one, or more days, the 
consideration of diet and nutriment is a matter of importance, and 
I am persuaded that this is a point on which much error has pre- 
vailed. I am convinced that the starving system has, in many 
instances, been carried to a dangerous excess, and that many per- 
sons have fallen victims to prolonged abstinence in fever. This 
was one of the errors which sprung from the doctrines of those 
who maintained that fever depended on general or topical irffiam- 258 
graves’s clinical lectures. 
mation. They supposed that fever arose from inflammation, and 
immediately concluded that, to treat it successfully, it was necessary 
to reduce the system by depletion and low diet, and to keep it at 
this point during the whole course of the disease. Hence the strict 
regimen—the diete absolue—of the disciples of the physiological 
school, and of those who looked on inflammation as the essence of 
fever. The more the symptoms appeared indicative of inflamma- 
tory action, the more rigorous was the abstinence enforced. If a 
patient’s face was flushed, or his eyes suffused, no matter what the 
stage of the fever was, they said, “here is inflammation of the 
brain, and nourishment will exasperate it.” If he had red or dry 
tongue, and abdominal tenderness, they immediately inferred the 
existence of gastro-enteritis, and all kinds of food, even the lightest, 
were strictly forbidden. That this proceeds from false notions on 
the nature of fever is beyond doubt, and I pointed out this fact 
many years ago, long before the appearance of Piorry’s work. Let 
us, in the first place, examine the results of protracted abstinence 
in the healthy state of the system. Take a healthy person and 
deprive him of food, and what is the consequence? First, hunger, 
which after some time goes away, and then returns again. After 
two or three days, the sensation assumes a morbid character, and, 
instead of'being a simple feeling of want and a desire for food, it 
becomes a disordered craving, attended with dragging pain in the 
stomach, burning thirst, and some time afterwards epigastric ten- 
derness, fever, and delirium. Here we have the supervention of 
gastric disease, and inflammation of the brain, as the results of pro- 
tracted starvation. Now, these are in themselves very singular 
facts, and well deserving of being held in memory. Read the ac- 
counts of those who perished from starvation after the wreck of the 
Medusa and the Alceste, and you will be struck with the horrible 
consequences of protracted hunger. You will find that most of the 
unhappy sufferers were raging maniacs, and exhibited symptoms of 
violent cerebral irritation. Now, in a patient labouring under the 
effects of fever and protracted abstinence—whose sensibilities are 
blunted, and whose functions are deranged—it is not at all impro- 
bable that such a person, perhaps also suffering from delirium or 
stupor, will not call for food, though requiring it; and that if you 
do not press it on him, and give it as medicine, symptoms like those 
which arise from starvation in the healthy subject may supervene, 
and you may have gastro-enteric inflammation, or cerebral disease, 
as the consequence of protracted abstinence. You may, perhaps, 
think that it is unnecessary to give food, as the patient appears to 
have no appetite, and does not care for it. You might as well 
think of allowing the urine to accumulate in the bladder, because 
the patient feels no desire to pass it. You are called on to interfere 
where the sensibility is impaired, and the natural appetite is dor- 
mant ; and you are not to permit your patient to encounter the 
horrible consequences of inanition, because he does not ask for 
nutriment. I never do so. After the third or fourth day of fever, 
I always prescribe mild nourishment, and this is steadily and perse- 
veringly continued through the whole course of the disease. 259 
TREATMENT OF FEVER. 
LECTURE IV. 
General treatment of fever—Dietetic management—The starvation system may pro- 
duce organic disease—Proper food for fever patients and convalescents—Allaying of 
thirst—Sedatives—Expergefacients—Efficacy of green tea in a case of narcotism— 
Flagellation effectual in a case of poisoning with opium. 
At my last lecture I spoke of some preparatory steps which 
should be taken before you enter on the treatment of a case of fever. 
I stated that one of the most essential requisites was a good nurse ; 
that you can readily find persons to undertake this office in every 
family, but that it is rare to meet with any individual among the 
patient’s relatives properly qualified to discharge so important a 
duty. There is a vast difference between readiness to undertake 
and ability to perform. Some persons are always adoing, blit never 
do right; always attempting, but never successful. There are 
many nurses who are extremely attentive, but inexpert and injudi- 
cious, and their ill-judged attentions are frequently prejudicial to 
the patient. A fever nurse has a vast deal in her power; if an 
enema is to be administered, the patient will be much less disturbed 
and annoyed than if it were given by an unskilful person. The 
mere handling of a patient—the moving of him from one bed to 
another—the simple act of giving him medicine or drink—the 
changing of his sheets and linen—the dressing of his blisters—and 
a thousand other offices, can be performed with advantage only by 
an experienced nurse. Always bear in mind that it is of the 
utmost importance to economise the patient’s strength in fever. The 
very act of lifting him up, or moving him from one side to another, 
tends to produce exhaustion. In the advanced stages of fever, the 
services of a properly qualified nurse are inestimable. Then there 
is the moral management of the patient, and this is an office which 
no one can undertake unless qualified by experience, and a correct 
knowledge of the habits of persons labouring under such forms of 
disease. Every one admits the value of moral superintendence in 
the treatment of the insane. Now there are very few patients who 
are not in a state analogous to insanity, for a longer or shorter 
period, during a course of typhus fever. There is a necessity for 
moral management in fever as well as in insanity, and this is un- 
derstood only by an experienced nurse. 4 Friends or relatives are 
seldom found capable of discharging this office. If they chance to 
discover from the physician’s remarks, or questions, the weak points 
of the patient’s case, they generally contrive to let him know them 
in some way or other. If the patient is restless, for instance, the 
ill-judged anxiety of his friends will most certainly prevent him 
from sleeping. They steal softly to his bed, draw the curtains, 
move the candle so as to make the light fall on his eyes, and wake 
him perhaps at the moment he is settling down to rest. If he hap- 
pens to take an opiate, and that they are aware of the nature of his 
medicine, they inform him of it, and his anxiety for sleep, conjoined 
with their enquiries, prevent its due operation. Hence, when you 260 
graves’s clintcal lectures. 
prescribe an opiate, you should not, in many cases, say any thing 
about it; and it should not be administered in such a way as to 
lead the patient or his friends to expect any decided benefit from it. 
It is only where I have to deal with prudent persons that I break 
through my rule of concealing both the nature of the medicine and 
the results which I expect from its operation. One of the best 
ways of giving an opiate is to administer it in the form of an enema. 
The patient’s attention is then turned away from the consideration 
of loss of rest—he supposes that the enema is to act on his bowels, 
and in expecting a motion he drops asleep. You will often, too, 
succeed in producing sleep in this way, where you would fail in 
bringing it on by an opiate administered by the mouth. Another 
recommendation attached to this mode of exhibiting opiates is, that 
it can be employed in cases of delirium, where the patient obsti- 
nately refuses to swallow any kind of medicine. Let me give you 
here another caution. Do not let the patient know the situation or 
extent of his danger, however you may feel bound to act in refer- 
ence to these matters towards his relatives or friends. If you 
apprehend mischief in the brain, do not commence by examining 
the head, or putting your questions in such a manner as to lead 
him to suspect the seat and nature of the affection. The same 
remark may be applied to the examination of the thorax and abdo- 
men. 
At my last lecture I endeavoured to impress upon you the fact 
that there can be no doubt that persons have been occasionally 
starved to death in fever; and laid before you some remarkable 
facts connected with the influence of protracted abstinence on the 
general system, as well as on the brain and digestive tube. I 
endeavoured to show that long-continued denial or want of food 
generates symptoms bearing a very close resemblance to those which 
are observed in the worst forms of typhus. Pain of the stomach, 
epigastric tenderness, thirst, vomiting, determination of blood to the 
brain, suffusion of the eyes, headache, sleeplessness, and, finally, 
furious delirium, are the symptoms of protracted abstinence; and 
to these we may add, tendency to putrefaction of the animal tissues, 
chiefly shown by the spontaneous occurrence of gangrene of the 
lungs. It has been shown by M. Guislain, physician to the hospital 
for the insane, at Gand, that in many instances gangrene of the 
lungs has occurred in insane patients who have obstinately refused 
to take food. Out of thirteen patients who died of inanition, nine 
had gangrene of the lungs. You perceive, then, that starvation may 
give rise to symptoms of gastric disease, to symptoms of cerebral 
derangement, and to mortification of the pulmonary tissue. It is not, 
therefore, wrong to suppose that when a system of rigorous absti- 
nence has been observed in fever, and when food has been too long 
withheld, because, forsooth, the patient does not call for it, and 
because his natural sensibilities are blunted and impaired—it is 
not, I say, unreasonable to suppose that gastric, cerebral, and even 
pulmonary symptoms may supervene, analogous to those which 
result from actual starvation. TREATMENT OP FEVER. 
261 
An attentive consideration of the foregoing arguments has led 
me, in the treatment of long fevers, to adopt the advice of a country 
physician of great shrewdness, who advised me never to let my 
patients die of starvation. If I have more success than others in 
the treatment of fever, I think it is owing in a great degree to the 
adoption of this advice. I must however observe, that great dis- 
crimination is required in the choice of food. Although you will 
not let your patients starve, do not fall into the opposite extreme : 
you must take care not to overload the stomach. When this is 
done, gastro-enteric irritation, tympanitis, inflammation, and exas- 
perated febrile action, are the consequences. I have witnessed 
many instances of the danger of repletion in febrile diseases. A 
case of this kind occurred some time back in this hospital, in a boy 
who was recovering from peritonitis. In another case, in private 
practice, an incautious indulgence in the use of animal food was 
followed by a fatal result. A young lady ate some beefsteak, con- 
trary to my orders, at an early period of convalescence from fever, 
relapsed almost immediately, and died in thirty-six hours. Food 
must be given with great care and judgment, particularly in the 
beginning of fever. For the first three or four days, particularly if 
the patient is young and robust, water, weak barley water, and 
whey, will be sufficient. After this I am in the habit of beginning 
with some mild nutriment. What I generally give is some well 
boiled gruel, made of groats, and flavoured, if there be no tendency 
to diarrhoea, with sugar and a small quantity of lemon juice. The 
ordinary oatmeal gruel does not answer sufficiently well for this 
purpose, for it is apt to produce griping and diarrhoea, symptoms 
which are extremely disagreeable in the commencement of fever, 
and which often lead to others of a more troublesome and formi- 
dable character. I am also much in the habit of giving a little 
thin panado, morning and evening, during the latter part of the 
first, and the beginning of the middle stage of fever. A small 
slice of bread is slightly toasted, and boiling water is poured on a 
tablespoonful of the crumbs, in sufficient quantity to make a thin 
panado, of which the patient takes a tablespoonful two or three 
times a day. It may be flavoured with a very small quantity of 
lemon juice and sugar, if there is no tendency to diarrhoea ; but 
where this exists, or where you are administering mercurials, I 
think you should be cautious in the use of acids. Although me- 
dical men are of late rather less cautious in giving acids during 
the use of mercurials, I think the practice is not entirely devoid of 
danger, and I think our predecessors were right in withholding 
them under such circumstances. You will begin, then, on the 
third, fourth, or fifth day, according to circumstances, with a little 
gruel ; and after two or three days you may add a little panado, 
giving, as I have already observed, a spoonful of either every third 
hour. As the fever advances you may add some mild animal jelly 
or broth ; and one of the best kinds of nutriment in the middle and 
latter stages of fever, is chicken broth. I do not speak here of 
chicken water ; I mean good and well made chicken broth. Give 262 
graves’s clinical lectures. 
this, but give it in small quantities, and with great caution at first 
Watch the effects of the few first spoonfuls ; it may act injuriously, 
and you should give it up, at least for some time, if it produces any 
bad effects. If it brings on heaviness, sickness of stomach, flushing 
of the face, excitement of pulse, and increased feverishness, give it 
up, and return for some time to the gruel and pan ado. You can 
try it again in a day or two; for although your patient does not 
bear it to-day, he may to-morrow or the day after; and it is a most 
fortunate circumstance when it agrees with him, for, as I have 
already observed, it is the best kind of nutriment you can give in 
the middle and latter stages of fever. The best mode of giving it 
is to make the patient take a tablespoonful of it regularly every 
third hour, or oftener if necessary. 
Recollecting the tendency to diarrhoea and intestinal irritation in 
fever, you will be extremely cautious in allowing your patient the 
use of fruits. Indulging patients in the use of grapes and oranges 
is a very popular, but, in my mind, very hazardous and improper 
custom. I have on many occasions seen persons injured by fruits 
of this description. Stewed and roasted apples are still more dan- 
gerous ; they are apt to produce tormina, flatulence, diarrhoea, and 
intestinal inflammation. All acid or raw fruits have a tendency to 
produce irritation of the stomach and bowels, and should be avoided 
altogether, or very sparingly used. 
One general observation as to the administration of food and 
nutriment in fever. All kinds of food and nutriment should be 
given by day, and the patient should, if possible, be restricted to 
the use of fluids by night. The natural habit is to take food by day 
and not by night., and in sickness, as well as in health, we should 
observe the natural habits of the economy. With respect to drinks, 
the mildest, of course, should be preferred: on this point most per- 
sons are generally agreed, and it will be unnecessary for me to 
detain you with any particular observations. There is one error, 
however, which is very frequently committed in the use of drinks 
in fever ; patients are generally allowed to drink too much. It 
may be urged that they have a strong desire for fluids; but they 
should not be gratified in every thing they wish for. They labour 
under a constant state of nervous irritation and restlessness, and 
will beg of you to do twenty different things to relieve their imme- 
diate feelings; but it would be just as improper to give them large 
quantities of drink every time they desire or call for it, as to in- 
dulge them in any momentary whim which may be the offspring 
of their disordered and changeable fancy. The continued swilling 
of even the most innocent fluids will bring on heaviness of stomach, 
nausea, pain, and flatulence, and predisposes to congestion and 
intestinal irritation. From the mere ingestion of a large quantity 
of the simplest fluid, you will frequently see well-marked symptoms 
of gastric irritation arise during the course of fever. This is not a 
picture drawn from imagination ; I have witnessed it on many 
occasions during the course of my practice. It is extremely painful, 
indeed, to be obliged to refuse drink to a patient labouring under 263 
TREATMENT OF FEVER. 
intense thirst; but you should never allow them to take a large 
quantity of fluid at a time : you should impress upon them the 
danger attendant on such a practice, and tell them that a spoonful 
or two, swallowed slowly, allays thirst more effectually than drink- 
ing a pint at a time. The sensation of thirst, as you all know, is 
almost entirely confined to the fauces and upper part of the pharynx, 
and it is as much relieved by a small quantity swallowed slowly 
and gradually, as by a large quantity gulped down at once. 
Besides the simple fluids, there are other drinks required in fever. 
Beer, ale, porter, wine, tea, and coffee, are also frequently used in 
the treatment of fever, and are of the utmost value when employed 
on appropriate occasions; they are adjuvants of the highest im- 
portance in the dietetic management of fever, and it will require 
some time to explain the rules by which you should be guided in 
their administration. I shall therefore speak of them according to 
the indications with which they are given ; and, first, of tea and 
coffee. You are aware that we are constantly in the habit of 
ordering medicines to diminish nervous irritation or restlessness, 
and to procure sleep ; but I believe we are not much in the habit 
of prescribing remedies which produce an opposite state of the sys- 
tem. We give sedatives and narcotics to tranquillise, to produce a 
species of exhaustion of the mental faculties, and to bring on sleep ; 
and I do not see any reason why we should not also administer 
expergefacients, or remedies calculated to maintain intellectual ac- 
tivity, and keep the patient awake. .Among those remedies which 
are most frequently employed for the latter purpose, are tea and 
coffee. You have lately seen the use we made of an infusion of 
green tea, in a case of narcotism which occurred in the fever ward. 
A man who was in the latter stage of fever, and labouring under 
great nervous excitement and total loss of sleep, was ordered an 
opiate enema, after we had tried various other means without suc- 
cess. During the course of the evening he got twelve drops of 
black drop, with two ounces of mucilage of starch, in the form 
of enema, and soon after fell into a sound sleep. When we came 
next morning and enquired after him, every thing was reported to 
have gone on well; the opiate enema had answered the purpose 
completely, and the man was still sleeping soundly. We found, 
however, on a more accurate examination, that he was in a kind 
of lethargic state, and could scarcely be roused. When addressed 
in a loud tone of voice, he raised himself heavily and slowly, half 
opened his eyes, gave a brief answer to our questions, and then, 
leaning back on his pillow, dropped asleep. Observe here the 
danger connected with this state. He was in an advanced stage of 
fever, had been restless and sleepless, and had suddenly passed to 
an opposite state. The rapidity with which coma had supervened 
on sleeplessness, and the danger of fatal congestion of the brain 
coming on, gave me considerable alarm. There was no use, how- 
ever, in thinking of what had been done ; the man’s state called for 
prompt and decided measures, and we proceeded at once to attack 
the symptoms of our own creation. One of the gentlemen went 264 
graves’s clinical lectures. 
down and got some green tea, of which he made a strong infusion, 
and administered a strong dose of it to the patient. This had the 
desired effect; the symptoms of coma gradually disappeared, and 
when I came to see him in the afternoon, he was quite out of dan- 
ger. Green tea was first introduced here as an expergefacient in 
the treatment of coma by Dr. Edward Percival, son to Dr. Percival 
of Manchester ; and some years back he read a paper at a meeting 
of the College of Physicians, in which he brought forward several 
cases of coma and stupor, in which green tea had produced the 
most favourable effects. On the continent they generally use strong 
coffee for the same purpose. Whether these beverages produce 
this effect by their influence on the circulation, or on the nervous 
system, I am not prepared to say; but there cannot be a doubt of 
their efficacy and value in many cases of this description ; and I am 
frequently in the habit of using both with this intention. 
While on the subject of expergefacients, I shall beg leave to read 
for you a very curious case from the 13th number of the Boston 
Medical and Surgical Journal, in which an expergefacient of a less 
agreeable character was employed to rouse a patient from the 
lethargic stupor brought on by a large dose of laudanum. There 
are some transatlantic peculiarities of expression in the detail of 
this case, but I have no doubt of its being correct. It is entitled 
“ a case of successful treatment by flagellation, where a large dose 
of laudanum had been taken.” And the author, Dr. Joseph Barrett, 
of Middleton, Connecticut, proceeds as follows:— 
“ Tincture of opium is not unfrequently resorted to for destruc- 
tive purposes. It is also, unfortunately, and too frequently, taken 
by mistake, and proves fatal before efficient means can be adopted 
to counteract its deleterious effects on the system. I am induced, 
therefore, to offer a short statement of a case of poisoning with 
laudanum that fell under my care several years since, for the fol- 
lowing reasons : first, the success that attended the mode pursued, 
and, secondly, from not having met with any such means recorded, 
to my knowledge,1 either in works on medicine, or in treatises on 
poisons.” 
Observe, it is not I that am speaking here, but Dr. Barrett, of 
Middletown, Connecticut. 
“In the year 1822, February 23d, I was called on to see Mr. 
Wright Harris, (this was in the state of New York,) who had 
intentionally taken a large dose of laudanum for the purpose of 
destroying himself. He had committed this act during his absence 
from home, under circumstances which it is not important to relate. 
Much time, about three hours, was therefore lost, before any effec- 
tual measures could be adopted for his relief. His case, as I found 
him, appeared to be altogether hopeless. Before my arrival, eme- 
tics and various drinks had been tried, besides frictions, and con- 
stant, though ineffectual attempts, had been made to irritate the 
1 This practice, though not generally adopted, has been recommended by 
several authors in Europe. FLAGELLATION IN A CASE OF POISONING. 
265 
oesophagus by feathers. All these means had failed, and the 
patient was in such a profound sopor, that apparently nothing but 
warmth remained to indicate that life had not already become ex- 
tinct. The quantity of laudanum taken was ascertained to he one 
ounce and a half. The case appearing so desperate, justified me 
in the course of treatment which I was, under existing circum- 
stances, then obliged to adopt. 
“ Internal remedies having entirely failed, there was no chance 
left but for high external excitements. I therefore determined to 
use vigorous measures. I commenced with flagellations, using 
long, pliant, fresh twigs to the palms of the hands and soles of the 
feet. These were briskly applied, and in a short time gave indica- 
tions of uneasiness and pain. This treatment was unremittingly 
pursued till the man spoke, and complained of being pained by the 
whipping, when this severe appliance was relaxed ; but on so 
doing, he instantly sunk into a profound stupor, from which he 
was again only roused by the severity of the whipping. It required 
the aid of a number of men to take turns in the flagellation, as well 
as to support and walk him about; for a cessation of the use of the 
rods was followed by instantaneous stupor. After about six or 
eight hours under this course, the stupor was lessened, and the 
severity of the flagellation mitigated ; but as the case required con- 
stant high excitement, it was still repeated at intervals, till event- 
ually the exercise of walking was sufficient to keep him awake. 
This was in about twelve hours from the commencing with the 
flagellation. He afterwards experienced but little inconvenience 
from his hands and feet, and was perfectly restored in a few days 
to his usual health. I would here state that the first proposal 
made by me to adopt flagellation, as the only hope, was objected to 
by the persons present, from its carrying with it the semblance of 
unkindness towards what was regarded by them as a corpse ; and 
it was not till the application of the rods by myself, in the first 
instance, that I obtained the aid of those present; but as soon as 
the patient began to move, and at last spoke, they took hold with 
alacrity, and by dividing themselves into relief parties, they very 
cheerfully, and rather amusingly, kept up the castigation so long 
as the state of the patient required it at their hands. He by no 
means seemed to relish this harsh proceeding, and in return gave 
his attendants several severe blows. If while lifting his arm to 
give a blow, the flagellation was then entirely suspended, the arm 
would instantly sink powerless ; to such a degree had the effects of 
the narcotic drug prevailed over the nervous system, that nothing 
but the torture of the rods could rouse him. On his recovery, it 
was said that the man’s wife was highly satisfied with this reme- 
dial course, which was believed to have a good effect upon his 
subsequent conduct.” 266 
graves’s clinical lectures. 
LECTURE Y. 
Treatment of typhus fever—Tympanites often the consequence of inattention to diet, 
or to overdosing with purgatives—Thirst in fever frequently dependent on the state 
of some internal organ—Blisters, employed as stimulants or evacuants, excite the 
vital action of the capillaries—An important remedy where cerebral affection is ap- 
prehended—Signs of approaching cerebral symptoms—Tartar emetic solution, and 
ointment—The latter used with success in some desperate cases. 
Before I proceed to speak of the diet and remedies to be employed 
in the treatment of typhus, allow me to make a few observations. 
There is a patient at present in the fever ward, whose case shows 
the necessity of strict attention and incessant watchfulness on the 
part of those who have the management of bad cases of fever. A 
man who has been labouring under delirium, with symptoms of 
cerebral excitement and congestion, was ordered the tartar emetic 
solution, with the view of reducing the increased vascular action ; 
but on enquiry this morning, we find that he has taken no medi- 
cine, and that his symptoms have been allowed to go on unchecked 
for twenty-four hours. He refused to take his medicine, and the 
nurse very improperly neglected to report the circumstances of the 
case, in order that proper steps might be taken to remedy so dan- 
gerous an omission. Thus a whole day has been lost at a most 
critical and important period of fever. There can be no excuse 
for such negligence as this, for it could be easily remedied. Pa- 
tients in this state have always more or less thirst, and a spoonful 
of the tartar emetic solution could be mixed with whey or cold 
water, and administered in this way without his knowledge, or if 
he refused to drink any fluid, it might be given in the form of 
enema. There is no excuse, therefore, for such negligence ; and 
when you recollect the state that such patients are in—their nervous 
excitement, incessant raving, agitation, struggling, and sleepless- 
ness—you will be able to appreciate the dangerous, and even fatal, 
consequences that may arise from culpable neglect of this kind. 
At our last meeting I spoke of the use of food and drink, and 
laid before you my views of the most appropriate articles of diet 
in the various stages of fever. I told you that I attributed much 
importance to the use of a proper regimen, and that I looked upon 
the observance of this principle as a main cause of success in the 
treatment of typhus. I think it is chiefly owing to our care in this 
respect, that so few of our patients have tympanites. Now and 
then we have cases of fever with tympanites and diarrhoea, but in 
the majority of instances, these are persons who have been under 
treatment before admission, and who have been too much purged. 
The use of drastic purgatives in the early and middle stages of 
typhus, is one of the most fertile sources of subsequent evil, and 
there are few evils of greater magnitude than tympanites with 
diarrhoea, and gastro-enteric inflammation, particularly in the latter 
stage of fever. Now, if you enquire into the history of the cases 
in which these symptoms are most distinctly marked, you will find TREATMENT OF FEVER. 
267 
that in at least two thirds, powerful cathartics have been employed, 
not once, but repeatedly, in the commencement of the disease. 
Almost all cases, in which calomel and colocynth, or aloes, fol- 
lowed by black draught, have been liberally used in the commence- 
ment, become tympanitic, frequently at a very early period. The 
same mischief, but in a less degree, is apt to occur where a system 
of strict abstinence has been enforced, and continued undeviat- 
ingly for a considerable length of time. Want of food, even in the 
healthy state of the system, is apt to produce flatulence, Aveakness, 
and distension of stomach, and in many instances gives rise to 
very serious forms of gastro-intestinal irritation. The diete absolue 
is very apt to produce the same effect in fever. Even the abuse of 
drinks of the simplest and most innocent description, is apt to pro- 
duce flatulence, distension, and a tendency to tympanites. Hence 
the value of the rule which I laid down in a former lecture, viz. to 
allow the patient only small portions at a time, and to order him 
to swallow them slowly. The abuse of the ordinary drinks, as 
common water, whey, barley-water, soda and seltzer waters, and 
effervescing draughts, is a frequent source of tympanitic swelling 
in fever. In this hospital we seldom prescribe effervescing draughts, 
and never give them in the ad libitum quantity which some per- 
sons recommend. Thirst can be sufficiently assuaged by the use 
of whey, or common water, acidulated with currant jelly or rasp- 
berry vinegar, given in small portions, and at certain intervals. 
Sometimes you will succeed effectually in controlling feverish 
thirst by the use of a very light infusion of cascarilla, acidulated 
with a small quantity of muriatic acid. I have seen this employed 
with success by Mr. Kirby, and I have often prescribed it myself 
with the best effects. Very often you will find that a small quan- 
tity of some light bitter, slightly acidulated, will appease the mor- 
bid thirst of fever more effectually, and for a much longer period, 
than large draughts of water, or any of the fluids usually employ- 
ed for the same purpose. You should always bear in mind, that 
thirst in fever does not exclusively depend on a dry or parched 
state of the mouth or fauces, but lies much deeper in the system, 
and has its origin in some peculiar derangement of the nerves, most 
probably of those belonging to the ganglionic system. In going 
through a fever ward, you will meet with numerous illustrations 
of the truth of this position ; for you will find one man with a 
moist tongue and fauces, and yet labouring under insatiable thirst, 
while you will observe another with parched tongue and throat, 
and yet without any desire whatever for fluids, or any choice as to 
their temperature. We had two examples of this in the fever ward 
during the past week. One patient with a moist tongue was inces- 
santly calling for drink, while another man, who had his tongue 
almost perfectly dry, exhibited a very remarkable indifference to 
fluids. 
There is one curious circumstance connected with the sensation 
of thirst in inflammatory diseases, which deserves attention. I 
lately attended a fatal case of metritis after delivery, in consultation 268 
GRAVEs’s CLINICAL LECTURES. 
with Mr. Hayden and Dr. Ireland. These gentlemen pointed out 
to me the singular fact, that the patient’s thirst was instantly in- 
creased to an intolerable degree, by pressure applied to the womb. 
I merely notice the fact here as being extremely curious, leaving 
the explanation of it to those who are more conversant with such 
investigations. 
Having said so much of food and drink in fever, I come now to 
speak of external and internal remedies, and first of blisters. 
Blisters are employed in a variety of diseases, but are followed by 
very different physiological effects, and capable of serving very 
different purposes, according to their mode of application. In 
fever they are generally employed either as stimulants, or as eva- 
cuants and derivatives. As stimulants, they may be used with the 
intention of rousing the depressed energies of the system in general, 
by their action on the nervous and circulating systems, or of sti- 
mulating the torpid functions of some particular part or organ. 
With this object in view, they are applied as flying blisters—that is 
to say, for a space of time not exceeding two or three hours, and 
solely with the intention of producing a stimulant effect. You 
have seen some cases of fever in our wards, in which the powers 
of life were greatly depressed, the extremities cool, the action of 
the heart feeble, the pulse weak, respiration short and imperfectly 
performed, and a tendency to faintness and sinking ; and you have 
observed that in such cases we derived great benefit from the ap- 
plication of flying blisters over the region of the heart, the epigas- 
trium, chest, and inside of the legs and thighs. We applied our 
blisters in these situations, left them on for two or three hours, and 
then removed them; and you have seen them, when employed in 
this way, succeed in rousing the vital energies, the depressed action 
of the heart, and capillary system, and the flagging state of the 
respiratory function, as shown by the increased strength of the 
pulse, the more general diffusion of heat, and the renewed play of 
the various functions. 
In such cases, where the stimulant effect alone is required, it 
would be wrong to leave the blisters on longer than two or three 
hours ; it will be quite sufficient if they prove merely rubefacient, 
or, at most, vesicate so slightly as to give to the blistered surface 
the appearance of a miliary eruption. Here you have all the sti- 
mulant effects of blistering, but not followed by their debilitating 
consequences. You are aware that blisters applied in the ordinary- 
way have a twofold effect; they first rouse, and then depress; 
acting primarily as stimulants, and secondarily as evacuants. 
They first act as stimulants, producing pain, heat, and redness of 
the part; after a few hours these symptoms diminish, and are fol- 
lowed by an effusion of serum—in fact, a quantity of white blood 
is abstracted from the cutaneous capillaries, and in this way an 
evacuation is produced, calculated to diminish any accidental con- 
gestion in neighbouring parts. The capillaries, by means of their 
increased action, draw a quantity of white blood to the part; and 
in saying this, I think I am only using a perfectly physiological TREATMENT OF FEVER. 
269 
expression ; for the quantity of circulating fluid in any part of the 
body must depend on the vital action of the capillary vessels of 
that part. It is to the peculiar state of the capillary vessels that 
the quantity of blood in any part is to be referred, and not to the 
force or frequency of the heart’s action. It is by means of changes 
produced in them that the phenomena of active congestion and 
inflammation are produced: the capillaries of the affected part 
enlarge, increase in number, and multiply, and those which were 
invisible become visible. These phenomena have been falsely at- 
tributed by Hastings and others to debility and impaired action of 
the capillaries. 
Enlargement or distension of the capillary vessels, whether the 
result of active local congestion or inflammation, is quite a different 
process, and bears a very close analogy to the enlargement of the 
anastomosing arteries of a limb in which the principal vessel has 
been tied. The afflux of blood, and the vascular distension, are 
not the consequences of debility or of relaxation, but of an actual 
increase of vital action. In the-enlargement of the anastomosing 
arteries which takes place in cases of collateral circulation, the 
increase of size is not confined to the arteries connected with the 
main trunk; it commences simultaneously in the more distant set 
of branches, beginning in the smaller ones, and then gradually 
extending to the larger. This is a proof that the enlargement of 
the vessels depends solely on a vital action inherent in themselves, 
and is not the result of a mere passive distension, or of an in- 
creased determination of blood to the part, produced by the action 
of the heart. 
Dr. Houston, in a very important paper on the circulation in a 
monstrous foetus, without head or brain, published in the last 
number of the Dublin Medical Journal, has proved almost to a 
demonstration, that, in the case referred to, the circulation in the 
placenta could not be carried on, unless by the vital attractive 
power of the capillaries. It is owing to this power that vascular 
tumours bleed so profusely when wounded or scratched : and yet, 
if you cut through the artery which supplies them, there will not 
be any considerable hemorrhage. When you divide the artery, 
the capillaries cease to draw blood to the part, and the hemorrhage 
is slight; but if you wound the tumour itself, the blood is attracted 
to the part as fast as it drains off, and a profuse hemorrhage is the 
result. 
You should also bear in mind, that there are many animals 
which are without a heart, and yet in which the functions of the 
circulation are adequately performed. We have numerous in- 
stances of human monsters born without any trace of a heart, and 
yet well nourished and developed. In cases of this description 
how is the circulation carried on, or by what power is the blood 
impelled through the vessels? Ido not see what cause we can 
refer it to, except the vital agency and attractive power of the ca- 
pillary system. I mention these facts because, in the treatment of 
inflammatory and febrile affections, it is important that you should 270 
graves’s clinical lectures. 
have correct physiological views, and that you should bear in mind, 
that each part and organ of the body may have its vital action de- 
ranged, or, in other words, may become congested and inflamed, 
independently of the action of the heart or the general circulation. 
Blisters, then, produce first increased action of a part, and then 
act as evacuants. They also stimulate the system generally; but 
if left on until full vesication is produced, they act as evacuants 
and depletives, and lower the general tone of the economy. I have 
frequently observed this succession of events in chronic cases, in 
which it was found necessary to blister repeatedly during the course 
of the disease. The patients generally told me that they felt better 
and lighter on the day on which the blister was applied, but on the 
next day they usually felt weaker and more depressed ; and this 
state-sometimes lasted more than a single day. You may therefore 
apply blisters as excitants and stimulants, or you may employ them 
as evacuants and depletives; yet there are many persons who seem 
to forget this distinction. If in a case of inflammation, occurring 
in a low state of the system, you propose to apply a certain number 
of leeches over the inflamed organ, they say no ; but they have no 
hesitation in applying a large blister, leaving it on until it produces 
full vesication, and thus abstracting a considerable portion of white 
blood from the system. 
You will not expect me to lay down any general rules for the 
use and application of blistering in fevers ; you will find all these 
matters sufficiently explained in your books and manuals. I am 
not giving any thing like a regular outline of the treatment of 
fever; in fact I pass, per saltum, from one point to another, without 
any attention to order or method. You can read methodical trea- 
tises, and then compare them with such detached observations as I 
shall make. And here allow me to make some detached observa- 
tions on that peculiar state of the brain which we most commonly 
observe in the middle stage of typhus, and in which blisters form 
one of our most efficient, and in some instances our only mode of 
relief. In many of the cases of typhus which come under our 
observation in hospital, we frequently meet with a train of symp- 
toms strongly calculated to perplex and puzzle, and which should 
seldom exist in fever regularly treated ; these are chiefly cases 
which are admitted in the middle or latter stage of the disease, and 
at a period when the patient’s state of intellect is such as to preclude 
the hope of obtaining any satisfactory information from a personal 
examination. 
A man in the lowest class of life, and at a distance from medical 
aid, is attacked with fever; for the first eight or ten days he is 
either improperly treated or altogether neglected, and in this state 
symptoms arise and superinduce others, giving rise to the most 
unfavourable complications, and rendering the cure difficult, if not 
impossible. Now of all the symptoms which occur in cases of 
fever, where the state of the principal organs has been neglected, 
there are none more formidable, or more fatal, than the cerebral; 
nor is there any local affection in fever, in which the value of pre TREATMENT OF FEVER. 
271 
vention is so unequivocal and decided. What I wish to impress 
upon you is, that you should always anticipate the cerebral symp- 
toms in fever. Never allow the cerebral symptoms to explode— 
watch the first scintillas of cerebral excitement—repress the com- 
mencing mischief, and do not allow your patient to be overtaken 
by formidable inflammation of the brain. This is one of the points 
in which I have changed my practice. I never allow cerebral 
symptoms to become established in any of the cases which I have 
treated of late. Every writer will tell you that when the patient’s 
face is flushed, his eyes suffused, and when he complains of head- 
ache and intolerance of light, you should leech and blister his 
head, give him purgatives, tartar emetic, James’s powder, and the 
medicines calculated to bring down cerebral excitement: but a 
careful and observant practitioner will anticipate all these symp- 
toms, although there is as yet no particular flushing of the face, 
headache, or suffusion of the eyes ; and though the patient is still 
quite rational, he will recognise threatening disease of the brain 
long before it commences, and take proper steps to prevent its ex- 
plosion. Watch the functions of the brain attentively, and they 
will inform you, in almost every case, of the approach of cerebral 
symptoms. You will find in patients who are about to have cere- 
bral symptoms, a degree of restless anxiety, and a higher degree 
of energy than accords with their condition ; and they either do 
not sleep at all, or their sleep is broken by startings and incoherent 
expressions. When you speak to a person in this state, he answers 
in a perfectly rational manner; he will tell you that he has little 
or no headache ; and were you to be led away by a hasty review 
of his symptoms, you would be very likely to overlook the state of 
the brain. If you enquire closely, you will find that he scarcely 
ever sleeps, or even dozes—that he is irritable, excitable, frequently 
incoherent, and muttering to himself. Under such circumstances, 
although there is no remarkable heat of scalp, suffusion of the eye, 
or headache, I am frequently led to suspect the supervention of 
cerebral symptoms, particularly about the ninth or tenth day of 
the fever (for it is generally about this period that cerebral symp- 
toms begin to manifest themselves); and whenever I observe these 
premonitory indications, I never hesitate in taking proper measures 
to anticipate the evil. I immediately order the hair to be shaved 
off, and blister the whole scalp. Thus, at the period when disease 
of the brain would most probably have set in, I have the whole 
external surface of the head pouring out serum, or even suppurat- 
ing : and when by this treatment I have opposed a barrier to the 
further progress of the disease, the exhibition of a little tartar 
emetic will soon remove every trace of it. In laying down this 
plan of treatment, I have supposed that the patient has been pro- 
perly treated from the beginning, and that the earlier symptoms of 
inflammatory excitement have been combated by bleeding, leeching, 
and other appropriate depletory measures. 
There is, on the other hand, an opposite state of the patient, 
which in like manner informs me that danger to the brain is at 272 
graves’s clinical lectures. 
hand. In this case, the patient is almost continually sleeping. 
When you enter his chamber in the morning, and ask how he does, 
his attendant generally tells you that he has passed the night most 
favourably, and that he has slept without almost ever waking since 
your visit on the preceding afternoon. If he awakens to take 
drink, he quickly drops asleep again, and when you arouse him he 
looks rather heavy; there is some slight effusion of the tunica 
adnata, and some appreciable congestion about the external parts 
of the face and head. Persons in this state, though apparently 
doing well, and even where they have been properly treated in the 
beginning, about the ninth or tenth day begin to rave, and exhibit 
undoubted proofs of congestion and excitement of the brain. Now, 
in all cases of this description be on your guard, and do not allow 
symptoms of dangerous import to steal on you. Here you will 
derive great benefit from the use of blisters. I was lately called to 
a very remarkable case of this kind, at some distance from Dublin. 
The patient slept almost constantly, and complained of no head- 
ache or heat of scalp. From an attentive examination of the case, 
however, I was led to predict the approach of cerebral symptoms. 
Observe, this was a case of spotted fever; and in this form of 
fever you can predict the occurrence of such symptoms with a 
greater degree of confidence. The patient’s pulse was 96, his 
tongue presenting nothing worthy of remark, his behaviour and 
speech rational, and his sleep almost constant. Recollecting, how- 
ever. the period of the fever, and observing carefully the condition 
of the cerebral functions, I had his head shaved and blistered. 
Notwithstanding this precaution, his cerebral symptoms had pro- 
ceeded so far that he subsequently got a slight attack of paralysis 
of the face and tongue, accompanied by a fixed state of the pupils, 
which would neither contract nor dilate. After having blistered 
his head extensively, I gave him the tartar emetic solution, to the 
amount of one eighth of a grain every second hour. These mea- 
sures were completely successful in removing the cerebral symp- 
toms, and I have no doubt that the active precautions which had 
been taken were the means of saving his life. 
Now there is one symptom connected with cerebral excitement 
in fever which is well worthy of your notice, as its existence is 
often sufficient of itself to give timely intimation of the approach 
of irritation or inflammation of the brain. This is, the state of the 
respiratory function. In fever, the breathing will often announce 
the approach of cerebral symptoms for days before their actual 
occurrence. When, in cases of typhus, you find the patient’s 
breathing permanently irregular, and interrupted by frequent sigh- 
ing—when it goes on for one or two minutes at one rate, and then 
for a quarter or half a minute at another rate, you may rely upon 
it that sooner or later an affection of the brain will make its ap- 
pearance. You will frequently observe the same kind of breathing 
preceding attacks of apoplexy and paralysis, and indeed it was the 
occurrence of this symptom, in these and other cases in which the 
functions of the brain were deranged, that first drew my attention TREATMENT OF FEVER. 
273 
to this kind of breathing. The first time it engaged my attention 
was in a remarkable case of an apoplectic nature, which I sat up a 
whole night to watch. On recollection, I found that I had fre- 
quently observed an analogous state of the respiratory function in 
fever, on several occasions, although its connection with excite- 
ment of the brain had not struck me before. I speak here of irre- 
gularity of breathing, independent of any pectoral affection. But 
when the patient breathes in a permanently irregular manner, at one 
time at a certain rate, and at another at a different rate,—when his 
respiration is suspicious and heaving, without any disease of the 
chest or great debility,—you will have some grounds to suspect the 
existence of cerebral derangement. I am in the habit of calling 
this kind of breathing cerebral respiration, because my experience 
has told me that it is almost invariably connected with oppression 
and congestion of the brain. To recapitulate:—When you find a 
patient in fever lying constantly awake, or when, on the contrary, 
you find him continually slumbering,—when there is a certain 
quickness of manner and irritability,—and when the cerebral re- 
spiration has been noticed for some time, without any concurrent 
debility or pulmonary disease,—under such circumstances, you 
may, in cases of maculated typhus, predict the approach of cere- 
bral symptoms ; and the period about which they generally mani- 
fest themselves, is the eighth, ninth, or tenth day. Now, in cases 
of this description,—if you have previously used leeches and anti- 
phlogistics to a sufficient extent,—your best plan will be to shave 
and blister the whole scalp. Dr. Little, of Belfast, and Mr. Kirby, 
of this city, have fallen into the same train of ideas, and employ 
blisters at a very early period of the disease, with the view of com- 
bating cerebral excitement. In a recent instance, in private prac- 
tice, I think I saved the life of a young gentleman in Harcourt 
street by extensive blistering of the scalp on the fourth day of fever. 
We were not accustomed to blister at this early period of fever. 
Formerly it was the practice to bleed and apply leeches for several 
days together, and never to have recourse to blistering until to- 
wards the latter stage of the disease. In common inflammation, or 
in arachnitis, we do not blister until we have carried depletion by 
the lancet, leeches, and purgatives, as far as the patient’s strength 
will allow. But this is not the case in fever: the cerebral conges- 
tion and irritation, or inflammation, (call it which you will,) which 
accompanies typhus, differs essentially from ordinary arachnitis or 
encephalitis, and requires very often a treatment strikingly dif- 
ferent. 
One physiological fact connected with sleep may be noticed here. 
It has been stated by Mr. Mayo, that the pupils are contracted 
during sleep. This is in itself a very curious fact, and I was 
anxious to verify it. Now we had an excellent opportunity yester- 
day morning of trying what the state of the pupil was in two pa- 
tients who lay soundly sleeping in the fever ward. We came up 
softly to them as they lay on their backs, and in a most favourable 
situation for observation, just under one of the windows ; and 274 
graves’s clinical lectures. 
having opened the eye-lids, found that the pupil was actually con- 
tracted to the size of a pin-hole. It remained in this state for a 
while, and then expanded, when they awakened. This is a very 
curious fact, and appears to be a very beautiful instance of the pro- 
tective care of nature. To protect the eye while we sleep, nature, 
as it were, draws the curtain, and thus defends the delicate organ 
from any accidental dazzling, at a period when consciousness slum- 
bers, and is oft' its guard. 
Blisters applied extensively to the shaven scalp, are not only 
valuable in fever, but also in other diseases, and that under cir- 
cumstances in which little benefit could be expected. The same 
effects may be produced by rubbing the whole scalp with tartar 
emetic ointment; but from the pain and inflammation it produces, 
this proceeding is seldom adopted. I have, however, occasionally 
employed it; and on two recent occasions with the most fortunate 
results. A friend of mine had lost two children from hydrocepha- 
lus. About five weeks ago another child, an extremely fine boy, 
was attacked with symptoms of the same disease. After having 
laboured for a fortnight under fever, with great restlessness, vomit- 
ing, and diarrhoea, he was observed to utter frequently that faint 
cry which is so characteristic of hydrocephalus, and to roll his 
head constantly from side to side. These symptoms were soon 
afterwards succeeded by constant motions of the right arm and leg, 
and subsequently by paralysis of the opposite side. I was con- 
sulted before the paralysis occurred, and advised the child’s father 
to have the whole of the blistered scalp well rubbed with tartar 
emetic ointment. The boy recovered completely. I derived also 
a very striking advantage from the use of the same remedy in a 
very remarkable epidemic which attacked a family in the neigh- 
bourhood of Rathmines, and which was witnessed throughout its 
whole course by my friend Dr. Burke and myself. One of the 
family, a young lady, was attacked with symptoms of fever, ac- 
companied by pain in the back of the head and stiffness of the 
neck. After a few days, symptoms of inflammation of the cere- 
bellum and upper part of the spinal cord became developed. About 
the seventh day she got strabismus, and soon afterwards was at- 
tacked with convulsions : the pupil became permanently dilated, 
and she was quite blind. I was called to see her at this period, 
and found her almost in a state of insensibility, with involuntary 
discharge of urine and faeces, cold extremities, and irregular pulse. 
Thinking that nothing could be done for her, I was about to leave 
the room, when I asked the nurse, could she swallow ? She re- 
plied she could, and immediately proceeded to offer the young lady 
some drink, which she swallowed without any difficulty. This at 
once arrested my attention. I said to myself, if this patient can 
swallow, she must be still conscious, and while she is so, there is 
a chance of saving her. I ordered the whole of the scalp, which 
had been previously blistered, to be rubbed with tartar emetic oint- 
ment ; violent inflammation ensued, and she recovered completely. 
But the curious part of the case is this:—her brother and sister 275 
were attacked, in exactly the same way, a few days afterwards, 
although less formidably, and were cured by the same treatment. 
Shortly afterwards two of the servants got pain in the back of the 
head and stiffness of neck, followed by signs of an inflammatory 
affection of the cerebellum and spinal cord. They were treated in 
the same way, and recovered. 
What could be the cause of this peculiar fever, manifesting itself 
in exactly the same way in all the individuals of the family who 
were attacked? I endeavoured to arrive at the cause, but could 
not; and I merely state the facts, without wishing to attempt any 
thing like an explanation. But the history of this extraordinary 
form of disease is exactly as I have told you. It has been witnessed 
by Mr. King and Dr. Burke, and they, as well as myself, were 
very much struck with the novelty of the phenomena. 
TREATMENT OF FEVER. 
LECTURE YI. 
Further remarks on the treatment of fever—Management of delirious patients—Advan- 
tages of tartar emetic in the form of enema—Subsultus tendinum sometimes from 
disturbance of the nervous extremities, independently of the brain or spinal cord— 
Vomiting and purging at the commencement of fever, indicative of cerebral affection 
—Scrofulous inflammation of the brain—Chronic scrofulous fever. 
In speaking of the use of drinks in fever, I alluded to the abuse 
of soda or seltzer water, and effervescing draughts. It is very much 
the custom both in hospital and private practice, to look upon the 
latter as a remedy which may be administered at the pleasure of 
the patient, or the discretion of the nurse. They are certainly to 
many persons a most grateful means of cooling thirst; but the 
cautious physician will never allow his patient to indulge too much, 
for he knows that their frequent use distends the stomach, and 
produces a tendency to tympanites and bowel complaint. I am 
also of opinion that the exhibition of large quantities of free car- 
bonic acid is a very doubtful, if not a dangerous, practice in fever, 
and may increase that tendency to narcotism and functional de- 
rangement of the nervous and respiratory systems, which is ob- 
served in every case of genuine typhus. In addition to this, the 
evolution of a large quantity of fixed air in the stomach frequently 
causes a very disagreeable sense of distension and suffocation, and 
acts injuriously on the mucous membrane. 
Allow me here to digress a moment from my subject, and make 
a few observations on a case which terminated fatally in our wards 
within the last twenty-four hours. I wish to call your attention to 
this case more particularly, as I think a different plan of treatment 
might have succeeded in saving the man’s life. This man was 
admitted into the fever ward about the seventh or eighth day of 
his illness. I cannot exactly state how he was treated in the com- 276 
graves’s clinical lectures. 
mencement, but I believe he was very badly attended, and that the 
state of the principal organs was wholly neglected. It will be 
sufficient to state, that when he came under our care the chief fea- 
tures of his case were delirium, accompanied by total want of 
sleep, and a violence of conduct and behaviour calling for the re- 
straint of the strait waistcoat. Now under circumstances of this 
nature the most diligent attention and promptitude are imperatively 
demanded on the part of the physician, and every step calculated 
to anticipate danger should be instantly taken. I regret to say that 
I did not at the time take a correct view of the treatment, or pre- 
cautions necessary to be adopted under such exigencies. I did not 
expect that the case would terminate fatally in such a short time, 
and I anticipated benefit from the remedy prescribed. He was 
ordered to take the tartar emetic solution in full doses ; but on visit- 
ing him next morning, we found that he had obstinately refused 
to take his medicine, and that his symptoms were greatly ag- 
gravated. 
In delirium of this kind it is certainly very difficult to manage 
the patient, and we are frequently obliged to have recourse to force 
or stratagem to make him take his medicines. I regret extremely 
that this man’s head was not leeched on his admission, as, from 
the state of his pulse, I think he would have borne it well. Eight 
leeches might have been applied to his temples, and repeated two 
or three times the same day, according to the state of his pulse and 
strength. I think I was wrong in contenting myself withordering 
the tartar emetic solution and a blistbr to his head, and I should 
have anticipated from the violence of his behaviour that it would 
be very difficult to manage him. 
In cases of this kind, where it is necessary to give tartar emetic, 
(and this is one of the best remedies you can employ in cases of 
cerebral excitement in fever,) you should be always prepared to 
obviate any omission arising from the obstinacy of the patient; and 
when he will not take his medicine voluntarily, you may secure 
its effects on the system in two different ways. In the first place, 
it may be secretly mixed with the patient’s ordinary drink ; and as 
such persons are generally thirsty, and seldom refuse drink alto- 
gether, an intelligent nurse will readily find means to make the 
patient take a sufficient quantity of it to secure its full effect on the 
cerebral circulation. 
Another expedient which you may resort to on similar emergen- 
cies, is to give the tartar emetic in the form of enema. I had re- 
course to this plan some time back, in a similar case of delirium, 
and with the best results. After leeching the head, I gave the so- 
lution of tartarised antimony in enema; and this can be always 
done, whether the patient likes it or not, if you take care to prevent 
his struggles by confining him in a strait waistcoat. The best 
way of administering it is to dissolve two or three grains of tartar 
emetic in four or five ounces of mucilage of starch or isinglass, 
and inject it with the aid of a long flexible tube, so as to make the 
contents of the syringe pass high up into the bowel. In this way TREATMENT OF FEVER. 
277 
you can secure all the good effects of tartarised antimony in over- 
coming the congestion of the brain, and procuring sleep. In all 
cases of alarming congestion of the head in fever, I have been long 
in the habit of using tartar emetic in this way, if the stomach be 
deranged, and incapable of bearing it safely; and I can assure you 
that it is a most fortunate thing to have such a powerful resource 
in all cases of the kind. I have also not given expec- 
torant medicines in the same way, where from the state of the 
stomach, or the debility of the patient, the ordinary remedies could 
not be administered by the mouth with sufficient rapidity, or in 
sufficient quantity to produce the desired effect. In this way I have 
often given the infusion of ipecacuanha—a remedy of very consi- 
derable value, and not sufficiently appreciated by most modern 
practitioners. I may also remind you that vomiting, and all the 
benefits derivable from it, may be likewise produced in this way. 
Now where the stomach is irritable, and yet there exists a necessity 
for such remedies, it is a very fortunate circumstance to be in pos- 
session of a means of employing them without inflicting any injury 
on the stomach, and thus counterbalancing the good effects of the 
remedy by the injury done to the stomach. Of course the cases 
in which these expedients are required are comparatively rare, but 
the practical physician must be always prepared for such exigen- 
cies, and be provided with every means of meeting them. 
Another of our patients died also within the last few days in the 
fever ward. He laboured under a very bad form of maculated 
fever, and when admitted was evidently in a hopeless state. I 
shall not say any thing about this case, except to use it as an occa- 
sion for making a few observations on a particular state of the 
cerebro-spinal system, which we not unfrequently observe in cases 
of maculated typhus, and occasionally in other varieties of fever. 
Now you observed that this man had not the slightest tendency to 
sleep ; that he lay with his eyes constantly open, raved incessantly, 
had subsultus tendinum, floccitatio, and cold extremities, and often 
attempted to get out of bed. Yet we could not find in him any 
thing like decided evidence of cerebral inflammation. The tunica 
adnata was of a clear pearl-white, the face pale, and the scalp and 
integuments of the face cool. You perceive, then, that sleepless- 
ness, delirium, and subsultus tendinum, may depend on a state of 
the nervous system having no connection with congestion of the 
brain, or determination of blood to the head. This occurrence has 
struck me very forcibly in many cases of fever. But I have been 
most particularly struck with the occurrence of subsultus tendinum 
in such instances. In the present case we had a patient with 
sleeplessness and subsultus. But this concurrence of symptoms 
does not always exist. You recollect the case of the boy in the 
small fever ward, who laboured under excessive subsultus, and to 
whom we gave the spirit of turpentine in dram doses with so much 
benefit. Yet this boy, as you all remember, slept remarkably well. 
I have frequently pointed out to the class patients labouring under 
subsultus tendinum, who slept well, and in whom the tunica 278 
graves’s clinical lectures. 
adnata was of a pearl-white colour, without the slightest suffusion. 
We have subsultus, therefore, occurring in two very opposite states 
of the nervous system; we have it accompanied with loss of sleep, 
and we have it existing in that condition of the system where the 
patient slumbers long and heavily, and cannot be easily roused. 
Hence I was inclined to think that the cause of subsultus resides 
not so much in the nervous centres as in their extremities. I 
would even go so far as to advance the proposition, that if it were 
possible for the fever to go on, and life to continue after the remo- 
val of the brain and spinal cord, I am quite sure that the subsultus 
would continue. I am almost confident that subsultus tendinum is 
the result of some derangement of the nervous extremities. I have 
shown on a former occasion, when lecturing on the subject of pa- 
ralysis, that the nervous periphery may become diseased primarily, 
and without any antecedent affection of the brain or spinal cord. 
I think it extremely probable that in fever the nervous centres are 
subject to certain derangements producing coma, sleeplessness, and 
delirium, but that there are other nervous symptoms which are to 
be referred rather to a derangement of the nervous extremities, and 
among the latter I would particularly include subsultus tendinum, 
a symptom which we find co-existing with such opposite conditions 
of the nervous centres. 
But to return to the case to which I first alluded. Never blister 
in the early stage of fever, until you have applied leeches in suffi- 
cient quantity. In this case, it is true, we could not well ascertain 
what the period of the fever was ; for the man was brought in in 
a state of delirium, and there was nothing known respecting his 
previous history. Yet you are all aware that a great deal must 
depend on our knowledge of the period of the fever, and the medi- 
cines which have been employed. Had we been acquainted with 
these circumstances, it is probable we would not have fallen into 
the error we committed. What I wish to impress on you, is, that 
in all cases of maculated typhus, you should be careful in examin- 
ing the head and ascertaining whether there are any evidences of 
cerebral congestion present. If there is headache, strong pulsation 
of the carotids, suffusion of the eyes, and heat of the face and 
scalp, along with the other signs of functional lesion of the brain 
present, you should always have recourse to leeching; beginning 
cautiously, and continuing their application as long as the patient 
will bear it with safety. When you have the symptoms already 
mentioned, and the patient is in the early stage of fever, you may 
commence by applying one or two leeches to the nostrils, or six or 
eight to the temples, or behind the ears, repeating them two or 
three times a day, according to the exigency of the case. The best 
way of using leeches is to apply them in small numbers every six 
or eight hours, so as to keep up a constant drain from the head. 
After you have leeched sufficiently, you may then have recourse 
to blisters. In making this change, much will depend on the saga- 
city and skill of the practitioner; for it requires no ordinary tact to 279 
hit on the proper time when you should give up leeching and com- 
mence with blisters. 
TREATMENT OF FEVER. 
I shall make no apology for introducing here what I consider to 
be an important observation, with reference to the pathology and 
treatment of fever. We had a striking instance of the fact on 
which I am about to offer some comments, in the case of a little 
girl who died lately here, in a very remarkable manner. I men- 
tioned in a former lecture, that vomiting and purging in the com- 
mencement of fever are, generally speaking, indicative of a cerebral 
affection. Every fever which commences with vomiting and 
diarrhoea, whether it be scarlatina, or measles, or typhus, is a fever 
of a threatening aspect; and in all such fevers the practitioner 
should be constantly on the watch, and pay the most unremitting 
attention to the state of the brain. There is much difference be- 
tween the vomiting and diarrhoea of gastro-enteritis and this cere- 
bral diarrhoea and vomiting. The latter sets in generally at a very 
early period of the disease, perhaps on the first or second day, and 
is seldom accompanied by the red and furred tongue, the bitter 
taste of the mouth, the burning thirst, and the epigastric tender- 
ness, which belong to gastro-enteric inflammation. There is also 
another source of diagnosis, but of a less valuable kind; and this 
is founded on the results of treatment. Gastro-enteric vomiting 
and diarrhoea are relieved by leeching the belly; but I need not 
tell you that this mode of treatment can have no effect on the 
vomiting and purging produced by cerebral disease. There is also 
another source of diagnosis: the vomiting and diarrhosa which 
results from gastro-enteric inflammation is never accompanied by 
such copious discharges of bile as that which depends on disease 
of the brain. In diarrhasa from derangement of the brain, the 
quantity of bile passed is very remarkable ; and it is equally cu- 
rious, that when vomiting follows derangement of the cerebral 
circulation, in ordinary cases, and without fever, bile is thrown up 
in very large quantities. This is frequently observed in persons 
who become sick from swinging, or sailing. In such instances, a 
larger quantity of bile is vomited than could occur from mere gas- 
tric irritation. Now in the commencement of cerebral disease, 
where congestion or inflammation is present, one of the first symp- 
toms is copious vomiting, and purging of a bilious character. 
This is very often the case in scarlatina, and there are few cases in 
which there is more danger to be apprehended. We had these 
symptoms, under very unfavourable circumstances in the little 
girl to whom I have just alluded. From the imperfect history of 
the case which we were able to obtain, it appeared that she had 
been ill of fever for fourteen days before her admission, and had in 
addition a severe attack of bronchitis and pneumonia. She then 
got inflammation of the stomach, and finally congestion of the 
brain, as indicated by the cerebral vomiting and purging. We 
employed every means in our power to check these symptoms, but 
without success ; she went on from bad to worse, and she ulti- 
mately sank under a combination of affections, which you will 280 
graves’s clinical lectures. 
frequently observe in many forms of disease as well as in fever; 
and it is to this point in particular that I wish to direct your atten- 
tion. You will frequently observe that at a certain period of fever, 
whether it be inflammatory, nervous, bilious, or typhoid,—and 
very often in other forms of disease, whether depending- on a gene- 
ral affection of the system, or connected with inflammation of 
important organs, when the patient has been going on pretty well 
for some time,—you will find that about the period when you would 
naturally expect that the fever would go off, and convalescence 
begin, a new form of fever makes its appearance, and carries off 
the patient in spite of all your exertions. To this form of second- 
ary fever I would give the name of scrofulous, because it resem- 
bles in its chief features the intractable form of fever which is 
frequently observed in persons of an originally scrofulous habit, or 
who have become so from the abuse of mercury or other debilitat- 
ing causes. This is a form of fever which is not well understood, 
and I am not acquainted with any author who has devoted to it 
that share of attention to which, from its great importance, it has 
such decided claims. Its chief characters are, that the patient, 
during its existence, exhibits a strong tendency to inflammatory 
affections, which bear a close analogy to the scrofulous, both in 
their intractable character, in the facility with which they pass 
from one organ to another, and in their frequently unfavourable 
termination. A patient of this description, while labouring under 
fever, will frequently exhibit a very remarkable succession of in- 
flammatory affections. If, during the course of his fever, he gets 
an attack of gastro-enteritis, you will have great difficulty in 
managing it; and no sooner is this overcome, than he is seized 
with bronchitis or pneumonia; and when, by great care and the 
most skilful treatment, you have overcome this also, he gets scro- 
fulous inflammation of the brain, and dies. Now you will fre- 
quently meet with patients who, during the course of typhus, will 
be attacked with this bad form of fever, and get what may be 
termed scrofulous inflammation of the brain, which carries them 
off in five or six days, in spite of all your care. You are aware 
that persons who are much in the habit of observing diseases of the 
brain, can generally distinguish between scrofulous inflammation 
of the brain and its membranes and that inflammation which occurs 
in persons of healthy habit. In cases of the latter description, the 
treatment, if commenced at the first appearance of the disease, is 
simple and successful. Appropriate bleeding and leeching, with 
the use of calomel and James’s powder, are almost always suffi- 
cient to accomplish a cure. When once you have succeeded in 
touching the gums with mercury, the patient’s safety is tolerably 
certain, and recovery is in general rapid; but in the scrofulous 
affections of the brain, although you may have fully mercurialised 
your patient, you will too often discover that you have merely 
retarded the progress of the complaint for a brief period ; it returns 
again, and carries him off in spite of all your efforts. In the 
scrofulous hydrocephalus, a much greater time elapses from the TREATMENT OF FEVER. 
281 
appearance of coma and strabismus until death takes place, than in 
the ordinary forms of meningitis. This fact was well illustrated 
in the case of the little girl to which I have just now referred: she 
continued to live on for a long time after the appearance of symp- 
toms which you would think ought to terminate fatally in a few 
hours after they had become developed. There is also a great deal 
of irregularity in the way the symptoms come on in cases of scro- 
fulous inflammation of the brain. Sometimes blindness is one of 
the first symptoms. I recollect having been called, with Dr. 
Beatty, to see a very fine boy, living in Merrion square, and was 
very much struck, on entering the drawing-room, to find him 
walking about, and in apparent good health, but quite blind. 
Here amaurosis was the first symptom. This was subsequently 
succeeded by others, and he died in a convulsive fit about a fort- 
night afterwards. 
We have many excellent observations on the chronic scrofulous 
fever, but I think that there is no author who has described this 
acute form with the precision and care which it deserves. It is, 
however, a very frequent form of fever, and you will see many 
examples of it among the chronic patients in the medical and sur- 
gical wards. You will frequently observe persons who are labour- 
ing under acute disease, from accidents or other causes, become 
feverish and ill again at a time when you expected a remission of 
their symptoms, or even recovery; and, without any assignable 
cause, they will get scrofulous inflammation of some other part 
or organ, and quickly fall into a state of hopeless and incurable 
disease. 
LECTURE VII. 
Scarlatina without eruption, followed notwithstanding by desquamation—Thoughts on 
the nature of desquamation—Latent scarlatina, followed by anasarca—General pro- 
position respecting the symptoms of animal poisons—Morbid appearances after 
delirium in fever—Treatment in anticipation of cerebral symptoms—Great advan- 
tage of blisters judiciously employed—Notice of the old mode of blistering. 
Before I resume the thread of my discourse, permit me to men- 
tion some curious facts recently observed. Dr. Marsh and I 
attended, not long since, a lady who had been affected for some 
days with fever and sore throat. She had no eruption on any part 
of her body, but from the character of the fever, and the peculiar 
appearance of the throat, we suspected she was labouring under an 
attack of scarlatina. Her family were very anxious to ascertain the 
precise nature of her complaint; and I visited her twice a day for 
the first four or five days of her illness, carefully examining the 
skin at each visit, but could not discover the slightest trace of an 
efflorescence of any description. She continned for several days to 282 
graves’s clinical lectures. 
suffer from the fever and sore throat, and was at one time in a dan- 
gerous condition, but ultimately recovered by great care and the 
use of appropriate remedies. Now I watched this case from the 
sixth hour after its commencement to its termination, and repeat- 
edly examined the skin, particularly that of the breast, abdomen, 
and inside of the knee and elbow joints, places in which the erup- 
tion shows itself when it appears at all, but could not discover any 
vestige of it. You will often find a diffused redness about the 
knees and elbows, in cases where the eruption does not appear on 
any other part of the body ; but in this instance there was not the 
slightest deviation from the natural hue. Yet the result proved 
that it was scarlatina ; for the desquamation of the cuticle, which 
always attends this disease, took place, and the lady communicated 
the infection to several members of the family. A young gentle- 
man residing in the house got a bad attack of scarlatina, two of the 
servants were also attacked, and the lady’s father got sore throat; 
in fact, there could be no doubt as to the nature of the disease. 
During her convalescence she had desquamation of the cuticle; 
and this is a point to which I would particularly call your atten- 
tion. We are taught to look upon desquamation as the result of 
cutaneous affections of an inflammatory character; and it is an 
opinion very generally maintained, that in scarlatina, as in psoriasis, 
the peeling off of the cuticle depends on a peculiar state of the skin 
produced by inflammation. It is stated that the increased vascu- 
larity of the skin occasions a morbid secretion, and subsequent 
detachment of the epidermis, and that the same phenomenon is 
observed in all cutaneous affections of an inflammatory character. 
This may be generally, but not universally, true; for here we had 
an extensive desquamation of the cuticle without any eruption, 
without any previous redness, pain, or remarkable heat; in fact, 
without any of the phenomena which are regarded as constituting 
inflammation. This seems to prove that there is something more 
than inflammation concerned, as preparatory to that process which 
is termed desquamation, and that the change which the skin under- 
goes is not to be looked upon as a mere consequence of inflamma- 
tion occupying the external surface of the corium. 
Another curious fact observed in this lady’s case: since the 
attack which I have just described she has been shedding her 
nails; that is to say, the nails of the fingers are all dropping off, 
and yet there is no appearance of inflammation of any kind about 
the hands to explain the occurrence. You are, of course, all aware 
that the dropping off of the nails is a species of desquamation. 
From the peculiar structure of the nail, and the mode in which it 
is formed in the matrix, it does not drop off at once like a scale of 
epidermis ; still I think we are authorised in looking upon the 
shedding of the nails as a species of desquamation. This affords 
a very curious subject for investigation, as connected with the his- 
tory of fever. It is an opinion entertained by many persons, that 
desquamation of the skin takes place at a particular period of typhus, 
and that this is not an occasional, or varying, but a constant and TREATMENT OF FEVER. 
283 
general phenomenon. This statement has been put forward most 
strongly by Dr. Perry, of Glasgow ; and he is also of opinion, that 
the period in which typhus is most contagious is during the des- 
quamation of the cuticle. It is also asserted, that scarlatina is more 
contagious during desquamation than at any other period of the 
disease. This is at least the popular idea ; how true it may be my 
experience or observation does not enable me to decide; nor am I 
prepared to offer any thing like an explanation of the occurrence. 
All I shall say on the present occasion is, that the occurrence of 
desquamation of the cuticle in typhus, and in cases of scarlatina 
without eruption, has greatly altered my ideas as to the connection 
between it and cutaneous inflammation. I think, at least, that the 
process of desquamation in such cases is very different from inflam- 
mation, and that the morbid action of which desquamation is the 
result, has very little in common with the ordinary process of in- 
flammation of the cutaneous surface. 
A gentleman who is in the habit of attending my lectures informs 
me that he has seen three cases of this form of scarlatina, character- 
ised by the absence of the external efflorescence. They occurred 
in young persons, after puberty, and between the ages of fifteen and 
twenty-five. Each of these cases exhibited a considerable degree of 
fever, with increased quickness of pulse, thirst, heat of skin, dimi- 
nution of the urinary secretion, and, after the first or second day, 
much depression, which continued for two or three days, and then 
yielded to treatment. The tongue was moist, but pointed, tremu- 
lous, red, and injected. The velum, isthmus faucium, tonsils, and 
upper part of the pharynx, were somewhat swollen, and of a very 
peculiar dark red colour, the redness being general, and equally 
diffused over the whole of the upper part of the pharynx as far as 
it could be examined. But the following case, which was very 
lately communicated to me by a practitioner of very great eminence 
in this city, is still more curious. Some years ago scarlatina broke 
out in this gentleman’s family, and attacked all his children with 
the exception of one young lady, who, although in constant attend- 
ance on her sisters during their illness, did not exhibit any symp- 
toms whatsoever of the disease. When all the children had become 
convalescent, they were removed to the country for the benefit of 
air, whither she also accompanied them. Here she was, much to 
the astonishment of her family, attacked by the peculiar anasarca 
observed in persons who have recently laboured under scarlatina. 
Her father, under whose observation she had been during the whole 
time, was very much struck with the occurrence; he paid particu- 
lar attention to the case, and feels convinced that it was the result 
of latent scarlatina. This case, connected with those already 
detailed, is of great interest in a general pathological point of view. 
They appear to prove the fact, that in some instances diseases pro- 
duced by contagion do not give rise to the whole train of pheno- 
mena by which they are ordinarily characterised. 
Let us turn for a moment to some of those diseases caused by 
the action of animal poisons on the system, as for instance measles. 284 
graves’s clinical lectures. 
The symptoms which generally attend and characterise measles 
are universally known. After an attack of fever, on the third or 
fourth day, coryza, sneezing, hoarseness, and cough, are complained 
of, and then a rash appears, first on the face, and afterwards on the 
body and limbs. But it is not necessary that all these symptoms 
should appear, and that the sequence of morbid phenomena should 
be uninterrupted throughout; on the contrary, it frequently hap- 
pens at particular periods, and in certain constitutions, that some 
of the most usual symptoms are scarcely observed, or altogether 
absent. You will find this point insisted on by Dr. Bateman, who 
has given a detailed description of a form of measles in which the 
catarrhal symptoms are wanting, and which he has termed rubeola 
sine catarrho. The same remark applies to many other forms of 
disease. Thus we may have pneumonia without cough, and pleu- 
ritis without pain in the side. Those who have witnessed the 
course of the late epidemic cholera in this country, will recollect 
that many cases occurred in which vomiting, purging, or cramps 
were not observed. 
If we turn to fever, we find that the animal poison to which it 
owes its origin generally exhibits a certain number of symptoms* 
congregated together, or observing a determined order and succes- 
sion ; and these we meet with in most of the cases which come 
before us in practice. But we now and then see fever patients in 
whom one or more of the most prominent symptoms are absent. 
Thus occasionally there is no quickness of pulse or appearance of 
vascular excitement; in some there are no cerebral symptoms ; in 
others no increase in the temperature of the skin. Indeed, I might 
go through the whole group of symptoms which accompany fever, 
and show that almost every one of them may be occasionally 
absent, and yet the fever of a severe and dangerous type. I recol- 
lect pointing out to the class last year the case of a man labouring 
under chronic enlargement of the spleen. He had been working 
for two or three seasons in some of the marshy districts of England, 
and had been occasionally ill, but never had symptoms of regular 
intermittent; in fact, he had escaped the intermittent itself, but not 
what are usually deemed the consequences of it. We have been 
in the habit of explaining the enlargement of the spleen by refer- 
ring it to the conflux of blood towards the internal organs, particu- 
larly the liver and spleen, during the cold stage of intermittent; 
and we have endeavoured to explain the subcutaneous oedema 
which follows scarlatina, by attributing it to previous inflammation 
of the skin and subcutaneous cellular tissue ; but the observations 
and facts which I have now brought forward will show that these 
opinions were founded on erroneous ideas. Turning to cases of 
chronic disease, we find in some, as for instance syphilis, that the 
poison taken into the system gives rise in most cases to a determi- 
nate order of symptoms, e. g. bubo, sore throat, eruptions on the 
skin, nodes, and syphilitic cachexy. Mr. Hunter has been at great 
pains in determining the order of the parts, and pointing out the 
tissues which are successively affected, and it is of considerable 285 
importance to have correct notions on this point; but although the 
number and order of symptoms marked out by Mr. Hunter and 
others may be observed in most cases, they are not so in all; and 
the same remark which has been made on the occasional absence of 
one or more important symptoms in scarlatina will apply with equal 
force to syphilis. Now and then the morbid poison which excites 
syphilis does not affect the constitution in such a manner as to occa- 
sion the production of all the symptoms which usually characterise 
this disease, and thus a variety of venereal is formed, which often 
proves a source of great embarrassment not only to the young and 
inexperienced, but even to the senior members of the profession. 
It is of great consequence, in a practical point of view, to bear in 
mind the general proposition I have announced, viz. that in both 
acute and chronic diseases a constitutional affection may display 
its existence by only one or two of the numerous symptoms which 
usually accompany it; and this occurrence seems more frequent 
in the case of diseases produced by contagion and morbid animal 
or vegetable poisons, than in the case of maladies generated by 
causes developed in the system itself. 
I spoke at my last lecture of a man named Cassels, who died in 
the fever ward with symptoms of cerebral excitement, and stated 
that I regretted having omitted to leech his head, and prescribe 
tartar emetic in the form of enema. Since that time we have had 
an opportunity of examining his body, and the results of the dis- 
section are well worthy your attentive consideration. He was a 
young man of robust habit and apparently good constitution, and 
laboured under the ordinary form of maculated typhus. Shortly 
after his admission he was attacked with delirium, which was soon 
afterwards followed by coma and death. Now, suppose you were 
called to see a patient, not labouring under typhus, but exhibiting 
a similar train of symptoms,—that is to say, violent delirium, 
accompanied by flushing of the face, suffusion of the eyes, head- 
ache, and a tendency to get dut of bed—in fact, a state of furious 
excitement requiring the restraint of the strait Waistcoat,—what 
idea would you be likely to form of the condition of the brain ? Tf 
a patient of this kind had no typhoid symptoms, you would cer- 
tainly say that he was labouring under meningitis or cerebritis ; 
and if the case proved fatal, you would naturally expect to find 
lesions of the brain fully sufficient to account for all his symptoms. 
And you would in all probability find extensive thickening of the 
membranes of the brain, with subarachnoid effusion, or you would 
discover softening, increased vascularity, and suppuration of the 
encephalic mass. But, here, a man in fever exhibits all the symp- 
toms of cerebral inflammation; the cerebral affection runs on to a 
fatal termination with great rapidity; he dies comatose. And what 
do we find on dissection? Doubtful signs of congestion, and no 
distinct evidence of inflammation ; a slight opacity of the arach- 
noid at the base of the brain, and about a teaspoonful of clear sub- 
arachnoid effusion. Now this is a point to which I would earnestly 
call the attention of every enquiring student. A patient, during 
TREATMENT OP FEVER. 286 
graves’s clinical lectures. 
the course of typhus, is seized with symptoms which are generally 
regarded as characteristic of congestion and inflammation of the 
brain ; he dies, to all appearance in consequence of the intensity 
and violence of these symptoms, and on dissection little or no trace 
of cerebral disease is found. Tn the case under consideration, the 
symptoms present were strongly indicative of congestion if not of 
inflammation ; and had the man been free from typhoid symptoms, 
you would expect to find decided traces of inflammatory mischief. 
This seems to prove that in the production of cerebral symptoms 
in typhus, some cause not to be recognised by the production of 
cerebral lesions, or in other words something besides mere conges- 
tion or inflammation, exists. I have now examined a great number 
of cases of this description, and the examination has brought home 
to me a strong conviction, that the delirium of fever depends upon 
something more than mere inflammation or congestion. There is 
another fact, the study of which is well worthy of attention, as it 
appears to support very strongly the views I have put forward ; 
and this is the occurrence of analogous symptoms under opposite 
conditions of the cerebral circulation. Take, for example, the phe- 
nomena of vertigo and headache. Now these symptoms are found 
in states of the brain which are directly opposite. In incipient con- 
gestion of the brain, in that turgescence of the cerebral vessels 
which precedes apoplectic seizures, one of the most frequent symp- 
toms is vertigo, and the same thing may be affirmed with respect 
to headache. But we observe the very same symptoms under cir- 
cumstances totally dissimilar. Frequently while bleeding a patient 
for some affection of the lungs or bowels, or for some accident, we 
find that after a certain quantity of blood has been lost, the patient 
becomes pale; and while the pallor is coming on, he often gets 
quite giddy, and sometimes complains of headache. Gentlemen 
who are attending lying-in hospitals are well acquainted with the 
headache, giddiness, and tinnitus aurium, so constantly complained 
of by females who have suffered from excessive uterine hemor- 
rhage. Hence you perceive facts are not wanting to show that 
opposite states of the cerebral circulation, a superabundance or 
deficiency of pressure on the brain, may give rise to similar pheno- 
mena. You saw an illustration of this in the case of one of our 
patients in the fever ward this morning. He was quite free from 
headache as long as he remained in the horizontal posture, but the 
moment he sat up in bed he complained of headache. Yet this 
was a man who had not the slightest symptom of determination to 
the head, and who had been sufficiently depleted during his illness. 
You will also recollect the fact, that persons who have had a long 
illness, and remained for many days in the horizontal posture, 
generally get weakness, giddiness, and sometimes headache, at first 
when they attempt to sit up during convalescence. This is a point 
which should always be borne in mind. You are consulted by 
one person who complains of giddiness, tinnitus aurium, and fre- 
quently recurring headache. You examine the patient carefully, 
and you find all the symptoms of unequivocal determination to the TREATMENT OP FEVER. 
287 
head. You are applied to by another person labouring under the 
same symptoms ; but how different is the state of the brain found 
to be on a careful examination. One patient is robust, of florid 
complexion, and with a hard bounding pulse ; the other is a weak 
chlorotic female, who has been ailing for months, and whose pulse 
is so weak, that a slight degree of pressure obliterates the canal of 
the artery. Yet the tinnitus aurium, giddiness, and headache, 
complained of by the latter, is just as bad and as troublesome as in 
the case of the former. 
From a consideration of these points, you will perceive that, for 
the production of cerebral symptoms in typhus, there must be 
something more than mere congestion or inflammation of the 
brain ; but you are not to infer from this that there is no necessity 
for taking any steps to obviate or remove congestion of the head in 
fever. On the contrary, I am of opinion that in typhus one of the 
principal sources of danger is connected with the head, and that 
the cerebral symptoms should be always watched with the most 
unremitting and anxious attention. It is this which constitutes 
the great difference between the mortality in private and hospital 
practice. In private practice the physician is called at an early 
period of the disease, and has an opportunity of checking the cere- 
bral symptoms before they rise to a dangerous height; but hospital 
patients, in general, are admitted at an advanced stage of fever, and 
in many instances have been improperly treated, or wholly neglected 
from the commencement. I am also of opinion, that when there is 
any evidence of determination to the head, the best way of prevent- 
ing dangerous cerebral symptoms is to deplete the head by the 
application of a sufficient number of leeches, and then to proceed 
to the use of blisters. You should direct your attention as much 
to the head as to the bowels, and one of the best modes of doing 
this is to apply six or eight leeches behind the ears, and repeat 
them every six hours until relief is obtained. You should then 
order the head to be shaved, and kept constantly covered with 
cloths wet with warm vinegar and water, and at the same time 
have recourse to the internal use of tartar emetic and nitre, or blue 
pill, with James’s powder. Should this plan fail in giving relief, 
you. have a powerful aid in the application of blisters to the scalp, 
and this must be done extensively, and at once. 
Most of the fatal cases of typhus at present die of cerebral disease. 
But in the majority of instances you will find that these were cases 
in which the head was neglected, and in which the appropriate 
remedies were used too late. In cases treated from the commence- 
ment with judgment, decision, and attention, although the head 
may be threatened, you will not have one twentieth of the mortality 
observed in those cases where the early prevention of cerebral 
symptoms has not been an object of care. One of the worst cases 
of cerebral disease which I have witnessed for many months, and 
which would have probably terminated fatally before the seventh 
day, I saw in consultation with Mr. Daly, and yet this case was 
saved by prompt and decided measures calculated to counteract 288 
graves’s clinical lectures. 
the cerebral symptoms. I have also very recently witnessed an- 
other very remarkable case of this description at Bray. 
The patient, a gentleman very full and plethoric, but remarkably 
temperate, aged thirty-five, was attacked after exposure to cold by 
intensely violent maculated fever, for which aperients of an active 
nature were exhibited. I saw him in consultation with Dr. Heffer- 
nan on the fifth day. His headache had been relieved by leeching, 
but his breathing was very quick, and he was almost constantly 
asleep. Skin very hot; eyes somewhat suffused; most copious 
crop of macuke. We at once blistered the whole scalp; and on 
the eighth day blistered it again, and also the nape. On the ninth 
day the cerebral symptoms, which we had been endeavouring to 
anticipate, came on, but probably our treatment prevented them 
from being fatal ; for when they appeared, the application of tartar 
emetic ointment induced a purulent discharge from the whole sur- 
face of the twice blistered scalp, in the course of a few hours, and 
three grains of tartar emetic given in divided doses that day pro- 
cured a complete cessation of the symptoms, after—mark, after— 
the pupils had been dilated, and one fit of slight paralysis of the 
mouth and tongue had taken place. 
The result of all my experience in fever is, that the majority of 
fatal cases are rendered so, in this country at least, by severe cere- 
bral symptoms supervening sooner or later in the disease. Deli- 
rium, sleeplessness, stupor, convulsions, extreme subsultus, jactita- 
tion, sluggish and dilated, or else extremely contracted, pupils ; 
these are the symptoms we have to fear after the fever has lasted 
some time; and let me repeat it, the chief art of the physician con- 
sists not so much in remedying these symptoms as in anticipating 
them. When he judiciously attempts this, he may not, indeed, 
always succeed in altogether preventing their supervention, but he 
will, in the great majority of cases, be successful in diminishing 
their violence, and preventing their usual disastrous effects. 
I shall now resume the subject of blistering in fever, on which I 
made some observations in my last lecture. I have spoken of it 
chiefly as a powerful revulsive remedy in the treatment of cerebral 
congestion ; let us now treat of its employment with other objects 
in view. In the first place, as has been already explained, blisters 
may be used as most energetic stimulants in cases where the 
powers of life flag, and threaten a sudden cessation. Occasionally, 
in fever, you will find the vital tone reduced to a very low pitch, 
the heart uncertain in its action, the pulse irregular, the respiration 
feeble, the skin cool, and the patient so weak that he cannot be 
lifted up, or even turned in bed, without having a tendency to faint. 
Here we have to superadd to the ordinary treatment of fever the 
prompt exhibition of remedies calculated to meet such emergencies, 
and in addition to internal stimulants, we have recourse to power- 
ful stimulation of the cutaneous surface by what are termed flying 
blisters. One of the best remedies in such cases is a large blister 
applied over the region of the heart, to be left on for two or three 
hours, or until the vascular action of the skin is sufficiently excited. TREATMENT OF FEVER. 
289 
When the patient appears to labour not only under sudden weak- 
ness of the heart, but also of the capillary and nervous systems, as 
shown by coldness of the extremities and sinking of the pulse, it 
will be necessary to apply flying blisters, not only over the region 
of the heart, but also over various parts of the chest, the epigas- 
trium, and the inside of the legs and thighs. You will find this 
plan of treatment frequently succeed in cases which have a very 
unpromising aspect. I have now witnessed many instances of this 
description, in which, from cold, neglect, or debilitating treatment, 
the patients appeared moribund, with lividity of the extremities, 
hippocratic face, cold skin, and failing pulse ; and I have seen them 
saved, as it were miraculously, by the use of carbonate of ammonia, 
musk and wine, and the application of warm fomentations to the 
limbs, followed by a succession of flying blisters. 
The next use to which we apply blisters is in the treatment of 
those pulmonary affections which arise during the course of typhus. 
From what you have seen of the present epidemic, you must be 
convinced that bronchitis is one of its most frequent complications, 
and that few patients pass through fever without having some 
affection of the bronchial mucous membrane. You are also aware, 
that when bronchitis attacks the more minute ramifications of the 
bronchial tubes, it is very apt to produce congestion and engorge- 
ment of the lung. We meet with pneumonia much less frequently 
in fever, but it is occasionally observed, and requires the most 
prompt and decided treatment. In pneumonia, as well as in con- 
gestion of the lungs, accompanied by inflammation of the smaller 
bronchial tubes, blisters afford us a most valuable adjunct to the 
other means which we employ, and admit of being used in cases 
where no other mode of depletion could be safely borne. The 
affections of the lung in fever are of no small importance, and the 
stethoscope has not conferred a greater benefit on practical medi- 
cine, than by indicating, in diseases of the chest, not merely the 
existence of disease, but also its locality, extent, and precise nature. 
It points out to us the portion of the chest in which the bronchial 
tubes are chiefly engaged, and informs us with certainty when the 
affection of the smaller tubes and air-cells has given rise to pulmo- 
nary engorgement. The experienced stethoscopist will in such 
cases be aware of the exact site and nature of the affection, where 
the mere symptomatic practitioner would be unable to acquire any 
thing more than a loose and undefined notion of pulmonary dis- 
ease. The latter employs his depleting means at random, and fre- 
quently abstracts a large quantity of blood with little benefit to his 
patient; the former, aware of the exact situation and extent of the 
disease, applies his leeches or cupping glasses immediately over the 
engorged or inflamed portion of the lung, and relieves his patient 
at the expense of a comparatively small loss of blood. The same 
observation will apply, with equal force to the use and application 
of blisters. A good and accurate knowledge of the various stetho- 
copic phenomena is besides of so much more value in the treat- 
ment of fever, as, at certain seasons of the year, almost every case 290 
graves’s clinical lectures. 
of fever will be complicated with pulmonary derangement; and it 
may happen, during the course of an epidemic, that the lungs may 
be the organs which are chiefly engaged. Although cerebral dis- 
ease is at present the principal source of danger in fever, it may not 
be so always. A change may take place in the character of the 
epidemic ; the cerebral symptoms which are now of such frequent 
occurrence may become infrequent or inconsequential, and we may 
have the organic affections chiefly limited to the viscera of the 
thorax. I have seen many cases of fever in which the principal 
source of danger was connected with the chest, and where an 
accurate knowledge of the stethoscope was indispensable to a cor- 
rect and successful plan of treatment. 
Now when you have recourse to blisters in treating pulmonary 
affections, whether these affections be simple or complicated with 
typhus, it would be well to recollect that much good may be effected 
without leaving the blisters on for a long time, or until they rise 
fully; and also that when risen, it will not be necessary to cut 
them at once and let out the effused serum. In treating the bron- 
chitis of children, and in the bronchial affections of fever, I have 
frequently directed the blister to be left unopened ; and I can state, 
from experience, that this plan answers very well. The effused 
serum forms one of the best dressings for the excoriated surface of 
the skin, and the formation of troublesome sores is avoided. I fre- 
quently have recourse to this mode of treating blistered surfaces in 
children, and persons of irritable habit, in whom the cutis is ex- 
tremely tender and vascular. Such persons, when blistered, will 
often have profuse discharges, first of serum and afterwards of sero- 
purulent matter, from the denuded surface, accompanied by tortur- 
ing pain, loss of rest, and considerable irritation of the general sys- 
tem. I have seen the discharge continue to flow profusely for five 
or six days ; in fact, to such an extent as to wet several napkins in 
the course of a day, and expose the patient to the risk of an aggra- 
vation of the pulmonary symptoms, in consequence of his linen 
becoming so frequently moistened as to require repeated shifting.1 
In all cases of children and persons of an irritable habit, I would 
therefore advise you to let the blisters alone, particularly where 
they have been applied to the fore part of the chest, or any other 
part not exposed to pressure or friction. As soon as the blister 
rises, apply over it a piece of lint, smeared with spermaceti oint- 
ment, which can be renewed as occasion requires, and leave the 
rest to nature. I was forcibly struck some time since, with the 
difference of result between this and the ordinary practice, in the 
case of a young gentleman residing in Cambden street, who had a 
severe attack of bronchitis towards the termination of fever. A 
blister had been applied to his chest in the morning, and another 
1 In pulmonary diseases, this continued discharge is often very useful, and 
should be encouraged; but in fever the production of such an effect from 
blisters must be avoided, as a surface thus denuded of its cuticle and in- 
flamed, may be converted into a dangerous sore. 291 
in the middle of the day. The first had been opened freely, and 
dressed in the usual way; but the other, which had risen about 
the time I was called in, was left untouched at my request. The 
one which had been opened caused such a degree of irritation and 
restlessness, that it was found necessary to give him an opiate 
every night; the other gave little or no inconvenience, and healed 
up much sooner. If I have done nothing better, I think I deserve 
some merit for being the first to reprobate the practice of keeping 
on blisters for twelve, eighteen, and twenty-four hours, and for 
having shown, by numerous experiments, that a much shorter 
period of time was required to ensure the full effect of these reme- 
dies. When I commenced the practice of medicine, blistering was 
looked upon by most sick persons as one of the severest trials of 
their patience, and the agony which it caused in some irritable 
habits was almost insupportable. Blisters were left on for twelve, 
eighteen, and even twenty-four hours, and when at length they 
were removed, the whole epidermis of the blistered part came, or 
was torn away, leaving behind a raw irritable surface, from which 
large quantities of serum and pus were effused for several days, to 
the great torture and inconvenience of the patient; and, not con- 
tent with this, the practitioners of that time generally dressed the 
excoriated surface with some sharp stimulant ointment, so that the 
blistered surface most commonly resembled that of a severe burn. 
Ask those who are our seniors in practice, and they will tell you 
what blistering was twenty or thirty years ago. They first pro- 
duced excessive irritation of the skin, by leaving the blisters on too 
long, they then irritated the denuded surface with stimulant oint- 
ments, and in this way brought on extensive sores of a bad charac- 
ter, which remained long after the disease for which the blisters 
were applied had disappeared, and which formed, in fact, a new 
ailment, requiring new medicines and additional attendance. If 
you look over Mr. Moore’s account of the principal remedies em- 
ployed in the practice of Dublin physicians, about the period I 
allude to, you will find that nothing was more common then than 
the application of stimulant and, as they were termed, digestive 
ointments, to blistered surfaces. I was among the first who assailed 
this barbarous treatment, and showed that all the good effects of 
blisters might by secured by leaving them on for a much shorter 
space of time. I proved by numerous experiments, that in many 
cases it was not necessary to leave them on more than four or five 
hours, in the adult,1 and that they might then be removed and the 
blistered part dressed with spermaceti ointment. Under this dress- 
ing the blister rises well, and there is no danger of tearing away 
the cuticle, or producing an irritable sore. In addition to this, you 
entirely avoid the irritating effects which blisters are known to pro- 
TREATMENT OF FEVER. 
1 Of course blisters applied to the scalp must be excepted. They require 
at least twelve hours. In old persons generally the skin is much less vas- 
cular than during youth and middle age; and consequently, in the old, blis- 
ters require a much longer time to produce the required effect. 292 
graves’s clinical lectures. 
duce on the urinary organs. You will very rarely meet with 
dysuria, or haematuria, where the blister has been left on for the 
spaces of time I have mentioned. 
Blistering is then to be used with the restrictions I have men- 
tioned, and you will find it a most valuable aid in the treatment of 
fever and its complications. It may be employed either as a deriva- 
tive and revulsive, or you may have recourse to flying blisters over 
various parts of the body, in certain forms of fever, where there is 
marked and sudden depression of the powers of life. 
Speaking of depression ef the powers of life reminds me of a 
curious incident, which occurred some time since in my practice, 
and which shows the value of being acquainted with the peculiar 
habits and idiosyncrasies of families. I attended, with Mr. Kirby, 
about three years since, a gentleman of middle age and active pro- 
fessional habits, who had been attacked with fever. I was first 
called to see him on the ninth day of fever, and found him appa- 
rently moribund. His pulse was intermittent and irregular, the 
action of the heart tumultuous, the respiration feeble, and the ex- 
tremities cool. Mr. Kirby had instantly ordered internal stimu- 
lants, and blisters over the region of the heart and epigastrium. 
The patient rallied, and ultimately recovered. It is to be observed, 
that the group of formidable symptoms just enumerated had super- 
vened quite out of the usual course, and without any previous 
warning. They were consequently not only alarming but unex- 
pected. About a month afterwards Mr. Smyly and I were called 
to see this gentleman’s brother, who was living at Dundrum, and 
who was supposed to have caught fever from his close attention to 
his brother during his illness and convalescence. What was most 
remarkable in the case, was, that his pulse began to flag and inter- 
mit, and he likewise suddenly and unexpectedly got the same symp- 
toms of depression of the vital powers on the very same day and 
hour as his brother. His symptoms also continued for the same 
length of time, and yielded, or spontaneously ceased, under the 
same plan of treatment. In some families you will find a very 
curious coincidence between the play of the various functions in 
disease as well as in health, and you should neglect no opportunity 
of making yourself acquainted with the family peculiarities and 
idiosyncrasies of your patients, as knowledge of this description is 
of the greatest value and importance in the treatment of disease. GLANDERS. 
293 
LECTURE VIII. 
Glanders and button-farcy in the human subject—Particulars of a case of glanders, 
with the post-mortem appearances—Remarks on the variety of skin diseases produced 
by the introduction of an animal poison into the system—Case of button-farcy— 
Analogous appearances, where, as in typhus, an animal poison is sometimes gene- 
rated in the body—Furuncular inflammation, or carbuncle, generated by animal 
poison ; also tubercles—Sometimes a preternatural whiteness precedes the purple 
hue of mortification—Remarks on phlegmasia dolens—Phlegmasia dolens of the eye. 
In pursuance of my intention, as announced in a former lecture, 
I shall proceed to-day to the consideration of two affections result- 
ing from animal poison, one of which has been but recently intro- 
duced to the notice of the medical profession; of the other, I am 
not aware that there are any published cases in existence. I allude 
here to glanders and button-farcy in the human subject. 
The profession is chiefly indebted to the researches of Dr. Elliot- 
son for the first accurate account of glanders in the human subject 
—a disease which has now excited a very large share of attention 
here and on the continent. Many other observations, published 
since Dr. Elliotson undertook the illustration of this disease, have 
established the fact, that the morbid matter secreted by horses 
labouring under glanders may communicate the infection to the 
human subject, and thus give rise to a loathsome, painful, and 
generally fatal disease. From the notices which I have beeu able 
to collect, it appears that glanders in man is of very frequent occur- 
rence in Ireland—so frequent, indeed, that I think the legislature is 
called on to imitate the wise example of the Prussian government 
in placing glandered horses under the surveillance of the police. 
Like many other animal poisons, that of glanders does not seem 
capable of affecting every individual indiscriminately; indeed, the 
average susceptibility must be small, for grooms and veterinary 
surgeons take few or no precautions in examining the diseased ani- 
mals ; and yet the proportion infected, compared with the number 
exposed, is by no means considerable. That such persons exhibit 
great carelessness in examining glandered horses, appears from the 
directions given in books on farriery, “that the finger should be 
introduced into the nostrils for the purpose of ascertaining whether 
certain spots suspected to be ulcers are so or not.” Now, when the 
viscid gluey nature of the discharge from the nostril is taken into 
account, we cannot but conclude that this operation of introducing 
the finger into such a mass of vitiated and poisonous secretion 
would more frequently prove the means of infection, were the 
human constitution very susceptible of the poison—for we are to 
recollect that the fingers of such persons are seldom free from 
scratches and abrasions. 
I shall now read the following case of glanders in the human 
subject. It is one of extreme interest, and has been most faithfully 
and graphically detailed. It occurred in the Richmond Hospital, 
and has been communicated to me by Dr. M'Donnell. You will 294 
graves’s clinical lectures. 
find in it many points of resemblance to a series of cases translated 
from a German journal, and published in a late number of the 
Medico-Chirurgical Review. 
Patrick Wallace, a healthy muscular man, aged twenty, was 
admitted into the Richmond Surgical Hospital on the 6th October, 
1836. It was stated that he had been in care of a glandered horse 
—driving, cleaning, &c.—and that he had been in the habit of 
drinking out of the vessel from which the horse drank. It ap- 
peared, also, that he had had an abrasion on one of his ears. On 
admission, he had much of the appearance of a person labouring 
under cynanche tonsillaris: he could only open his mouth to the 
extent of half an inch; this was the only uneasiness complained 
of. The left tonsil was very much enlarged, red, hard, and pro- 
jecting towards the middle line; no fluctuation could be felt; there 
was a general fulness about the angle of the jaw, extending upwards 
nearly as far as the zygoma. The sub-maxillary gland on the same 
side was also enlarged and indurated. These symptoms had been 
ushered in by feverishness, a few days previous to admission. He 
was ordered to have eight leeches to the throat, to be followed by a 
poultice, and a bolus composed of calomel and jalap. 
Next day the external swelling was found to be increased; greater 
difficulty of opening the mouth; the tonsil still hard and swollen. 
Twelve leeches were applied to the fauces, and the patient took the 
tartar emetic mixture of the hospital, with sulphate of magnesia. 
On the 15th of October, the disease is reported to be on the 
increase. Tonsil still hard, but no fluctuation; left side of the 
face greatly swollen; eye of same side nearly closed, from tume- 
faction of the lids; general inflammatory appearance over the 
cheeks, and great hardness of the tissues about the angle of the jaw 
of the same side, extending towards the chin; several circumscribed 
spots of redness, varying in extent from the size of a sixpence to 
that of a halfpenny, with irregular margins, scattered over different 
parts of the body; two pustules observable on the left leg. 
16th.—A vesicle containing a yellowish serum observable on the 
left tonsil; the same inability of opening the mouth continues; 
increase of swelling over the left side of the face ; a small abscess 
has formed on the posterior part of the left fore-arm; some delirium 
during the night; three evacuations from the bowels. The tonsil 
to be brushed over with a solution of nitrate of silver; a blister to 
the fauces; the tartar emetic mixture to be continued. 
17th.—Some sleep during the night, interrupted by delirium of a 
low muttering character. Patient appears willing to answer ques- 
tions, but cannot, from obstruction in the mouth. This, however, 
lasts but for a moment, and he then lapses into a state of inco- 
herency. Mouth open to the extent of half an inch; left eye closed; 
considerable swelling of the left side of the face, which is indurated, 
hot, tense, and shining; all the glands on both sides of the jaw, but 
particularly on the left, are swollen and hard; same state of tonsil; 
nares dilated ; breathing stertorous, somewhat hurried, about 28 in 
the minute, and interrupted by frequent sighs. Pulse very small, GLANDERS. 
295 
rapid, intermitted, and cannot be counted; skin hot, tongue furred, 
teeth covered with sordes. He complains of great thirst, but says 
he feels no pain ; it is evident, however, that he feels great uneasi- 
ness in the joints and limbs when moved. There is, however, no 
swelling or redness of the joints; there is no discharge from the 
nostrils, nor is there any perceptible ulceration of the mucous mem- 
brane of the nose. No apparent affection of the absorbent glands 
in any other part of the body. 
During this period, vesicles and pustules of various sizes, and at 
various stages of growth, had made their appearance on different 
parts of the body, particularly on the back. They varied in size, 
from the head of a pin to the section of an almond. In the first 
stage, they resembled very minute vesicles, scarcely surrounded by 
any inflammatory border, and containing a limpid serum. In the 
second stage, the serum was replaced by pus; there was a con- 
siderable blush of redness around each pustule, which at this period 
became greatly increased in size. When one of the vesicles was 
punctured, the serum appeared to come from a single cavity under 
the cuticle: this operation did not produce any subsidence of the 
tumour, a considerable hardness still remaining in the cutis or 
beneath it, with a cavity in the centre in which the serum was 
contained. A number of achores existed in various parts, congre- 
gated together, and not much larger than the head of a pin. These 
clusters were surrounded by white raised margins, having much 
the appearance of wheals, and about a line and a half or two lines 
in breadth ; between these margins and the achores there existed a 
line of redness. The whole taken together are rather of an oval 
shape. There also existed numerous inflammatory spots on the 
right shoulder, left arm, and other parts of the body. These were 
of a dark brown, approaching to a livid colour; when pressure is 
made on them the colour disappears, but returns immediately when 
it is removed. On running the finger over them, a small hard 
tumour was felt in the centre; the margins of these spots were 
irregular. 
On the 17th, the character of the disease became more plainly 
developed: at three o’clock, p. m., pus in considerable quantity was 
observed to issue from both nostrils. The patient was ordered to 
take the solution of chlorate of soda internally, in dram doses, three 
times a day; and also a mixture composed of carbonate of ammo- 
nia, liquor aetheris oleosus, and camphor mixture. At 5 o’clock, 
p. m., he was found half out of bed, his head resting on the pillow ; 
still able to express his wants ; pulse not to be counted ; legs and 
feet cold ; breathing stertorous ; numerous stigmata scattered over 
the surface of the body. The purulent discharge from the nostrils 
has ceased, but there is a discharge of mucus from the mouth, with 
considerable fetor of breath. 
8 o’clock, p. m.—A copious perspiration has broken out over the 
body; face red, tense, shining, and very much swelled ; swelling 
has now extended to the right side of the face; right eye nearly 
closed; can open the left better; a few pustules have made their 296 
graves’s clinical lectures. 
appearance at the inner canthus of the eye. Pulse, tongue, and 
skin, as in last report; delirium and muttering continue. 
Died at 4 o’clock, a. m., October 18th. 
On examining the body ten hours after death, the redness was 
found to have disappeared from the face ; the glands about the left 
angle of the lower jaw as before mentioned: they were found 
matted to the surrounding parts. The cellular tissue covering the 
submaxillary and parotid glands was infiltrated with serum, and 
indurated; numerous depositions of pus were found in the tissue 
of the submaxillary and parotid glands. The brain was firm, but 
its ventricles contained a considerable quantity of fluid; the arach- 
noid membrane was opaque in many places; several patches of 
vascularity were observed on the pia mater. The lungs presented 
a congested appearance; numerous pustules were scattered over 
their surface—some separate, yellow in the centre, and surrounded 
by an ecchymosed border; others existing in clusters. They resem- 
bled, in every respect, those found on the surface of the body. The 
lining membrane of the larynx was very much inflamed, especially 
about its upper part and about the epiglottis. The inflamed parts 
in this situation were of a livid hue. There was some appearance 
of vesicles in the trachea, but this could not be satisfactorily ascer- 
tained. The bronchial tubes were filled with mucus. The stomach 
contained a quantity of yellowish green mucus; its lining mem- 
brane presented an ecchymosed and inflamed appearance. The 
liver was somewhat enlarged, and adhered by its inferior margin 
to a few folds of intestine. The periosteum did not exhibit any 
appreciable deviation from the normal state. 
One of the chief things to be noticed in the foregoing case is the 
variety of inflammatory affections observed in the skin, as the result 
of the introduction of an animal poison into the system. There 
was, in the first place, the general diffused redness of the face, then 
superficial inflammatory spots on the shoulders and arms, resem- 
bling erythema nodosum; in the next place, scattered pustules of 
various sizes, commencing in the form of a vesicle, which after- 
wards became a pustule surrounded by an inflammatory zone ; and 
lastly, achores congregated together and surrounded by an elevated 
white margin, within which there existed an inflammatory ring of 
a red colour. Another point worthy of notice is the state of the 
lungs and bronchial mucous membrane. The lining membrane 
of the larynx, particularly in the vicinity of the epiglottis, was 
inflamed and of a livid colour, and there was an indistinct appear- 
ance of vesicles in the trachea. But what was particularly deserv- 
ing of note in the lungs, was the existence of pustules on their 
surface, bearing the closest resemblance to those found on the 
surface of the body. It is not stated whether there was any appear- 
ance of vesicles or pustules in the nose, pharynx, or oesophagus, 
but we are told that the stomach was ecchymosed and inflamed. 
The following case was witnessed by myself and Dr. Halahan, 
and seems more nearly allied to the variety of glanders termed 
button-farcy. 1 regret that want of time has prevented me from BUTTON-FARCY. 
297 
arranging its details in a form more worthy of your attention ; and 
were not the disease one of comparatively rare occurrence, I should 
not have ventured to lay the case before you in its present imperfect 
state. 
The subject of this case was a gentleman residing at Rathmines, 
an extensive proprietor of horses, and who. having originally gra- 
duated as a surgeon, exhibited much skill in the veterinary art. 
About the time of his illness he had had some horses in his esta- 
blishment labouring under glanders and button-farcy, to which he 
paid particular attention. After having laboured for some days 
under considerable lassitude and derangement of the stomach and 
bowels, he was attacked, on the 8th of July, with rigors, followed 
by great thirst, excessive heat of skin, and pains in his limbs. The 
moment he felt himself attacked in this way, he said he was sure 
that he had got some dangerous infection from the horses, and 
would never recover. He took some blue pill and colocynth, which 
produced a few dark and very fetid evacuations. On the 9th, his 
pulse was 94, his urine very high coloured, his thirst and feverish 
symptoms rather increased, and he suffered greatly from constant 
nausea and vomiting. A tumour now began to appear about three 
inches above the inner ankle of the right foot. He applied a poul- 
tice over it, but was obliged to remove it in a short time, in conse- 
quence of the pain occasioned by its weight. The tumour was 
about the size of half a walnut, of a dull red colour, tense, shining, 
and exquisitely painful. Its external aspect was peculiar, and 
might be compared to something intermediate between a boil and a 
spot of erythema nodosum. On the 10th, another tumour of the 
same character appeared near the outer ankle of the same leg; and 
in this way the disease went on, tumour after tumour appearing on 
different parts of the body, with an increase of the feverish symp- 
toms, until the 20th of July, when he was first seen by Dr. Hala- 
han. At this time several tumours had appeared on different parts 
of his body; there was one of an extremely painful character on 
his head, and he complained of great tenderness and pain along the 
right clavicle. His thirst was still urgent, his restlessness excessive, 
the slightest motion gave him exquisite pain, and sleep had com- 
pletely abandoned him. He had endeavoured to regulate his 
bowels by purgative medicines, and had applied leeches to the 
tumours and to the clavicle at various times, but without any de- 
cided benefit. There were eight or nine tumours on different parts 
of the body, of the character before mentioned, without any ten- 
dency to suppuration, and so exquisitely painful that he could only 
bear a single sheet over him. The inflammation about the clavicle, 
which was of a diffuse character, had extended up the neck and 
over the right shoulder; there was not much swelling, except about 
the clavicle; the colour of the affected parts was a peculiar dusky 
red. Immediately over the clavicle two vesicles were observable, 
filled with a transparent fluid. Three dozen leeches were ordered 
to be applied over the clavicle and shoulder, and the patient was 298 
graves’s clinical lectures. 
directed to use chicken-broth, beef-tea, and other light nutritious 
articles. 
On the 21st, all symptoms are stated to be on the increase. His 
fever, thirst, and sleeplessness, are undiminished; his tongue furred 
and dry; his teeth covered with sordes; his pulse small, weak, and 
rapid; his nausea and vomiting not so troublesome. He had re- 
ceived no benefit from the application of the leeches ; the swelling 
and stiffness of his neck was increased, and he had now some 
difficulty of swallowing. The erysipelatous surface of the neck, 
clavicle, and shoulder, were lightly brushed over with lunar caustic, 
which gave the patient an agreeable sensation, and from which he 
stated that he derived much relief. This was repeated the next 
day at his own request, and with equal benefit; the difficulty of 
deglutition diminished, and for two days he went on pretty well. 
On the 25th, there was an evident increase of fever; the tumours 
over the body and limbs were increasing in size and number; and 
his anxiety, restlessness, and sufferings unabated. He had taken 
alterative doses of calomel and James’s powder, and his bowels had 
been regulated by mild aperients and enemata. I saw him for the 
first time on the 28th. His pulse was then 98, small, and easily 
compressed; his thirst excessive; his restlessness and agony such 
as would strongly excite the pity of persons most conversant with 
scenes of human suffering. He had several tumours over different 
parts of his body, all exquisitely painful, and in their aspect some- 
thing between boil and erythema nodosum. Some of them were 
hard to the touch; others, which appeared more advanced, were 
softer, and had a boggy feel. There was, however, no appearance 
of any thing like suppuration. He was ordered sulphate of quinine, 
chicken-broth, ale, and other light nourishment, and an opiate at 
night. On the 31st, a tumour appeared on the right side of his 
forehead, larger and more painful than any of the rest. Another 
of a similar character showed itself on the right clavicle, which 
had been previously affected. Shortly after their appearance, 
vesicles were observable on their surfaces, such as generally pre- 
cede mortification in cases of anthrax and malignant carbuncle. 
Next day he was evidently worse; his pulse was 108; his fever, 
pain, and restlessness, unabated.; and a miliary eruption began to 
make its appearance over his chest and abdomen. The vesicles 
now began to increase on the surface of the tumour; his fever and 
restlessness were aggravated ; and his mind, which had been 
hitherto collected, began to wander. His restlessness was so exces- 
sive, that he could not remain for a moment in the same position ; 
and being a person of much mechanical ingenuity, he had a set of 
pullies constructed and fastened to his bedstead, so that he could 
move himself in various directions. His medicines and diet, with 
the addition of claret, and opiates at night, were continued as 
before. 
On the 6th of August he was still worse; the tumour on the 
head continued to enlarge, and decided sloughing had taken place. 
The tumour on the clavicle presented the same aggravation in SYMPTOMS OF GLANDERS. 
299 
appearance and character, and a fresh tumour had appeared on the 
back of his head. A pustular eruption now began to make its 
appearance over his body, chiefly over the abdomen and limbs; 
his symptoms became aggravated in every respect; the delirium 
and watchfulness increased; and he died on the 10th of August, 
about thirty-three days from the commencement of the disease. He 
attributed his illness to attending horses, four of which had died of 
button-farcy; and what is also curious, his nephew, who had also 
been engaged about the diseased animals, had fever of a typhoid 
character, with petechise of a larger sort than usual, but ultimately 
recovered. 
The symptoms of glanders in the human subject have been so 
fully detailed by Dr. Elliotson and others, that it only remains for 
me to make a few observations connected with this subject. In the 
first place, it may be observed-, that most diseases produced by the 
deleterious effect of animal poisons on the economy, show a ten- 
dency to cause not only fever, often of a malignant character, but 
also various forms of external disease, chiefly limited to the super- 
ficial glands, subcutaneous cellular tissue, and skin. In urticaria, 
small-pox, and measles, the external disease is chiefly limited to 
the skin; in scarlatina, we have often swelling of the parotid gland, 
with infiltration of the adjacent cellular tissue in addition to the 
cutaneous eruption ; in syphilis, and cases of dissecting wounds, 
we have disease of the skin frequently combined with an affection 
of the superficial lymphatic glands. The same observation applies 
to typhus, many cases of which are characterised by an eruption 
of spots over different parts of the body, or by the occurrence of 
what are termed petechioe. On these matters I need not enlarge, 
as you are all well acquainted with them; but that vesicles and 
pustules very similar to those observed in dissection wounds, and 
other diseases produced by the direct introduction of animal poison 
into the system, may arise from the action of morbid changes spon- 
taneously occurring in the body, is a fact which admits of being 
proved, and opens to us a new and interesting field of enquiry. 
Thus, in cases of typhus, where the effect of pressure or some 
other accident has occasioned bed-sores of a bad character, and 
even where there are no bed-sores present, I have on several occa- 
sions seen low secondary fever produced, and have observed vesi- 
cles or pustules appear on the skin, similar to those described by 
Mr. Colies as accompanying the fever of dissection wounds. An 
example of this occurred some time ago at this hospital, and you 
have recently witnessed another in the case of a young man reco- 
vering from typhus. It might be argued that the secondary fever 
and eruption in such cases arise from the absorption of morbid 
matter into the system, and lam willing to admit that there is some 
colour of argument for this statement, where the patient labours 
under bed-sores of a bad and gangrenous character; but that this 
explanation is not the one appears from the case of the young 
man to which I have alluded. He had no bed-sores to account for 
the secondary fever and eruption; and we can only explain by 300 
graves’s clinical lectures. 
supposing that it js the result of a poison generated in the system 
during the course of fever. This is particularly deserving of 
notice, as I am not aware that any author on typhus has noticed 
this symptom, or pointed out the circumstances under which it 
occurs. The same phenomenon is occasionally observed, where, in 
consequence of external injury, diffuse cellular inflammation has 
taken place. Thus, several years ago, a woman was admitted into 
the Meath Hospital, who had diffuse cellular inflammation in con- 
sequence of receiving a kick on the chest. After a few days, 
Colles’s pustules appeared on different parts off the body, and she 
died with symptoms of croup. On dissection, the croupy symp- 
toms were found to depend on an eruption of vesicles filled with 
opaque serum, over the lining membrane of the larynx and trachea. 
Something analogous to this was observed in the case of Wallace; 
and the coincidence is further strengthened by the frequent occur- 
rence of disease of the lining membrane of the larynx and trachea 
in many other febrile affections, accompanied by cutaneous erup- 
tion—as small-pox, measles, syphilis, and scarlatina. 
Another point which is deserving attention with reference to the 
phenomena of external disease, in cases where animal poisons have 
been generated in the system or arisen from infection, is the occur- 
rence of tumours in different parts of the body, partaking of the 
characters of furuncular inflammation or carbuncle, and running 
through a somewhat similar course. These tumours formed a very 
prominent feature in the case of Wallace; and, in the gentleman 
who laboured under button-farcy, they constituted one of the most 
important symptoms of the disease. We also observe something 
similar to this in that form of venereal which Mr. Carmichael terms 
tubercular, and which is characterised by the appearance of small, 
hard, dark red tumours, on various parts of the body, which exhibit 
a very imperfect tendency to suppuration, and frequently give rise 
to sores of a bad and unfavourable character. Another circum- 
stance observed in Dr. McDonnell’s case deserves some share of 
attention; I allude to the white elevated margins, like wheals, 
around the redness which more immediately encircled each cluster 
of achores, and which we are to look upon as in a less advanced 
stage of its progress, being as it were only the first stage of the 
latter. It is a curious fact, that on many occasions a preternatural 
degree of whiteness precedes the redness and congestive purple hue 
which ushers in mortification. This is generally known in the 
case of the nose when frost-bitten, and which always appears pre- 
ternaturally white in the commencement. Something analogous to 
this was observed in some cases of bad typhus treated here in 1826 
and 1827. The nose sometimes assumed a peculiar white colour, 
and not unfrequently exhibited a tendency to mortification. When 
first seen it had a preternatural whiteness, and looked very like a 
nose made of white wax ; in the course of a few hours it changed 
to a purplish red. and exhibited symptoms of approaching gangrene. 
Again, in urticaria, we often see some portions of the inflamed skin 
assume a white colour, and the same occurrence may be noticed REMARKS ON ANIMAL POISON. 
301 
likewise in the wheals caused by nettles or the stings of bees. In 
general, we connect the idea of integumental inflammation with 
the appearance of redness; and this phenomenon is explained on 
the hypothesis that a preternatural quantity of blood is circulating 
in the inflamed parts. How, then, are we to account for the facts J 
have mentioned ? To what cause are we to attribute the co-exist- 
ence of increased vascularity, and a remarkable whiteness or pallor 
of the parts ?—a state displayed in a very remarkable manner in 
'phlegmasia dolens. I think the explanation is not very difficult, 
when we recollect that the capillary vessels of the white tissues of 
the body contain no red blood in their healthy state. It is easy to 
conceive that in certain stages of inflammation the quantity of 
serous or white blood circulating in any of these tissues may be 
suddenly much increased, and that this increase may be accompa- 
nied by all the phenomena of inflammation except redness. In 
certain cases, as phlegmasia dolens, the colour is permanently 
white; in other cases the white is exchanged for redness, when 
the inflammation has increased in intensity: but perhaps we should 
not use this expression, for the phenomena of phlegmasia dolens 
prove that a white inflammation may be quite as intense as red 
inflammation,—a fact which I saw exhibited in a remarkable 
manner in the case of a woman in this hospital, labouring under 
phlegmasia dolens, and in whom the disease suddenly attacked the 
eye, and destroyed it in a short space of time—disorganising it 
rapidly without the supervention of any redness during this de- 
structive process. Phlegmasia dolens of the eye constitutes a 
disease never before remarked in that organ, and its occurrence 
and phenomena were peculiarly valuable in explaining the true 
nature of that remarkable disease. Having already published an 
account of this case, I shall not at present enter into further details, 
but merely state that the woman affected laboured under well- 
marked phlegmasia dolens of the leg, occurring after delivery, and 
that the disease of the eye came on very suddenly, and was accom- 
panied by agonising pain and exquisite tenderness in the conjunc- 
tiva covering the sclerotic. This membrane was in a very few 
hours tumefied, and distended in its subjacent cellular tissue by a 
perfectly colourless effusion of fluid, apparently sero-gelatinous, and 
which raised up the membrane itself so as almost to conceal the 
cornea from view. In the course of the day the internal structures 
of the eye became engaged, and vision was speedily destroyed. 
This case appears conclusive against the doctrine that phlegmasia 
dolens depends on inflammation of the veins. I am sorry that Mr. 
Middlemore has failed to notice phlegmasia dolens of the eye in 
his late admirable work on the diseases of that organ. 302 
graves’s clinical lectures. 
LECTURE IX. 
On the use of emetics at the commencement of fever; not so well adapted to a later 
period—Domestic remedies for feverish colds; these colds prove to be fevers, and 
time is lost—Protest against the abuse of purgative medicine in fever—The idea of 
curing fever by purging is absurd—Treatment where the bowels have become 
almost paralysed from the cure of preceding diarrhoea—Venesection as a means of 
checking fever—Beneficial even within the first twelve hours after seizure by typhus 
—Various cautions respecting leeching and cupping-glasses—Mode of applying 
leeches when pneumonia or hepatitis supervenes on fever. 
I have already observed, that it is not my intention to give a 
regular sketch of the practice to be adopted in the treatment of 
typhus. I have designedly passed over many important points, 
being unwilling to trouble you with any observations on practical 
matters in which my opinions coincide with the latest and best 
authorities. I shall therefore touch very briefly oil the subject of 
emetics in fever, as the rules by which the adminstration of these 
remedies are regulated have been laid down with precision by 
many modern writers. I am not in the habit of using emetics in 
fever, except when called in at the very commencement of the dis- 
ease. Here emetics are of great value, and will often succeed in 
stopping the fever. There is no way in which you would be more 
likely to cut short an attack of fever than by the administration of 
an emetic, if you chance to see the patient when the fever is just 
beginning. I speak here without any subterfuge, and without 
grounding my opinions on the results of doubtful or merely suspi- 
cious cases. I speak not of cases of bad feverish cold, in which 
the symptoms, at the commencement, bear a very strong analogy 
to those which usher in typhus; I speak of cases where the patient 
gets rigors, followed by the usual symptoms of feverish excitement, 
after exposure to contagion, and is seen on the evening of seizure. 
If I were called to visit a patient who had been attacked with 
shivering, headache, quickness of pulse, increased temperature of 
skin, and lassitude, during the prevalence of an epidemic, or after 
exposure to contagion, and happened to see him a few hours after 
the attack, I should certainly bleed him, and administer an emetic : 
and I think he would have a very good chance of escaping the dis- 
ease. I think the exhibition of emetics an excellent practice in the 
commencement of fever, but I must observe, that the period of 
their exhibition is very brief. After the lapse of twenty-four or 
thirty-six hours from the occurrence of the rigor, they will not suc- 
ceed in cutting short the fever. A few hours make a vast differ- 
ence in the chances, and after the lapse of twenty-four hours, there 
is, generally speaking, very little hope of extinguishing the disease. 
At the termination of this period, it has in most cases seized hold 
of the constitution too firmly to be shaken off by an emetic, even 
though aided by bleeding. But for the first few hours after 
seizure, the plan I have mentioned affords you a reasonable hope 
of being able to put a stop to the mischief at once. Army surgeons, 
and practitioners who have opportunities of treating incipient dis- TREATMENT OF FEVER. 
303 
ease, are well aware of the truth of these observations. I have 
myself witnessed many cases, in private practice, of medical men 
and students, who had been attacked with symptoms of fever after 
exposure to contagion, and who escaped by taking an emetic, and 
being bled in proper time. 
Except at the commencement, I am not an advocate for the use 
of emetics in fever. They fail in checking the disease, and they 
are apt to be followed by considerable debility of the stomach and 
general system—states which it would be better to avoid, where the 
patient has to run through the course of a long and exhausting 
disease. If called to a case of fever in which you cannot give an 
emetic, there are two or three other remedial agents you may 
employ to moderate the feverish excitement, and render the disease 
milder and more manageable during its progress. One of these is 
James’s powder, with which you may combine blue pill or hydrar- 
gyrum cum creta, if necessary, giving two or three grains of each 
every third or fourth hour, according to circumstances. Another 
remedy, which many are in the habit of using, particularly where 
the fever is accompanied with symptoms of inflammatory excite- 
ment, is a weak solution of tartar emetic. Two grains of tartar 
emetic may be dissolved in a pint of barley water, and of this mix- 
ture a table-spoonful may be taken every second hour. These are 
good and useful remedies in the first stages of fever; they moderate 
the feverish excitement, act gently on the bowels, and produce 
more or less diaphoresis. 
It most commonly happens that the physician is not called to see 
a case of fever until forty-eight hours, or perhaps three or four days, 
have elapsed, from the period of seizure. In this climate, feverish 
colds are extremely frequent; and as their symptoms bear con- 
siderable resemblance to those of incipient fever, and very few are 
capable of making a distinction between them for some time, a per- 
son attacked with fever usually regards it, at the first onset, as the 
result of cold, and expects to be able to alleviate or remove it in a 
few days by bathing his feet and taking a warm drink at night, 
with, perhaps, some opening medicine on the following morning. 
The usual period, however, at which the feverish cold had been 
accustomed to decline, passes over without the expected amend- 
ment, the patient feels himself weaker and worse, the conviction is 
brought home to him that his disease is something more than an 
ordinary cold, and he sends for a physician about the third or 
fourth day. Now at this period, I believe, you must be content to 
let the fever run its course; for it has taken root too deep to be 
expelled by a coup de main, and yet many persons seem to think 
they can still succeed by what they term bold and decided treat- 
ment. The mode which they generally adopt is, first, to administer 
an emetic, and then to have recourse to copious and continued pur- 
gation. This leads me to say a few words on the use of purgatives 
in fever. 
The abuse of purgatives, particularly in the first stage of fever, 
continues, I am sorry to state, even to the present day, a blot on 304 
graves’s clinical lectures. 
the character of practical medicine. Large doses of calomel, and 
vegetable purgatives, in the form of pill or bolus, and followed up 
by draughts composed of infusion of senna, Epsom salt, and elec- 
tuary of scammony, form the chief part of the treatment in fever 
with too many practitioners. I know well that this is a mode of 
proceeding too commonly employed, and I have frequently heard 
those who adopt it, when questioned as to the remedies they have 
used, declare, with much self-satisfaction, that the patient’s bowels 
have been well cleared out. This, I believe, is a very common 
mode of treating fever in the incipient stage; and though there can 
be no objection to the administration of a purgative, as a cautionary 
measure, particularly where an accumulation of fsecal matter in the 
bowels is suspected, I must confess that my experience does not 
authorise me to say, that fever can be either checked or mitigated 
by continued purgation. If active purgation does not check fever 
in the commencement, what benefit, then, can be expected from it? 
People will tell you that full purging must act beneficially in two 
ways; by unloading the bowels, and by evacuating the general 
system. With regard to evacuating the bowels, I think it can be 
done well and sufficiently by the use of mild aperients. It is sel- 
dom necessary to give active purgatives, and we never have occa- 
sion to continue their employment from day to day. The bowels, 
I repeat, can be sufficiently unloaded by the exhibition of mild 
aperients and enemata, and even these will seldom be required 
more than once or twice in the commencement, and occasionally 
during the course of the disease. The second question (in refer- 
ence to the use of purgatives as general evacuants) is, whether it 
is prudent or safe to act antiphlogistically on the system through 
the medium of the intestinal canal, during the first stage of fever ? 
My opinion is, that it is not. I grant that the administration of 
active purgatives is followed by a copious evacuation of the fluid 
secretions of the intestinal canal, and that in this way you deplete 
the system to a very considerable extent. Admitting all this, and, 
moreover, that depletion is required, still I am of opinion that this 
is not the best way of effecting it, and shall always give a prefer- 
ence to the action of other remedies. I prefer the action of James’s 
powder, or tartar emetic, or nitrate of potash, or leeches, or, in fact, 
any remedy which will act with less risk of subsequent mischief. 
I have observed that the abuse of active purgatives in the com- 
mencement of fever—nay, even the exhibition of cathartics two or 
three times, in the beginning of fever, in persons with irritable 
bowels, is very apt to induce excitement of the gastro-intestinal 
mucous surface, giving rise to early and profuse diarrhoea, tympa- 
nites of a bad and unmanageable character, and not unfrequently 
to disease of the mucous coat of the digestive canal. Great tender- 
ness of the belly, meteorism, and exhausting diarrhoea, are the 
general consequences of early and continued purgation. In private 
practice I can generally tell, by examining the patient’s belly, 
whether he has been actively purged in the commencement of the 
disease or not. I invite you to study the cases that come before TREATMENT OP FEVER. 
305 
you in hospital, with reference to this point; I think you will find, 
in most instances, that the patients who have escaped active purga- 
tion before admission, will get through the disease with little or no 
tympanites. The physician who merely employs mild aperients 
and enemata—who does not use active purgatives from day to day, 
as is too often done—will not have his plans of treatment embar- 
rassed by the occurrence of dangerous tympanites, or obstinate and 
debilitating diarrhoea ; nor will he have the melancholy prospect 
before him of having an inflammatory affection of the gastrointes- 
tinal mucous membrane to treat, at a period when neither the con- 
dition nor the constitution of the patient will bear any thing like 
antiphlogistic measures. As to purging in general, the idea of 
curing fever by it is quite absurd. In fever, all the secretions are 
affected, and it would be idle to think of altering and improving all 
by acting on the bowels. Take the skin, for example. Consider 
what a departure there is from the normal state ; observe the quan- 
tities of moisture which exude from it without any apparent cause, 
or its equally inexplicable dryness. Its odour, its feel, its nervous 
and vascular conditions, are all more or less altered. Take the 
lungs, in the next place. There is generally some change in the 
smell of the patient’s breath; there is some change also in the quan- 
tity of the pulmonary exhalation ; there is an alteration in the rate 
and mode of respiration; and I have ascertained, by experiment, 
that a person in fever does not consume as much oxygen, or give 
out as much carbon, as he would in a state of health. Observe 
the functions of the brain, or those of the liver or kidneys, and see 
how much they have departed from the normal state. Every 
secretion, every function, is more or less deranged, and will remain 
so as long as the fever lasts. You have no right to think that you 
will be able to restore the healthy state of the stomach and bowels 
any more than that of any other organ. The secretions of the 
lungs, liver, pancreas, kidneys, stomach, and skin, are all deranged, 
or more or less suppressed, and will not be restored to a healthy 
state until a crisis comes on, or the disease begins to decline. As 
long as the belly is soft and fallen, and where the bowels have been 
sufficiently opened in the commencement of the disease, I do not 
feel the least anxiety if the patient remains without having a stool 
for two or three days. I have, on some occasions in private prac- 
tice, been induced to consent to the exhibition of a purgative where 
I did not think it required; and have seldom done so without 
regretting it afterwards. The patient has been going on well, the 
belly soft and fallen, no tenderness present, and no distinct evidence 
of faecal accumulation. All this I have pointed out to the practi- 
tioners in attendance with me, but to no purpose. They would 
generally observe, in reply, “ Oh ! this may be all true; but you 
see the patient has had no stool for the last thirty-six hours, and it 
would be quite wrong to let him go on in this way any longer.” 
Indeed, you will frequently meet with cases in which you should 
exercise much caution in the administration even of enemata. An 
illustration of this remark occurred to Surgeon Ferrall and me 306 
GRAVES’s CLINICAL LECTURES. 
lately in practice. In a case of fever in which the patient’s friends 
were importunate as to the necessity of opening the bowels, the 
ordinary purgative injection was prescribed. It proved too active, 
and produced much irritation of the bowels, giving rise to an 
increased secretion of gas into the intestines, and a considerable 
degree of temporary tympanites. 
You will be guided, therefore, in the administration of purgatives, 
not by the rule of those who are not satisfied with less than two or 
three motions in the day, but by the circumstances and exigencies 
of the case ; and you will be cautious in giving purgatives, except 
where you have good reasons to conclude that there is an accumu- 
lation of faeces. In this way you will avoid tympanites, diarrhoea, 
and inflammatory affections of the bowels; symptoms which always 
give great annoyance to a practitioner, and tend greatly to embarrass 
his practice in the treatment of all fevers of a typhoid character. 
So far concerning the administration of purgatives as a cure for 
fever, or as a means of diminishing its violence. You perceive that 
I think their employment more than questionable, and in this par- 
ticular am consequently at issue with Hamilton, and a great number 
of writers. There are, however, circumstances which may arise 
during the course of typhus, and may require a free use of purga- 
tive medicines ; we are then forced to have recourse to purgatives, 
not in the hope of curing the fever itself, but for the purpose of 
removing or alleviating certain superadded symptoms. It may be 
well to mention some of the chief of these symptoms. One of the 
most common is determination of blood to the head, producing 
delirium, headache, &c. <fcc. In many examples of this nature, 
occurring at an early period of typhus, purgatives of a very active 
nature are amongst our most efficacious remedies. Nay, even in 
the advanced stages of fever, delirium and determination to the 
head are seldom relieved by tartar'emetic, unless it produces very 
copious, yellow, watery stools. Many patients become uneasy and 
restless at night, in the latter periods of fever, in consequence of 
insufficient, evacuations from the bowels; whenever, therefore, 
restlessness or sleeplessness supervene unexpectedly, and that the 
bowels are confined, the occurrence of these symptoms call for 
aperients, even though the belly be not very full and tumid. Pre- 
ternatural fulness of the belly, and tympanites, often demand pur- 
gatives at every period of the disease. In some cases, when a 
troublesome diarrhoea has yielded to astringents, a very obstinate 
and long-continued state of constipation comes on, apparently con- 
nected with impaired muscular power of the intestinal tube. At 
first, this confinement of the bowels produces no uneasiness on the 
part of the medical attendant, inasmuch as it is unattended by any 
fulness or tension of the abdomen, and the patient may, in other 
respects, appear to be doing well. After some days, however, it is 
judged prudent to excite alvine evacuations, which is attempted 
cautiously, for the practitioner bears in mind the violence of the 
previous diarrhoea. He therefore chooses mild purgatives at first, 
and next day, finding them ineffectual, he ventures on the exhibi- TREATMENT OF FEVER. 
307 
tion of more active medicines, and orders a frequent repetition of 
injections. Even these steps fail, and constipation continues for 
several days after the efforts to remove it have been commenced. 
This is a juncture full of difficulty. In such cases, much caution 
must be used in employing active cathartics, and great care should 
be taken to remove any accumulation of hardened fasces which 
may have accumulated in the rectum or sigmoid flexure of the 
colon. This must be done partly by the finger, or by means of an 
appropriate scoop, as, for instance, a marrow-spoon, and by injec- 
tions of soap and water. When no such mechanical obstructions 
exist, to account for the failure of the cathartics, we must proceed 
cautiously, and not rashly accumulate medicines of this description 
in the stomach and bowels of the patient. Very active purgatives, 
though they fail to stimulate the paralysed bowels so as to evacuate 
their contents, may yet irritate the intestinal mucous membrane, 
and cause destructive inflammation. For this reason, where mode- 
rate doses of colocynth, gamboge, jalap, scammony, rhubarb, &e., 
have failed, they must not be repeated; neither, except in desperate 
cases, ought we to administer croton oil internally. The neutral 
salts, senna, magnesia, and, above all, castor oil, given combined 
with spirits of turpentine, or uncombined and very frequently 
repeated, must be our chief internal medicines. In some cases, the 
compound decoction of aloes, with small doses of sulphate of mag- 
nesia, will succeed in exciting the paralysed bowels to action, 
where other and more powerful purgatives have failed. Injections 
should be perseveringly repeated, and varied both in quality and 
quantity; and they should be always thrown as far as possible into 
the bowel, by means of a flexible tube and Read’s syringe. When 
they are retained, and excite swelling of the belly, as too frequently 
happens in these cases, we must desist from their use. 
This obstinate state of constipation may be supposed to depend 
on a degree of paralysis of the bowels; for usually in such cases 
an evident paralysis affects the bladder, causing retention; or its 
sphincters, giving rise to an involuntary dribbling of urine. 
On the subject of bleeding in fever, I have but very few remarks 
to offer. In the first place, with respect to the power which vene- 
section possesses of checking fever, it may be observed, that there 
can be no doubt that it has frequently been found capable of effect- 
ing this purpose, particularly where it has been properly employed, 
and in conjunction with other means. I speak here with reference 
to cases in which bleeding has been used under favourable circum- 
stances, and very soon after seizure—as in students, medical prac- 
titioners, hospital attendants, soldiers, and seamen. In such per- 
sons, and others whose circumstances have been equally favourable, 
there is no doubt that venesection has frequently succeeded in cut- 
ting short fever ; and if called to a case of typhus within the first 
ten or twelve hours after seizure, I should have no hesitation in 
having recourse at once to venesection, followed by an emetic ; 
and my own experience convinces me that I should afford my 
patient a very good chance of escaping the disease. I have on 308 
graves’s clinical lectures. 
several occasions succeeded in arresting the progress of fever by 
these means; and the records of naval and military practice furnish 
many proofs in corroboration of my statements. I have also the 
authority of Dr. Cheyne (whose experience on every point con- 
nected with fever was immense) in favour of the efficacy of bleed- 
ing in commencing fever, as a mode of treatment which has fre- 
quently proved successful in his hands. But it is only in the very 
commencement, and almost only during the stages of rigor, that 
you can hope to derive any advantage from venesection in cutting 
short an attack of fever. I do not mean to say that you have in 
typhus, as intermittent, distinct rigors, lasting each for half an hour, 
or even longer; by the stage of rigor in typhus, I mean to designate 
the period of formation, during which the patient complains of 
recurrent chills, although his skin feels hot to the touch when 
examined by another person. This stage lasts generally from 
twelve to twenty-four, and in a few cases to thirty-six hours; and 
it is only during this stage that you have a chance of extinguishing 
the fever at once, by the abstraction of blood from the system. 
You may also have recourse to venesection within the first day 
or two, for the purpose, not of arresting fever at once, but of lower- 
ing inordinate vascular action, in persons of a robust habit, and 
where the fever sets in with violent headache, great heat of skin, 
and a firm bounding pulse. We do not, however, at present meet 
with many such cases, nor are we often called in at a period when 
venesection might be advantageously practised. The physician 
seldom sees a case of fever until the third or fourth day, and then 
it is too late to think of general depletion by the lancet. This 
explains why venesection is so seldom employed in typhus in our 
hospitals. Moreover, in entering on the treatment of any case of 
fever at present, you should bear in mind the nature of the prevail- 
ing epidemic, and be careful how you proceed with respect to 
bleeding; and if you take away blood, do not go so far as you 
would if treating a case of fever under different circumstances, and 
of a genuine inflammatory character. I know that many persons 
have asserted that you can bleed in all cases of fever, no matter 
what the state of debility may be ; because this, they say, is only 
apparent, and depends upon congestion and oppression of vascular 
action. I do not know how far this doctrine may be applicable to 
other epidemics, but in the present fever it certainly does not hold 
good; and no man in his senses would think of adopting it as a guide 
for his practice. I have seen some of the most intense, dangerous, 
and protracted cases of fever, commence without any appreciable 
increase of vascular action, with a soft slow pulse, a cool skin, no 
symptoms of congestion of any internal organ; in fact, without any 
thing which would, even in the youngest and most robust habits, 
call for the use of the lancet. Increased vascular action, and this 
you should always bear in mind, is not in itself a proof of an 
inflammatory diathesis in fever, but rather one of a set of symptoms 
produced by the same morbid cause. The heat of skin and 
rapidity of pulse are, just like the debility, products of the same 309 
TREATMENT OF FEVER. 
morbid cause, and not the results of inflammation, or increased 
action of the heart, depending on a general inflammatory condition 
of the whole mass of the blood. You should also recollect that in 
fever, as well as in other diseases in which the nervous system is 
greatly deranged, the pulse is not unfrequently a very deceptive 
guide. In many cases of fever, where the patient happens to be of 
an irritable habit, the pulse exhibits a degree of thrill and apparent 
hardness, which might lead an inexperienced or inobservant prac- 
titioner into serious errors. I do not mean to say that an inexpe- 
rienced finger will not be able to distinguish a pulse of this kind 
from one of genuine hardness, but I know that many persons have 
been misled by it, and I warn you against the danger. 
Again, never use the lancet when there is any, even the slightest, 
appearance of maculae, no matter how intense the headache, heat 
of skin, or signs of general vascular action, may be. I have seen 
some cases in which the lancet was used during the presence of 
maculae, and I have seen its employment followed by the most 
lamentable consequences. You should, therefore, never omit to 
examine the skin, for circumstances might occur which would 
authorise a moderate use of the lancet, provided there was no 
sign of maculae present. Formerly, persons were very much in 
the habit of employing arteriotomy when the headache and deli- 
rium were violent, regardless of the period or stage of fever ; and 
nothing was more common than to see a physician ordering the 
temporal artery to be opened on the eighth, ninth, or even tenth 
day. This was very much the practice during the time when the 
doctrine of typhus being the result of inflammation of the brain 
prevailed in this country and England, and a very unsuccess- 
ful practice it was. You perceive we seldom have recourse to 
arteriotomy here ; it may be occasionally necessary, and when it is, 
we employ it; but as a general practice it does not appear entitled 
to any merit, nor can we give it our recommendation. 
The examples which you have seen in hospital show you that 
local inflammation arises, generally speaking, at a period when 
general bleeding is no longer admissible. Here you must have 
recourse to cupping and leeching; and this leads me to say a few 
words on this part of the subject. I have observed that local 
inflammations in typhus are most usually seen after the stage of 
excitement has arrived at its acme, and that it is generally about 
the middle of fever that they begin to fix themselves in various 
internal organs. We have, it is true, very severe affections of the 
internal organs, particularly of the brain and digestive system, in 
the commencement of fever, but these are most frequently the 
results of mere irritation or excitement, and not of true inflamma- 
tory action. They are, however, of considerable importance, and 
frequently require the application of leeches. I have spoken already 
of the mode in which leeches are to be applied to the head, with 
the view of relieving headache and cerebral congestion ; it is not 
necessary that I should say any thing respecting their application 
to the epigastrium or abdomen, for the relief of gastro-intestinal 310 
graves’s clinical lectures. 
symptoms, in the beginning of fever, as there is very little chance 
of your doing any mischief, even by the free use of leeches, at this 
period; it only remains for me to make a few remarks on the use 
of leeches and cupping-glasses, in the more advanced stages of the 
disease. Well; your patient, suppose about the ninth or tenth 
day, gets pain in his side, cough, and increased frequency of respir- 
ation, and, on examination, you find sufficient evidence of the exist- 
ence of pneumonia. Or he complains of abdominal symptoms, and 
you have strong reasons to think that hepatitis or enteritis is pre- 
sent. Here you will have recourse to leeches or cupping, according 
to the circumstances of the case. An attack of pneumonia, coming 
on in fever, frequently acts as a stimulus to the economy; the col- 
lapse of fever disappears more or less, and the pulse becomes more 
firm and resisting. This is a fortunate occurrence, for under 
such circumstances the patient is better able to bear depletion, and 
you may proceed at once to apply cupping-glasses or leeches to his 
chest, regulating the quantity of blood you abstract, not only with 
reference to his present symptoms, but also to his future condition. 
But it sometimes happens that pneumonia occurs at a later period 
of the disease, and when you cannot use cupping-glasses, or even 
leeches, to any great extent. In such cases, (and the same remark 
will apply to enteritis, or any other inflammation occurring in the 
advanced stage of fever,) you should leech with great caution; 
begin with four or six at a time, and when they drop off, cover the 
leech-bites with a cupping- glass. In this way you will know pretty 
nearly the exact quantity of blood which the patient has lost, and 
you can arrest it with less difficulty afterwards. You can then 
have recourse to calomel and opium, or tartar emetic, according to 
circumstances. Leech as far as you can, and then have recourse 
to immediate blistering, and such other means as the exigencies of 
the case may demand. 
You may leech, then, freely, and without any particular caution, 
in the commencement of fever, whether it be for cerebral, or for 
thoracic, or abdominal symptoms; but as the fever advances, you 
must exercise more discrimination and care, both as to the number 
of leeches you apply, and the time you allow them to bleed. In 
applying leeches to the head, I would advise you not to put them 
on both temples, or behind both ears at once, as this is awkward, 
and prevents the patient from lying on either side. You may also, 
in cases of cerebral irritation, apply them to the nostrils or septum 
narium ; in this way you will be able to get away a large quantity 
of blood by means of very few leeches, for one or two at a time will 
be sufficient. The application of leeches to the abdomen or thorax, 
so far as the place for their application is concerned, does not 
require any observations. You will frequently have to employ 
them in the treatment of gastro-intestinal inflammation, and you 
will find them most valuable agents in many cases, when scarcely 
any other mode of depletion is admissible. In leeching the chest 
and abdomen in particular, I would advise you never to have 
recourse to fomentations with the view of getting more blood from ABDOMINAL ANEURISM. 
311 
the leech-bites. Fomentations are too often a source of fresh mis- 
chief in cases of this kind, leading to exposure of the patient to 
cold, and to the annoyance of having his linen and bedding kept 
wet for hours together. Always give directions to have cupping- 
glasses, or hot dry flannel cloths, applied as soon as the leeches 
drop off, and you will avoid the inconveniences attendant on 
fomentations, at the same time that you will be able to procure 
quite as much or even more blood, within the same space of time, 
and you will have less difficulty in arresting its flow afterwards, a 
point of some importance in cases where the loss of even a trifling 
quantity of blood is often of great moment, and likely to have a 
very powerful effect on the state of the patient. 
I had purposed concluding to-day my observations on the prin- 
cipal remedial agents used in the treatment of fever, but find that 
time will not permit me to go further. At our next meeting, I shall 
say a few words on the employment of mercury, and some other 
remedies, and will then proceed to the consideration of some cases 
of importance which are now under treatment in our wards. 
... I* 
Abdominal aneurism—Effect of posture on the bruit de soufflet—Limitation of this 
sound to one spot in aneurism—Its extension in mere nervous affections—Letter 
from Dr. Corrigan on the subject—Case of diabetes—Discovery of casein in the 
urine—Different varieties of diabetes. 
LECTURE X. 
I shall draw your atention to-day to the consideration of some 
cases which occurred before the commencement of the present 
session—that is, during the months of August, September, and 
October—and which were attended with circumstances of peculiar 
interest. 
The first of these cases was one of aneurism of the abdominal 
aorta, a disease which has been studied with much care and atten- 
tion within the last few years. It is unnecessary for me to enter 
here into any detail of the symptoms and morbid phenomena which 
characterise this affection; you will find sufficiently ample accounts 
of them in various works of pathology: the chief symptoms you 
will find briefly but accurately given in Dr. Cowan’s excellent 
11 Bedside Manual of Physical Diagnosis.” Ten or twelve years 
ago, the diagnosis of this disease was extremely obscure and imper- 
fect, and an aneurism of the abdominal aorta was rarely detected 
in its incipient or even in its advanced stage, when it did not pre- 
sent the phenomena of a large pulsating tumour, the existence and 
nature of which could be scarcely passed over even by the most 
superficial observer. In the commencement, when the aneurismal 
tumour was small, and did not manifest itself by any external pul- 
sation, or even when it was of considerable size, but happened to 312 
graves’s clinical lectures. 
be protected from an examination by its situation, connections, &c, 
it not unfrequently remained undiscovered during the patient’s life- 
time, and was detected only on dissection. A very remarkable case 
of this description has been recorded by Dr. Beatty, in the 5th vol. 
of the Dublin Hospital Reports. The patient was a relative of my 
own, and I had frequent opportunities of studying his case. I did 
not see him in the commencement of his illness, but I afterwards 
accompanied him to London and Paris, where he had the advice of 
the most eminent professional men. He died about two years after- 
wards, and it was only on dissection that the nature of his disease 
was discovered. The case was subsequently published by Dr. 
Beatty, chiefly from the gentleman’s own notes, and excited a great 
deal of attention in London and Paris, as well as here. I mention 
these facts to show you that it is only very recently that aneurism 
of the abdominal aorta has been studied properly. I feel perfectly 
convinced that an error in diagnosis of this description would not 
be committed at present, and that, with the light which we now 
possess, the disease would have been speedily recognised. You 
will find the case in the 5th vol. of the Dublin Hospital Reports, 
and it is well worthy of your attentive perusal. 
I do not intend to enter into any general considerations on the 
subject of aneurism of the abdominal aorta; I shall confine myself 
at present to the examination of a single point of diagnosis, on 
which Dr. Corrigan has published some observations, in a recent 
number of the Dublin Medical Journal. With tjje view of illus- 
trating this matter more fully, I shall read for you the notes of the 
following case. 
Michael Whelan, a gardener, aged 40, was admitted into the 
Meath Hospital on the 19th of August, 1836. He had no remark- 
able illness, except an attack of venereal about nine months pre- 
viously, for which he was salivated and cured. His health con- 
tinued as good as usual, until about five months before admission, 
when he was attacked with pain in the stomach and bowels, and 
occasionally in the back and right hypochondrium. About six 
weeks before admission, this pain became constant, and was accom- 
panied by epigastric tenderness, nausea, and vomiting. For these 
symptoms he was admitted into Sir P. Dun’s Hospital, where he 
had leeches, sinapisms, and blisters, to the epigastrium and right 
hypochondrium, and internally, turpentine, with castor oil. but 
without any benefit whatever, and he left the hospital pretty much 
in the state he entered it, about four days before he was received at 
the Meath. His symptoms, on admission, were pain and tender- 
ness on pressure over the epigastrium, pains shooting through the 
whole abdomen, no tumour or hardness discoverable, anorexia, 
nausea, with occasional vomiting. Tongue clean, bowels free, no 
thirst. He complained of loss of sleep, his spirits were dejected, 
and there was more or less emaciation; pulse 102, full and regular; 
action of the heart normal. He stated that he generally obtained 
transient relief from the abdominal pains by taking a draught of 
warm water. 313 
BRUIT DE SOUFFLET. 
From the history of this case, and the consideration of the 
patient’s symptoms, we were led to conclude that it was a case of 
dyspepsia. You perceive he had many of the symptoms which 
characterise derangement of the digestive system—as anorexia, nau- 
sea, with occasional vomiting, epigastric tenderness, pain, and 
emaciation: and in addition to these, there was no tumour or hard- 
ness present which would lead us to infer the existence of organic 
disease. We therefore had recourse to the usual remedies employed 
on such occasions. We ordered a large enema of warm water and 
oil, to be thrown up the rectum with the aid of Read’s syringe. 
This treatment is generally employed on such occasions, whether 
the patient reports his bowels costive or not; for we have frequently 
observed, that after using enemata in this way, once or twice daily, 
for three or four days, many of the usual phenomena of indigestion, 
as pain, nausea, irregularity of bowels, and abdominal tenderness, 
are greatly relieved, or disappear altogether. We also applied 
leeches to the epigastrium, and prescribed hydrocyanic acid, to be 
taken in doses of two drops, three times a day. Under this treat- 
ment, assisted by a carefully regulated diet, the patient seemed to 
improve at first, and experienced some relief of many of his distress- 
ing sensations. His pulse fell to 84, and subsequently to 76, and 
the vomiting ceased ; but the pain in the epigastric and umbilical 
regions continued to recur at intervals, sometimes depriving him of 
sleep, and at the same time whep. we expected a favourable result 
from our treatment, he would suddenly, and without any apparent 
cause, become as bad as ever. On the 24th, Mr. Harnet, a pupil in 
this hospital, noticed a feeble and indistinct pulsation in the epigas- 
tric region, and, on applying the stethoscope over this part, a distinct 
bruit de soufilet was heard, which diminished in intensity as the 
instrument was carried downwards, ceasing altogether at the 
umbilicus. Under these circumstances, I requested my friend Dr. 
Corrigan to examine the patient, which he subsequently did, and 
gave the diagnosis of aneurism of the abdominal aorta. He found 
the bruit very distinct when the patient was in the recumbent 
position, but it nearly ceased when he sat up or stood erect. By 
elevating the pelvis, and depressing the shoulders, a fremissement 
was felt once or twice when deep pressure was made in the imme- 
diate neighbourhood of the place where the bruit was heard. 
The man continued to suffer in various ways during the time he 
remained in hospital. Sometimes he was quite free from pain, had 
a tolerable appetite, and improved in his looks and spirits. At other 
times, he had severe attacks of pain in the stomach, accompanied 
with nausea and severe pain in the spine, about the termination of 
the dorsal vertebrae. When the pain in his stomach was severe, 
the pain in the back was generally relieved. These pains fre- 
quently affected him during the day, but the most usual, as well as 
the severest paroxysms, occurred at night. He suffered some incon- 
venience and sense of weight and fulness after eating, but this was 
by no means a prominent symptom. He also had occasional fits 
of emesis, and generally felt more or less relief after vomiting. 314 
GRAVES’S CLINICAL LECTURES. 
Towards the latter period of his illness, the paroxysms of pain be- 
came more frequent and severe, and lasted for a longer period. 
On the 16th and 17th, he had acute pain in his back and stomach, 
accompanied with nausea. On the 18th, he was seized with 
violent pains while eating his dinner, and expired about half-past 
five in the afternoon. 
His body was examined by Mr. Porter, eighteen hours after 
death. On opening the abdomen, an aneurism of the abdominal 
aorta, immediately below the cseliac plexus, was discovered. It 
was evidently a true aneurism, and originated in a dilatation of the 
coats of the vessel with rupture, for the lining membrane of the 
artery was continued into the aneurismal sac, from which, also, 
several branches were given off. The edge of the aperture, 
through which the blood escaped into the cavity of the abdomen, 
was very thin, and presented a fringed appearance. There was 
an immense quantity of coagulable blood effused, which adhered 
firmly to the sac, and also to the kidney. The aneurismal sac was 
about the size of a hen’s egg, or a little larger. The external iliac 
arteries were diminished in size. 
Some time after this case had been examined by Dr. Corrigan, he 
favoured me with the following communication :— 
“My dear Doctor,—I thank you for your kindness in having 
given me an opportunity of seeing the case of Whelan, who died in 
your hospital of aneurism of the abdominal aorta. You have ex- 
pressed a wish that I should explain on what grounds I gave the 
diagnosis of aneurism, which chanced to turn out correct. On the 
symptoms I have nothing to observe ; they simulated, as well as I 
can recollect, the ordinary symptoms of chronic gastro-enteritis. 
“ The opinion which I gave was altogether founded on the phy- 
sical signs, viz. the permanent existence of bruit de soufflet, the 
remarkable increase of the sound by change of position, and the 
limitation of the sound (when thus increased) to a particular spot. 
“ The bruit de soufflet was heard a little below, and to the left side 
of the ensiform cartilage ; it was indistinct when the patient stood 
up or sat erect, but when he was made to lie in a perfectly hori- 
zontal position, the sound became very loud, and with the increase 
of loudness it became the more evident that it was quite circum- 
scribed, and that it did not extend downwards alons: the aorta. 
This case made the third of abdominal aneurism which I have 
seen at so early a period of the disease, and in the Dublin Medical 
Journal for January, 1833, where I have related the two previous 
cases, I have endeavoured to explain the principle on which I have 
used change of position as a means of rendering distinct a bruit de 
soufflet which might otherwise escape detection. While a patient 
with aneurism of the abdominal aorta sits or stands erect, the 
column of blood in the descending aorta is exerting a considerable 
hydrostatic pressure upon the sides of the aneurism, which, even 
in the intervals of the heart’s contraction, is sufficient to keep the 
aneurism very tense. The sides of the aneurism thus kept tense BRUIT DE SOUFFLET. 
315 
cannot thrill or vibrate, and hence there is little or no bruit de 
soufflet; but when the patient is placed in a horizontal position, 
the aneurism is relieved of the hydrostatic pressure, and being no 
longer constantly acted upon by a force which would keep it very 
tense, its sides are more at liberty to vibrate, each new rush of 
blood gives to the now comparatively flaccid side of the aneurism a 
thrilling vibration, and the bruit de soufflet becomes proportionally 
loud. In the latter pages of the article on Bruit de Soufflet, which 
I have sent for insertion in the November number of the Dublin 
Journal, I have endeavoured to explain the rule which regulates 
the connection between aneurism and bruit de soufflet. 
“ There are cases of bruit de soufflet in the abdominnl aorta, in 
which the sound arises from nervous irritation or other causes, and 
which sometimes simulate aneurism; but in all such cases which 
have come under my own observation, it could be perceived that 
the bruit de soufflet extended along a considerable portion of the 
aorta, and in most of the cases the vessel could be traced of its 
natural size. Laennec, you remember, has already made a similar 
observation. ‘ Le stethoscope me donnait la sensation de la forme 
et des dimensions de Partere, dont le calibre semblait tout a-fait-egal, 
et de grandeur naturelle,’ &c. 
“It remains, of course, for further observation to confirm or cor- 
rect the principle on which change of position was used to assist in 
forming the diagnosis. Excuse me for trespassing on your patience 
with this long letter, and 
“ Believe me, my dear doctor, 
“ Yours sincerely, 
“ D. J. Corrigan.” 
You perceive, then, that Dr. Corrigan dwells on the circumstance 
of bruit de soufiiet being heard louder in the horizontal position, 
not because he thinks it a diagnostic of aneurism of the abdominal 
aorta, but because a knowledge of this fact leads us to the discovery 
of bruit de soufflet in cases where otherwise it would be very likely 
to escape observation. Thus, according to his views, it will not be 
sufficient, in a case of suspected abdominal aneurism, to examine 
the patient standing, or in the erect position ; you must place him 
in the horizontal position, in order to hear the bruit distinctly, and 
if you depress the shoulders, and elevate the pelvis, so as to dimi- 
nish still farther the hydrostatic pressure, you will render the sound 
still more distinctly audible. When Dr. Corrigan first published 
his views, I fell into the error of supposing that he intended to put 
this forward as a diagnostic mark between aneurism of the abdo- 
minal aorta and diseases which simulate it. This, however, is not 
the case; Dr. Corrigan’s meaning is, that the change of position 
will enable you to discover a bruit de soufflet, which, under other 
circumstances, could not be detected. He afterwards proceeds, as 
you may have observed, to distinguish the bruit de soufflet of 
aneurism from that which accompanies other affections, and his 
chief diagnostic is the limitation of the bruit de soufflet to a par- 316 
graves’s clinical lectures. 
ticular spot of the track of the artery. In cases of nervous irrita- 
tion, accompanied with bruit de soufflet, you hear the bellows 
murmur all along the course of the vessel; but in the bruit de 
soufflet of aneurism, the murmur is confined to a certain spot, and 
becomes more indistinct the farther you remove the end of the 
stethoscope from the place where it is situated. I would refer you, 
for farther information on this point, to Dr. Corrigan’s paper on 
bruit de soufflet, in the Dublin Journal for November, 1836, where 
you will find enumerated all the causes which Dr. Corrigan looks 
upon as capable of giving rise to this peculiar variety of sound. 
Shortly after Whelan’s death, another case offered itself to our 
notice, which promised to throw some further light on the subject 
of aneurism of the abdominal aorta. A woman named Sarah 
Smith, aged 48, was admitted into the Meath Hospital on the 23d 
of September, 1836. She stated that she had been ill for three 
months, and complained of headache, pain and weakness of the 
loins, loss of strength, and palpitations of the heart. Her appetite 
was impaired, her stomach irritable, and for a considerable length 
of time she had been subject to attacks of vomiting, in which she 
threw up large quantities of sour fluid. Her bowels were habitually 
costive, and consequently required the stimulus of purgatives. She 
had frequent rigors, followed by heat of skin and perspirations, 
which sometimes attacked her two or three times a day. The 
pain in the head was chiefly confined to the occipital and mastoid 
regions; she had some tenderness on pressure in this situation, but 
no appearance of swelling. She complained of slight cough, 
aggravating the headache, but on examining the chest no morbid 
sound could be discovered, and the action of the heart appeared 
healthy and normal. The abdomen was soft and natural, but on 
applying the stethoscope over the epigastric region, a loud distinct 
bruit de soufflet was heard when the patient lay in the horizontal 
position; this sound became altogether indistinct when she stood 
or sat erect. Owing to the emaciated state of the patient, and the 
thinness of the abdominal parietes, the aorta could be felt quite 
plainly throughout nearly its entire course. It appeared to run 
rather tortuously, but no evidence of any kind of dilatation could 
be discovered. The patient had no pain in the epigastric region, 
but had constantly suffered from a sense qf tightness in this situa- 
tion. She complained, however, of constant pain in the spine, 
about the upper part of the lumbar region. The catamenia had 
ceased, and she was subject to a leucorrhmal affection of some 
years’ standing. Her tongue was clean, her appetite bad, bowels 
confined, no remarkable thirst or nausea ; pulse 76, weak, but 
regular. 
Her bowels were kept open with rhubarb and magnesia, and 
subsequently with pil. aloes cum asafoetida, and her diet properly 
regulated. Under this treatment she improved rapidly, and left 
the hospital greatly relieved on the 5th of October. In this case, 
the bruit de soufflet was nearly, or altogether, permanent; for it 
could be heard still at the period when the woman left the hospital. DIABETES. 
317 
It extended along the track of the vessel, and depended, most pro- 
bably, not on aneurism, but on nervous irritability, combined with 
dyspepsia. The woman was greatly emaciated, and we could feel 
the artery distinctly for nearly its entire course, but could not detect 
any thing like an aneurismal tumour. I may observe, also, that in 
this case a phenomena was observed, which was also noticed in 
the case of Whelan. Mr. Dillon observed that when the woman 
lay on her face, the bruit de soufflet could be heard on the left side 
of the spinal column, but not on the right. 
From a consideration of this case, you will perceive that change 
of position, as employed by Dr. Corrigan, is applicable not only 
to cases of bruit de soufflet connected with actual disease of the 
aorta, but also to cases in id Inch the bellows murmur depends on 
nervous irritation. When this woman stood or sat up, no morbid 
sound could be heard; but when she lay in the horizontal position, 
a loud and distinct bruit de soufflet was heard along the track of 
the artery. The same observation will apply to hysterical bruit de 
soufflet, which is increased in the horizontal, and diminished in the 
erect position; and the very same arguments which Dr. Corrigan 
has used to explain this sign in aneurism of the abdominal aorta, 
will apply to other cases in which there is bruit de soufflet without 
aneurism. 
Having made these observations, I shall proceed to direct your 
attention to a very remarkable case of diabetes, now under treat- 
ment in the chronic ward. When the patient was admitted, he 
complained merely of emaciation, weakness, and thirst; and as we 
could not find any thing to account for the last symptom, I 
requested the gentleman who had charge of the case to attend care- 
fully to the state of the urinary secretion, as I suspected it was a 
case of diabetes, which afterwards turned out to be the fact. On 
examining the urine, shortly after his admission, no urea could be 
found in it; within the last two days, it has been analysed with 
great care by Dr. Aldridge, and he informs me that at present it 
contains a considerable quantity of urea. You perceive, then, that 
the result of our treatment has been favourable ; the urea, which 
had disappeared while the disease had existed in a more intense 
state, is now beginning to return. Dr. Aldridge has not been able 
to discover any sugar in this man’s urine, but he has found in it a 
peculiar animal matter, the existence of which, in the urinary 
secretion, is worthy of attentive consideration, and presents some 
points of great physiological interest. I may observe, that some 
time before Dr. Aldridge made his analysis, it was reported to me 
that the man’s urine was albuminous—a fact which did not at all 
surprise me, as the presence of albumen has been frequently 
observed in the urine of dropsical and diabetic patients? and it has 
been observed that in some cases of diabetis mellitus, the sugar 
became replaced by albumen in proportion as the disease declined, 
and that this process went on for some time after the diabetic 
symptoms continued to diminish in intensity. But in the present 318 
graves’s clinical lectures. 
instance, Dr. Aldridge has discovered that the animal matter con- 
tained in our patient’s urine is not albumen, but casein. It may 
be necessary, for the benefit of the younger students, to state that 
casein is not precisely analogous to cheese; it is, however, the 
principle from which cheese is formed, after it has undergone cer- 
tain chemical alterations, the most important of which appears to 
be fermentation. Casein, as you will find in your works on 
chemistry, is in its chemical composition closely allied to albumen; 
indeed, the chemical relation is so very strong, that you might be 
inclined to say that the difference between them was altogether 
unimportant, since analysis has failed in detecting any remarkable 
difference in the ultimate elements of which both are composed. 
They certainly differ very little in their ultimate principles, but 
then they differ so much in their properties, that it is to the latter 
alone we must look in order to draw between them a sufficiently 
well-marked line of distinction. If we examine casein in reference 
to its physical properties, we shall find it very different from albu- 
men. Ferment albumen as long as you like, you will not be able 
to produce any thing like cheese; and if the fermented substance 
be allowed to mould and putrefy, it will not produce mites. Again, 
casein is not like albumen, separated from water and precipitated 
by boiling, as is well known from the familiar example of submit- 
ting milk to the boiling process. It is in these, and properties of a 
similar nature, that we discover the difference between casein and 
albumen. 
Now if this discovery of Dr. Aldridge’s be confirmed by further 
investigation and experiment, it will form a very remarkable inci- 
dent in the history of diabetic urine. It is also interesting, in a 
physiological point of view, to find the animal principle of cheese in 
the urine of the human male. The only human secretion in which 
it is met with in any considerable quantity, is the milk of the female, 
and also occasionally in the urine of pregnant women—a fact 
noticed by Dr. Cummin, in his able lectures on Forensic Medicine, 
now in course of publication in the London Medical Gazette; 
casein has been also found, in some instances, in the male, as an 
abnormal secretion from the mammas. You are aware that Hum- 
boldt has given some instances of this secretion occurring in the 
male, and, with the facts which we have before us, there does not 
appear much difficulty in admitting the statements of Humboldt, 
when he says, that he has seen an infant nourished for the space of 
twelve months with milk secreted by the male breasts. Here, you 
perceive, we have casein secreted in abundance by the kidneys, 
and you are all aware that sugar is secreted by the same organs in 
very remarkable quantities. You perceive, then, we want nothing 
but the oil to make up a secretion from the kidneys analogous to 
that formed in the breasts of the female. Now, when we recollect 
the abundance in which oily particles are present in the blood of 
some dropsical patients, the separation of oil from the blood may be 
easily conceived to be within the power of the kidneys, and, conse- TREATMENT OF FEVER. 
319 
quently, it is just within the range of possibility that some of the 
strange tales told about persons passing a milky urine may be 
founded on fact. 
These facts are extremely curious as connected with the history 
of secretion. I think Dr. Aldridge’s discovery is likely to throw 
some additional light on the nature of diabetic urine, and I am 
happy to find that a new path of investigation has been struck out 
by a gentleman who has been for a long time a diligent and 
talented pupil in this hospital. 
Before I close this lecture, I shall run briefly over the principal 
varieties of diabetes. In the first place, then, we have the diabetes 
insipidus, in which there is merely an increase in the quantity of 
the urine, without any secretion of sugar, &c. We had some time 
ago a very remarkable example of this form of the disease in one of 
the porters of Stephen’s Green. This man passed generally from 
twelve to fourteen pints of urine in the day. He was treated with 
Dover’s powder and vapour baths, and is at present in the enjoy- 
ment of good health, although the disease had continued for many 
months. He still requires, however, the exercise of much caution, 
for any imprudent exposure to cold, or irregularity of diet, renders 
him liable to relapse. The next form is that termed diabetes mel- 
litus, and is remarkable for the quantity of sugar contained in the 
urine. Then we have the diabetes ureosus, characterised by the 
existence of a large quantity of urea in the renal secretion, and by 
the greater specific gravity of the urine. Next we have the 
diabetes albuminosis, in which albumen is found to exist in the 
urine; and lastly, (should Dr. Aldridge’s observation turn out to 
be correct,) we shall have to add another species, or the diabetes 
caseosus. It remains, however, for further investigations to decide 
what peculiar modifications of treatment are to be made in those 
various forms of diabetes. At present, we are not quite au fait as 
to the treatment adapted to each particular species of diabetes, and 
much remains to be discovered in a field presenting extensive room 
for speculation and enquiry. 
LECTURE XI. 
Fever—Application of cold to the head ; particular apparatus for this—Warm applica- 
tions recommended—Use of mercury in fever—Effects of intemperance—Illustra- 
tions afforded by particular cases—Necessity of active attention to cerebral symp- 
toms—Occasional absence of morbid appearance after death—Contraction and 
dilatation of the pupils—Coup de soleil. 
Let us now return to the subject of fever. 
I have already laid before you my views as to the use of general 
and local bleeding in fever, and pointed out the circumstances 
under which they might be employed. In treating of general 320 
graves’s clinical lectures. 
bleeding, I stated that we used it at the commencement of fever, 
with a view of checking the disease altogether, or of rendering it 
milder and less dangerous, by moderating excessive inflammatory 
action, and controlling cerebral excitement. I have also spoken of 
the use of leeches and blisters, and it only remains for me to say a 
few words respecting the application of cold to the head as a means 
of moderating or removing symptoms of cerebral excitement. In 
Dr. Southwood Smith’s Treatise on Fever, you will find many 
cases and arguments to show that where headache and delirium 
are present, and where the lancet is inadmissible, if you place the 
patient in a warm bath, and direct a forcible small stream of very 
cold water on his head, he soon becomes more calm, experiences 
great relief of his headache, and is frequently brought back to his 
bed quite free from cerebral symptoms. The burning heat of the 
skin is quickly replaced by a sensation of coolness, or even cold, 
the flushing of the face disappears, the delirium vanishes, and a 
favourable crisis is often produced. Indeed, the effects of this 
remedy are extremely remarkable, and I have no doubt that many 
of the cases in which I have employed tartar emetic with such 
signal advantage would derive equal benefit from this mode of 
treatment. The cold affusion, as recommended by Dr. Smith, 
and practised at the Charite Krankenhaus, at Berlin, is most cer- 
tainly an excellent and energetic remedy, and I regret that we 
have not apparatus in this hospital for applying it; but I fear its 
utility must be, at least for some time, limited to public institutions, 
and that it cannot be employed to any extent in private practice. 
There is a good deal of prejudice against applications of the kind 
in this country. At the time that cold affusions were used in the 
treatment of scarlatina, much mischief was done by their indiscri- 
minate employment, and this added to the general feeling of dislike 
towards them. At all events, cold affusion is a remedy which 
requires an apparatus seldom at the command of the physician in 
private families, and, indeed, I think that in most cases we may do 
very well without it. 
You are all aware, that in cases of determination to the head, 
the common practice is to shave the scalp, and apply cold lotions. 
In my published lectures, I have endeavoured to point out the im- 
perfect, and even hurtful, mode in which this remedy is ordinarily 
applied, and to show that it is calculated rather to increase than 
to diminish the heat of the integuments. Cold lotions act as a 
powerful refrigerant, if constantly repeated, so as to keep the part 
below the standard temperature of the body. But this is seldom or 
never done. The nurSe applies the lotion, and then, perhaps, drops 
asleep, or occupies herself with some other business, until at last 
she is attracted by the vapour arising from the patient’s head, and 
then she renews the application. I need not say that in this way 
all the good effects of cold as a refrigerant are entirely lost, and 
that a degree of reaction is produced which must altogether mar 
and nullify its application. I have, therefore, given up, except in 
very few cases, the practice of applying cold lotions, and give a TREATMENT OF FEVER. 
321 
preference to the use of warm fomentations of equal parts of vinegar 
and hot water, applied to the temples and shaven scalp, and fre- 
quently repeated. I am quite sure we employ warm applications 
for the relief of headache and cerebral symptoms much less fre- 
quently than we ought. You are aware that surgeons are in the 
habit of treating some local inflammations with warm, and others 
with cold applications, and that the rules laid down for distinguish- 
ing the cases in which cold, and those in which warm, fomenta- 
tions should be used, are deficient in precision, and that most com- 
monly the practitioner has to refer to his own individual experience 
for the guidance and determination of his choice. So it is, also, 
with respect to the use of fomentations, to relieve the pain and con- 
gestion of internal parts. Among these, I include determination to 
the head in fever, accompanied by intense headache, restlessness, 
and delirium. In some cases of this description, cold applications 
will give ease ; in others, most relief is obtained by fomenting the 
head with water as hot as it can be borne. 
The idea of employing hot fomentations in cases of this descrip- 
tion was first communicated to me in 1833, by Mr. Swift, who 
became accidentally aware of their value while washing his face 
one day in very warm water, at a moment when labouring under 
severe headache. The sudden relief obtained by the application 
of hot water, induced him to try it extensively in the headache of 
influenza, and with the most satisfactory results. You are aware, 
that in the influenza which appeared in this country in 1833 one 
of the most remarkable symptoms was intense headache. This 
was accompanied with great debility, and was not amenable to the 
ordinary modes of depletion. Now, Mr. Swift found that by apply- 
ing water, as hot as it could be borne, to the forehead, temples, and 
back of the head, great and almost instantaneous relief was obtained, 
and that in this way he was able to keep a most unpleasant symp- 
tom in check, while he was taking measures to remove the disease. 
I afterwards heard from my friend, Dr. Oppenheim, of Hamburg, 
that he had also discovered that this was the best means of afford- 
ing relief under the same circumstances. This led me to think of 
applying hot fomentations to the head in other diseases, and 
although I cannot give you any particular rules for determining 
the cases in which you should employ them, I can say that you 
will generally find warm vinegar and water the best and most 
efficacious application in the ordinary headache of fever. 
I shall close this lecture with a few observations on the use of 
mercury in fever, and this will include all I have to say at present 
on the remedies most generally employed in the treatment of typhus. 
Are we to have recourse to mercury, or not, in typhus ? I do not 
allude here to its use as an aperient, but when called to treat a case 
of fever, are you to proceed at once to bring the patient’s system 
under the influence of mercury? Are you, in addition to the 
other measures usually adopted in the treatment of fever, to go on 
with the administration of mercury until you affect the mouth, and 
bring on salivation? This was the practice in my time, and great 322 
graves’s clinical lectures. 
confidence was placed in it by the majority of practitioners. It has 
been also very extensively recommended by army and navy sur- 
geons, in the treatment of tropical fevers, which all partake, more 
or less, of the typhoid character. 1 must confess that I am not at 
all inclined to adopt this practice, and that I have seen abundant 
reasons why I should neither employ nor recommend it. In the 
first place, we have observed in our wards that patients with other 
diseases have frequently caught fever from exposure to infection, at 
a time when they were fully under the influence of mercury. In 
the next place, we have observed that persons who were thus 
attacked with fever while in a state of salivation did not escape 
better than others, and that in them the disease ran its full course, 
aggravated rather than diminished in its danger by the pre-existing 
mercurialisation. These facts I have frequently seen verified in 
hospital and private practice. You perceive, then, that mercuriali- 
sation neither protects a man from the contagion of typhus, nor 
does it produce a favourable modification in its type or progress. 
Again, I have repeatedly witnessed the daily and continued exhibi- 
tion of mercury in fever, and I cannot recollect a single case in 
which it appeared to check the disease, moderate its symptoms, or 
bring about a favourable crisis. I am aware, that in entering my 
protest against this practice, I dissent from a very considerable 
body of my brethren, who, from the beginning to the end of fever, 
never cease in their attempts to bring the patient’s system under the 
influence of mercury. I am convinced that, in the cases in which 
recovery is stated to have followed this practice, the post hoc has 
been mistaken for the propter hoc. Besides, fever is one of those 
affections in which you find it extremely difficult, and often impos- 
sible, to bring the system fully under the influence of mercury. 
There are certain states of the system which prevent altogether the 
full operation of mercury, and bad typhus is one of these states. 
Where fever has laid deep hold of the constitution, you cafinot 
affect it with mercury. Besides, when a patient recovers who has 
been mercurialised during the course of fever, he does not recover 
because his system came under the influence of mercury, but he 
comes under the influence of mercury because he recovers from 
the fever. Add to this, that mercury is a remedy which requires a 
peculiar regimen, and that it is very apt to engross the prac- 
titioner’s attention, and prevent him from the exhibition of reme- 
dies which are more directly indicated, and in reality more useful. 
These considerations, and others, have convinced me that the 
exhibition of mercury in fever, with the view of touching the 
gums, is injudicious and unnecessary. There are, however, cases 
in which you will be compelled to have recourse to mercury, 
whatever the stage or type of the fever may be. Whenever inflam- 
mation of some internal organ—as, for instance, of the lungs— 
arises during the progress of fever, you must employ mercury at 
once; and cases of pneumonia, which would have proved fatal, 
have, on numberless occasions, been treated successfully by mer- 
curialisation. But under ordinary circumstances, and were there TREATMENT OF FEVER. 
323 
no indication similar to that which I have just pointed out, I do 
not see any advantage to be derived from the use of mercury. I 
am not, therefore, in the habit of employing mercury in fever. 
Sometimes I use calomel as an aperient, and I frequently prescribe 
small doses of hydrargyrum cum creta, with the view of gently 
stimulating the liver, and preventing the tendency to congestion of 
the intestinal canal; but farther than this I am not in the habit of 
going; and I never, except in cases of pneumonia, or inflamma- 
tion of some internal organ, attempt to bring the patient’s system 
under the influence of mercury during the course of typhus. 
Permit me next to direct your attention to the case of the patient 
Murphy, who died last week. This case excited a good deal of our 
attention at the time, and I wish to make some further observations 
on it while it remains fresh in your minds. 
It was one of those mixed cases of typhus in which, as the fever 
advances, we observe the usual phenomena of determination to the 
head, accompanied by a train of symptoms which bear a close 
analogy to those of delirium tremens. Among the pauper popu- 
lation which we have to treat, you will frequently meet with cases 
of this description. We witnessed many examples of it here, but 
not so many as are to be seen in other hospitals. It is a melan- 
choly but well-known fact, that a great proportion of the diseases 
which come under our notice, in the acute as well as in the chronic 
form, are more or less complicated with intemperance. This you 
should never forget. In persons of the lower class, who are 
addicted to the daily use of spirituous liquors, you will find disease 
assuming a thousand unfavourable shapes and complications. 
You will find their fevers intermixed with various symptoms of 
an anomalous or dangerous character, and their chronic affections 
embarrassed by organic and visceral disease. You will be repeat- 
edly struck with the strange and protean character which disease 
assumes under the influence of an habitual intemperance; and you 
will often, in the course of your practice, have to endure the annoy- 
ance and disappointment of seeing your patient carried off by some 
new and unexpected malady, after you have succeeded, by infinite 
toil, ingenuity, and patience, in removing every trace of his primary 
affection. 
The case of Murphy was one of those which have been neglected 
in the beginning, where the vantage ground has been lost, and the 
chances of success are diminished almost to nothing. You have 
observed that all the fatal cases of fever which we have had in 
hospital were cases admitted at an advanced period of fever, and in 
which the head had been neglected. You have also observed how 
exceedingly difficult it must be to treat cases of this description. 
The patient is admitted at an advanced stage of fever, and at a 
period when he can give no account of his present or past symp- 
toms, or the mode of treatment to which he has been submitted. 
He comes in with delirium, or coma, and subsultus tendinum; his 
symptoms are certainly cerebral, and he exhibits, perhaps, a blis- 
tered scalp; but we can have no means of ascertaining whether he 324 
graves’s clinical lectures. 
has had headache, heat of scalp, throbbing of the carotid and tem- 
poral arteries, or vertigo—we cannot, in fact, decide with precision 
as to the exact state of the brain, and our practice must be embar- 
rassed by more or less doubt and obscurity. I have already 
impressed upon your attention the urgent necessity of watching the 
head in fever, and I think I cannot too often reiterate the advice 
which I have given you, to endeavour to check cerebral symptoms 
before they amount to any degree of absolute danger. The fate of 
those who have died here, will convince you that wheu cerebral 
disease has once arrived at its acme, the most energetic measures 
will often fail in arresting it. It is a matter of vital importance, 
then, to prevent this lamentable state of things, and, without wait- 
ing until the symptoms of cerebral disease manifest themselves, to 
anticipate it in its very origin, and thus be enabled to control with 
certainty symptoms which assume such a fearful aspect in cases 
where cerebral disease has been allowed to go on unregarded. 
This is the practical lesson which I wish you to draw from the 
four fatal cases which have occurred in this hospital within the 
last month. 
There are some points in the case of Murphy to which I wish to 
recall your attention, as I am anxious that you should make them 
the subject of reflection. For some days before his death, he had 
been delirious and unmanageable, with total loss of sleep, and a 
contracted state of the pupil. The antiphlogistic and derivative 
treatment had been employed without effect; and seeing that his 
symptoms were advancing, and his sleeplessness undiminished, I 
ventured to give him an injection, consisting of two grains of tartar 
emetic with ten drops of laudanum. I am cautious in the adminis- 
tration of opium in the advanced stage of fever, where there is 
evidence of determination to the head; and it was on this account 
that I ordered it to be combined with tartar emetic, giving also 
directions that the effect of each dose should be carefully watched. 
He got three enemata during the course of the night—that is, thirty 
drops of laudanum altogether. He dozed after the last injection, 
and appeared more tranquil; but at our morning visit we found 
him in a state of coma, with rapid sinking of the powers of life, and 
death took place in the course of a few hours afterwards. I must 
confess the issue of the case gave me some degree of uneasiness at 
the time, as I thought it might have been precipitated by the admi- 
nistration of the opium. I could not say but that even this small 
quantity of opium might have greatly aggravated the cerebral 
symptoms, and accelerated the fatal event. Dissection, however, 
revealed the true cause of death. On opening the brain, we found 
extensive arachnoid inflammation, some effusion on the surface of 
the brain, and an intensely congested state of its vessels. The 
patient, altogether dissipated in his habits, and greatly reduced by 
fever, had been a young man of rather robust constitution previous 
to his illness; he had been neglected in the beginning of his fever, 
which, from the phenomena observed after death, must have been 
characterised by early and decided determination to the brain, 325 
TREATMENT OP FEVER. 
producing delirium, watchfulness, coma, and a contracted state of 
the pupil, which all our antiphlogistic measures were inadequate 
to remove or control. We did every thing in our power: we 
leeched, blistered, and gave tartar emetic, but without effect; the 
case had not come under our care until symptoms of unmanageable 
cerebral disease had been established. This state of delirium, fol- 
lowed by contraction of the pupil and coma, and terminating in 
death, occurs in two classes of cases: first, in hospital patients of 
the lower class, who have been neglected in the commencement of 
fever; and secondly, in persons in the better classes of life, in whom 
the mind is frequently subjected to over-exertion, and who, when 
attacked by fever, exhibit a strong tendency to the early develop- 
ment of cerebral symptoms of a bad and unmanageable character. 
One of the worst symptoms observed in such cases is extreme con- 
traction of the pupil. I have seen the pupil in some cases con- 
tracted to the size of a pin-hole; and I think I can state, that out 
of all the cases of this description which I have witnessed, there 
were but two recoveries. I have seen persons who had exceed- 
ingly bad and alarming symptoms of cerebral derangement recover, 
although accompanied by great dilatation of the pupil; but I think 
I have seen but two cases recover in which the pupil was con- 
tracted to the small size observed in Murphy’s case. 
With these facts fresh in your minds, allow me to direct yonr 
attention to the case of another man, who died lately in the fever 
ward with cerebral symptoms of an intense character. Now, in 
this man the very same train of phenomena were present which 
we observed in Murphy’s case. He had, you recollect, typhus of a 
low character, accompanied by delirium, subsultus, and the ordi- 
nary symptoms of determination to the head. I could defy any 
man who would compare these two cases together to point out any 
remarkable difference between them. The delirium, nervous ex- 
citement, and watchfulness, commenced the same way in both, and 
ran through the same course; both had contraction of the pupil, 
constant muttering and delirium, persistent watchfulness, and sub- 
sultus tendinum; and in both the cerebral symptoms terminated in 
coma and death. I would defy the most accurate symptomatolo- 
gist to point out any marked distinction between them. Yet how 
different were the phenomena observed on dissection ! In the one 
there was extensive lesion of the membranes of the brain, effusion 
on its surface, and intense congestion of its vessels; in the other, 
there was no appreciable departure from the normal condition. 
These are very strange things, and well worthy of attentive con- 
sideration. But it is not in typhus alone that we meet with the 
occurrence of analogous symptoms—in cases which exhibit a very 
different state of the brain after death. We are encountered with 
the same puzzling contrarieties in many cases of scarlatina. Cases 
come under our notice in which the patients appear to die entirely 
from the violence of the cerebral symptoms, and yet, on examina- 
tion, we find very dissimilar states of the brain. In some, there is 
palpable and fatal lesion—in others, there are some dubious marks 326 
graves’s clinical lectures. 
of congestion, quite insufficient to account for the symptoms ; or 
the brain is found to be perfectly sound and normal. 
It would appear that in scarlatina and fever, the poison of the 
disease exercises a deleterious influence on the brain, independent 
of inflammation, but capable of producing an analogous train of 
symptoms. Hence it is in many instances extremely difficult to 
distinguish the cerebral symptoms produced by the mephitic influ- 
ence of fever on the brain, from those which depend on true in- 
flammation. The one gives rise to delirium and fatal coma as well 
as the other; and in the advanced stage of fever, when the mani- 
festations of nervous energy are feeble and imperfect, and when the 
circulating and respiratory organs act with diminished power, the 
distinction between mere irritation and actual inflammation becomes 
a matter of great difficulty. 
In alluding, on a former occasion, to the occurrence of analogous 
symptoms under opposite conditions of the brain, I noticed that 
headache, tinnitus aurium, and giddiness, have been observed in 
cases where there was distinct evidence of determination to the 
head, as well as where there was every reason to believe that the 
supply of blood to the brain was greatly diminished. You will 
find a very curious illustration of this fact in the last number of 
Guy’s Hospital Reports, which contains a very interesting paper 
from Sir Astley Cooper, on the effects produced by tying the caro- 
tid and vertebral arteries. Among other results, it appears that 
when the supply of arterial blood destined for the brain is dimi- 
nished, the animal experimented on becomes stupid, is to a certain 
extent incapable of voluntary motion, and exhibits a very remark- 
able dilatation of the pupils. This is an extremely curious fact. 
You are all aware that dilatation of the pupils has been long re- 
garded as one of the most characteristic signs of extravasation and 
increased pressure on the brain ; and yet it appears the very same 
condition of the pupil is observed when you cut off the supply of 
arterial blood to the brain. We are, I fear, as yet very much in 
the dark as to the changes which occur in the brain under opposite 
states of its vessels; and I think we have equally imperfect and 
confused notions of the changes which occur in that organ as the 
result of fever. We perceive these changes frequently accompanied 
by a train of symptoms, which, if not identical, have so close a 
resemblance, that it is often a difficult matter to distinguish between 
them. 
Dilatation of the pupils is usually regarded as a sign of increased 
pressure on the brain; and when hydrocephalic symptoms are pre- 
sent, it is generally looked upon as pathognomonic of effusion. 
Yet from the experiment just alluded to, we find that dilatation of 
the pupil is also the result of a state of things in which we cannot 
suppose the existence of any thing like increased pressure on the 
brain. When I speak of increased or diminished pressure on the 
brain, I am not prepared to maintain that such is actually the case, 
or that when a man becomes giddy and faints, after bleeding, the 
actual quantity of blood circulating in the brain is diminished, 
and consequently the amount of pressure; but when a man gets TREATMENT OF FEVER. 
327 
headache, vertigo, or syncope, from loss of blood, it must depend 
upon causes different from those which are connected with conges- 
tion of the brain, or extravasation on its surface, or into its sub- 
stance. What I wish to impress upon your minds is, that dilatation 
of the pupils may be connected with very opposite states of the 
cerebral circulation ; and that in fever it cannot be regarded as a 
sign of any value in determining the existence of congestion or 
inflammation of the brain. 
It may not be amiss to mention briefly on the present occasion 
the details of a very remarkable communication, by Surgeon Rus- 
sel, of the 73d regiment, formerly a pupil in this hospital. This 
communication was read by Dr. Wilson, at one of the soirees of 
the College of Physicians in London, and afterwards published in 
the Medical Gazette. Mr. Russel observes— 
“ I was led, by the following circumstance, to reflect on the 
nature of ‘ coup de soleilwhich, as well as I can recollect, is 
treated of by all authors, and is generally considered to be nothing 
more or less than true apoplexy, produced by the direct influence 
of the sun’s rays ; that its pathology is the same, and its mode of 
treatment similar—that is, that all the efforts of the medical attend- 
ant should be directed to the head, as the chief, nay, almost the 
only, seat of the disease: and here it strikes me a fallacy exists, 
leading to erroneous principles of practice. In May, 1834, while 
I was in medical charge of the 68th regiment (a fine corps, com- 
posed of men in robust health,) then recently arrived at Madras, 
the funeral of a general officer took place; to which, unfortunately, 
the men were marched out at an early hour in the afternoon, but- 
toned up in red coats and military stocks,—at a season, too, when 
the hot land winds had just set in, rendering the atmosphere dry 
and suffocating even under shelter of a roof, and when the sun’s 
rays were excessively powerful. The consequence was, that after 
proceeding two or three miles, several men fell down senseless. As 
many as eight or nine were brought into hospital that evening, and 
many more on the following day ; three died—one on the spot, and 
two within a few hours. The symptoms observed (and they were 
alike in these three cases) were, first, excessive thirst, and a sense 
of faintness ; then difficulty of breathing, stertor, coma, lividity of 
the face, and in one, whom I examined, contraction of the pupil. 
The remainder of the cases, in which the attack was slighter, and 
the powers of re-action perhaps greater, or at all events sufficiently 
great, rallied ; and the attack in them ran on into either an ephe- 
meral or more continued form of fever. The symptoms of these 
three cases did not more closely resemble each other than did the 
post mortem appearances. The brain was, in all, healthy; no 
congestion or accumulation of blood was observable; a very small 
quantity of serum was effused under the base of one, but in all 
three the lungs were congested even to blackness through their 
entire extent; and so densely loaded were they, that complete ob- 
struction must have taken place. There was also an accumulation 
of blood in the right side of the heart, and the great vessels ap- 
proaching it.” 328 
graves’s clinical lectures. 
LECTURE XII. 
On constitutional inflammation in general—On fugitive swellings and pains—Curious 
case of erratic gout causing transient swellings—Gout affecting the lobe of the ear— 
Fatty hypertrophy of the ears—Gouty grinding of the teeth—Gouty neuralgia of the 
skin—Remarks connected with Dr. Kingston’s recent researches on consumption. 
I take the present occasion of making a few remarks on certain 
varieties of the gout, of which I have seen several singular exam- 
ples, premising some observations on constitutional inflammation in 
general. 
There is no proposition in pathology better established than that 
there exist certain constitutional affections capable of generating 
and modifying local inflammatory action ; and that local inflam- 
mations, depending on a constitutional cause, are subject to very 
different laws from those which regulate the phenomena of common 
inflammation. 
Another fact of equal importance in many points of view is, that 
local inflammations depending on a constitutional cause differ re- 
markably from each other, and in general present specific characters 
easily recognised. Thus, local affections arising from scrofula are 
not likely to be confounded with those depending on gout or rheu- 
matism, and the inflammations produced by syphilis and other 
animal poisons exhibit peculiarities by which their respective origin 
and nature may be satisfactorily ascertained. It must however be 
admitted, that although advanced considerably in our knowledge 
of the phenomena of local disease depending on a constitutional 
cause, the subject still displays a wide field for investigation, and 
many points of much importance in pathology and practice require 
still further investigation. Professor Cayal, in his Legons Orales, 
has made some observations on this subject well worthy of atten- 
tion. Speaking of the dependence of local disease on constitutional 
causes, he says, “ II faut necessairement conclure que les degenera- 
tions organiques ne sont pas cause, mais effet. Et deslors, nous 
sommes fondes a vous dire, qu’au lieu d’user votre vie a chercher 
toujours quelles sont les degenerations organiques et les alterations 
de texture qui produisent les symptomes des maladies, il serait bien 
temps de s’inquieter un peu de savoir ce qui produit ces degenera- 
tions ellesmemes, en etudiant serieusement les caracteres, la marche, 
et la tendance des actes vitaux qui les preparent, et qui les pro- 
duisent reelment.” 
There is one fact connected with local inflammation depending 
on a constitutional cause not sufficiently noticed, namely, that cer- 
tain affections of this kind are sometimes remarkably fugitive and 
transient. We are accustomed to regard the process of inflamma- 
tion, whether common or specific, as one which generally lasts for 
some days ; but it occasionally happens, that a peculiar diathesis 
will give rise to local affections having the characters of inflamma- 
tion, and which run their course and terminate in the space of a 
few hours. This observation, which should be borne in mind in 329 
the investigation of diseases connected with the general habit, will 
serve to explain some of the anomalies which strike us occasionally 
in the study of constitutional maladies. The first instance of this 
kind that came under my notice occurred in the case of a florid 
healthy looking boy, aged six years, in whom, on attentive exa- 
mination, I was led to suspect the existence of a scrofulous taint. 
At the time I saw him he was subject to a sudden and rapid forma- 
tion of bumps, or tumours, on various parts of his body ; sometimes 
on the arms, sometimes on the legs, and occasionally on the trunk. 
These circumscribed tumefactions were accompanied by a feeling 
of heat and tenderness, and apparently depended on local conges- 
tion, or effusion in the subcutaneous cellular tissue. But what 
was most remarkable in them was, they arose, ran through their 
course, and terminated in the space of four or five hours ; they 
were suddenly developed, and disappeared with equal rapidity. In 
the course of a month, other more permanent inflammations were 
set up ; scrofulous ophthalmia, glandular swellings, and ulcers, su- 
pervened ; the joints became affected, and the boy died in about a 
year and a half, with all the characteristic marks of the scrofulous 
diathesis. T have detailed this case before, and shall not dwell on 
it any further at present; but it is well worthy of notice in con- 
sequence of the very brief duration of the first local affections. 
Gout is another disease which occasionally exhibits examples of 
its peculiar inflammation attacking various parts and tissues of the 
body, and that for an extremely short period of time. It is well 
known that persons of a gouty habit are subject to sudden pains or 
twitches, which last only for a few minutes, or even seconds. I 
shall not stop here to consider what may be the nature of these 
fugitive pains ; I may observe, that certain facts seem to prove that 
these pains are the result of a momentary congestion. Thus, in 
various neuralgic affections, and in inflammatory diseases in which 
the nerves are considerably engaged, pain is suddenly produced by 
coughing. If a man labours under neuralgia of the frontal or 
facial nerves, or if he be affected with sciatica, how are his suffer- 
ings increased when he has unfortunately at the same time a 
cough ! Every time he coughs, the affected nerve gives notice 
that it feels the congestion by a sudden pain. Now, the only way 
in which coughing can increase a local pain, is by favouring local 
congestion ; that it is capable of doing this is proved by the redness 
of the face it occasions, as also by the hemorrhage from the nose, 
or from recent wounds, which is so often produced by a fit of 
coughing. 
As there can be no doubt, then, that a momentary congestion 
may produce a momentary pain, we may infer that in many 
instances gouty twitches are owing to some cause which determines 
an instantaneous congestion of the affected part. Sometimes the 
congestion is more lasting, and then the pain is proportionally 
intense and persistent. Thus Mr. Daly, of Henry street, knows a 
gentleman, the lobe of whose ear is sometimes attacked suddenly 
GOUT. 330 
graves’s clinical lectures. 
by gouty congestion, accompanied by agonising pain, but which 
never lasts more than a few hours. 
This fact brings to my mind a curious case which some years 
ago came under the notice of the surgeon-general, Mr. Ferrall, 
and myself. A young gentleman of fortune perceived that the- 
pendant lobes or tips of his ears were becoming elongated; they 
increased gradually in such a manner that he considered himself 
disfigured by their unseemly length, and therefore attempted their 
concealment by allowing his hair to grow in long curls, so as to 
hide his ears. This gentleman soon afterwards became dropsical 
and died; and, on dissection, Mr. Ferrall found his liver in a state 
of fatty degeneration. On slitting up the elongated portion of the 
ears, he discovered that their hypertrophy had been occasioned by 
the deposition of a large quantity of fat. The subcutaneous adi- 
pose tissue, and the omentum, were likewise much loaded with fat. 
This observation is of some importance, as teaching us that fatty 
degeneration may be the consequence of a general tendency in the 
system to manufacture and deposit fat in the textures of the differ- 
ent organs. In this point of view the change of structure in the 
liver must be regarded as an effect, and not as a cause, of the gene- 
ral derangement of the system, and the fatal termination of the 
case. 
One of the most remarkable instances of fugitive inflammation 
affecting various parts of the body, which has come under my 
notice, occurred in the person of a gentleman lately under my 
care. I shall not go through the whole history of his disease, of 
which he has favoured me with a very minute account, but shall 
merely state, that he is of a gouty habit, has had an attack of gout 
in the stomach, and is at present subject to a gouty affection of a 
very extraordinary character. After labouring for some time under 
languor and weakness, accompanied by spasms, pain, and sense of 
weight in the stomach, the pain of the stomach ceases, and his face 
begins to swell at various points, generally commencing on the 
forehead, and involving the cheek and eye, so as to close up the 
latter. He first feels as if a small current of air was directed on 
the face ; then, as it were, the fillip of a finger, or the bite of a gnat; 
and, on looking in the glass, he suddenly perceives a tumour rising 
on the forehead, which, in the space of half an hour, becomes as 
large as a pigeon’s egg, and, as he expresses it, moves down until 
it closes the eye. Sometimes it attacks his lips, and other parts of 
his face, but never affects his nose. These tumours have also ap- 
peared on various parts of his body ; and he observes, in his letter 
to me, that he is sometimes led to think that they attack his sto- 
mach also. Before and during an attack of the face, which gener- 
ally occurs on the left side, the discharge from the nostril of the 
affected side ceases. But what is chiefly remarkable in this case 
is the singular character of the local affection. The tumours arise, 
run through their course, and disappear, in the space of a few 
hours; and on the following day there is no trace of their exist- 
ence. Sometimes the lips, inside of the mouth, palate, and uvula, are GOUT 
331 
attacked, giving rise to very considerable inconvenience. Were 
such tumours to occur in the neighbourhood of the glottis, I need 
not say that they would be pregnant with danger of no ordinary 
character. I may observe that this gentleman has derived great 
benefit from the use of hydriodate of potash, and from decoction of 
sarsaparilla with nitric acid, and that his health is at present much 
improved. His case presents a very curious example of transient 
local inflammation depending on the gouty diathesis. 
Having touched on the subject of anomalous local affections as 
connected with the gouty habit, I may be allowed to refer to a 
subject on which I have already published some observations. 
In a paper inserted in the Dublin Medical Journal for March, 
1S36, I noticed the morbid habit which some individuals have of 
grinding the teeth, and detailed some facts in illustration of this 
affection. I have now seen several cases of this kind, and I have 
observed that they all occurred in persons of the gouty diathesis. 
The grinding of the teeth continues for years as a daily habit, and 
produces very remarkable changes in the conformation of these 
organs, affecting sometimes one side of the jaw, sometimes both ; 
so that in confirmed cases we frequently find the teeth ground 
down to the level of the gums. There is not at present the slightest 
doubt on my mind, that the irritable state of the dental nerves, 
which gives rise to this irresistible tendency to grind the teeth, 
depends chiefly on the existence of gout in the constitution. 1 may 
observe, however, that in many persons in whom the teeth are 
found worn nearly to the gums, there appears to be another cause 
in operation. Thus, in cases of indigestion, it is not unusual to 
find the enamel of the teeth partially or considerably worn away, 
long before the natural time; and in such instances we used for- 
merly to attribute the injury to the generation of acids in the sto- 
mach. The researches of Donne and Thomson, however, have 
shown that the saliva is subject to very remarkable alterations in 
certain forms of dyspepsia, and that whenever the disease is ac- 
companied by much irritation of the gastric mucous membrane, 
and derangement of its secreting functions, the saliva becomes 
extremely acid, and, of course, capable of corroding the enamel of 
the teeth. The following case has recently come under the notice 
of Mr. Pakenham, of Henry street:— 
A gentleman, aged 45, slightly made, but muscular, and born of 
healthy parents, was attacked with shivering and loss of power of 
the right side after a severe wetting. He recovered under appro- 
priate treatment; but about a year afterwards began to observe in 
himself a tendency to grind his teeth, which gradually increased to 
such an extent as to prove a nuisance to himself and every one 
about him. Under these circumstances he consulted an eminent 
surgeon in Dublin, who applied the actual cautery behind one of 
his ears, slightly affected his system with mercury, and extracted 
one of his teeth—all with considerable relief, which lasted for about 
six months. He then became as bad as ever, and applied to ano- 
ther surgeon, who tried iron in every form without success ; and 332 
graves’s clinical lectures. 
subsequently to a third practitioner, who used in addition leeching, 
blistering, pustulation with tartar emetic, and various other reme- 
dies, but without any favourable result. All this time his medical 
attendants, so far from suspecting the presence of gout, ridiculed 
the idea of its existence. 
About three months ago this gentleman came to Dublin, went to 
dine at the house of a friend, and with some others, supped late at 
night, and drank some whiskey punch. Next day he had vomiting, 
purging, and epigastric tenderness, and on the following day the 
ball of his great toe became swollen, hot, and exquisitely painful, 
leaving no doubt as to the nature of the affection. In this gentle- 
man’s case the grinding of the teeth is not constant, but it is always 
greatest when the stomach is most deranged. The teeth in the 
under jaw are all sound ; three or four of the molars of the upper 
jaw have been extracted. The four upper incisors are ground 
nearly half way through to the gum, on the inside, while the lower 
are very little worn. By pressing the tongue against the upper 
incisors, or by touching a certain point of one particular tooth, he 
can at any time arrest the tendency to grind, and can suspend it as 
long as pressure is continued in the manner just described. 
With the view of further illustrating the varieties of gout, I shall 
detail the following remarkable case, whieh came recently under 
my notice:—The patient, a gentleman of large fortune, is of a 
strong and athletic frame, about five and thirty years of age, and a 
member of a family subject to gout. He was much addicted to 
field sports, and accustomed, in cold weather, to frequent immer- 
sion of his feet in cold water, in pursuit of his favourite amusement, 
snipe-shooting. The consequence of this exposure has been, that 
he has been labouring for some time under a neuralgic affection of 
the lower extremities, which commenced in his feet and ankles, 
and extended gradually upwards, involving the whole of the 
lower extremities as far as the hips, and giving rise to sufferings of 
a very intense character. In a lecture formerly published, on 
creeping paralysis, I noticed that repeated exposure of the feet to 
cold seems often to lay the foundation of this disease. Now in this- 
case there is some danger that the gentleman, were proper measures 
neglected, may ultimately become paraplegic, or even generally 
paralytic. I do not bring this case forward as an example of gouty 
pains gradually advancing from the extremities towards the spine ; 
for although I strongly incline to the opinion that his complaint is 
of a gouty nature, and although most of his medical advisers have 
suspected a gouty complication, still this is by no means a decided 
point.1 Be this as it may, his case presents a very interesting spe- 
cimen of creeping neuralgia, chiefly affecting the cutaneous nerves, 
(nerves exclusively destined to perform the function of sensation,) 
but. gradually implicating the nerves of motion in the disease. I 
1 I have since seen his usual attendant, Dr. Little of Sligo, one of the 
most experienced and skilful physicians in Ireland, and am much gratified 
by finding that Dr. Little’s opinion exactly agrees with mine, as he considers 
the case to be gouty neuralgia. GOUT. 
333 
shall now proceed to lay before you the details of this case, which 
have been noted with singular accuracy and ability by the gentle- 
man himself. In a letter to me he observes— 
“ As you wish for a description, in writing, of the manner in 
which I am affected, I subjoin every particular I can think of which 
seems likely to throw any light on the subject. 
“ It is now nearly five years since I began to suffer severely from 
pains in my limbs, which for the last two or three years I have 
looked upon as neuralgic. About a year previous to that time I 
had occasional pains in one foot, which increased so as to become 
violent on one occasion, after a long ride. I had, however, been 
always in the habit of riding, and considered that exercise to agree 
particularly well with my health. Indeed, I had found hunting of 
great use to me, when suffering from liver complaint, having had 
inflammation of the liver twice in my life. It is now fourteen 
years since I had the last attack of liver disease, and I very seldom 
have pain in my side; whenever it occurs, it is generally removed 
by the use of a little blue pill. 
“When first the pains in my limbs commenced they were con- 
fined to my feet; then, for a long time, extended no higher than 
my knees ; latterly they have ascended as far as my hips, where, 
and in the groin, I sometimes experience great suffering. I have 
had occasional twitches in my arms, and very slightly across the 
chest. The pain always comes on with sudden violence, which 
renders it very hard to bear, especially when it attacks me during 
sleep. I am frequently aware of its approach, from a general feel- 
ing of discomfiture and depression ; from which, in the beginning 
of my complaint, I used to suffer very much for two or three days 
before an attack. These paroxysms have, for four years, shown a 
great tendency to periodicity, recurring generally once every week, 
commencing on Saturday or Sunday, sometimes on Friday, and 
lasting till Monday. They have twice or thrice lasted for a week 
together, but sometimes continue only a few hours. In the com- 
mencement I had occasionally been free from them for two or three 
months together; and within the last year was free from them, at 
two different periods, for a whole month. When in pain, I have 
never experienced the slightest alleviation from any thing, except 
at times from a full meal with wine, particularly champaigne. I 
have often been unable to remain in bed, from the violence of the 
pain, which is increased by the weight of the bedclothes, or the 
slightest touch of any thing; even the air blowing on the part 
brings on violent torture: at the same time I can bear strong press- 
ure, or even a blow on the parts, without making me worse. The 
pain appears to be quite on the surface, except that sometimes it 
seems deeply seated, particularly in the ankle-joint and shin-bone. 
It is unaccompanied by any redness or swelling, and flies instanta- 
neously from one limb to the other, rarely occurring in both at the 
same time. It leaves behind great weakness of the affected limb, 
so as to oblige me to walk with a stick for some time, and occa- 
sionally with two, 334 
GRAVES’S CLINICAL LECTURES. 
“One very unpleasant consequence of the pains in my limbs is, 
that I now find that I cannot use exercise on horseback, if I leave 
it off for any time. I have found this and walking at all times 
conducive to my general health. Indeed I can still walk a good 
deal, even during the attack, although it is very painful, particu- 
larly when setting out. I find it necessary almost constantly to 
have recourse to aperient medicine—generally rhubarb pill. At 
times I have had giddiness of my head, and noise in my ears, to a 
very distressing degree ; and have had recourse to powerful purga- 
tives, and even bleeding, to remove the symptoms, without effect. 
A medicine, principally nervous, in which gentian was an ingre- 
dient, relieved me at one time after finding the above remedies 
ineffectual. I have already tried iron, mercury, nitro-muriatic acid, 
stramonium, arsenic, and the external use of croton oil, without 
benefit, except that 1 felt rather better for a month after two of 
these remedies, but no longer, and the pain returned with great 
violence at the end of that period. The counter-irritation appeared 
to increase my sufferings. I have also tried anodyne embrocations 
without effect. Anxiety of mind, or annoyance, often brings on 
an attack. I even remarked, the other day, that it came on instan- 
taneously on breaking a tooth whilst eating. On the other hand, 
excitement, whether from a sudden necessity for exertion, as on 
occasion of an accident, or any thing that gives a pleasing interest 
and occupation to my mind, such as traveling through an interest- 
ing country, seems to keep off, and sometimes even remove an 
attack.” 
In general, a regular attack of gout in the extremities is preceded 
by a longer or shorter period of constitutional disturbance and dys- 
pepsia. We must not, however, in making the diagnosis between 
gout and rheumatism, consider this distinction as not liable to 
exceptions, for I have seen more than one case of hereditary gout, 
in which the arthritic attacks came on suddenly, without the slight- 
est precursory derangement of the health, or the operation of any 
assignable cause. I have as yet seen no instance of a similar 
nature in acquired gout. 
Another exception to the general rule is also worthy of notice. 
In general, a fit of the gout is preceded and accompanied by a 
scanty secretion of turbid high-coloured urine. As the fit goes 
off, the urine increases in quantity, becomes clearer and paler, and 
loses its tendency to deposit the lithates and purpurates. Now, in 
two cases of hereditary gout, I have seen this order reversed, and 
the approach of the fit announced by a great increase in the secre- 
tion of urine, which was quite watery and limpid, and continued 
so until the violence of the articular inflammation began to decline. 
The urine then became scanty, and deposited the lateritious and 
pink sediment in great abundance. 
That the gouty diathesis may excite its specific inflammation in 
most of the tissues of our organs, is a fact generally admitted ; but 
I regret to state that our knowledge concerning the effects which 
it produces in these various tissues is far from being accurate or REMARKS ON CONSUMPTION. 
335 
extensive. Beere, M‘Kenzie, Middlemore, and others, have done 
much towards elucidating its effects on the eye and its appendages ; 
and we are tolerably well acquainted with its progress in serous, 
synovial, and fibrous membranes. What changes it produces in 
the secretions of mucous membranes, is a question which has not 
been studied with an attention commensurate to its importance. 
Thus, though all acknowledge the existence of gouty cough or 
bronchitis, the diagnosis and history of this affection are still very 
incomplete. This has been acknowledged by Dr. Stokes, who has 
published by far the best account of bronchitis which has yet 
appeared.1 The effects of gout on the lining membrane of the 
urethra and bladder are better known and studied, but I think that 
much still remains to be done in this as in every other class of 
inflammatory diseases where the inflammation depends upon a 
constitutional taint. 
In my published lectures I have long since expressed an opinion 
at variance with that generally taught concerning the bronchitis 
and pneumonia which accompany pulmonary consumption, and I 
have brought forward strong reasons for believing that too much 
importance has been attached, and attention too exclusively de- 
voted, to the tubercles in this disease. Thus authors talk of tuber- 
cular pneumonia, where it would be more correct to designate the 
affection as scrofulous pneumonia accompanied by tubercles ; they 
speak of tubercular davities and abscesses in the lung, in cases where 
scrofulous cavities and abscesses exist. In fact, I repeat it em- 
phatically, that the essential characteristics of phthisis pulmonalis 
are derived from scrofula. This it is which converts what would 
be common into consumptive pneumonia or bronchitis ;—this it is 
which so often renders both incurable. 
Tubercles and tubercular infiltration are mere results of nutrition 
morbidly modified by scrofula; they are effects, not causes ; they 
often exist without scrofulous inflammation, and the latter may 
exist without them. It gives me much pleasure to find that these 
opinions, which I published two years ago, have received ample 
confirmation from the observations of Dr. Kingston, in a paper 
read before the Royal Medical and Chirurgical Society of London 
in .April last, and shortly noticed in the Medical Gazette, April 29th, 
1837. 
At our next meeting I propose to follow up the important subject 
of gout. 
1 See a treatise “On the Diagnosis and Treatment of Diseases of the 
Chest,” by William Stokes, M. D. This work places its author among the 
first medical observers of the day, and will acquire for him an European 
fame. 336 
graves’s clinical lectures. 
LECTURE XIII, 
On paralysis in general—On paralysis depending on affections spreading from the ex- 
tremities of the nervous system to its centre—Gouty ramollissement of the spinal 
marrow ; two remarkable cases of—History of this hitherto undescribed form of 
disease. 
In pursuing the subject of my last lecture, I shall now turn to 
the consideration of some phenomena connected with the gouty 
diathesis, which possess a much deeper interest, and lead to views 
of far greater importance. I mentioned before, that we frequently 
observe flying pains, or twitches, in various parts of the body, aris- 
ing from a rheumatic or gouty cause ; that in some instances these 
affections appear to be limited chiefly to the nervous trunks or 
branches, and that we have thus what may be termed gouty or 
rheumatic neuralgia. We are familiar with rheumatic and gouty 
sciatica, and we know that the history and termination of this 
form of disease often prove it to be inflammation of a specific cha- 
racter, chiefly confined to the trunk of the sciatic nerve. Now it 
is not unreasonable to suppose that this specific inflammation of a 
nervous trunk or branch may, like other inflammations, extend 
farther, so as to involve parts of more importance to the economy. 
What I wish to draw your attention to is this—that in certain cases, 
where gout attacks the nerves, giving rise to gouty congestion or 
inflammation, frequently recurring, and acquiring increased strength 
and deeper root as it proceeds, the morbid affection may, after years, 
or even months, run on until it reaches the spinal cord, involving 
a certain portion or portions of that organ, and producing loss of 
sensation and motion commensurate to the amount of spinal de- 
rangement. This is by no means an anomalous occurrence; it is 
merely an instance of disease originating in the periphery of the 
nervous system, passing along the trunk of the affected nerve with 
a retrograde motion, and finally reaching the central parts. In my 
lectures published two years ago, in the London Medical and Sur- 
gical Journal, I pointed out this peculiarity in many affections 
commencing in the periphery of the nervous system, and showed 
how the disease extends gradually until it reaches the spinal cord, 
giving rise to various forms of paralysis. It is too much the cus- 
tom to look upon paralysis as depending upon original disease of 
the nervous centres. I have proved, that, very often, disease com- 
mencing in the nerves of some particular part or organ may be 
gradually propagated to the spine, producing all the symptoms 
which are referable to an original affection of the nervous centres, 
In my lectures on this subject, I have brought forward numerous 
facts in proof of the propagation of disease from the circumference 
to the centre of the nervous system ; and the pathological deduc- 
tions I drew from these facts seem to me to include all the physio- 
logical discoveries made by Muller and Marshall Hall, concerning 
what the latter terms the reflex functions of the spinal marrow. In 
these lectures I showed that enteritis, arising suddenly in two young GOUTY RAMOLLISSEMENT OF THE SPINAL MARROW. 
337 
and healthy persons, from indigestion and obstruction caused by an 
error in diet, was followed in both by well marked paraplegia. I 
instanced, likewise, examples of paraplegia connected with stricture 
of the urethra, and which were relieved by curing the stricture; 
and I detailed cases of acute and chronic affections of the uterus 
and kidneys, which had entailed on the patients, as a remote con- 
sequence of the original disease, loss of the power of motion in the 
lower extremities, sometimes partial and curable, sometimes irre- 
mediable and complete. The cases I am now about to relate form 
a most interesting and valuable addition to those referred to, and 
enable me to carry the principle then advanced still farther, by 
proving that gouty inflammation of the nerves and the neurilema 
may, in process of titne, extend to the spinal marrow and its 
investments, and give rise to derangements of the latter, termi- 
nating in ramollissement and structural degeneration. 
The subject of gouty degeneration of the spinal cord has not 
been alluded to distinctly by any author with whom I am ac- 
quainted, and is, as far as I can learn, quite new. The deductions, 
therefore, which are drawn from my cases, must, of course, be 
subject to such modifications as may be derived from future expe- 
rience, and must remain to be confirmed by further observation. It 
has been long known that gout may attack the brain, and the 
existence of gouty paraplegia is well known by practitioners who 
have studied attentively the progress of arthritic affections. Thus, 
in a case which I witnessed some time back, in consultation with 
Mr. Kirby, he prognosed the supervention of paraplegia at a time 
when the indications of its approach could not have been disco- 
vered by an observer of less experience and sagacity. I have 
already stated that gouty affections of the brain have long been 
known, and I am not sure that some of the older authors may not 
have alluded to gouty affections of the spinal marrow; but as our 
knowledge of the peculiar state of the brain and spinal cord, termed 
ramollissement, is comparatively recent, and not dating with any 
degree of accuracy earlier than the works of Abercrombie, Rostan, 
and other modern authors, it is obvious that any observations made 
by the older writers, concerning gouty affections of the nervous 
centres, ean have no distinct reference to this lesion. The con- 
nection, therefore, of ramollissement of the spinal cord with gout, 
may be considered as now, for the first time, distinctly pointed out. 
As one of the cases which I am about to detail presented an exam- 
ple of the most extensive ramollissement of the spinal marrow on 
record, it would, on this account alone, be especially deserving of 
attention ; but its interest is increased tenfold when placed in juxta- 
position with the second case, so as to exhibit, in a striking point of 
view, the close resemblance observable in the march or progress of 
both, as well as the identity of the lesions discovered after death. 
Mr. , residing in the island of Anglesey, was very much 
addicted to field sports, and, while thus engaged, would occasion- 
ally remain for a whole day without food. He was also very fond 
of angling, and has been frequently known to wade up to his 338 
graves’s clinical lectures. 
middle in water for many hours together, during very cold weather. 
His general health was good, and his habits were abstemious. In 
1825, when about twenty-five years of age, he had fever, attended 
with inflammation of the joints, and said to be rheumatic: some 
pain and stiffness, and an evident enlargement of the knee-joints, 
remained after the other articular affections had disappeared ; these 
symptoms however yielded, in a few months, to rest and appropriate 
treatment. His health also improved greatly, and he had no com- 
plaint of any kind whatever until the autumn of 1828, when he 
had a slight attack of ordinary cholera, after returning from a 
shooting excursion. In the spring of 1832, he was attacked with 
pain in one foot, supposed to be of a gouty nature: this pain disap- 
peared during a drive of fifteen miles in an open carriage, but a 
certain degree of tenderness remained, and was always felt, more 
or less, in the part originally affected. He had a similar attack of 
pain and tenderness in the same foot in the following autumn. At 
the time when this attack commenced he was twenty miles from 
home, and observed that during his journey the pain became dimi- 
nished as before, and in a few days subsided altogether. In August, 
1833, he had a similar, but much more severe attack; the pain 
was much more violent than before, and both feet were affected. 
This, however, did not prevent him from following field sports as 
usual; he went on horseback to the mountains to shoot grouse, 
and to this exercise, and drinking a bottle of wine, he attributed 
his speedy, or rather sudden recovery from the pain in his feet. 
Hitherto we have seen a naturally strong constitution struggling 
successfully against exposure to cold, imprudent habits, and a most 
injudicious method of disturbing, or rather repelling, local inflam- 
mation depending on a gouty diathesis. It is not easy to explain 
how it happened that driving in an open carriage, or riding over 
the mountains, so effectually cut short the paroxysms of gout in the 
feet ; but it is enough to know that the fits were suddenly and 
imprudently arrested, to be prepared for the consequences which 
ensued—viz. an irregular distribution of the gouty effort, and its 
determination to internal organs. 
In September, 1833—that is, about a month after the sudden 
subsidence of the last attack—he was seized with a violent colic, 
accompanied by obstinate constipation. The pain was very severe, 
but he suffered more from a general feeling of restlessness (a rest- 
lessness beyond belief, as he expressed it) than from actual pain. 
He was also greatly annoyed by singultus, and was jaundiced, after 
recovering from the attack of colic. In a lecture already published, 
I have mentioned some cases of jaundice supervening on arthritic 
affections; in such instances I am inclined to think that it depends 
on rheumatic or gouty hepatitis. In January, 1834, he had ano- 
ther attack of colic, preceded by a fit, the precise nature of which 
I was unable to ascertain. As these abdominal attacks frequently 
recurred, I shall give a description of one of them, as communicated 
to me by Dr. Llewelyn Jones, jun., his attending physician, a gentle- 
man who justly enjoys a high reputation in his profession. “ A GOUTY RAMOLLISSEMENT OF THE SPINAL MARROW. 
339 
dull, wearing1, and fixed pain would attack the patient in the 
region of the colon : this pain was not increased by pressure, and 
was accompanied by nausea, occasionally by vomiting, and always 
by obstinate constipation. These symptoms were attended by a 
most distressing sensation of restlessness and anxiety. They lasted, 
on one occasion, for three days and nights before I could get the 
bowels opened, when they were immediately mitigated. The pulse 
was never quickened, and in general remained natural; but if the 
attack was prolonged, it became weak. There never was any 
fever, or any well-marked indication of inflammation in the abdo- 
men. These attacks were always preceded or followed by a gouty 
affection of the feet.” 
The attacks in the stomach and bowels recurred frequently, and 
always with the same symptoms, until August, 1835, when a 
visible tremor of the fingers became observable : during some pre- 
ceding attacks he used to complain of weakness of the wrists and 
pains in the fingers, particularly the last joints. As the disease 
progressed, these pains became more intense and extensive, and 
the torture he felt in the hands and arms was beyond description. 
After August, 1835, he began to lose the use of his arms, the tre- 
mors increased, and he began to complain of stiffness about the 
neck, with great restlessness and anxiety. The abdominal attacks 
came on occasionally, but not so severely as before. The arms 
became gradually weaker, until the loss of muscular power was 
complete, and they were greatly emaciated; but Dr. Jones, who 
had the patient under his observation until August, 1836, could 
not detect any evident diminution, either in the upper or lower 
extremities, and the intellectual faculties remained perfectly unim- 
paired. In October, 1835, two months after the state of the upper 
extremities had indicated the approach of paralysis, the lower 
extremities became similarly engaged: they were affected with 
tremors and weakness, and in the following December the patient 
had an attack of violent pain, with swelling and increased heat in 
the ball of one foot, which was pronounced to be of a distinct 
gouty character. After each attack of pain in the feet, as I have 
been informed by this gentleman’s sister, the loss of power in all 
his limbs increased, and if he gained a little strength in the inter- 
vals between these attacks, a recurrence of the paroxysm always 
made him worse than before. 
In February, 1836, I went to Anglesey to visit this gentleman, 
and saw him in consultation with Dr. Jones and Dr. Williams of 
Denbigh. After a minute examination of the history and symp- 
toms of the case, I declared it to be my opinion that a gouty inflam- 
mation had attacked the nerves of the extremities, and had finally 
extended to the spinal cord and its sheath. I said, that at an earlier 
period of the disease I would have advised salivation by mercury, 
but as that was inadmissible under the existing circumstances, we 
should have recourse to other measures. I forgot to state that from 
the commencement of the disease the advice of Sir B. Brodie and 
other eminent practitioners in London had been obtained by letter. 340 
graves’s clinical lectures. 
It would be useless to detail the various general and local reme- 
dies fruitlessly employed in this gentleman’s case. He went to 
Liverpool in August, 1836, for the benefit of further advice, but 
finding no relief, returned to Denbigh, where he died in the ensu- 
ing October. For some time before his death he was greatly ema- 
ciated, and quite paralytic in all his limbs, but retained his intel- 
lectual faculties entire to the last. His body was examined by Mr. 
Williams, whom I had met in consultation in the preceding Febru- 
ary. This gentleman informs me that the viscera of the thorax 
and abdomen were healthy and normal, that no derangement or 
lesion of the brain could be detected, but that the spinal cord oppo- 
site to the last cervical and first dorsal vertebrae was softened to the 
consistence of thick cream; the remainder of the cord was also 
softer than natural, but did not present any thing peculiar in other 
respects. 
In a letter which I have since received from Mr. Williams, (to 
whose kindness I am much indebted, and to whose zeal and pro- 
fessional skill I can bear ample testimony,) he expresses himself 
with regard to the nature of the patient’s disease in a way which 
confirms the views I have taken. He observes, “ I once saw Mr. 
in an attack of gout in the feet about three years before his 
death. There was much pain, and a decided gouty blush. Expo- 
sure in fishing and shooting to a very imprudent degree, while 
under the influence of these gouty attacks, I have no doubt did 
much to render the disease irregular and erratic.” 
The fact that the tremors and loss of power commenced in the 
arms two months before indications of paralysis of the lower extre- 
mities appeared, is sufficient evidence to prove that the spinal 
marrow was not the point from which the diseased action proceeded 
originally; for had this been the case, an affection of this organ, 
sufficiently violent to give rise to paralysis of the upper extremities 
so gradual in its progress and so well developed, must long before 
this period have occasioned paralysis of the legs also. There is a 
striking analogy between the progress of the tumours and paralytic 
symptoms in this case and in cases of painter’s colic ; and the 
analogy likewise holds good as to the violent spasmodic affection of 
the bowels and the constipation observed in both. It is further 
worthy of notice, that in painter’s colic the nervous affection is 
accompanied by pain and weakness of the extremities, and ulti- 
mately, although long after the commencement of the disease, by 
spinal tenderness—a fact which has been already noticed by Dr. 
Bright. Again, in painter’s colic, as in the disease which I have 
just detailed, the affection of the spinal cord, and the consequent 
paralysis, are evidently subsequent to the disease of the peripheral 
portion of the nerves. 
The next case, which I shall now proceed to detail, is one of 
equal interest and importance. A gentleman of robust frame, aged 
about 55, and having an hereditary predisposition to gout, to which 
his father had been a martyr, and which had exhibited itself in one 
of his sons at the early age of 13, consulted me on the 7th of June, GOUTY RAMOLLISSEMENT OP THE SPINAL MARROW. 
341 
1836. Being a man of extensive landed property, he resided chiefly 
in the country, and was in the habit of using much active employ- 
ment and exercise, but indulged rather freely in the pleasures of 
the table. After suffering much annoyance from dyspeptic attacks, 
and various premonitory symptoms, he had a regular paroxysm of 
gout in the spring of 1828; he had a similar one in 1830, and another 
in 1832, each occurring, as before, during the spring season, and 
remarkably severe. During the year 1832 he had several slight 
returns of the complaint, and in January, 1833, had an alarming 
attack of an enteritic character, accompanied by spasms of the sto- 
mach and acute pain of the extremities. In the autumn of 1834 
he suffered greatly from a nephritic affection, and got relief after 
passing a considerable quantity of uric acid gravel. In the spring 
of 1835 he had a fall from his horse, and for some time afterwards 
complained of pain in the small of the back and around the-trunk. 
He recovered, however, and during the summer and autumn of 
that year remained pretty well; but in the last week of December 
caught cold, which was followed by severe cough and pains in the 
chest and feet: the latter were then considered to be the effects of 
gout. From this period his health, though often apparently re- 
stored, was never firm : he became subject to sudden attacks of 
pain, particularly in the chest, which gave him much uneasiness. 
On the 3d of June he consulted a physician in his neighbourhood, 
to whom he described his ailment as “ a slight pain in the right 
side, which troubled him only a short time before he got up in the 
morningthis he stated he had felt occasionally for two months 
before. A very careful examination was made over the situation 
of the liver, the place in which he said he felt pain, but no tender- 
ness or swelling whatever was detected, nor was there any in the 
direction of the spinal cord. His pulse was at this time perfectly 
regular, his bowels natural, and no dyspeptic symptoms existed. 
He used, by the advice of his physician, tonic and laxative pills, 
and a stimulant embrocation. 
When he consulted me on the 7th of June, 1836, I found him 
labouring under what appeared to me to be pleurodynia of an in- 
termittent and gouty character. During the day he was perfectly 
free from pain, but in the evening the pain commenced, and con- 
tinued with violence until morning. It is unnecessary to detail 
here the various local and constitutional remedies which I employed 
in this gentleman’s case, but without any favourable result. From 
the middle of June his symptoms became worse; during the first 
part of the night his pains were very severe ; towards morning he 
usually obtained relief by lying on his face, and carefully avoiding 
all motion. About the latter end of July, the pain, which had been 
almost constantly felt at the right side, moved to the left, imparting 
at one time the feeling as if a spear were passing through the dia- 
phragm, and at another resembling the sensation as if these parts 
were squeezed in a vice. When he was in the horizontal position this 
pain was accompanied by a sense of weight; and at times the pain 
would shoot upwards to the clavicles, producing tenderness of the 342 
graves’s clinical lectures. 
intercostal spaces. When the diaphragm was free from pain, it most 
commonly attacked the postero-inferior edges of the scapula, and 
the dorsal region in its vicinity. In August he tried the use of the 
warm bath, and found temporary relief from the first he took ; he 
remained too long in the second, which was heated to the tempera- 
ture of 100, and nearly fainted. He used the warm bath six or 
eight times, but found no material benefit from it, and could not 
Jpear the pain produced by the jolting of his carriage in going 
thither. About this time there was a visible alteration in his gait 
and figure : the left shoulder was elevated, his whole frame attenu- 
ated, and his face pale; he had nearly lost all power of bending 
the spine, and walked with a peculiar stiffness of gait, as if his 
arms were pinioned. On the morning of the 21st of August he 
stated that he had suffered great agony during the night, and on 
its abating, considerable tumefaction was observable under the 
right ribs. Dyspeptic symptoms now became urgent, his urine 
scanty and turbid; he became melancholy, and his mind was 
wholly occupied with sad presentiments. At my recommendation 
he came to town, in order to place himself under my more imme- 
diate observation, and to have the benefit of a consultation. 
About the 30th of August he got, to his great joy, an attack of gout 
in both feet; while this lasted, which was for about six days, he 
had complete relief from the agonising pains in the diaphragm and 
chest. The interval of tranquillity was, however, but of brief 
duration ; the inflammatory affection of the feet suddenly subsided, 
and the pain attacked the diaphragm with increased intensity. His 
strength, which had been rapidly failing, now gave way, and he 
became quite paraplegic. About the 10th of September the abdo- 
men became engaged, without any alleviation of the thoracic 
symptoms, and he began to complain of constipation, tympanitis, 
and abdominal tenderness. The mucous membrane of the bladder 
became next affected ; he had retention of urine, with great irrita- 
tion of the prostate gland, and it was necessary to draw off the 
water with the catheter several times in the day. This state con- 
tinued from the 22d of September to the 10th of November, when 
the sphincter of the bladder became paralysed, and the urine 
drained off as fast as it was secreted. During all this time the 
urine continued to present the characteristic marks of the lithic 
acid diathesis in an extreme degree, and contrasted strongly with 
the secretion furnished by the inflamed mucous membrane of the 
bladder, which consisted of a grayish or whitish yellow, viscid, and 
somewhat puriform mucus, containing either a free alkali, or an 
alkaline carbonate. This secretion was extremely adhesive, and 
hung down in long ropy filaments when the vessel in which it 
stood was inverted. The nature of this mucus was such as to pre- 
vent any reaction from taking place between its own alkali and 
the acid of the urine. The co-existence of two secretions in the 
bladder—the one alkaline, and the other acid, as observed in this 
case—is extremely curious. 
In this way the patient’s sufferings went on every day increasing, GOUTY RAMOLLISSEMENT OF THE SPINAL MARROW. 
343 
and requiring the most extraordinary care to produce any allevia- 
tion, a task which was discharged with the most indefatigable 
humanity and attention by Mr. Richardson of Sackville street, to 
whom I am indebted for most of the details connected with the 
earlier history of this case. About ten days before his death, the 
extremities, upper as well as lower, and the trunk, became quite 
paralytic ; and from the cervical vertebras downwards, all power of 
motion and sensation was lost. His voice now became weak and 
inarticulate, deglutition was greatly impeded, and he finally sunk 
on the 27th of November, 1836. 
It may be necessary to state, that, at the time the paraplegia was 
beginning to seize on the extremities, the patient was much annoyed 
by occasional involuntary jerkings of the weakened limbs. This 
morbid action of the voluntary motion had completely ceased. 
This gentleman’s body was examined twenty hours after death, 
by Mr. Adams. The body and limbs were greatly emaciated, 
and there were several sloughing sores on various parts of the 
body and limbs, particularly over the scapulae, sacrum, and ileum. 
The brain was perfectly healthy, with the exception of a slight 
effusion under the arachnoid, and into the fourth ventricle. On 
opening the spinal canal, which was done with extraordinary care 
and accuracy, the spinal marrow, from the fourth cervical vertebra 
down to its dorsal termination, was found converted into a morbid 
mass, of an ash-gray colour and pulpy consistence. The theca 
was quite healthy; but on the first transverse section of it a great 
quantity of yellow serum flowed out, emptying at the same time 
the fluid contained in the fourth ventricle of the brain. When the 
medulla spinalis was slit from above downwards, various shades of 
colour were noticed on the surfaces of the sections. Opposite to 
the third dorsal vertebra a blackish colour prevailed ; and from this 
downwards a yellowish hue was noticed. Two little tumours, 
about the size of filberts, were found attached to the crura of the 
fourth dorsal vertebra ; these, as Mr. Adams remarked, were in all 
probability merely accidental formations. The bladder was very 
much thickened in all its coats, and was so contracted that it could 
not contain more than three ounces; its internal surface was of a 
dark green colour, approaching to black. The ureters were also 
thickened, the kidneys enlarged, and their lining membrane of the 
same dark colour as the bladder. The pelvis and infundibula of 
the kidneys were dilated, and contained a reddish diseased urine, 
with some puriform matter, the odour of which resembled that of 
the urine passed during the three weeks previous to his death. 
The other viscera did not present any thing worthy of remark. 
In order to understand the nature and progress of a disease like 
this, which traveled in a retrograde direction along the nerves and 
their sheaths to the spinal marrow, it may be well to point out 
some of the more striking phenomena by which it was characterised. 
In the first place, the long continuance of the pains at one side of 
the body only is in itself a demonstration that the disease was then 
situated in the peripheral extremities of the nerves, and not in the 344 
graves’s clinical lectures. 
spinal marrow; for it has been well observed by Ollivier, that 
inflammation of the spinal marrow or its sheath can never remain 
confined to one half of either for more than a very limited period. 
Indeed, so narrow is the cavity in which these parts are contained, 
and so intimate is the connection of their constituent parts, that it 
is quite impossible for inflammation to remain more than a few 
hours, or at most a day or two, confined to either side. 
Some facts connected with disease of the spinal vertebra, and 
the pains accompanying the progress of that disease, may appear 
to contradict this view of the subject; for in vertebral caries pains 
are often felt at one side, or in one limb—nay, they often cease, or 
seem intermittent. Now, in order to explain this we have only to 
recollect that here the inflammation does not commence in the 
spinal marrow or theca, but in the bones, and that the nerves, after 
their exit from the spinal cord, are affected in all cases before the 
cord itself. The reason is obvious ; the affection of the nerves is 
secondary, and solely derived from their proximity to the inflamed 
bone and investing tissues; and consequently the nerves on one 
side may be affected, while the corresponding nerves on the other 
side escape for the time, and until the disease in the bone extends 
itself to their neighbourhood also. This view of the subject has 
not escaped the notice of German pathologists. 
In the case above related the pains continued in one side for 
months, and were then suddenly transferred to the other, an occur- 
rence which is quite irreconcileable with the idea of their dependence 
on primary spinal disease. The well-marked ease the patient 
experienced when the gout appeared in the feet, and the perfect 
intermissions of pain which he frequently enjoyed during the ear- 
lier stages of the complaint, afford strong evidence that the pains, 
however violent and excruciating they might have been during 
the paroxysms, did not depend on an original affection of the spinal 
cord. Had the fall which this gentleman received, or any other 
injury, induced inflammation of the spinal cord, and subsequent 
degeneration of structure, the order and course of his symptoms 
would have been very different, and long intervals of comparative 
ease would not have intervened between the appearance of the first 
pains and the subsequent paralysis. 
When paraplegia originates in disease of the spinal cord itself, 
retention of urine, or irritability of the bladder, often announces the 
approach of the disease long before the loss of power in the limbs 
becomes evident; whereas, in all those cases in which the paralysis 
creeps from the extremities along the nerves towards the spinal 
marrow, the bladder is affected only at a late period of the disease, 
as occurred in the case which I have just detailed. Finally, the 
remarkable similarity which exists, in various points, between this 
case and that of the Welsh gentleman, who had never met with 
any accident or injury, and in whom a considerable degree of ra- 
mollissement was observed, leaves no doubt that in both instances 
the disease commenced with gouty neuralgia, and inflammation of 
the nervous extremities and their sheaths, which gradually extended GOUT MAY AFFECT THE SPINAL MARROW. 
345 
to the central portions of the nervous system, and ultimately 
involved the spinal cord. 
It is of great importance that practitioners should be aware of 
this termination, and know that in gouty habits the sad results 
already noticed may be produced, particularly as a knowledge of 
this fact may lead them to the timely adoption of preventive mea- 
sures. Having experienced the total inefficacy of colchicum, hydri- 
odate of potash, strychnine, and all the usual remedies, in relieving 
or removing this form of disease, I would be strongly inclined to 
recommend the early insertion of issues over the spine, with prompt 
and decided mercurialisation. Mr. Colies has recommended the 
use of mercury in paraplegia, and cites some cases in support of the 
utility of the practice. It is to be regretted that he has not given 
any hints as to the mode of diagnosing the cases likely to be bene- 
fited by the mercurial treatment, from those in which mercury 
would be inadmissible. Hence his recommendation loses much of 
its value, and cannot serve as a guide to those who have to treat 
spinal diseases connected with paralytic symptoms. It appears, 
however, sufficiently plain, that mercury, employed at an early 
period of the disease, is most likely to prove serviceable where 
symptoms of paralysis arise from inflammatory affections of the 
nerves or their neurilema, or of the spinal cord and its sheath. 
So far at present on the subject of paralysis, as connected with 
the gouty diathesis. I hope to be able, at some future period, to 
bring it again before you in a more complete and extended form. 
LECTURE XIY. 
Gout may affect the spinal marrow—Combination of arthritic inflammation with bron- 
chitis—Effects of various remedies, particularly mercury—Effects of this in chronic 
bronchitis—Dr. O’Beirne’s plan of rapid mercurialisation in certain affections of the 
joints—Application of the same method to inflammation of the lungs of scrofulous 
character—Cases in illustration. 
In the two preceding lectures we proved that gout often attacks 
the nerves of the extremities in the first instance, and then pursues 
a retrograde course until it reaches the spinal marrow. It is an 
acknowledged character of gout that it wanders from one organ to 
another, and that it is very uncertain as to the periods and duration 
of its attacks, sometimes appearing to have ceased altogether, again 
only to return with redoubled violence. These characters of gout 
are strikingly displayed in the two cases I have related, where it 
finally seized on the spinal marrow ; and it is quite possible that 
what took place towards the fatal terminations of these cases, may 
in other gouty subjects occur at a much earlier period, and without 
the previous occupation by the disease of the nerves of the extre- 
mities : indeed, there is no reason why gout should not attack the 346 
GRAVES’S CLINICAL LECTURES. 
spinal marrow and its investing membranes in the first instance, or 
in consequence of metastasis. That rheumatism, the disease most 
closely allied to gout, may do so, has been proved by numerous 
examples, of which we owe some of the most striking to Dr. Cop- 
land and Dr. Prichard, for the result of whose researches on this 
subject I must refer you to the article Chorea, in Copland’s Dic- 
tionary of Practical Medicine, where you will find that rheumatism 
not unfrequently produces botli acute and chronic inflammation of 
the spinal membranes. These observations I make with the inten- 
tion of proving that my views concerning gouty affections of the 
spinal cord are borne out by analogy, and the experience of others 
with respect to rheumatism. 
The case of Coghlan, who has been for some time an inmate of 
our chronic ward, demands a few observations. He was admitted 
for an attack of arthritis on the 10th of December, and since that 
period has been subjected to various modes of treatment. You 
will recollect that on his admission he stated that he had been at- 
tacked several times with rheumatic inflammation of the joints. 
Like most persons of his class, he has suffered greatly from re- 
peated fits of illness, brought on by exposure to the same causes. 
One of the greatest misfortunes that can fall upon labouring men, 
is a severe attack of rheumatic fever accompanied by inflammatory 
affections of the joints ; it not only renders them helpless and use- 
less for a considerable time, but also in some cases leaves them 
cripples for life, and in addition, the nature of their employment 
constantly exposes them to relapses, which at length bring on in- 
curable affections of the joints : we have, moreover, in this young 
man’s case, a combination not unfrequent in patients of this descrip- 
tion, namely, the effects of cold on the chest as well as on the joints, 
arthritis combined with inflammation of the bronchial mucous 
membrane. Now, where the arthritic affection is very severe, and 
accompanied by high fever, the addition of bronchitis is a great 
aggravation. Every time the patient coughs he feels like one 
stretched upon the rack; at every convulsive motion of the chest 
a severe pang is felt in every joint, and the ordinary rate of suffer- 
ing is increased to positive agony. A case of this kind is often 
hard to be managed, even when the disease is recent and the con- 
stitution sound ; but when you have to treat a severe attack in a 
person who has repeatedly laboured under the disease, and whose 
vigour has been consequently impaired, the difficulty is greatly in- 
creased. Here much attention is required on the part of the phy- 
sician. Where the combination is met with in a primary attack, I 
am generally disposed to regard both affections as of the same 
character, and not requiring any difference of treatment: I there- 
fore attack the arthritis and the bronchitis with the same remedies, 
that is to say, venesection, leeches to the affected joints and over 
the chest, and large doses of nitre and tartar emetic. These reme- 
dies, however, are only calculated for the acute stage of a primary 
attack, and where the patient’s strength is unimpaired; for when 
the disease is chronic, and debility present, you cannot venture on MERCURY IN ARTHRITIC INFLAMMATION. 
347 
the use of large doses of tartar emetic and nitre. In such cases 
much benefit is derived from the use of colchicum, particularly 
where the patient labours under more or less fever. The follow in g 
is the form which I am in the habit of using, and from which I 
have occasionally derived much benefit. 
R. Misturse amygdalarum, 3 viij.; aceti colchici, 3 ss.; acetatis morphise, 
gr. i.; nitratis potassae, 3 ss.; sumat cochleare unum amplum omni vel 
secunda quaque hora. 
In Coghlan’s case we tried this mixture with local applications 
to the joints and a blister to the chest, but found at the end of some 
days that there was no visible improvement in the patient. Now 
whenever a state of things of this kind occurs, no time should be 
lost; for rely on it, that where colchicum does not afford relief in 
a short time, and in moderate doses, there is no use in giving it a 
further trial. You have here to contend with two affections of a 
very serious character—one capable of rendering your patient a 
cripple for life, the other threatening him with suffocation, from an 
extension of the inflammation into the minute bronchial tubes, an 
occurrence which is most commonly followed by dangerous con- 
gestion of the lung. Under such circumstances, the only treatment 
you can adopt with a hope of speedy relief and ultimate success, is 
to lay aside all other remedies, and trust almost exclusively to the 
use of mercury. In cases of this kind do not hesitate a moment, 
but mercurialise your patient at once, if his constitution be at all 
capable of bearing it. The treatment which was followed in the 
case under consideration was this :—we gave the patient ten grains 
of hydrargyrum cum creta, four times a day; and with the view 
of relieving pain and the irritation of the bronchial mucous mem- 
brane, he took one drop of hydrocyanic acid and ten drops of tinc- 
ture of hyoscyamus, in half an ounce of almond emulsion, three 
times daily. 
Permit me here, to direct your attention for a moment to the in- 
fluence which mercury exercises over inflammatory affections of 
the joints, and over certain forms of inflammation of the mucous 
membrane. I, in common with most practitioners, look upon 
mercury as a most valuable remedy in the treatment of arthritic 
inflammation, and in certain forms of bronchitis, but I do not, 
however, advise its indiscriminate employment, or bid you mercu- 
rialise every case of bronchitis or arthritic inflammation ; you can 
cure very many cases of both without mercury, and you should 
only have recourse to it in emergencies, of which I shall speak 
afterwards, and where other remedies have failed. In treating 
bronchitis in general, I always try bleeding, leeching, blisters, and 
expectorants, before I have recourse to mercury. But where these 
fail, and the disease continues to wear a threatening aspect, you 
will often find that mercury will cure it in a very rapid and sur- 
prising manner. You had an example of this in a boy who was 
lately under treatment in the chronic ward. He had severe laryn- 
gitis, with an extensive inflammation of the smaller bronchial tubes, 
great dyspnoea, and considerable congestion of the lung, and you 348 
graves’s clinical lectures. 
perceived that the moment he came under the influence of mercury- 
all his symptoms were ameliorated. We gave the mercury ori- 
ginally for the laryngeal affection, but in giving it remarked that 
it would also cure the bronchitis, and such was actually the case. 
Observe, I do not give mercury in bronchitis as a general rule,— it 
is often unnecessary, and even sometimes wholly inadmissible. I 
will except from this that severe form of bronchitis, with conges- 
tion of the lung, in children after measles, which is best treated 
with calomel and ipecacuanha, as recommended by Dr. Cheyne. 
Many children were lost by severe attacks of this form of bronchi- 
tis, and by hooping-cough, accompanied by congestion of the lung, 
until Dr. Cheyne hit upon this simple but effectual plan of treat- 
ment. But in ordinary bronchitis of an acute character, and pro- 
ducing a tendency to congestion of the lung, I do not prescribe 
mercury until other means have failed. 
Now I believe every practical man is aware that mercury is one 
of the best remedies we can employ in many cases of acute and 
subacute bronchitis, but perhaps it is not generally known, that 
even in some cases of chronic bronchitis, that is to say, where the 
patient labours under chronic catarrh, with asthmatic symptoms, 
not only relief, but even a complete cure, is occasionally effected 
by the use of mercury. One of the first cases of this kind which 
struck me very forcibly, was under the care of Mr. Porter. The 
patient, who laboured under an attack of venereal laryngitis, had 
at the same time chronic bronchitis, with puriform expectoration 
and hectic, and as the use of the stethoscope was not then well 
understood, was supposed to be labouring under phthisis. From 
the violence of the laryngeal symptoms, however, Mr. Porter was 
obliged to give mercury, which not only arrested the laryngeal 
inflammation, but also cured the chronic bronchitis. I recollect, 
also, the case of an elderly gentleman, treated by surgeon Mitchell, 
of Harcourt street, for an attack of very long-continued chronic 
bronchitis, with asthmatic symptoms, and who was subject to parox- 
ysms of coughing and violent dyspnoea, which sometimes lasted for 
twelve hours together. Now this gentleman, after the failure of 
various remedies, took mercury, and with the most marked and 
permanent relief of his pulmonary symptoms. I was, it must be 
confessed, greatly surprised by the effects of mercurialisation in 
this case, and it was quite a novel thing to me to witness a chronic, 
a very chronic bronchitis, with copious expectoration and frequently 
recurring dyspnoea, aggravated so as to endanger life by the least 
cold; it was, I say, novel to me to see a patient so affected, radi- 
cally cured by a mercurial salivation. Perhaps, however, nothing 
but the absolute refusal of the disease to yield to other remedies, 
could authorise the adoption of such a plan in the present state of 
our knowledge. 
This puts me in mind of a plan which I have adopted within 
the last year, in the treatment of certain diseases of the lungs, and 
on which I shall make a few observations, as it has not been spoken 
of by those who treat of the cure of pulmonary affections. 1 must SCROFULOUS INFLAMMATION OF THE LUNG. 
349 
here in justice confess that the idea of this plan of treatment is not 
solely mine, but was founded on an analogy derived from the re- 
searches and experiments of Dr. O’Beirne on scrofulous inflam- 
mation of the joints. An extensive experience and deep reflection 
first led Dr. O’Beirne to think that the acute stage of scrofulous in- 
flammation of the hip and knee joint might be made amenable to 
active and energetic treatment; in other words, that inflammatory 
affections of the joints, which terminate in some of the worst and 
most fatal forms of disease, namely, morbus coxae and white 
swelling, might be checked in limine, and before the stage of 
hopeless ulceration was established. He therefore proceeded boldly 
and at once to try whether the disease might not be arrested in the 
commencement by rapid mercurialisation. 
Observe, this idea was completely new, it had never occurred to 
any other person, and was diametrically opposed to the theories of 
the day. The prevailing opinion on this subject was. that mercury 
was inadmissible, and could only produce mischief in persons of 
the scrofulous diathesis. Every one said, do not give mercury in 
such a case, it exacerbates scrofula, it even brings on scrofula in 
many instances where there had been no appearance of it pre- 
viously : you can do no good with it, and may do infinite mischief. 
Dr. O’Beirne, however, knew the difference between the proper 
and improper exhibition of mercury—between mercurialising the 
patient at once and fully, and then stopping, and the pernicious 
custom of giving long and irregular courses of mercury. He tried 
the remedy and succeeded, and the surgeons of Europe have justly 
appreciated the value and importance of his discovery. About two 
or three months before Dr. O’Beirne made his discovery public, I 
had translated, for the Dublin Medical Journal, a paper from a 
German author on the use of corrosive sublimate in baths, in the 
treatment of white swelling, and Dr. O’Beirne states that the pub- 
lication of this paper gave him courage at the time in pursuing a 
plan of treatment so much at variance with the opinions of the day. 
I published this paper, however, at the time merely as a curiosity ; 
it was a novelty in practice of which I had no experience, and 
could not offer any explanation. This was reserved for Dr. O’B. 
He has shown in his memoir on the subject, that if you give mer- 
cury so as to affect the system rapidly, you will frequently succeed 
in curing the disease, particularly in the commencement. 
From this I was led by analogy to apply the Same principle of 
treatment to incipient scrofulous inflammation of the lung, and I 
think T have often succeeded in checking at once this most formi- 
dable of human maladies. Phthisis, as every medical man knows, 
is capable of assuming a variety of forms, and presents at its origin 
much difference of aspect. In some, it arises slowly and insi- 
diously, and the pulmonary symptoms are so quietly and gradually 
developed that it would puzzle an intelligent practitioner, who had 
the most ample opportunities of observing his patient from the be- 
ginning, to say at what particular period distinct evidence of danger 
had been noticed. The reason of this is because the tubercular 350 
graves’s clinical lectures. 
affection of the lung is in such patients only of secondary import- 
ance, the disease which produced it having affected the whole 
system before the lung was contaminated. This happens in some, 
but in others an opposite train of phenomena is observed, and 
scrofulous inflammation commences in the lung before any general 
contamination of the system has taken place. It is in such cases, 
and such only, that mercury ought to be tried, and it will avail 
nothing except where the commencement of the scrofulous inflam- 
mation of the lung has arisen suddenly, and in consequence of the 
operation of some obvious cause, as catching cold or the occurrence 
of haemoptysis. I think that too much stress has been laid on the 
affection of the lung by writers on phthisis. In some cases (I will 
admit even in the majority of instances) the disease commences in 
the lung, but in others it passes through many changes, and affects 
various organs before it attacks the lung. You will frequently see 
persons labouring under scrofulous irritation, accompanied by 
hectic, emaciation, loss of appetite, and excitement of pulse, long 
before you can find any trace of tubercular deposition in the lung. 
I am of opinion that many persons would die of phthisis even sup- 
posing they had no such organ as the lung. 
But let us suppose the case of a person of scrofulous habit who 
gets an attack of fever, with local inflammation, and that this in- 
flammation fastens on the lung. Take for instance the following 
case : a young man of robust and vigorous frame, but evidently of 
the scrofulous habit, who has laboured repeatedly under scrofulous 
ophthalmia in his infancy, and who has lost several members of 
his family by consumption, gets, we will suppose, a severe cold 
by overheating himself in walking into Dublin from the country 
on a damp evening. He is attacked next day with feverish symp- 
toms and severe catarrh, which soon becomes a formidable bron- 
chitis ; but the young man being of a vigorous habit and fond of 
company, continues to go out and expose himself to night air, 
until at length the catarrhal fever is changed into hectic, the bron- 
chitis into organic disease of the lungs, tubercles become developed, 
and the disease passes into phthisis. Here, you perceive, a man 
gets an ordinary cold, which becomes a bronchitis ; he neglects 
this, and it passes into disease of the pulmonary tissue and tuber- 
cular ulceration. Now this is a very common course of diseased 
action in persons of a scrofulous habit, and I have in many such 
cases been able to trace the fatal malady to a common cold exacer- 
bated by neglect and bad treatment. You perceive that I do not 
use the ordinary nomenclature of writers on consumption ; I do not 
recognise the terms “tubercular inflammation” as connected with 
cases of this description ; indeed, I am inclined to think that the 
whole theory of inflammation being excited in the lung by the pre- 
sence of tubercles is founded on erroneous views. I have repeatedly 
found tubercles in the lungs of persons who died of other diseases, 
without any trace of inflammation around them, and I believe 
every pathologist will confirm this statement. From this and other 
reasons, I have been led to the conclusion that tubercles do not act SCROFULOUS INFLAMMATION OF THE LUNG. 
351 
in all cases as foreign bodies, and that the theory which attributes 
the origin of inflammation to their presence is wrong. In one of 
my published lectures, I have brought forward numerous argu- 
ments to show that we are in possession of a much truer and more 
intelligible pathological explanation of the fact in question. You 
may have scrofulous inflammation of the bronchial mucous mem- 
brane, or you may have scrofulous inflammation of the lung, singly 
or combined, or, what is most frequently the case, you may have 
either or both accompanied by tubercular development. The deve- 
lopment of tubercles, however, in a case of scrofulous bronchitis 
or scrofulous pneumonia, is a coincidence, and not a cause; and 
you may have either of those affections singly or combined, with- 
out any coexistent or preceding tubercular development. Most 
commonly scrofulous bronchitis and scrofulous pneumonia are con- 
joined ; the former seldom exists for any length of time without 
producing the latter, and the latter is usually attended by more or 
less derangement of the brochial mucous membrane. 
But what I chiefly wish to direct your attention to on the present 
occasion (and it is a matter of the deepest importance) is, can we 
prevent the development of phthisis in a person of scrofulous habit 
who has caught cold, got a dangerous attack of bronchitis or 
pneumonia, and is threatened with hectic? I do not wish to enter 
here into any disquisition concerning the means to be adopted with 
the view of preventing tubercular deposition, or producing absorp- 
tion when tubercular matter has been deposited in the tissue of the 
lung. To prevent tubercular deposition you must cure the scro- 
fulous diathesis, if you can. But suppose you are called to a case 
of the kind I have already described, where a young man of scro- 
fulous diathesis gets a bad bronchitis or pneumonia, exacerbates it 
by neglect, and is threatened with hectic, what is the best plan you 
can pursue? My impression is that you should treat it as you 
would treat acute scrofulous inflammation of the knee or hip-joint; 
in other words, that you should mercurialise your patient rapidly 
and at once: do it suddenly and decidedly, but without pushing 
the mercury too far, and you will often arrest all the symptoms of 
the disease as it were by a charm. I could mention many cases 
which have been treated successfully in this way. I was very 
much struck by the case of two eminent medical practitioners who 
came to Dublin within this last year to place themselves under the 
care of Dr. William Stokes and myself. One was a person of 
scrofulous habit, who had caught cold after taking mercury, and 
neglected it for three weeks. At the time we saw him he laboured 
under severe and harassing cough, considerable fever and emacia- 
tion, and was greatly alarmed about his condition. He had been 
several times leeched over the trachea by Dr. Stokes, but this, 
although an admirable remedy in many cases of bronchitis, failed 
in producing an amelioration of his symptoms, and from the per- 
sistence of his feverishness, emaciation, and harassing cough, 
serious apprehensions were entertained that his disease would ter- 
minate in phthisis. Having explained to our patient our views of 352 
graves’s clinical lectures. 
the case, and our impression that mercury was the only remedy on 
which we could rely with any hopes of success, we ordered him 
to confine himself to his room, continue the application of leeches 
to the trachea, and take mercury. Now as this gentleman had 
come up to town under the impression that he was consumptive, 
we found some difficulty in persuading him to submit to this mode 
of treatment. He yielded, however, but with great reluctance. 
In the space of a week all his bad symptoms had nearly disap- 
peared. As soon as he came under the influence of mercury the 
cough became notably diminished, and he recovered flesh and 
strength with surprising rapidity. The other was a physician from 
the north of Ireland, who was suddenly attacked by pufmonary 
apoplexy, and in a few weeks came to Dublin, harassed by a con- 
stant dry cough, which prevented sleep at night, and he was visibly 
emaciated and anxious. In him no hereditary tendency to phthisis 
could be ascertained, but nevertheless Dr. Marsh, Dr. Stokes, and 
myself, considered the case as very unpromising, for although there 
was no acceleration of the pulse, the breathing was easily disturb- 
ed, and we could detect crepitus and some dulness above the right 
mamma, where it was evident the original seat of the hemorrhage 
had been. This case, too, which had resisted a mere antiphlo- 
gistic treatment, yielded in a most satisfactory manner to mercury. 
Bearing these facts in mind, I think you will be prepared to 
admit that mercury is a most valuable remedy in the treatment of 
scrofulous bronchitis and scrofulous pneumonia—diseases which 
too often resist the ordinary modes of treatment, and which are 
unfortunately so often followed by fatal disease of the lung. Where 
a sudden attack of cold has produced inflammation of the substance 
or lining membrane of the lung in a person of scrofulous habit— 
where the attack is recent, and has occurred under circumstances 
which preclude any suspicion of previous tubercular disease—in 
such a case as this you will find mercury a most admirable remedy 
in checking symptoms often not amenable to other plans of treat- 
ment, and which if neglected or maltreated would in all probability 
end in phthisis. I was led to the adoption of this plan by the suc- 
cess which has attended Dr. O’Beirne’s practice in acute scrofulous 
inflammation of the joints, and from observing that cases of un- 
manageable chronic bronchitis had been occasionally cured per- 
fectly where mercury had been exhibited for other affections ; and 
it is a curious fact that about the time I had fallen upon this mode 
of treatment, it suggested itself likewise to the minds of Dr. Stokes 
and Dr. Marsh, who can testify its utility: of course it will not 
succeed in all cases; and I have seen it fail in two where I had 
confidently expected benefit. Notwithstanding this it is a most 
valuable addition to our resources in certain cases that would end 
in phthisis. 
About a year ago I attended a young gentleman, apparently of 
robust constitution, who died of phthisis ushered in lay a frequently 
recurring haemoptysis. Shortly after his death, Mr. William Grady, 
one of our most diligent and intelligent pupils, called on me to HYDRIODATE OF POTASH IN RHEUMATISM. 
353 
visit the elder brother of my former patient. He had a constant 
hard, dry, and very distressing cough, which deprived him of 
sleep, and having continued many weeks had produced a most 
formidable degree of emaciation. Consumption was naturally 
dreaded. His pulse, however, was normal, and the stethoscope 
did not indicate any pulmonary lesion : still, as the case had re- 
fused to yield to all the ordinary remedies, including change of air, 
we felt very apprehensive as to the result. I confined him to bed, 
applied leeches over the trachea several times, and rapidly mer- 
curialised him, and with complete success. He has continued well 
ever since. 
LECTURE XY. 
Hydriodate of potash in rheumatism—Sarsaparilla and nitre in chronic cough—Remarks 
on percussion—Clear sound with solidified lung—Fever with cerebral irritation— 
Employment of tartar emetic and opium—Success of turpentine. 
I have spoken on a former occasion of the utility of mercury in 
certain cases of rheumatic fever, where the inflammation of the 
joints will not yield to other means : I have now to add, that within 
the last year the hydriodate of potash has been found to be a most 
useful adjunct to mercury, and well calculated for following up 
and completing the beneficial effects produced by that remedy. In 
fact, in treating arthritic or rheumatic fever, when I have reduced 
the violence of the fever and of the inflammatory affection of the 
joints by means of bleeding and leeching, followed by tartar emetic 
or nitre, or both combined, or when after the antiphlogistic treat- 
ment, both local and general, I have produced a marked alleviation 
of the patient’s sufferings, either by the use of colchicum or by the 
use of mercury combined with opiates,—then, I say, we can employ 
thy hydriodate of potash with the greatest possible advantage, as it 
quickly dissipates the remaining pain and swelling of the joints, 
and contributes powerfully to bring the disease to a speedy termi- 
nation, while at the same time it greatly diminishes the danger of 
a relapse. I have experienced much comfort and feel much confi- 
dence in the treatment of rheumatic fever since I adopted this 
practice; and it now never happens to me to meet with cases 
which, in spite of all my efforts, become chronic, and confine the 
unfortunate sufferers to bed for months. You have observed, that 
in most cases of acute rheumatism affecting the joints, no matter 
what mode of treatment I adopt in the commencement and during 
the acme of the disease, I generally complete the cure with the 
hydriodate of potash, beginning with doses of ten grains, which 
are quickly augmented to twenty or thirty grains three times a day. 
It is generally given in decoction of sarsaparilla, to which some 
preparation of morphia forms an useful addition. 354 
graves’s clinical lectures. 
Iodine and the hydriodate of potash exert a very powerful influ- 
ence over scrofulous inflammation, but their influence, as has been 
proved by recent experience, extends likewise to inflammations 
connected with other states of the constitution, and they are fre- 
quently exhibited now with the best effects in certain varieties of 
syphilis, pseudo-syphilis, gout, mercurial cachexy, and rheumatism. 
The power of iodine in moderating mercurial salivation, and the 
severe ulceration of the mouth which frequently accompanies it, 
has been asserted by some and denied by others. Be this as it may, 
it certainly is an excellent adjuvant to our usual means for dimi- 
nishing the pain and inflammation which attend periostitic affec- 
tions, and many of the troublesome sequelae of syphilis. I may 
observe also, that the hydriodate of potash has been found to prove 
a most valuable auxiliary in the treatment of chronic anasarca and 
ascites; and Mr. Swift informs me, that he has employed it with 
the most satisfactory results in the dropsy of scarlatina, particularly 
in children of a weak and cachectic habit. He uses the hydriodate 
of potash in combination with liquor kali, to which the tincture of 
digitalis is occasionally added. 
I have been told likewise by some excellent practitioners, that 
they have derived much advantage from the ioduret of iron in rheu- 
matic affections of the joints, after the acute stage has subsided. 
My own experience of the effects of this remedy is too limited to 
allow me to express any opinion on its merits. 
Having spoken of mercurial salivation, it occurs to me this mo- 
ment, that the remarkable fact of the difficulty of salivating infants 
and very old persons must depend in some measure on the undeve- 
loped state of the parotid glands in the former, and their shrunken 
and atrophied condition in the latter. The apparatus connected 
with the insalivation of the food is comparatively but little required 
before the teeth appear in infancy, or after they have fallen in ad- 
vanced age. 
I wish now to make a few observations on the use of decoction 
of sarsaparilla and nitric acid in certain cases of chronic cough. 
The utility of this combination has been long recognised in cachec- 
tic states of the system and affections of the skin, whether syphilitic 
or mercurial; and it has also proved itself very efficacious in va- 
rious species of sore throat, chronic pains, and other textural 
derangements of a slow and tedious character. The marked effects 
which the decoction of sarsaparilla and nitric acid produce in these 
diseases of the general habit, skin, and mucous membrane of the 
throat, led me to infer that the same combination might be employ- 
ed with advantage in cases of chronic cough, attended with redness 
and relaxation of the mucous membrane of the fauces, elongation 
of the uvula, and some degree of general debility. I have ob- 
served that such cases are almost invariably accompanied by more 
or less derangement of the digestive organs and an irritable state 
of the general system; and from their analogy to other states of the 
constitution, in which nitric acid and sarsaparilla have proved ex- 
tremely beneficial, I was induced to give this combination a trial; CLEAR SOUND WITH SOLIDIFIED LUNG. 
355 
and 1 can now state that it has not disappointed my expectations. 
Decoction of sarsaparilla, given in doses of a pint daily, with a 
dram or more of nitric acid, has proved a most useful and valuable 
remedy in the treatment of cases of this description. It is scarcely 
necessary to observe, that in addition to the use of this remedy, 
change of air, moderate exercise and recreation, and a nutritious 
but not heating diet, are required. In some of these cases it will 
be also necessary to apply lotions of the nitrate of silver or sul- 
phate of copper to the fauces and tonsils ; and where the uvula is 
greatly relaxed, it will require to be frequently touched with the 
nitrate of silver, or even to be shortened by an operation. Guided 
by the same principles, I have frequently exhibited decoction of 
sarsaparilla with nitric acid in cases of persons of a reduced and 
relaxed habit who are troubled with a slight but frequently recur- 
ring cough or hem, and the expectoration of a few bronchial sputa, 
occasionally mixed with blood, which appears to come, not from 
the lungs, but from the eroded mucous membrane at the top of the 
pharynx and larynx. In such cases I have observed that the cough 
and expectoration took place chiefly in the morning after awaking, 
and in some had continued for weeks without any dyspnoea, pain 
in the chest, or fever. I may also remark, that the same combina- 
tion may be often given with advantage to patients whose mouths 
have been recently made sore by mercury administered for the cure 
of bronchitis or pneumonia, and will occasionally be found useful 
in removing the still lingering remnant of pulmonary disease, at a 
time when mercury could not be pushed farther with safety. 
Speaking of pulmonary affections leads me to notice a collateral 
subject of very great importance : I allude to percussion as a means 
of arriving at a true diagnosis in cases where solidification of the 
lung has taken place. It is generally believed, that in cases where 
the actual quantity of air in the lungs is morbidly increased or 
diminished, percussion furnishes us with means of information 
adapted to every variety of case, and capable of unlimited applica- 
tion. This, however, is not the fact. It is true that when percus- 
sion furnishes positive evidence of increased pulmonary solidity, 
we may be pretty sure that solidification exists ; but such evidence 
is not furnished by percussion in every case of the kind indiscrimi- 
nately, for it now and then happens that percussion elicits a very 
clear sound from the parietes of the chest, corresponding to consi- 
derable solidification of the lungs within. Of this I have now 
witnessed several instances. You will ask, how then are we to 
explain this apparent contradiction between the results afforded by 
percussion? This is a question of much importance, and I hope 
the solution which I am about to offer will be found adequate and 
satisfactory. 
An old man, named Foy, died lately, at Sir P. Dun’s Hospital, 
of hepatisation of the inferior lobe of the right lung, with nume- 
rous tubercular depositions in the upper lobes of both lungs. 
During his illness, I pointed out the existence of extensive hepa- 
tisation of the lower lobe of the right lung, in which perfect and 356 
graves’s clinical lectures. 
decided dulness marked oat accurately the space occupied inter- 
nally by the solidified pulmonary tissue. But anteriorly and above, 
the parietes of the chest returned a clear sound on percussion, nor 
could a vestige of dulness be any where detected. Yet the whole 
of the upper lobes of this patient’s lungs were occupied to such an 
extent by crude tubercles, that no portion of the upper lobes could 
be selected, equal to half the size of a fist, which would not sink 
in water. This was owing to tubercular matter, which occupied 
the pulmonary tissue in detached infiltrated masses, or in single 
crude tubercles. How, then, did it happen that such extensive 
solidification of the upper lobes existed without any corresponding 
dulness on percussion ? A careful examination of the pathological 
condition of these lobes satisfactorily explained the anomaly. On 
accurate inspection, we found that although the solidified masses 
of the pulmonary tissue were extremely numerous, and predomi- 
nated over the parts which still retained their natural vesicular 
texture, so that an extensive portion of the upper lobes seemed to 
be quite solid, yet the solidified portions were insulated and divided 
from each other, throughout the interior of the lobe, by intervening 
laminae of healthy pulmonary tissue, and on their surface were, for 
the most part, covered by a stratum of healthy vesicular lung, from 
a quarter to half an inch in thickness. Indeed, although the soli- 
dified masses (to use a geological expression) sometimes cropped up, 
and came to the surface, yet this was comparatively a rare occur- 
rence ; and by far the greater portion of that surface was composed 
of a thin stratum of pervious vesicular tissue. To this was owing 
the clear sound elicited by percussion. 
You will recollect, therefore, that in certain (I will admit rare) 
cases of tubercular deposition in the lungs, the tubercular develop- 
ment may have proceeded to the extent of rendering the greater por- 
tion of the upper lobes impervious to the air, and may have solidified 
those lobes considerably, and yet the solidified portions may be so 
divided from each other by laminae of healthy lung, and may be 
so covered by a stratum of vesicular tissue, that the general result 
of percussion is to elicit a clear sound over the whole of the pa- 
rietes of the chest corresponding to the affected lobes. 
Since our last meeting, some cases of fever have occurred in our 
wards, which have presented too many points of interest to be 
passed over without any observation. A very curious case occur- 
red here, in a man named Toole, who was admitted on the 4th of 
January. This patient is a robust labouring man, about thirty 
years of age, and had been labouring under maculated fever for 
ten or eleven days before admission. Of his history previous to 
admission we could learn nothing; but when he came under our 
care he appeared very ill, and exhibited great depression of the 
vital energies, so that we found it necessary to encourage reaction 
by the application of heat to the surface of the body, frictions, 
warm fomentations, and the internal administration of wine and 
carbonate of ammonia. On the following night reaction became 
established ; next day he became irritable and restless, and towards 357 
FEVER WITH CEREBRAL IRRITATION. 
night was seized with delirium. The nurse omitted to report his 
state to Mr. Parr, or the resident pupil; he was thus left without 
any treatment until next morning. Now, this is a matter of much 
regret to me, and I think I cannot do a more essential service to 
those who are about to enter on the practice of their profession 
than to impress, as strongly as I can, the indispensable necessity 
of watching fever patients with the most anxious and unremitting 
diligence. In a case of bad fever, a single visit in the day will 
never suffice ; two, and even three, visits a-day will be required ; 
and, when the patient is in a doubtful or dangerous condition, it 
will be often necessary to have a properly educated medical person 
in constant attendance, prepared to meet every emergency, and 
counteract or modify every unfavourable change. Fever will often 
run on for several days without any change calculated to arrest 
our attention, or call for the adoption of any new measures, and 
yet, in the space of six hours, an alteration may occur, of which 
the physician should have early and full information. 
Well, this man remained without any treatment for several hours 
after delirium commenced. On the 6th, we ordered his head to be 
shaved and leeched, and prescribed tartar emetic, in doses of a 
quarter of a grain, every second hour. Next day we found him as 
bad as ever. The tartar emetic had failed in diminishing the cerebral 
symptoms, and his delirium had rather increased. We found also, 
on enquiry, that he had had no sleep for the last three nights. His 
pulse was weak and rapid, his eyes suffused, his restlessness and 
delirium such that he required a person to sit by him constantly, 
and prevent him from getting out of bed. Under these circum- 
stances, we ordered five drops of black drop to be added to each 
dose of the tartar emetic mixture, of which he took an ounce every 
third hour, that is, about a quarter of a grain of tartar emetic. 
He took four doses of this during the night; and next morning we 
found that the delirium and sleeplessness continued still unabated, 
and that the man was sinking fast into a state of stupor and insen- 
sibility. He neither answered questions, nor put out his tongue 
when desired; he had great subsultus, and was muttering to him- 
self with great volubility and rapidity of utterance. Indeed, his 
condition was such that I had no hope. Among other symptoms, 
I should mention that he had contraction of the pupils, a symptom 
of very unfavourable augury in fever. Having failed with tartar 
emetic alone, and afterwards with tartar emetic in combination 
with opium, I had now to seek for some other means of subduing 
cerebral irritation, and in this emergency had recourse to the use 
of turpentine,—a remedy which I was inclined to adopt in prefer- 
ence to any other, as there was some fulness of the abdomen, and 
other symptoms indicating the existence of congestion of the intes- 
tinal mucous membrane. I therefore ordered two drams of the 
spirit of turpentine to be made up into a draught with a little oil 
and mucilage, and administered every second hour. Now this is a 
point in the treatment of this man’s case to which I would particu- 
larly direct your attention. 358 
graves’s clinical lectures. 
I was guided here by a knowledge of the fact, that turpentine 
exercises a very remarkable influence over many forms af nervous 
irritation. I can refer for illustration to many affections of the ner- 
vous system characterised by excitement, in which turpentine has 
been employed with the most signal benefit. Thus, we frequently 
find it a most valuable agent in the treatment of chorea, of epilepsy, 
and of the convulsive fits of children. We have frequently expe- 
rienced benefit from its use in the treatment of spasmodic affections 
of the stomach and bowels; in hysteria, tympanitis, and the sub- 
sultus of fever, we often derive from it the most rapid and effectual 
relief. You recollect a case of typhus which was lately under 
treatment in our wards, and of which one of the most prominent 
symptoms was general and continued subsultus ; and you have all 
witnessed how much relief the patient obtained from small doses of 
oil of turpentine. Hence I was led to conclude that it might be 
employed with benefit in the latter stages of fever, where vascular 
excitement is greatly abated, and where the most prominent symp- 
toms are irritation of the nervous centres, with more or less con- 
gestion of the gastro-intestinal mucous membrane. In this case, 
however, I must confess I used it as a last resource, and did not 
anticipate the very striking results which followed so unexpectedly. 
After the second or third dose the patient had two or three full mo- 
tions from the bowels, and shortly afterwards fell into a sound and 
tranquil sleep, from which he awoke rational and refreshed. He 
is now wonderfully improved in every respect, and I have no doubt 
that his convalescence will go on favourably. 
There is one symptom in this man’s case which is worthy of your 
attention, as connected with the history of fever, although in other 
respects it does not seem to possess much importance. I allude to 
the bullae which have appeared on the calves of his legs, on the 
inside of the ankles, and on the soles of the feet. This affection 
seems to belong to that class of eruptive diseases which are occa- 
sionally observed during the course of idiopathic fevers, particu- 
larly those which have arisen from the introduction of an animal 
poison into the system. Thus we sometimes find an eruption of 
pustules, sometimes of vesicles (as the miliary); occasionally we 
have bullae, and not unfrequently erysipelas. 
We have had another case of spotted or eruptive typhus, in a 
man named Henry Harpur, which has exhibited in the strongest 
manner the value of a combination of tartar emetic and opium in 
diminishing cerebral irritation, and bringing about a favourable 
change in cases characterised by symptoms of alarming and immi- 
nent danger. Those who have witnessed Harpur’s case will con- 
fess that few cases could present a more unpromising appearance. 
He had violent delirium, requiring the restraint of the strait waist- 
coat, a furious aspect, suffusion of the eyes, constant raving and 
muttering, and perfect sleeplessness. His pulse was weak, thready, 
and rapid; his tongue and lips parched, fissured, and black; his 
breathing quick and irregular; and his cerebral symptoms of such 
intensity as to leave little or no ground for hope. In addition, he 359 
FEVER WITH CEREBRAL IRRITATION. 
had continued and general subsultus, and constant irregular mo- 
tions of the extremities. Now this man has been rescued from a 
state of the most imminent danger, and restored to convalescence, 
by the use of tartar emetic and opium. Those who saw the case 
two days since, and who have noticed the remarkably improved 
state of the patient to-day, will agree with me in saying, that so 
favourable a result could scarcely be expected. In this case the 
tartar emetic and opium were combined with musk and camphor. 
Where great subsultus tendinum is present, in addition to the usual 
symptoms of cerebral excitement, I am in the habit of combining 
musk and camphor with tartar emetic, in the following form. 
R. Mucilaginis gummi arabici, 3 ss-5 syrupi papaveris albi, 3j-5 antimo- 
nii tartarizati, gr. ij.; camphors, gr. xv.; moschi, 9ij.; aquas fontis, 
3 ivss. M. 
The camphor should be previously triturated with a few drops 
of alcohol, and the whole must be rubbed up into the form of an 
emulsion, of which a table-spoonful is to be taken every second 
hour, until copious discharges of fluid yellow faecal matter take 
place,—an occurrence always attended by much relief of the cere- 
bral and nervous symptoms, and which marks the period at which 
we dught to desist from the further use of tartar emetic. In the 
case which we are now considering, the medicine was administered 
in draughts, each of which contained half a grain of tartar emetic, 
ten grains of musk, five grains of camphor, and about ten drops of 
laudanum. After taking three such draughts the patient fell into a 
quiet sleep, which continued for several hours. He awoke quite 
rational ; and since that period his improvement has been steady 
and progressive. I have not time to enter any further into the 
particulars of this case at present, and merely allude to it as one of 
those instances in which we have succeeded in allaying symptoms 
of cerebral excitement, where the state of the patient afforded very 
little grounds for any hope of a favourable termination. 
At my next lecture I purpose to lay before you, in detail, the 
history of the results which have attended the employment of tartar 
emetic and opium in fever, with some observations on its value as 
a therapeutic agent, and on the cases to which it is most peculiarly 
adapted. 360 
graves’s clinical lectures. 
LECTURE XYI. 
On the efficacy of tartar emetic and opium in fever with much cerebral disturbance ; 
illustrated by cases. 
At my last lecture, I alluded to the use of tartar emetic in the 
treatment of the cerebral excitement and determination to the head, 
which are so frequently witnessed in the advanced stage of the 
present epidemic, typhus ; I shall now proceed to mention some of 
the beneficial efFects derived from this plan of treatment, as illus- 
trated by cases which have recently occurred in my own practice, 
or in that of other members of the profession. 
Did I bring forward this plan of treatment as infallible, or if I 
boasted that it never failed, then indeed you might well doubt my 
judgment in recommending it to your notice, for infallible remedies 
never earn the sanction of experience ; but such is not the fact. 
This treatment we ourselves have seen will not always succeed ; 
nay, we must acknowledge that it has occasionally disappointed us 
even where we seemed justified in calculating upon success. But, 
gentlemen, we must recollect that every useful remedy is subject to 
the same charge, and that in the long list of therapeutic agents, 
there does not exist a single medicine which is fairly entitled to the 
appellation of a true and infallible specific. 
We have failed in several cases with tartar emetic, either alone 
or combined with opium and other medicines, and patients labour- 
ing under typhus have fallen victims to cerebral disease, although 
we applied the remedy with all due diligence. Yet I think it but 
fair to observe, that most of the instances in which we failed were 
cases that had come under our notice at an advanced stage of fever, 
and where the cerebral symptoms had been wholly overlooked or 
improperly treated in the commencement of the disease. I may 
observe also, that cases of this description, in which the cerebral 
symptoms have been permitted, before admission into hospital, to 
form themselves fully, are exceedingly difficult to manage, and ter- 
minate fatally at a much earlier period than the ordinary cases of 
typhus observed in private practice. 
Maculated typhus with determination to the head, when im- 
properly treated, terminates not unfrequently about the tenth, 
eleventh, or twelfth day; sometimes it is protracted to the thirteenth 
or fourteenth, but most usually it ends fatally about the eleventh or 
twelfth. In neglected cases, the cerebral symptoms frequently as- 
sume a fearful violence on the seventh, eighth, or ninth day, and 
in such instances it must be expected that, the best and most appro- 
priate plan of treatment will fail in rescuing the patient from im- 
pending dissolution. If, however, we can find out a remedy, which, 
in many cases, apparently desperate, succeeds in rescuing the 
patient from the jaws of death, we must be satisfied. A case of 
this description has occurred since our last meeting. It has excited 
the attention of all who witnessed it, as well from the violence of TARTAR EMETIC AND OPIUM IN FEVER. 
361 
the symptoms, and the apparently hopeless state of the patient, as 
from the rapidity with which the exhibition of the remedies em- 
ployed was followed by a striking and decided alteration in the 
symptoms. Any one who saw him yesterday, would scarcely re- 
cognise him as the same individual to-day. 
This man, named Fogarty, was admitted about the seventh or 
eighth day of his fever, according to the account of his friends. Of 
course, in such cases, we cannot give implicit credence to those 
loose statements, for the lower class of persons in this country never 
calculate the time during which the patient remains out of bed 
struggling against the disease,—a period which, in a people inured 
to suffering and privation, frequently lasts three, four, or even six 
days. Well, this man, aged five-and-twenty, and of rather robust 
constitution, was admitted on the 20th of December, being then 
about eight or nine days ill. Previous to admission he had taken 
purgative medicines, had his head shaved, and six leeches applied 
behind his ears, or to his temples, I forget which. Now all these 
measures, although perhaps insufficient, were extremely proper, 
and must have produced more or less benefit. When we examined 
him on the 21st, we found him in a state of high excitement, as 
manifested by continued mental wandering, incessant talking and 
raving, and frequent attempts to get out of bed. He had illusions 
of the senses of sight and hearing, consisting of terrific ocular 
spectra1, and alarming sounds, which threw him into a state of in- 
tense agitation ; his eye was red and watchful, and he never slept. 
Here then was a very threatening array of symptoms ;—perfect in- 
somnia, ocular spectra, illusions of the sense of hearing, a fiery eye, 
and incessant mental wandering. To this was added, great de- 
rangement of the whole nervous system; his body was agitated 
from head to foot by continual tremors, and he had violent and 
persistent subsultus ; his respiration was interrupted, suspirious, and 
irregular, amounting at one time to forty in the minute, and a few 
minutes afterwards not exceeding twenty-five; the acts of inspira- 
tion and expiration were extremely unequal, and occasionally ac- 
companied by blowing and whistling. In a former lecture, I made 
some observations on this form of respiration, which I termed 
cerebral, from having first observed it in persons subject to apo- 
plectic attacks, either before or during the paroxysms; it is fre- 
quently observed in bad cases of fever, and is a symptom of the 
greatest importance. He also lay constantly on his back ; his pulse 
120, soft, and very weak, so that the canal of the artery could be 
obliterated by very slight pressure; his pupils were somewhat 
dilated ; tongue parched and brown in the centre, red at the edges 
and tip; skin covered with maculae ; abdomen soft and full. Those 
1 In a former lecture I mentioned that analogous symptoms result from in- 
creased or diminished sanguineous pressure on the brain; the ocular spectra 
in Fogarty’s case evidently depended on determination of blood to the head, 
but in the case of a lady, the wife of an eminent physician, a continued and 
varied succession of spectral illusions formed one of the chief symptoms, 
produced by exhausting hemorrhage after delivery. GRAVES’s CLINICAL LECTURES. 
who have witnessed the case will acknowledge that the picture I 
have drawn is not too highly coloured, but, on the contrary, falls 
far short of the reality, and no doubt you all expected that if we did 
not succeed at once in arresting the progress of his symptoms, the 
case must have proved rapidly fatal. Observe the position in which 
we were placed. In the commencement of the fever, certain ap- 
propriate but inadequate remedies had been employed, and, under a 
treatment proper but insufficient, the disease had progressed ; it 
was an example of one of the worst forms of fever, characterised 
by intense cerebral excitement, and accompanied by total want of 
sleep, persistent delirium, and excessive disturbance of the nervous 
functions ; all these symptoms had come on gradually, and arrived 
at their acme at a period when the low and debilitated state of the 
patient precluded the use of depletive measures to such an extent 
as to exert any efficient control over the most dangerous symptoms. 
The application of a few leeches would be extremely hazardous, 
and blistering would have been wholly useless and nugatory, for 
before a blister could rise the man would be dead. For these 
reasons, we concluded that the only remedy we could have re- 
course to with any prospect of success was tartar emetic. We 
therefore ordered a draught composed of two drachms of mint 
water, two of common water, and a quarter of a grain of tartar 
emetic, to be given every hour until it produced some decided effect 
on the constitution. You will recollect, here, that the scale was 
vibrating between life and death, that it was necessary that our 
plan of operation should be at once prompt and prudent, decisive 
and cautious. One of the pupils promised to stay by him the 
whole day and watch the effects of the remedy, and I determined 
to visit and examine him personally in the afternoon. In the 
course of four hours, he took four doses of the tartar emetic; the 
first and second, in fact almost every, dose vomited him, but not 
immediately. He retained each dose for a considerable time, and 
then threw it up. After the fourth dose, it began to act on his 
bowels, and then the medicine was suspended for some time, and a 
small quantity of porter administered. When I saw him at eight 
o’clock in the evening, he had been freely purged, and had dis- 
charged a considerable quantity of bilious yellow fluid from his 
bowels. He had also enjoyed about an hour's sleep; his respiration 
was now more uniform and natural; his raving greatly diminished; 
the subsultus and tremors were nearly gone, and the man appeared 
quite tranquil. I then ordered him a wine-glass full of porter, with 
two drops of black drop, to be repeated every second hour for three 
or four turns successively. I saw that the cerebral symptoms were 
evidently diminished, and that there was a tendency to returning 
tranquillity and repose, and I wished to follow up and assist the 
operations of nature. To-day this man is in a most favourable 
state. His skin is covered with a profuse warm perspiration, he 
has slept well, belly soft and natural, respiration slow and regular, 
and pulse diminished in frequency; he is calm, rational, and com- TARTAR EMETIC AND OPIUM IN FEVER. 
363 
posed, and I think I am not too sanguine in anticipating for him a 
speedy and certain recovery.1 
It is always an unpleasing and ungracious task for any individual 
to be obliged to come forward with proofs of the originality of his 
contributions to science : this task some have endeavoured to im- 
pose on me, and have sought to impugn both the originality and 
utility of my method of using tartar emetic and opium in typhus 
fever. Their arguments do not require any answer, and may 
be passed over in silence without any loss to you or prejudice to 
me, for certainly you could derive little profit from hearing the 
statements of my opponents, and I but slight credit from their re- 
futation ; suffice it then to say, that the prescriptions filed by the 
apothecaries of Dublin establish my claims, for you will search in 
vain among them for one, bearing a date prior to the publication of 
my papers on the use of tartar emetic and opium in the advanced 
stages of fever, and in which these medicines are prescribed in the 
way, or in any thing like the way, recommended and practised 
by me. Since that date such prescriptions have daily become more 
numerous, and I am proud to bear testimony to the general 
liberality of the profession, for the greater number of my brethren 
have not merely tried my plan of treatment, but have acknowledged 
its utility, and have hastened to assure me that until my publications 
they had not seen it practised. But enough of this, let us not employ- 
in general encomiums that time which maybe more profitably dedi- 
cated to instructive details; let us therefore again recur to facts. 
I have within the last fortnight received from Mr. Burke and Dr. 
Beauchamp the notes of an extremely interesting case of this de- 
scription. Mr. Burke is remarkable for his professional ability and 
his attention to his patients, and of Dr. Beauchamp I may state, 
that his experience in fever is most extensive. The case is ex- 
tremely valuable as having been observed by Mr. Burke from the 
commencement; I shall read the whole of it from his letter, as it 
is well worthy of attention :— 
“ I was called on the 25th of November to see Mrs. M., a married 
woman, without family, of a weakly and nervous habit, though 
generally enjoying good health. She complained of having had 
chilliness on the preceding day; and now, that she was hot, thirsty, 
had pain in the head and back, and great debility. On examina- 
tion I found that petechias covered the chest and abdomen ; the 
eyes suffused ; face red; scalp hot; pulse 110, small and hard; 
tongue covered with a creamy exudation ; no abdominal or chest 
affection; secretions and excretions arrested. She was ordered 
some aperient medicine, and directed to be kept very quiet. 
“ 26th.—Passed rather an uneasy night, frequent startings ; some 
raving; complains of headache, and that the light and noise are 
distressing; pulse as before, face more flushed, bowels open. I 
directed a cooling lotion for the head, and a diaphoretic mixture 
containing liquor acetatis ammonias and nitre. On the 27th, she 
1 He recovered rapidly and completely. 364 
GRAVES’S CLINICAL LECTURES. 
complained of the headache being made worse by the noise in the 
house, from which I determined to have her removed, and I there- 
fore did not put any active treatment into requisition. 
“ 30th.—This day she was removed to a quiet airy room. I then 
had her head shaved, eight leeches applied behind the ears, and a 
blister to the nape of the neck ; bowels opened by enemata. 
“ Up to the 5th of December, which was the tenth day of her 
illness, she went on tolerably well, occasionally raving at night; 
tongue dry and red ; pulse very weak, 110 ; eyes much suffused ; 
face occasionally flushed, then pale; scalp hot. At this period Dr. 
Beauchamp saw her, and from the weakly habit of the patient, and 
the peculiar tremulous feel of the pulse, he thought it advisable to 
let her have some weak chicken broth and light negus; the latter 
had soon to be discontinued on account of the excitement it pro- 
duced. 
“ On the 14th day she became more delirious and somewhat un- 
manageable, though previously very gentle ; however, when spoken 
to she answered tolerably reasonably. Ordered to continue the 
lotion, enemata, and saline draughts. 
“ Dr. Beauchamp and I saw her next day about ten o’clock in 
the forenoon, being the fifteenth day of her fever. Previous to our 
going into the room, the nurse gave us a frightful picture of the 
way she spent the night. She had been perfectly unmanageable, 
continually screaming and imagining she saw frightful apparitions, 
and had been convulsed during the night. On entering the room, 
we found her with her hands outstretched and rigid ; a mixture of 
wildness and terror in her face, her eyes red and protruded, pupils 
contracted, pulse not to be counted, and scarcely to be felt; feet 
cold and stiff. When spoken to she made no answer, but kept her 
eyes steadily directed towards the foot of the bed. Her aspect was 
altogether frightful, and Dr. Beauchamp observed that her state ap- 
peared to be a combination of delirium with hysteria. 
“ The question now was, what were we to do ? we dared not ap- 
ply leeches, blisters would be doubtful, and the probability was that 
the patient would sink before they vesicated. There was no indi- 
cation for cold to the head, for the scalp was cool. Could we rely 
with safety on nervous medicines? their very stimulus might hasten 
her to the tomb. The indication was to relieve the brain, and the 
question was, what medicine or combination of medicines would 
affect this safely ? Under these circumstances, we happily thought 
of the treatment employed by you in somewhat similar case. We 
immediately ordered a mixture containing three grains of tartar 
emetic, half a drachm of laudanum, and six ounces of water: of 
this a tablespoonful was administered every half hour, its effects 
being watched. We saw her again at one o’clock on the same day, 
and had the pleasure of finding her much improved. She had 
taken three doses, and vomited twice. The expression of her 
countenance was much changed, it had lost its ferocity and wild- 
ness ; her tongue was now moist, perspiration was beginning to ap- 
pear over her body, the pulse was soft and about 100, and the in- TARTAR EMETIC AND OPIUM IN FEVER. 
365 
telligence, which had been absent for a considerable period, now- 
reappeared. She was able to answer onr questions, and expressed 
herself relieved. We ordered the medicine to be continued, giving 
a tablespoonful every hour. After taking two doses, she became 
perfectly quiet, fell into a profound and tranquil sleep, perspired 
copiously, and at our visit next morning at ten o’clock, we found 
her to our astonishment almost well. She looked cheerful and re- 
freshed, and spoke of the wonderful relief she obtained : her pulse 
was soft, and about SO ; her skin natural, her tongue moist and 
clean. Dr. Beauchamp did not think it necessary to continue his 
visits, and all that remained for me was to conduct her by proper 
regimen from convalescence to perfect health. She is now quite 
well. 
“ It is a source of gratification to me to have had the able assist- 
ance of Dr. Beauchamp on this occasion, and his presence during 
the eventful period adds much value to the case. Dr. B. remarked 
at the time when hope had fled, that he knew of no routine of 
practice which afforded a probability of being of service, so that 
we may fairly conclude, that but for your happy combination the 
patient must have died.” 
This is a very strong case, indeed there could scarcely be a more 
striking illustration of the value of tartar emetic and opium in the 
treatment of the cerebral symptoms of fever. The case too was 
one of great danger, the patient was of a nervous and weakly habit, 
and during the acme of the disease she had an attack of con- 
vulsions. This is a very important and most formidable symptom 
in fever, particularly when superadded to others indicating a de- 
ranged state of the sensorium. We had a patient here, some time 
back, who had two convulsive paroxysms during the course of his 
fever, and you recollect that I told you that it was a symptom of 
unusual danger. Some time ago a gentleman, in discussing my 
cases, said that convulsions in fever were not so dangerous, but I 
had the satisfaction of quoting for him the authority of Hippocrates, 
to show that persons who have been attacked in this way very 
seldom recovered. 
I shall conclude this lecture by detailing a very remarkable case, 
which has been communicated to me very recently in a letter from 
Mr. Swift:— 
“ J. Kinsela, a labourer, aged 23, of powerful make and robust 
constitution, was attacked with iever about the 14th or 15th of 
January. He complained during the ensuing week of intense 
headache, thirst, and debility, but had no medical treatment. On 
Saturday, the 21st, he was extremely ill and restless, and on 
Sunday morning, while his clergyman and several of his friends 
were with him, he got out of bed in a state of furious delirium, 
seized a knife, and having cleared the room, rushed out into the 
street in his shirt, where he was secured by a policeman and some 
of his neighbours, and brought back to bed, having previously 
wounded several of his captors in the struggle. He then fell into 
a state of coma, and when I saw him on the following Thursday, 366 
graves’s clinical lectures. 
the 26th, he exhibited the following symptoms :—Decubitus on the 
back; eyes nearly closed; lips red, dry, and chapped ; forearms 
bent and agitated by apparently unconscious movements; con- 
vulsive twitches of the eyebrows and angles of the mouth ; breath- 
ing irregular, heavy, and somewhat stertorous, (of that description 
which you have aptly termed cerebral) ; pulse oppressed, unequal, 
weak, and about 110 ; great heat of scalp and face ; temperature of 
the body normal; feet very cold. He had no pulmonary symptoms; 
his belly was soft and apparently natural, but he gave indications 
of uneasiness when firm pressure was made over the situation of 
the stomach and small intestine. He was raised up in bed, shaken 
roughly, and spoken to repeatedly, but gave no answer ; nor would 
he put out his tongue, or open his eyes, when requested. His 
tongue, as far as I could see it, appeared red, dry, crusted, and 
fissured ; and on raising his eyelids, I found the eyes greatly suf- 
fused, and the pupils contracted nearly to the size of a pin’s head. 
“ His face, hands, and head, were bathed with warm vinegar and 
water, jars filled with hot water applied to his feet, and about two 
o’clock p. m. he commenced taking tartar emetic in doses of a 
quarter of a grain every hour. It was combined with a small 
quantity of opium. 
“ When I saw him again, about nine o’clock in the evening, he 
was wonderfully improved. He could be easily roused, answered 
questions distinctly, put out his tongue when desired, and appeared 
quite rational. He had taken about two grains of the tartar emetic, 
the effects of which appeared to be chiefly confined to the circulat- 
ing system. His pulse was now equal and regular, the temperature 
of his body nearly uniform, and a slight degree of moisture could 
be felt on his skin, but he was neither vomited nor purged. A 
mixture, containing nitrate of potash and tincture of hyoscyamus, 
was substituted for the tartar emetic; the fomentations of warm 
water and vinegar were continued, and he had a purgative enema 
with turpentine, which was followed by a full discharge from the 
bowels and copious diuresis. On Saturday, the 28th, he had an 
indistinct but favourable crisis ; his tongue became clean and soft, 
and his pulse diminished in frequency. On the following Tuesday, 
his pulse was 76, his tongue clean, eyes clear, pupils natural, ap- 
petite returning, so that I considered it unnecessary to continue my 
visits beyond the following day. His convalescence is now com- 
pletely established. 
“I have been particular in describing the cerebral symptoms in 
this case, as the patient's head was neither shaved, blistered, nor 
leeched. A portion of his hair was cut off with a scissors, and this 
was all that was done in addition to what I have mentioned. I at- 
tribute his recovery to the tartar emetic and opium, as under its 
use he recovered in a few hours from a state of stupor and coma, 
which otherwise must have speedily terminated in death, and I 
think this valuable remedy has additional claims to notice, if (as it 
would appear from Kinsela’s case) it can be employed as a sub- 
stitute for all the ordinary and expensive remedies used on such SUPERVENTION OF OTHER DISEASES. 
367 
occasions,—remedies, which in dispensary practice, and among a 
pauper population like ours, it is often difficult, and sometimes im- 
possible, to procure.” 
LECTURE 
Supervention of other diseases on fever—Description of a peculiar form of low 
neuralgic inflammation, not identical with phlebitis—Local affections with morbid 
poison producing cutaneous eruption—Vesicles ofColles. 
There is one fact connected with the history of fever, which 
should never be forgotten by those who are occupied in its treat- 
ment : I allude here to the occurrence of sudden accidents, or the 
supervention of other diseases, producing a material alteration in 
the circumstances of the case, and leading to new and more alarm- 
ing dangers. You should not divest yourselves of all further 
anxiety for the patient, or relax in your attentions, because the 
fever has exhibited a tendency to decline, and a favourable crisis 
has taken place : crisis may occur, and convalescence may be es- 
tablished, and yet the patient may relapse, or he may be struck 
down again by the unexpected incursion of a new and dangerous 
malady, or he may expire suddenly in the course of a few minutes. 
The functions of the brain and heart may suddenly give way, and 
death may take place unexpectedly and at once. Thus it not un- 
frequently happens that a patient during his convalescence falls 
into a state of syncope, from remaining too long in the erect posture, 
and if assistance be not promptly afforded, life is speedily ex- 
tinguished. In the state of debility which follows acute and ex- 
hausting diseases, and where the patient is very liable to syncope, 
the most assiduous attention is required. During the epidemic of 
1826, death took place under such circumstances in five or six in- 
stances, and the convalescents lost their lives from incautiously 
sitting up or walking about the room too long, or attempting to 
reach the night-chair without assistance. There are many other 
causes capable of producing a sudden and alarming change in the 
state of convalescents from fever. One of the most obvious of 
these is error or excess in diet, which is apt to bring on a return of 
the fever in an aggravated form, accompanied by symptoms of 
gastro-enteritic inflammation, and sometimes terminating iatally in 
forty-eight hours. 
To-day I propose to lay before you a sketch of a very important 
form of disease which attacks convalescents from fever, and runs a 
course of remarkable intensity and rapidity. I am not aware that 
this form of disease has been described by pathological writers ; the 
nearest approach to a description of it is an account of the swelled 
leg which occurs after fever, given by a Glasgow physician. Dr. 
Stokes and I have given a description of swelled leg after fever, as 
observed during the epidemic of 1826, but the important and fatal 368 
graves’s clinical lectures. 
form of the disease which I am about to describe, did not come 
under my notice until within a very recent period. 
Before the commencement of the present session, a fine young 
woman, aged 24, previously healthy and robust, was admitted into 
our fever ward. She was admitted on the 26th of September, 
having been at that time eight days ill, and labouring chiefly under 
gastric and cerebral symptoms. Her treatment consisted in the 
application of leeches to the epigastrium and head, cooling drinks, 
and blue pill combined with James’s powder. Under the use of 
these and other appropriate remedies, the fever declined, and on the 
1st of October the cerebral and gastric symptoms had disappeared, 
and the patient complained merely of a slight degree of feverishness. 
On the 2d of October she was seized with rigors and horripilation, 
followed by intense pain of the left mamma, accompanied by numb- 
ness and loss of power of the corresponding arm. She was leeched 
with some relief, but passed a sleepless night, and next day an 
oblong patch of redness was seen extending upwards from the 
nipple; the pain was still violent, and she could not bear the 
slightest touch on the affected parts. The breast was leeched again, 
and fomented assiduously during the day. On the 4th the erysipelas 
was spreading, and the pain was still agonising. She screamed 
out whenever it was touched, and could not bear even the weight 
of her dress or covering. On examining the breast, no enlarge- 
ment or hardness could be observed; there was no remarkable heat 
or tension, and with the exception of a slight erysipelatous redness, 
and pain rivaling that of tic douloureux in severity, there was 
nothing to indicate the presence of disease. The left arm con- 
tinued numb and powerless. This state of things was accompanied 
by remarkable increase of fever, as manifested by foul tongue, ac- 
celerated pulse, and sleepless nights. She now began to complain 
of dull pain in the calf of the right leg, aggravated by pressure or 
motion, but not attended by any apparent increase of heat, swelling, 
or induration. On the 5th she is reported to have passed a sleepless 
night, although the watery extract of opium had been administered 
freely on the preceding day and evening; the erysipelatous redness 
had extended nearly as high as the clavicle, and the affected parts 
had now begun to swell considerably. On the 6th she is stated to 
have had some sleep, and the erysipelas was extending, in some 
parts covered with vesicles. She again complained of cramps in 
the right leg, and on making an examination we found considerable 
tenderness on making deep pressure, but no external indication of 
disease. Her debility was increasing, accompanied by a tendency 
to looseness of bowels, for which she was ordered enemata of 
sulphate of quinine and laudanum. On the following night she 
was attacked with intense pain in the leg, accompanied by ex- 
quisite tenderness to the touch, but no redness, swelling, or increase 
of temperature. The erysipelatous affection of the breast had now 
become pale, and ceased to spread. The enemata were continued, 
the parts dressed with mercurial ointment and extract of belladonna, 
and wine freely allowed. She passed the night in great agony SUPERVENTION OF OTHER DISEASES. 
369 
from the intense pain in the leg, and complained of frequently re- 
curring rigors, followed by perspirations. She also stated, that for 
the last two or three days she had experienced repeated attacks of 
tremor in the affected limb ; one of these tremors attacked the limb 
on the night of the 8th and continued for three or four hours, ter- 
minating in copious general perspiration. These increased on the 
following day, attended with increase of fever, thirst, and debility, 
and the pain in the leg continued with unabated violence. It is 
worthy of remark, that at this time there was no erysipelatous 
redness or discolouration of the affected limb, and scarcely any 
swelling. On the 9th, she is reported to have passed the night 
screaming and sleepless, she vomited three or four times, com- 
plained of intense pain in the abdomen, and had a violent rigor 
which continued from one o’clock to six in the morning, followed 
by profuse perspiration. The right leg continued exquisitely 
painful as before, became somewhat swollen, and its veins appeared 
more prominent than natural, but there was no discolouration of 
the integuments. Both arms were now painful on motion, and the 
left leg became painful and tender on pressure. Under this com- 
plication she sank rapidly, and died at three o’clock in the after- 
noon. 
On dissection, purulent matter was found under the integuments 
covering the left breast, but the gland itself appeared healthy. 
There was no vascularity or other traces of peritoneal inflamma- 
tion, and the abdominal viscera were healthy. The right leg was 
infiltrated; its veins were pervious and elastic, but their internal 
coat exhibited a rose-coloured tinge. 
Here, then, we have a very remarkable aud formidable train of 
symptoms, arising without any obvious cause, running a rapid and 
fatal course, and exhibiting a character of singular intractability. 
From all that we had previously seen or heard, this young woman’s 
constitution was robust and healthy, her fever had been treated 
successfully, and she appeared to be getting over it without any 
sinister accident, or any complication capable of disturbing her con- 
valescence : yet at this period she is attacked with fever of a new 
type, accompanied by local affections of the breast and extremities, 
which run a rapidly fatal course, and exhibit phenomena of a new 
and extraordinary character. She is first attacked with erysipelas 
of the left mamma, accompanied by pain and loss of power of the 
corresponding arm; then she gets exquisite pain of the right leg, 
and then of the left leg and right arm ; in fact, the whole four 
extremities are more or less implicated. Now by what name 
should we designate this affection, or what would be the most 
appropriate term to apply to it? Was it phlebitis, or erysipelas, or 
phlegmasia dolens? The affection of the mamma certainly resem- 
bled erysipelas, but differed from it in the agonising character of 
the pain, and I have already observed that in the legs or arms 
there was no appearance of redness or discolouration. That it was 
pure phlebitis I think we are not authorised in concluding, from the 
phenomena observed on dissection. There was no pus in the veins 370 
GRAVES’s CLINICAL LECTURES. 
(an occurrence which might naturally be expected from the acute 
character of the disease,) no thickening or induration, the coats of 
the veins were elastic, and to all appearance healthy, with the ex- 
ception of a rose-coloured tinge. Now considering the previous 
state of the woman’s system, I do not think that we can conclude 
as to the existence of pure phlebitis on such slight grounds, or say 
that the whole group of symptoms which characterised the second- 
ary attack depended solely on inflammation of the veins. The dis- 
ease of which [ speak simulated in many points phlegmasia dolens, 
but differed from it in the phenomena observed in the breast, as 
well as its more general diffusion, and the absence of that peculiar 
whiteness of the affected limb which characterises the latter affec- 
tion. It appears to be a form of disease resulting from the genera- 
tion of a morbid poison in the system, and manifesting itself in 
diffuse subcutaneous inflammation of a low and cachectic nature, 
affecting primarily the skin and subcutaneous cellular tissue, and 
afterwards involving all the subjacent parts more or less according 
to their different susceptibilities. It was accompanied from the 
commencement with increased irritability of the muscular and cu- 
taneous nerves ; indeed, in the case just detailed, the nerves appear 
to be the parts primarily affected. Another remarkable circum- 
stance connected with this case is the loss of power observed in the 
affected limbs. In all cases where a severe and painful affection of 
the nerves is present, you have more or less loss of power, but as 
far as my observation has gone, there appears to be a difference in 
the derangement of muscular motion connected with painful affec- 
tions of large nervous trunks, and that which accompanies an af- 
fection of the terminating fibrils or nervous extremities. In the 
latter case the degree of paralysis is always more considerable ; of 
this phlegmasia dolens affords a good illustration. In this disease 
the extremities of the nerves are chiefly affected, and the loss of 
power is always greater than when a large nervous trunk is affected, 
as for instance in sciatica. In the latter affection the pain is often 
extremely violent, but the motion of the limb is never so much im- 
peded as it is when the nervous extremities are the parts chiefly 
engaged. 
You perceive, then, that the affection which I have just described 
consists in the developement of low, malignant, and irregular in- 
flammatory affections in various parts of the body, but particularly 
in the extremities, commencing probably in the subcutaneous cel- 
lular tissue, but subsequently extending to all the neighbouring 
parts, and exhibiting many of the characters of those inflammations 
which result from the presence of an animal poison in the system. 
A peculiar feature of this affection, also, is the intense neuralgic 
pain which accompanied it, and I think it might with some pro- 
priety be designated as neuralgic diffuse inflammation after fever. 
It is accompanied by a fever of a peculiar type, ushered in by 
rigors, and characterised by remarkable derangement of the di- 
gestive canal, debility, and sleeplessness. A point also which 
deserves notice in this case was, the recurrent rigors and perspira- 371 
tions, marking the occurrence of new and additional mischief, and 
indicating the malignant and intractable nature of the disease. 
One word as to the connection of this disease with phlebitis. 
Some pathologists are of opinion that phlegmasia dolens and swelled 
leg after fever are nothing more than modifications of phlebitis. I 
cannot, I must confess, agree with this opinion, nor am I prepared 
to admit that the symptoms in the foregoing case were referable to 
mere inflammation of the veins. I do not deny that the veins may 
be affected, but phlebitis is not the first link in the morbid chain, 
and is itself merely a consequence of the same unknown cause 
which determined the inflammation of other tissues. I beg leave 
to observe here, that the affection I have just described seems like 
others capable of existing in very different degrees. Thus, I have 
seen some instances in which there was no other symptom but 
severe pain of the extremities, generally about the calves of the legs, 
and which was relieved by warm fomentations and mild aperients. 
Again, I have seen, in addition to this symptom, swelling and 
tenderness of the legs, which, however, generally yielded to leech- 
ing and other appropriate means. Probably we are authorised 
from this and other facts in concluding, that the disease is not 
always of a malignant and fatal character, and that there are at 
least certain forms of it amenable even to simple and ordinary 
treatment : you should, however, be always on your guard when 
patients recovering from fever are attacked with pain, in the lower 
extremities particularly, as this symptom not unfrequently ushers 
in a serious and alarming disease. 
The next case of this disease observed in our wards, occurred 
also in a young woman, named Dillon, aged 23, and apparently of 
good constitution. She was admitted into the fever ward on the 
2d of September, being at that time about seven or eight days ill. 
She had on admission the usual symptoms of fever, accompanied 
by intense bronchitis, dyspnoea, costiveness, and loss of sleep. 
Under the use of cupping, blisters, calomel, and other appropriate 
means, the fever and pulmonary symptoms declined, and she was 
pronounced convalescent on the 12th. On the 18th she had been 
up as usual, but towards evening complained of rigors, and said 
she felt her right leg very painful. The pain of the limb continued 
next day, intermitted during the following night, but returned on 
the morning of the 20th with increased violence. She was leeched 
without much relief, and on the 21st she is reported to be extremely 
feverish, her pulse frequent, her tongue foul, bowels loose. She 
had passed a bad night, and the leg was still exquisitely painful 
and somewhat swollen. She had twelve leeches again applied with 
some relief, but on the 22d the left shoulder became similarly 
affected with pain, and so tender as not to admit of the slightest 
pressure. On the 23d there was some diminution of pain in the leg 
and shoulder, but her pulse was jerking and unequal; her tongue 
parched; her countenance anxious ; and she complained of intense 
pain in the small of the back. She passed a sleepless night, and 
next day complained of exquisite pain in the left lower extremity. 
PECULIAR FORM OF NEURALGIC INFLAMMATION. 372 
graves’s clinical lectures. 
This was accompanied by an exacerbation of the febrile symptoms; 
she moaned constantly; her pulse became excessively feeble and 
rapid; and she died on the 24th. 
On dissection, the peritoneum, particularly that portion of it at- 
tached to the abdominal parietes, was found remarkably vascular, 
the vascularity being most intense over the hypogastric region. 
There was no effusion of lymph or serum, but about half an ounce 
of purulent fluid was discovered in the cavity of the pelvis. The 
viscera were healthy. The internal surface of the principal venous 
trunks were tinged red, and there was a small quantity of coagu- 
lated blood in their cavities. On making an incision into the right 
leg, along the course of the internal saphena, the subcutaneous cel- 
lular membrane was found infiltrated with sero-sanguineous fluid ; 
the texture of the veins was here apparently natural, their cavity 
pervious and filled with fluid blood, without any lymphy or pu- 
rulent admixture. No distension or enlargement of the lymphatics 
was observed. 
Here you have a ease corresponding in its main points with the 
former, and differing from it chiefly in being complicated with 
peritoneal inflammation and synovitis of the shoulder-joint. Its 
origin was similar; it exhibited the same kind of intense neuralgic 
pain ; the same fever; the same extensive diffusion of local inflam- 
mation, and the same unfavourable termination. The chief points 
of difference were, that in the latter case the disease attacked the 
synovial membrane of the shoulder-joint, and the serous membrane 
of the abdominal cavity. This, however, is by no means unusual. 
As to the synovitis, I have observed it in more than one instance 
after fever. I have witnessed a very remarkable instance of it in a 
man in this hospital who was attacked with swelled leg after fever. 
In addition to the affection of the leg, he had also synovitis of the 
knee-joint of so severe and intractable a character that he recovered 
with difficulty, with an anchylosed state of the joint. On the whole, 
the disease which we have been considering is one of great im- 
portance, and deserves particular attention. It is sometimes of a 
very unmanageable character, and baffles our best directed efforts. 
The treatment which appears best adapted for it consists in leech- 
ing, fomentations, and the application of mercurial ointment with 
extract of belladonna to the affected parts: these, combined with 
the internal use of quinine and opium, with occasional doses of 
calomel, seem to comprise the chief remedies on which we can place 
any reliance. 
Bearing some analogy to the foregoing, and requiring somewhat 
similar treatment, is another class of cases, in which, after some 
slight injury, and sometimes without any apparent cause, persons 
are attacked with local affections, attended by fever, remarkable 
sleeplessness, and an eruption of those pustules which were first 
described by Mr. Colies, and of which I have said something in a 
former lecture1. I shall read here for you the notes of an interest- 
1 See Lecture viii. of this series. LOCAL AFFECTIONS WITH ERUPTION. 
373 
ing case of this description which came recently under the notice 
of Mr. Trenor, a gentleman distinguished for the accuracy of his 
observation. 
A lady, aged about thirty, of dark hair and pale complexion, was 
visited by Mr. Trenor in October, being at that time three days ill. 
She had suffered some time previously from a cutaneous affection 
of the hands, which, from the appearance of the skin and the de- 
scription given by the patient, was supposed to be psoriasis. Three 
or four days before her illness she had pricked her finger with a 
needle, but did not pay any attention to it, as a similar accident 
had often happened before without any consequent inconvenience. 
On examination, three pustules or rather vesicles of different sizes 
were found on the inside of the finger and wrist, and there was an 
indistinct blush on the inside of the arm, which, however, the 
patient thought to be caused merely by the weight of the limb, as 
she lay on her side. The fore-arm was intensely painful, and the 
slightest touch excited extreme agony. The arm was also tender, 
and in the axilla was a small hard tumour, exquisitely tender to the 
touch, and from which the pain shot inwards over the anterior and 
upper part of the chest. The affected arm was powerless, and 
very painful on motion. Her pulse was 100; tongue white and 
moist; bowels opened by medicine ; skin not differing much from 
the normal temperature ; but she was extremely restless, and had 
not slept for the last two nights. She was ordered to take three 
grains of calomel and two of the watery extract of opium at bed- 
time, and an aperient draught the following morning : the tumour 
in the axilla was carefully poulticed. On the following day the 
pain of the limb continued, but she had rested much better. The 
tumour in the axilla was stationary. The calomel and opium were 
repeated in the same quantity night and morning, and she took a 
quinine mixture every third hour. Next day she appeared much 
easier, and under the same treatment, combined with occasional 
purgatives, she improved rapidly, and in the course of four or five 
days required no further treatment, except an opiate at bed-time, 
and the quinine mixture, which was continued for some time 
longer. The painful tumour of the axilla gradually disappeared of 
itself, for the local applications where given up at an early stage of 
the disease, being more inconvenient than serviceable. 
Here, you perceive, a train of severe constitutional and local 
symptoms arises from an apparently trivial injury, and the patient 
is atacked with fever, sleeplessness, and exquisite pain of the affected 
limb, accompanied by a slight blush of erysipelatous redness. 
There was also the same loss of muscular power which we observed 
in the cases of swelled leg after fever, showing that the extremities 
of the muscular as well as the cutaneous nerves were engaged. 
Now in this instance my friend took the same view of the case as I 
did in a somewhat similar one wich I am about to detail. He 
looked upon the irritative fever, the sleeplessness, the agonising 
pain, and the pustules, as symptoms not to be treated by bleeding, 
or leeches, or cold applications, or tartar emetic and nitre, but by 374 
graves’s clinical lectures. 
tonics, opiates, and a mild nutritious diet. He gave calomel or 
blue pill, with full doses of opium and quinine, and ordered her to 
take chicken-broth and beef-tea. During the course of four days 
she took fifteen grains of opium without any affection of the head 
or derangement of the stomach, and nine grains of calomel and a 
drachm of blue pill in the same period without any appearance of 
salivation. I have no doubt that in this instance the free use of 
opium tended not only to produce sleep and to relieve pain, but 
also to diminish the constitutional irritation on which the eruption 
of pustules seems to depend. 
The next case of this affection deserving of notice is that of a 
French sailor boy admitted into Sir P. Dun’s Hospital, labouring 
under a violent and dangerous form of fever, apparently typhous, 
but wanting the usual eruption of maculae. His pulse was but little 
accelerated at first., but he was very weak, restless and sleepless, 
and complained of exquisite pain in the side of the neck extending 
over the whole surface of the right side from the angle of the jaw 
to the tip of the shoulder. This region was very tender, and ex- 
hibited a diffused swelling and fulness with very slight redness, the 
latter only visible towards the centre. There was pain in the 
axilla, with incipient inflammation of one or two glands, and the 
right side of the chest, though neither red nor swollen, was very 
painful on pressure. Immediately after detecting the existence of 
this diffuse inflammation, I remarked to the pupils that this was a 
case likely to favour the development of Colies’s pustules, and 
accordingly I examined his skin and found two vesicles each as 
large as a shilling on the fingers of the right hand ; one of these 
vesicles was formed round a slight superficial wound on the knuckle 
of the middle finger. Here it was not easy to determine whether 
the diffuse inflammation of the neck was a consequence of the 
wound on the knuckle, or whether the former arising spontaneously 
had generated in the system a morbid poison which had reacted on 
the integuments around the wound, and formed a vesicle surround- 
ing it. I am inclined to adopt this latter opinion, for I have seen 
more than one similar case proving that where a poison is at work 
producing a tendency to cutaneous eruption, the existence of a 
small wound in the skin generally determines the morbid action 
towards that point of the surface, and causes, when any of Colles’s 
vesicles are formed, the formation of one around the wounded spot. 
Thus in a grocer, ill of typhus, whom I lately visited along with 
Mr. Bourke, of Camden Street, one of these vesicles formed round 
a sore on his knuckle inflicted by a sharp scoop prior to the com- 
mencement of the spotted fever. Here the fever evidently en- 
gendered the poison, while the wound determined its action on the 
skin to a particular place: the same is observed in psoriasis, in 
venereal cachexy, and in small-pox. While the constitution 
labours under any of these diseases, injuries of the skin frequently 
call forth the specific cutaneous affection in the injured part. 
But to return to the case of the French sailor.—At first the 
diffuse inflammation of the neck was not accompanied by much VESICLES OF COLLES. 
375 
fever, blit in a few days suppurative fever set in, and a circum- 
scribed swelling was observable in the centre of the inflamed part. 
After a short time this was opened by Mr. Houston, and a large 
quantity of pus evacuated; some improvement in his general 
health took place, and the peculiar distress produced by the diffuse 
inflammation in the neck, arm, and side, subsided ; the agonising 
tenderness had gone, and he seemed to be fast improving notwith- 
standing the profuse discharge of matter from the opened abscess, 
when suddenly he got acute hectic fever, rapid emaciation, and a 
sunken countenance, with cough and shortness of breath ; a moist 
crepitus was now discovered in the upper lobe of the right lung, 
just below the seat of the abscess. The case now assumed a most 
hopeless appearance, for in the exhausted state of our patient we 
had but slender hopes of his recovering from this pneumonia. The 
question occurred, what caused the pneumonia? Did it arise from 
a communication between the abscess at the lower part of the neck 
and the upper lobe of the lung, or was it phthisis rapidly developed 
in a constitution run down by previous illness, or was it simple 
and self-existent pneumonia? These are questions which it was 
not very easy to determine, and yet how important was the deter- 
mination with reference to prognosis. If the pulmonary affection 
depended on an extension of the inflammation from the neck to the 
upper part of the lung, there was a chance of recovery, but if it 
were phthisis the boy was lost. I declared to the class my con- 
viction that it was phthisis, and for a few days the boy seemed 
hurrying to the grave, when suddenly the abscess in the neck dried 
up and became consolidated, and at the very same time the pneu- 
monia in the lung just below the abscess disappeared as rapidly as 
it had arisen! All fever subsided, and the boy, getting rid of his 
pectoral affection, was at once out of danger. I cannot explain 
the remarkable and unhoped-for termination of this affection, except 
on the supposition, that the moist crepitus in the lung, and the 
pectoral symptoms, originated in a suppurative inflammation, sud- 
denly extended from the lower part of the neck to the contiguous 
portion of the lung, and as suddenly ceasing when the abscess 
healed. I have dwelt on the particulars of this curious case, as 1 
have neither seen nor read of any thing similar. 
An old man from Bray, admitted into the clinical ward of Sir P. 
Dun’s Hospital, exhibited extensive gangrenous erysipelas on the 
inside of the right knee and thigh, caused by a moxa applied for 
the cure of pain in the knee. In a few days, patches of diffuse 
inflammation, ending, some in sloughing, and some in suppuration, 
appeared on his hand, and other distant parts, and several of Colles’s 
vesicles developed themselves on his trunk. Shortly after, another 
man, young and athletic, who had been bled for pneumonia, and 
in whom the wound in the vein had caused ill-conditioned diffuse 
inflammation at the bend of the arm, was admitted under my care. 
In him, too, Colles’s vesicles formed in various parts. To conclude, 
you may gather from the numerous examples we have witnessed, 
that these vesicles or pustules constitute a peculiar feature accom- 376 
graves’s clinical lectures. 
panying many varieties of disease, which agree but in one circum- 
stance, the formation of a cutaneous eruption, caused by the 
operation of a morbid poison, generated in some cases in the system 
itself, in others introduced from extraneous sources. Among the 
most frequent causes that give rise to the evolution of this poison 
in the system, is diffuse inflammation, no matter how produced— 
whether by a bruise, a burn, a punctured wound, a bed-sore, or the 
poison of glanders. In fine, you may remark that the cutaneous 
affection thus caused bears some analogy to exanthematous diseases 
of a malignant character, and marks a state of the system requiring 
wine, opium, and quinine. In most instances the eruption is either 
pustular or vesicular, but in some it assumes the appearance of 
small patches of diffuse inflammation, or of ill-conditioned furuncles. 
LECTURE XVIII. 
Dropsy following- scarlatina ; utility of bleeding—Albuminous urine not necessarily the 
result of diseased kidney—Pulmonary affection after fever; smilax aspera—Phleg 
tnasia dolens not dependent on phlebitis; treatment—Case of metritis—Melaena; 
various kinds of black discharge from the bowels j green stools not always a sign of 
deranged liver. 
The case of William Young, who was admitted on Wednesday 
last, has some claims to your attention, and demands a few obser- 
vations on my part. This boy, who is about twelve years of age, 
had an attack of scarlatina some time ago, and had been dropsical 
for a week or ten days at the period of his admission. He was 
somewhat feverish, had thirst, heat of skin, and slight headache, 
cough, and difficulty of breathing, and on making an examination 
with the stethoscope, we detected numerous bronchial rales; his 
lower extremities were anasarcous, and he had some effusion into 
the peritoneal sac. We could not ascertain exactly the time when 
this train of symptoms commenced, but it is very probable that it 
was a week or ten days after the disappearance of scarlatina. 
When patients who have been recently labouring under an attack 
of scarlatina take cold, the anasarcous symptoms appear in a very 
short time after the attack ; but even where they are not exposed 
to cold, the dropsy appears generally about ten days or a fortnight 
after scarlatina, and is very often accompanied by some pectoral 
affection. The disease sets in with febrile exacerbations more or 
less marked; anasarca of the extremities is next noticed, and at the 
same time the patient has slight cough and difficulty of breathing, 
which generally proceeds from congestion of the bronchial mucous 
membrane, but may be the result (though less frequent) of pleuritis 
or pneumonia. 
If called to a case of this kind in the commencement, and where 
the patient is not greatly exhausted by previous disease, the treat- DISEASED KIDNEY. 
377 
ment is exceedingly simple. By opening a vein in the arm, and 
abstracting a quantity of blood proportioned to the age and strength 
oft he patient, you remove the inflammatory state of the constitution, 
and arrest at once the anasarcous and pectoral symptoms. It may 
occasionally happen that active measures of this kind cannot be 
taken in consequence of the great debility of the patient from pre- 
vious disease ; but, generally speaking, cases of anasarca after scar- 
latina bear antiphlogistic treatment well. It is not after cases of 
violent scarlatina, or where the patient’s life has been in imminent 
danger, that the supervention of dropsy is most commonly observed; 
the majority of dropsical cases of this kind are met with in patients 
who have had the disease mildly, and without any remarkable in- 
tensity either of the local or general symptoms. Hence, venesection 
is borne well, and its performance attended by the most decided 
good effects, particularly where the dropsy is complicated with 
pleurifis or pneumonia. 
In the case before us, however, being uncertain as to the exact 
duration of the disease, and finding several symptoms present indi- 
cative of weakness, we were obliged to proceed with more caution. 
The boy had been ill a week, and appeared to be under the influ- 
ence of digitalis administered before his admission, for his pulse 
was intermittent and wavering. Under these circumstances I de- 
termined to limit the antiphlogistic measures to the application of a 
few leeches over the abdomen. I did this with less hesitation, as 
an accurate examination of the chest showed that there was neither 
pleuritis nor pneumonia present. The internal remedies were cal- 
culated to increase the secretion from the kidneys. The boy’s 
urine was remarkably albuminous, and of the specific gravity of 
1027. This is a point worthy of remark. In many cases of dropsy 
after scarlatina, the urine is albuminous. Now, almost every case 
of this kind will get well, and as convalescence progresses, you 
will observe that the urine ceases to be albuminous. These facts, 
of the truth of which I can speak with the fullest confidence, are 
quite sufficient to show that those persons are wrong who assert 
that albuminous urine is the result of organic disease of the kidneys. 
Albuminous urine is here, as Dr. Blackall observes, merely an indi- 
cation of a peculiar inflammatory condition of the whole system, 
and not of degeneration of the kidneys. I may observe, however, 
that this is not always the case; for I could point out examples 
where albuminous urine is connected with an apparently opposite 
condition of the system; in fact, a condition demanding the use of 
a generous diet and tonics. Hence, there must be great diversity in 
the treatment of dropsy with albuminous urine. Where it occurs 
after scarlatina, and is accompanied by febrile symptoms, it is best 
treated by the lancet, nitre, purgatives, and digitalis ; but where it 
occurs in chronic cases, without any remarkable excitement of the 
vascular system, without organic disease, and with more or less 
debility, it requires to be treated with tonics, generous diet, and 
full doses of opium. In the present case I only applied a few 
leeches to the belly, and kept the bowels gently open for the first 378 
graves’s clinical lectures. 
few days, being determined to wait until the pulse became regular 
before I ventured on any decided plan of treatment. I then ordered 
mercurial frictions to the abdomen and axillae, and gave mercury 
internally combined with small quantities of digitalis. He also got 
a draught twice a day composed of carbonate soda, tincture of squill, 
and syrup of orange peel. These remedies we shall continue for 
some time, carefully watching their effects. 
From the state of weakness this boy was in at the period of his 
admission, and the length of time the disease has lasted, I have not 
thought it advisable to bleed him.1 When cases of this kind be- 
come chronic, they are very difficult of cure, and require very deli- 
cate management. You will frequently have to run through the 
whole list of remedies employed on such occasions, before you can 
hit on one that proves successful. I recollect a case of this kind, 
in which the anasarca was extreme, and the boy’s legs were enor- 
mously swollen ; the dropsy was accompanied by scanty secretion 
of urine, but without any distinct febrile excitement. After having 
used every remedy I could think of, for nearly three months, with- 
out any benefit, I resolved to try the effects of cold affusion, from 
which I had experienced much advantage some time previously in 
another case. I ordered a large vessel filled with pump water, in 
which a quantity of salt had been dissolved, to be poured over him 
twice a day, for the space of two or three minutes each time, im- 
mediately after which the boy was wiped perfectly dry and put to 
bed. The good effects of this measure became soon evident; a 
copious discharge of urine took place, the swelling of the limbs 
subsided, and in six or seven days the child was able to run about 
as usual. 
Allow me to refer briefly to the case of Garret Kane, of which 
I have spoken on a former occasion. You are aware that this man, 
after an attack of fever, had symptoms of tubercular deposition in 
the upper part of the left lung-. From the circumstances, however, 
of the other lung being perfectly sound, there being no fever or 
vascular excitement present, and the small extent of the disease, as 
1 This case went on unfavourably, and the boy died, after lingering several 
weeks, in a state of extreme dropsical swelling and great suffering, disten- 
sion, and dyspnoea. As his urine continued highly albuminous throughout, 
we were excessively curious to learn what was the condition of his kidneys. 
The post-mortem examination was made a few hours after death, and the 
kidneys were found in every respect healthy; their size, shape, consistence, 
and colour, were perfectly normal. So striking an exception to the general 
rule ought to shake the confidence of those who assert that albuminous urine 
results from Bright’s kidney. The long-continued presence of albuminous 
urine, in a case where no such state of kidney existed, forms conclusive evi- 
dence that this state of urine is not necessarily the result of that renal dege- 
neration to which it is referred by Dr. Bright; the occurrence of one positive 
exception is sufficient to disprove such a conclusion, even though supported 
by a thousand cases, and, consequently, when albuminous urine in chronic 
dropsy is found to occur along with Bright’s kidney, I consider this particular 
state of urine and of kidney as depending upon different causes, which often 
co-exist in chronic dropsy, and consequently I regard albuminous urine as a 
sign of Bright’s kidney, but not as its result. 379 
well as the patient’s youth and the season of the year, we were 
led to hope that we might be able to arrest the morbid process 
going on in the lung. After freely leeching the chest, we inserted 
a seton under the clavicle, and gave such remedies as are calcu- 
lated to relieve cough and pulmonary irritation. We first gave the 
cyanuret of potash, from which he derived some benefit, but for 
the last week we have been giving a dram of the syrup of smilax 
aspera in an ounce of water, three times a day. This remedy, 
which has been lately introduced into practice, possesses many of 
the properties of sarsaparilla, in addition to which it appears to 
contain a small portion of prussic acid, as denoted by its smell, 
which closely resembles that of laurel water. It has been very 
highly spoken of, and I believe it to be an excellent remedy, but, as 
in all cases of new medicines, I fear its powers are somewhat over- 
rated. That it will fail in some cases I am quite convinced, for in 
the case of a gentleman in Mount street, whose symptoms were 
chronic bronchitis, with violent and harassing cough, and who had 
been blooded, cupped, and used various internal remedies, I gave it 
a fair trial, and found that it did not produce any alleviation what- 
ever of his symptoms. 
Let me now direct your attention to the case of Rebecca Howard, 
who came into hospital on the first of this month, eight days after 
her accouchement, with painful swelling of both lower extremities. 
From the history of her case it appears, that three or four days 
after her confinement, she got severe pain about the heel and inner 
ankle, accompanied by swelling, which commenced about the same 
situation, and extended rapidly up the thigh as far as the groin. A 
similar swelling appeared likewise in the other limb, but instead of 
commencing below, it appeared first in the upper third of the thigh 
and afterwards spread downwards, attended with violent pain, ap- 
parently in the course of the great sciatic nerve. Along the course 
of the veins a number of hard cords, extremely tender to the touch, 
could be distinctly felt; the lymphatics, though somewhat tender 
also, did not seem to be so much engaged, and there was no inflam- 
mation of the glands of the groin. 
Here we had a case of phlegmasia dolens, or in other words, 
painful inflammatory oedema of the lower extremities, involving 
the skin, subcutaneous cellular tissue, veins, and lymphatics, more 
or less distinctly. I have before stated to you my opinion, that 
this affection does not necessarily depend on phlebitis; on the con- 
trary, I think that in the majority of cases the disease commences 
in the subcutaneous cellular tissue, and afterwards extends to the 
veins and lymphatics. Observe the course of the inflammation in 
both limbs. In one it commences in the vicinity of the inner ankle 
and extends up the thigh; in the other, it is first observed in the 
upper part of the thigh, and spreads downwards. Now, where 
oedema is the consequence of phlebitis, or where it is artificially 
produced by tying or compressing one of the large venous trunks, 
it is always first observed in the lower part of the limb. You 
perceive, then, that those who explain the occurrence of phlegmasia 
PHLEGMASIA DOLENS. 380 
GRAVES’S CLINICAL LECTURES. 
dolens by referring it exclusively to phlebitis, are not able to account 
for it as commencing in the thigh and spreading downwards. But 
how much easier is the explanation, if we look upon it as a peculiar 
inflammation of the subcutaneous cellular membrane of the limb, 
involving in its progress, to a greater or lesser extent, the veins 
and lymphatics, and sometimes extending to the joints. From this 
view of the pathology of phlegmasia dolens, you can understand 
why the upper part of the thigh may become primarily affected, 
and that effusion may take place above before it occurs below. 
So far with respect to the pathology of the disease: now with 
regard to treatment. In attempting to remove this inflammation, 
we were obliged to keep clear of any measures calculated to in- 
crease constitutional debility. The woman, though young, was of 
a delicate constitution; and there is this peculiar difficulty in the 
treatment of diseases after parturition, that they occur at a time 
when the patient has been more or less debilitated by the efforts of 
labour and its consequences. Our object, therefore, was to reduce 
the local inflammation, at the same time that we endeavoured to 
support the woman’s strength by a light and nutritious, but not 
heating diet. We commenced with the application of leeches, to 
the number of ten, along the inside of each limb; these we repeated 
to the same amount on the following day. In the application of 
leeches in cases of this kind, you must be guided by the circum- 
stances of pain, tension, and swelling ; these are sometimes greater 
in one portion of the limb than in another, most frequently in the 
course of the veins; but you should always take care to have them 
applied over those spots in which the inflammatory process seems to 
exist in the greatest intensity. Our next step was to open her bowels 
by means of purgative injections, to be repeated as occasion required. 
In addition to this, I directed the limb to be gently rubbed with an 
ointment composed of one ounce of mercurial ointment, two ounces 
of lard, and three drams of extract of belladonna. I have already 
dwelt so often on the local, antiphlogistic, and narcotic effects of 
this composition, that it is unnecessary for me to say any thing of 
it at present. 
With respect to internal remedies, I ordered her to take five 
grains of Plummer’s pill every night and morning ; but as this pro- 
duced griping and a tendency to diarrhoea, we were obliged to 
change it for hydrarg. c. creta, with Dover’s powder. On the 24th 
(the fifth day of her treatment) her mouth became affected, and the 
pain along the sciatic nerve, as well as the general soreness of both 
extremities, decreased. I forgot to observe, that from the com- 
mencement we had given opiates freely; indeed, this was one of 
the principal parts of our treatment. She first took the liquor of the 
muriate of morphia, in doses of twenty drops, three times a day: 
this we exchanged foj opiate injections, when her bowels became 
irritable under the use of Plummer’s pill. On the 24th there was 
a considerable improvement in her symptoms, as I have already 
stated ; but she was very weak ; there was still considerable sore- 
ness of the extremities, and she complained of pain and tenderness PECULIARITIES IN THE ALVINE DISCHARGES. 
381 
in the right groin, showing that the lymphatics as well as the veins 
were engaged. I ordered the opiate enema to be repeated, and al- 
lowed her the free use of chicken-broth, rice, and a small quantity 
of wine. On the 25th she was directed to take a pill containing 
half a grain of opium every third hour. Next day the report states 
that she finds herself much better, that her bowels are quite natural, 
that she feels no pain in the lower extremities, except when pressed 
or moved, and that she had regained the power of her limbs. Two 
days afterwards she was able to stand, and at present she is so far 
recovered that I intend to dismiss her to morrow. 
The treatment of cases of this description involves some very 
curious and important considerations. With the exception of leech- 
ing, the treatment which we employed in this case cannot be called 
antiphlogistic ; for throughout the whole course of the disease we 
gave opium freely, allowed her nutritious diet, and after the first 
four or five days the use of wine. This shows that, in diseases 
called inflammatory, no general rule of treatment can be laid down, 
and that our practice must vary in the most remarkable manner, 
according to circumstances. Had I treated this inflammation by 
leeching, low diet, purgatives, and antimonials, it is very probable 
she would have sunk. But while we were endeavouring to subdue 
local inflammation by leeching and mercurial ointment, we sup- 
ported the constitution by a proper diet, nourishing but not heating, 
and afterwards by the use of wine. At the same time we gave 
opium in free and repeated doses, with the view of diminishing pain 
and irritation, and procuring sleep—a most important matter in the 
treatment of all acute affections combined with irritability. We 
also gave mercury internally, because it has been found extremely 
valuable in such cases, when given rather as an alterative than 
with the view of rapidly and violently affecting the system. Under 
this plan of treatment her convalescence has been very rapid. It 
is a plan abundantly simple, but one which I can recommend to 
you with confidence. 
With respect to the after-treatment of this case, I have merely to 
observe that as soon as the hyper-sensibility of the limbs became 
diminished, I ordered them to be rubbed diligently twice a day 
with warm olive oil. How this acts I cannot distinctly say; but it 
appears to diminish tension, to promote absorption, and to increase 
the pliability of the limbs. Latterly we have given up this, and 
had recourse to dry friction and bandages. At present she is taking, 
three times a day, a mild tonic draught, composed of tincture of 
orange peel, half a dram; tincture of hops, twenty minims; carbo- 
nate of soda, five grains ; water, an ounce. 
Let me next turn your attention to the case of Esther Green, 
who was also admitted here shortly after her confinement. I may 
observe that our proximity to the Lying-in Hospital in Cumberland 
street, under the care of Dr. Beatty, assisted by Dr. Montgomery, 
gives us an opportunity of witnessing many cases of female com- 
plaints. This woman was delivered on the 5th of March, and 
dismissed about six days afterwards, apparently well. On the 382 
graves’s clinical lectures. 
29th. after having previously taken cold, she got symptoms of fever, 
accompanied by pain of the belly, chiefly affecting her in the hypo- 
gastric and right iliac regions. When she came in on the 31st, 
there was very little fever present, her pulse was slow and regular, 
and her skin cool; but she was pale and anxious, had general ten- 
derness of belly, with griping diarrhoea and nausea, and complained 
still of considerable tenderness on pressure over the region of the 
uterus. Having consulted with Dr. Montgomery, we ascertained 
that the uterus was enlarged and painful. The case, then, was one 
of metritis, but not of a very acute character, and which had 
produced by sympathy a disturbance in the functions of the sto- 
mach and intestinal canal. 
Eight leeches were applied over the region of the uterus, to be 
repeatedly daily, until the pain and tenderness were relieved. We 
next had recourse to the use of mercury; but as her bowels were 
in an irritable state, we prescribed the mildest of the mercurial pre- 
parations, hydrarg. c. creta, and to this we added Dover’s powder. 
Two scruples of the former to ten grains of the latter were divided 
into twelve pills, two to be taken every fourth hour. This combi- 
nation is extremely valuable in many cases of inflammation of the 
viscera of the abdomen, particularly when accompanied by irritation 
of the intestinal mucous membrane, as manifested by griping and 
diarrhoea. After two days there was a slight fetor of breath apparent, 
and we gave the pills twice a day instead of every fourth hour, as 
our object was to affect the system gently, and not bring on profuse 
salivation. These remedies, with the use of blisters over the region 
of the uterus, will be quite sufficient to remove the disease. The 
metritis is not very acute, nor has it any thing of a specific cha- 
racter ; there is no puriform or other morbid discharge from the 
vagina, and the patient is a young woman of good constitution.1 
A patient who is at present in the chronic ward presents some 
circumstances worthy of observation, as connected with peculiar 
varieties in the alvine discharge. She has been labouring for some 
time under melsena, and, as you have observed, passes daily a large 
quantity of dejections from her bowels, as black as ink. The colour 
of matters discharged from the bowels is subject to very great va- 
riety. In some cases they are clay-coloured or whitish, somewhat 
like barm ; and I have seen them still whiter, and approaching the 
hue of milk. It is in cases of the latter kind, where the discharges 
are of a milky appearance, that persons have been said to pass 
chyle, and their emaciation has been attributed to a deficiency of 
nutriment depending on this cause. This, however, is not the fact: 
in some cases of chronic dysentery and diarrhoea, a fluid whitish 
discharge takes place from the rectum, but this is not chyle, it is 
only the changed mucous secretion of the irritated portion of the 
bowel. It is very curious to observe what different products the 
same set of secreting vessels will give rise to, according to the mode 
in which their vital action is affected. 
1 This patient speedily and perfectly recovered. PECULIARITIES IN THE ALVINE DISCHARGES. 
383 
In other cases the discharges from the bowels consist of fatty- 
matter, which bears a strong resemblance to wax, or adipocire. 
Again, we may have them of a very dark, or even black colour. I 
have seen the stools quite black in particular forms of dyspepsia. 
Some time ago I attended a gentleman at Drumcondra, who ex- 
hibited this change in the colour of the intestinal secretions to a 
very remarkable degree. He was a very large man, accustomed to 
eat and drink very heartily, having, no doubt, a very capacious sto- 
mach and bowels, and a great quantity of fluids and solids. I 
mention this in order to give some explanation of the enormous 
quantities of this black fluid which he passed by stool and vomiting. 
After complaining for a considerable time of dyspeptic symptoms, he 
got an attack of vomiting; and as he drank freely of diluents 
during the act of emesis, the quantity of this black fluid which he 
threw up was amazing; indeed, I might say, without exaggeration, 
that he vomited by the gallon. With this he had eructations of 
sulphureted hydrogen to such an extent, that it was almost impos- 
sible to remain in the same room with him. His tongue was as 
black as ink, and though frequently cleansed, resumed in a short 
time its former hue. He also passed an enormous quantity of the 
same stuff by stool. This matter I ascertained, by numerous ob- 
servations and experiments, to be a secretion from the mucous 
membrane of the bowels, and not depraved bile, or blood changed 
by the acid secretions of the bowels. Black stools may also depend 
upon the presence of other matters, as in case of meleena. Melaena 
consists of a discharge of grumous blood from the intestines, either 
with or without black matter. The following is the way in which 
it occurs. Blood is secreted slowly into the intestinal tube ; while 
it remains there it is acted on by the acid secretions of the intes- 
tines, the effect of which is to change the colouring matter into a 
black, and in this state it is passed by stool. Again, there are other 
cases in which the discharges from the bowels are found of a tarry 
and viscid consistence, and having a greenish-black appearance : 
this would appear to be connected with a vitiated state of the biliary 
secretion. 
I have spoken here of three-species of black discharge, each of a 
different kind, and requiring to have a distinction made between 
them for practical purposes. Now it is said, if blood be present you 
can easily recognise it by putting a portion of the discharge, 
inclosed in a small linen bag, into warm water, when, after remain- 
ing some time, the linen will be stained of a reddish colour. If you 
take a portion of the tarry discharge, and drop a little of it into 
water, it will communicate to it a yellowish stain. On the other 
hand, the black fluid, which consists of vitiated mucous secretion, 
will not impart either a red or yellow tinge. 
I may further observe, that various substances used medicinally 
communicate a particular tinge to the alvine discharges. Thus 
acetate of lead, when it meets with sulphureted hydrogen in the 
intestines, changes the stools to a black colour. Again, many of 
the salts of iron have the same property. Other substances, such 384 
graves’s clinical lectures. 
as logwood, bilberries, &c., impart to them a red tinge, while the 
continued use of chalk mixture is apt to render them whitish or of 
the colour of pipe-clay. This is apt to give rise to suspicions of the 
existence of obstruction of the liver; and in one instance I was 
deceived for some time by it myself. With respect to the greenish- 
coloured discharges, they are those which are most frequently met 
with, particularly in children, and are therefore entitled to a greater 
degree of consideration. There is nothing more common than to 
meet with cases of this green discharge during the period of in- 
fancy ; and I regret to state that a great deal of error has prevailed 
on the subject. Greenish stools are generally looked upon as a 
sign that the child’s liver is out of order, and as an indication for 
giving calomel. This, however, is by no means true ; they not un- 
frequently depend upon irritation of the intestinal mucous membrane 
approaching to inflammation. The proper mode of treatment here 
consists in adopting measures calculated to remove irritability. In 
such cases, warm baths, the application of rubefacient liniments to 
the abdomen, the use of antacids, such as chalk mixture, the carbo- 
nates of soda and ammonia, small doses of laudanum, and hydrarg. 
c. creta with Dover’s powder, form the best remedies; and their 
operation will be very much assisted by a careful attention to diet. 
You will sometimes, it is true, meet with greenish discharges in 
adults, but then they are not so fluid as those of children, nor are 
they attended with the same irritability of the gastro-intestinal mu- 
cous membrane. Here the best plan of treatment is the Aberne- 
thiati: blue pill at night, and a mild aperient in the morning, will 
be sufficient to correct the intestinal derangement, particularly if 
assisted by a well-regulated diet, and exercise in the open air. But in 
children the greenish discharge is often of a much more acute cha- 
racter, and more closely allied to inflammation,or rather irritation; 
although in some cases it may go on for a considerable time without 
producing any acute disorganisation. It is on account of the pro- 
perty which calomel and other mercurials, exhibited internally, 
possess of causing irritation in the first instance, and if pushed far- 
ther, inflammation of the mucous membrane of the intestines, that 
they are also apt to produce discharges from the bowels, copious, 
fluid, and mixed with green mucous flocculi, resembling closely 
chopped spinach. Sometimes the dejections consist of this green 
mucus nearly unmixed with any thing else, and then they appear 
like semi-fluid boiled spinach. Now most practitioners think that 
this green colour is derived from bile which the mercurial has 
brought down in unusually great quantities from the liver, excited 
to a more energetic act of secretion. It has nothing to do with the 
bile in many cases, but is entirely derived from the irritated mem- 
brane of the intestines. Long ago I pointed out, and was the first 
to point out, this fact, in the Dublin Hospital Reports. It has very 
important practical bearings. INFLUENZA. 
385 
LECTURE XIX. 
On the influenza—Course and progress—Effect of climate, locality, &c.—Mortality 
Peculiarities of epidemic of 1837—Symptoms—Singular case with hernia. 
[Note.—Many of the following observations on influenza were added two 
months after the lectures had been delivered, but have been, for obvious 
reasons, incorporated in the lectures, rather than appended as notes. These 
lectures not being intended to furnish precise and complete details of all the 
symptoms of influenza—a task now unnecessary, having been performed by 
various writers in the Medical Gazette, and other periodicals—I have con- 
fined my attention chiefly to points from which general pathological conclu- 
sions, and views of the nature of epidemic diseases, may be derived.— 
R. J. G.] 
I adverted yesterday to the subject of influenza, and endeavoured 
to point out some of the principal features in which epidemics differ, 
as to their mode of spreading, from diseases which owe their diffu- 
sion chiefly to contagion. I stated that contagious disorders were 
comparatively slow in their progress, attacking different masses of 
the population in succession, and exhibiting, in general, a tendency 
to affect distinct classes of the community at different periods. On 
the other hand, when an epidemic like influenza makes its appear- 
ance, every thing comes under its influence almost simultaneously, 
and it overshadows the whole country in the space of a few weeks. 
Such is the course of the present epidemic, and so it was with the 
influenza of 1782, which traveled from the east, and left traces of 
its ravages in almost every quarter of the globe. In the case of 
epidemics which traverse the whole, or nearly the whole extent of 
the inhabited portion of the earth, it would be a matter of great 
interest to ascertain the place of their first appearance, or their 
point of departure. The cholera commenced in Hindostan, and in 
its route followed the great lines of communication and^commerce: 
its general progress has been northwest; but in Portugal, Spain, 
and Italy, it has traveled in various directions, its progress, how- 
ever, being in general along the great lines of communication lead- 
ing from the part of the frontier where it first broke out, towards 
the large towns in the interior. It is probable that influenza pur- 
sues some certain and uniform course, independent of the physical 
circumstances which retarded, accelerated, or stopped the progress 
of Asiatic cholera. It is likely, too, that its rate of spreading is 
subject to fewer variations. Cholera took years to accomplish its 
journey from Hindostan to Britain ; but, once established there, it 
crossed the Atlantic at a single step. The march of influenza has 
not as yet been mapped out, but, from the accounts which have 
reached us, it seems to have traveled at the same time in very 
different directions, arriving at Cape Town in January, during 
mid-summer, and in London in the same month, during mid- 
winter ; while it is reported to have reached New Holland, and to 
have raged among our antipodes, two months earlier. 
It is obvious that influenza does not depend upon mere variations 386 
graves’s clinical lectures. 
of temperature, for we have had many seasons as changeable as 
the present, without the occurrence of any such epidemic. Besides, 
influenza is known to be a disease which travels through the most 
different climates, preserving its peculiar character and identity in 
all. It is not to be supposed that the same temperature, or the 
same barometrical and hygrometrical conditions of the atmosphere, 
prevail here as in Spain, Prance, Germany, or Sweden ; yet in all 
these countries the present influenza has exhibited an uniformity of 
character, and an identity of type, proving beyond all doubt that it 
is one and the same disease. That influenza is not produced by a 
low temperature, is proved by the occurrence of the disease in the 
month of June, in the epidemic of 1762; and in the months of May 
and June, in that of 1782; as well as by its appearance at the Cape 
of Good Hope in the middle of summer, as I have already noticed. 
At present, influenza is rather on the increase in this city; and yet 
you have observed that, for the last week, the weather has been 
remarkable for its serenity and agreeable mildness. In London, 
many were led, by a limited view of the subject, to consider its 
origin as connected with the breaking up of the frost, and the 
peculiar state of atmosphere attending a general thaw. Influenza 
is not influenced in its progress by situation or locality ; it does not 
creep along the shores, or follow the course of large rivers, or select 
low marshy districts, in preference to drier and more elevated soils. 
From what has been said, it is obvious that influenza does not 
depend upon vicissitudes of temperature, peculiarities of situation, 
or supposed moist or dry states of the atmosphere ; neither does it 
arise from the prevalence of certain winds, for meteorological 
observation furnishes many instances of the prevalence of such 
winds without any influenza; and, on the other hand, it frequently 
travels against the wind. It is probable that influenza may depend 
chiefly on telluric influence—upon some agency connected with 
variations in the physical conditions which operate on the external 
surface of our planet; but on this point we can only speak con- 
jecturally, in the present state of our knowledge, and we should 
not allow ourselves to lapse into more speculative and fruitless dis- 
quisitions. How often the variations to which I have alluded 
occur, and whether they are subject to any general law, remains 
yet to be determined. Several epidemics of this description have 
been distinctly recorded in the eighteenth century, viz., in 1708. 
1712, 1729, 1732, 1742, 1762, 1767, 1775, 1782, 1789; while in 
the portion of the nineteenth century already elapsed, four influ- 
enzas have occurred, viz., in 1803, 1831, 1834, and 1837. This 
list is as complete as our medical annals will permit us to make it, 
but still we cannot rely on it as including all the epidemics of this 
nature which have occurred during the last one hundred and 
thirty-seven years. Supposing it correct, it would indicate the 
average return of influenza once every ten years. In making cal- 
culations of this kind, medical writers should always take care not 
to confound influenza, or disease which spreads rapidly over the 
whole globe, regardless of season and climate, with those local INFLUENZA. 
387 
catarrhal affections that occur in all temperate climates almost 
annually. One thing, at least, is certain with respect to this dis- 
ease, that it does not arise from exposure to cold, or, as it is termed, 
from catching cold. This I have repeatedly observed. Persons 
who took the best care of themselves, who always went warmly 
clothed, and were never exposed to the inclemency of the weather, 
took the disease just as readily as the half-clad labourer, who had 
to undergo daily exposure to all the vicissitudes of our changeful 
climate. But it should be observed, that although the attack of 
influenza in any individual was not necessarily dependent on 
exposure to cold, yet in many instances it was evident that catch- 
ing cold determined the immediate access of influenza, or increased 
its violence when present. 
I have also observed, that it seldom attacked persons labouring 
under acute diseases, until the period of convalescence arrived, 
when their immunity ceased, and they became just as liable to its 
invasion as others. Thus patients labouring under typhus escaped 
as long as the fever continued; but frequently, on the very day the 
crisis occurred, and symptoms of returning convalescence appeared, 
they were seized with influenza. This is a very unfortunate cir- 
cumstance. Just as a patient had struggled through a fever of 
seventeen, nineteen, or twenty-one days, he was attacked with a 
new and dangerous malady, which again placed him in a situation 
of imminent danger. 
You must have observed, that influenza does not appear in every 
individual with the same violence, or exhibit in all, symptoms 
identical in their intensity or duration. As in most other epidemics 
which affect society at large, the different constitutions and ages of 
the individuals, and the different states in which the morbid influ- 
ence finds them, modify greatly the nature of the attack ; so that, 
although a vast number are affected, they suffer in very different 
degrees, and the complaint exhibits every variety of shade, from 
simple coryza, or catarrh, requiring no treatment, to catarrhal fever 
of the worst and most unmanageable description. Many persons 
laboured under what vrould be termed a common cold, were it not 
from the extreme frequency of such symptoms, combined with 
other circumstances which mark the nature of the disease. The 
same thing was observed with respect to cholera: few persons, 
during the prevalence of cholera, escaped without undergoing 
some form of bowel attack; but the mode and character of such 
attacks varied very remarkably. It remains to be ascertained 
whether the poison which gives rise to intermittent fever, or to 
typhus, is also capable of being conveyed into the system in different 
doses, and of giving rise to corresponding derangements of health. 
Dr. Rush brings forward many facts to prove, that when the causes 
of yellow fever do not act with sufficient energy to produce in the 
constitution that particular form of disease, they may nevertheless 
occasion fevers of a less violent character, or may even give rise to 
chronic derangements of the general health, unaccompanied by 
fever. This is rendered more probable, when we recollect the 388 
graves’s clinical lectures. 
great length of time certain poisons continue to exert a baneful 
influence on the health. Thus, Assistant-Surgeon J. W. Macauley 
informs me, that one officer and several men, inmates of the Royal 
Hospital in Dublin, are suffering from ague, the poison of which 
they imbibed in the ill-fated Walcheren expedition. 
Very lately, an officer of rank, much distinguished in the Penin- 
sular war, came from England to consult Mr. Crampton, Dr. Ken- 
nedy, and myself. Among other ailments, he was affected with 
evident traces of a vernal tertian, contracted in Portugal about 
twenty-seven years ago, and which has seldom failed to return 
annually ever since. 
Influenza is not by any means so severe or so rapidly fatal a dis- 
ease as cholera, but the mortality which it has produced is greater, 
as it affects almost every person in society, while the ravages of 
cholera were comparatively limited. Consequently, although the 
proportion of deaths among a given number of individuals attacked 
was greater in cholera, the mortality for society at large is much 
greater in influenza. In Dublin, it is extremely difficult to obtain 
any thing like exact statistical details of the comparative mortality 
at different periods, for no general registry of deaths is kept in this 
city. Through the kindness of Mr. Eiffe, secretary to the Caledo- 
nian Insurance Company, I have been enabled to get an accurate 
return of the interments in Prospect Cemetery, at Glasnevin, in the 
suburbs of this city, for the months of January and February, 
during which influenza was very prevalent, as also for the corres- 
ponding months of the preceding year. He has also furnished me 
with an account of the burials during the months before and after 
influenza. 
Interments at Prospect Cemetery, Glasnevin; probably the largest in 
Ireland. 
In December, 1835, . . 355 
January, 1836, . . 392 
February, 1836, . . 362 
March, 1S36, . . 392 
Total for four months 1501 
In December, 1836, . . 413 
January, 1837, . . 821 
February, 1837, . . 537 
March, 1837, . . 477 
2248 
Increase during influenza, 747. 
Assuming, then, that in Prospect Cemetery alone, about seven 
hundred persons were buried who died of influenza, and that there 
are at least three times as many persons buried in the other church- 
yards of the city and suburbs, we may conclude that in Dublin 
alone more than four thousand people died of the influenza, not 
taking into account the great number who, although they got over 
the immediate attack of the epidemic, sank afterwards under 
various diseases, of which influenza had laid the foundation. In 
Paris, the influenza caused likewise a great mortality: for it 
appears, from a statement in the Revue that the average 
daily mortality, during the first fifteen days of February, amounted 
to one hundred and ten, which is more than double the usual 
average. This only refers to persons dying in their own houses, INFLUENZA. 
389 
and does not include the deaths in hospitals. Eighteen thousand 
die in private houses annually in Paris—i. e. on an average about 
fifty daily. The rate varies from twenty to seventy a day, accord- 
ing to the season; but during the first fifteen days of February, it 
rose from fifty-eight to one hundred and fifty-two in the day. 
Influenza has been very fatal where it attacked persons who 
had been subject to chronic bronchitis, or who had happened to 
labour under any form of asthmatic affection ; for this, I confess, I 
was not quite prepared. And when first called to attend asthmatic 
persons labouring under influenza, I expected that, from being 
accustomed to periodic attacks of dyspnosa and cough, they would 
be better qualified to bear the disease, and would continue to 
exhibit that tenacity of life for which asthmatic persons are so 
remarkable. The old also suffered considerably; but some very 
old persons had extremely severe attacks of influenza, and yet 
escaped. I attended, along with Mr. Maurice Collis, the venerable 
Judge Day, the cotemporary of Goldsmith, who, at the age of 
ninety-three, had sufficient strength of constitution to shake oflf a 
most violent seizure. Two gentleman, who had fought at the 
battle of Bunker’s Hill, also survived the disease in a severe form; 
but generally speaking, it was very fatal among the aged. Influ- 
enza was also very fatal among persons who laboured under dis- 
ease of the heart; and in this instance age made no difference as 
to result, for the young and old were equally liable to danger. I 
have also seen it fatal in cases of deformity of the chest, from cur- 
vature of the spine, and other causes. The mortality was also 
very great among persons in advanced life who laboured under 
tussis senilis: in a word, all persons labouring under pulmonary 
irritation, or weakness, were exposed to very considerable danger. 
Subsequent experience has proved also, that where influenza left 
behind it an obstinate and irritative cough, and where the consti- 
tution had a scrofulous taint, the disease was very apt to pass into 
tubercular phthisis. Among all the families I know, but two 
escaped the influenza altogether : one consisted of eleven children, 
besides the parents and servants, and resided in Pill Lane, in the 
very centre of the city ; the other family consisted of five females, 
advanced in life, and who lived in one of the fashionable streets. 
Allow me to digress here for a moment, for the purpose of 
making one observation, which a review of several cases of influ- 
enza, attended with severe pulmonary symptoms, suggests to me. 
It is a common error in pathology to confound effects with causes, 
and where the cause of a disease is not, and probably cannot be 
known, to fix on some peculiar and leading symptom, and attribute 
to it the origin of all the rest. But it is quite illogical to say that 
one symptom is the cause of another, or that because it has the 
precedence, it should also have the initiative. I alluded to this 
error in a former lecture, when speaking on the pathology of scar- 
latina. It has been over and over again asserted, that the dropsy 
of scarlatina arises from the previous inflammatory affection of the 
skin, or subcutaneous tissues ; and the same thing has been 390 
graves’s clinical lectures. 
asserted with regard to the desquamation of the cuticle. But I 
have brought forward facts and arguments to prove that this 
opinion is not founded in truth, and that dropsy, as well as desqua- 
mation of the cuticle, may take place where there has been no 
eruption whatever, and not the least trace of cutaneous or subcu- 
taneous inflammation. Now when a person, after exposure to 
cold, gets pneumonia or bronchitis, followed by anasarca, it is quite 
a common thing to hear it said, that the anasarca had its orgin in 
the pulmonary affection, and that the effusion of serum depended 
on obstructed transmission of blood through the lung. The same 
mode of explanation has been applied to disease of the heart as the 
cause of dropsy. This explanation, however, appears to me inade- 
quate and unsatisfactory. Many cases of influenza were accom- 
panied by extreme congestion of the lungs, and consequently 
imperfect aeration of the blood ; and yet I have not in a single 
instance noticed the occurrence of dropsy as an immediate or 
remote consequence. Were dropsy dependent on the state of the 
lung to which I have alluded, it would have shown itself in some 
cases at least; and yet I have seen individuals attacked with influ- 
enza labouring under orthopnoea and severe pulmonary symptoms 
for weeks, without observing, in any instance, the slightest anasarca 
or oedema.1 This has strongly impressed upon my mind the con- 
viction, that when dropsy comes on after disease of the lung, that 
the one is not always the consequence of the other, but that both 
often result from the same cause, and owe their origin to the same 
morbid impression on the system. This error has been further 
confirmed by the results of treatment, practitioners having found 
that measures adapted to remove congestion of the lung tended also 
to remove the dropsy; forgetting here, that where two symptoms 
closely allied together arise from the same cause, you will be most 
likely to relieve both by those means which are effectual in remov- 
ing either. The principles which I have here briefly alluded to, 
will apply to many other combinations of disease; it is one of 
general application, and, in my mind, of no ordinary importance. 
The present epidemic differs in many points from that which 
prevailed here about three years ago. The influenza of 1833-4 
was by no means so generally fatal as the present. It was charac- 
terised, like the present, by considerable irritation of the tracheal 
and bronchial mucous membrane, but not by the severe bronchitis 
and pneumonia which have been witnessed in many cases of the 
present disease. The former raged in Dublin chiefly during the 
months of March and April; it came on very suddenly, with rapid 
pulse, hot skin, great prostration, languor, and excessive sweating ; 
there was cough, coryza, and, not unfrequently, vomiting at the 
commencement. One of the most prominent symptoms, however, 
was headache, which was excessively severe. There was also, 
11 saw one old gentleman at Rathmines, whose feet and legs were much 
swollen; but this I attributed to his having remained so many days and 
nights in his chair, unable to lie down. He was under Mr. Crampton’s 
care, and recovered. INFLUENZA. 
391 
cccteris paribus, more debility, and the patients did not bear bleed- 
ing so well as they have done at present. But the most material 
point in which they differ is the comparative mortality. The dis- 
ease in 1834 carried olf some very suddenly with cerebral symp- 
toms, and proved fatal to others from oppression of the chest and 
dyspnoea. Few, however, died, who survived for a week after 
they had been attacked, and the disease rarely left behind it a 
cough at all approaching in violence and obstinacy to that which 
now harasses convalescents. On the whole, the fever accompany- 
ing the influenza of 1834 was more acute, and set in with more 
marked depression of the nervous system, than that which attends 
the present, and the disease was much less liable to become chronic. 
It would conduce greatly to the advantage of medical science, if 
a brief and accurate history was left to posterity of the character, 
symptoms, pathological phenomena, and treatment, of every 
epidemic. Such a record would prove a guide and beacon to the 
practitioners of future ages—would enable them to draw important 
comparisons between the existing and the past—and thus arrive at 
a more fixed and available knowledge of the nature and habits of 
epidemic complaints. 
There are, I have no doubt, many curious forms of epidemic 
disease which pass through society either wholly unnoticed, or 
confounded with others to which they have some slight affinity. I 
think I have seen particular forms of scarlatina, measles, small- 
pox, and fever, which have not been accurately noted, although 
they prevailed as epidemics. If every form of epidemic was noted, 
and the order of its succession marked, it would remain to be 
ascertained by posterity, whether there may not be what may be 
termed cycles of epidemics, and whether disease, after having 
manifested itself in determinate forms, following each other in 
determinate succession, may not commence again after the lapse of 
a certain number of years, and pursue the same course. This is 
not impossible, if we suppose that epidemics are connected with 
telluric or electrical influences, which are now known to observe a 
periodic course. Were this ascertained, a sort of observatory of 
epidemics could be easily established in the various civilised states. 
In treating of the nature of the present influenza, it will be 
proper to consider, in the first place, the general constitutional 
symptoms which attend it, and afterwards glance at those which 
are chiefly of a local description. In some cases of influenza there 
is little or no fever ; neither does the presence of fever seem essen- 
tial to the more severe or even fatal cases, although, generally 
speaking, fever occupies a very prominent position among the 
group of symptoms by which the disease is characterised. I have 
seen cases in which there was nothing like regular fever from 
beginning to end, and yet which terminated fatally. 
I am at present treating two patients who have been labouring 
under orthopnoea for the last ten days, and yet in these patients 
the skin is cool, the pulse in general soft, and very little above the 
normal standard, and the tongue, though furred, quite moist; yet 392 
graves’s clinical lectures. 
so great is the distress of respiration, that they are obliged to 
remain sitting np in bed night and day, panting for breath; and I 
am of opinion that both will die. This, however, is the exception 
with respect to severe cases, the majority being attended with very 
considerable fever. In the slight cases, the fever is scarcely per- 
ceived. or altogether absent; this was the case with myself and 
some of my friends. We had coryza, hoarseness, cough, and some 
degree of pulmonary irritation, without any fever. At first, I 
thought that fever was an essential part of the disease; but the 
cases to which I have alluded, and others of a similar kind, have 
convinced me that this is not the fact. Where the fever appears, it 
comes on with the usual symptoms of pyrexia—namely, sense of 
chilliness, particularly about the small of the back, without decided 
rigors, flying pains in the limbs and joints, and headache, generally 
referred to the situation of the frontal sinus. There is, from the 
commencement, great restlessness, jactitation, and more or less 
insomnia. Sickness of the stomach, loss of appetite, and tendency 
to diarrhoea, are also common symptoms. The skin is in general 
hot, and without any tendency to moisture, although, in some 
cases, there are occasional perspirations. These, however, are 
seldom general or regular, and last only for a few hours. The 
pulse is accelerated and tolerably full, occasionally even hard and 
wiry. These symptoms are very subject to slight exacerbations 
and remissions, and seldom continue the same for more than twelve 
hours together. Where the disease exists for any length of time in 
a violent form, the tongue usually becomes furred and loaded, the 
patient loses all relish for food, and in many cases complains of 
harassing thirst. In severe cases, the most prominent symptoms 
are cough, wheezing, restlessness, dyspnoea, and loss of sleep. 
The appetite is generally more or less impaired; but I have seen 
some severe cases in which it did not fail remarkably for several 
days; the restlessness and jactitation attend many cases throughout. 
You are not, however, to suppose that this always depends on the 
presence of pain or fever. The headache is not in all severe or 
distressing, and I have already stated, that the fever is not so 
general or so violent as one would suppose. The loss of sleep 
depends upon derangement in the tone of the nervous system, 
independent of fever ; for I have observed it in numerous patients, 
in whom scarcely any febrile excitement was observable; but when 
complicated with fever, both react upon and aggravate each other. 
The skin, where fever is present, is hot; this heat is interrupted by 
occasional perspirations, which, however, do not give much relief, 
or tend to diminish the amount of increased temperature. Some- 
times the skin is hot, and at the same time bedewed with perspira- 
tion during the whole course of the disease; but this is rather 
unusual. The pulse is seldom the same throughout; one time you 
will find it quick and rather hard ; in six hours afterwards it. will 
be quick and soft; in six or eight hours more it will appear as if 
about to fall to the normal standard, and next day you will find it 
quick and jerking again. These changes are accompanied by 393 
INFLUENZA. 
corresponding alterations in the temperature and humidity of the 
skin. But what is most remarkable with regard to the pulse is, 
that it sometimes becomes full, and rather strong and wiry, towards 
the termination of the disease; and this you will observe in patients 
who have been suffering for days, or even weeks. I have been 
attending for the last fortnight, with Mr. Colies, a gentleman in 
Castle street, aged sixty, of a full habit, and subject to attacks of 
dyspnoea and cough during winter. This gentleman was attacked 
with influenza, ushered in and accompanied by severe fever; and 
it was observed that, as the disease advanced, his pulse became 
fuller and stronger, so that it was thought advisable to bleed him. 
He was bled with apparent relief, and the blood was extensively 
buffed and cupped. This phenomenon I have observed in every 
case attended with fever, and indeed in some where no appreciable 
fever existed. Thus, a gentleman in Dame street, who had no 
fever, and who merely laboured under teazing cough, distress of 
respiration, and oppression of the chest, the blood, on being drawn, 
exhibited very distinct buffing and cupping. The same thing hap- 
pened in the case of a gentleman, in Dominick street, whom I 
ordered to be blooded under exactly the same circumstances. The 
gentleman in Castle street, whom I attended with Mr. Colies, 
exhibited a very curious state of pulse. In him, as in many 
others, the pulse was extremely variable as to its strength, being at 
one time hard and firm, and at another soft and weak. If you 
were to visit him in the morning, from the feel of the pulse you 
would be inclined to give him stimulants ; if you saw him for the 
first time on the evening of the same day, you would think vene- 
section indispensable. This gentleman’s state was hopeless; he 
laboured under great suffering, dyspnoea, and inability to cough up 
the viscid mucous secretion, and yet his pulse was both strong and 
firm. Mr. Colies, whose attention I directed to the state of the 
pulse, observed, that were he to feel it without seeing the patient, 
or knowing his previous history, he would be greatly inclined to 
bleed him immediately. I have adverted in a former lecture to 
this state of the pulse, as connected with irritation of the nervous 
system, rather than with any inflammatory state of the constitution 
in general, and therefore I shall not now recur to the subject, 
further than to remark, that I have never observed any disease in 
which the pulse formed so bad a guide as to the propriety of vene- 
section as the present epidemic. In some cases, venesection was 
most useful, although the pulse was in every respect natural ; in 
others, it could not be borne even to the smallest amount, although 
the pulse was hard and wiry. Neither was the state of the blood 
an unerring guide, for even in those who sank rapidly, from the 
debilitating effects of moderate bleeding, the blood was very much 
cupped and buffed. 
Before I conclude, I shall mention the particulars of a very 
remarkable case which came recently under my notice. I was 
called to visit a lady, somewhat advanced in life, but of a good 
constitution, and labouring under the ordinary form of influenza, 394 
graves’s clinical lectures. 
with considerable dyspnoea and cough. In the course of eight or 
nine days, her symptoms began to decline ; she got up, and seemed 
convalescent. As the cough and pulmonary irritation still pre- 
vailed to a certain extent, it was thought advisable not to allow her 
to eat meat, but she obtained leave to take some fresh haddock. 
After dinner, her cough becoming more troublesome than before, 
she had frequent recourse to a stale and rancid cough-bottle, con- 
taining squill and ipecacuanha. During the evening and night, 
she felt her dinner like an undigested load, and her stomach 
turned. She vomited, and was purged and griped incessantly, 
until I saw her next day. On the third day, the medicines I had 
ordered moderated the purging, but the nausea and occasional 
vomiting continued. On the fourth day, the purging had entirely 
ceased, but the sickness of stomach persisted. I sought to appease 
this by the ordinary means, which failing, I examined her with 
care on the following day, and discovered a strangulated hernia. 
At this time the pulse had scarcely risen above the natural standard. 
Mr. Cusack operated that night with his usual skill, and all the 
symptoms depending on incarcerated hernia ceased. Rut they had 
scarcely disappeared, when the pulmonary symptoms, and the 
copious secretion from the bronchial tubes, recurred, and she did 
not survive this relapse of the influenza more than a few days. 
This is an instructive example of an insidious combination of 
circumstances very likely to mislead a practitioner. For as the 
vomiting was for a day or two accompanied by a looseness of the 
bowels, the suspicion of hernia would not strike the attention. It 
is plain that in this case indigestion produced an increased and 
morbid activity in the motions of the alimentary canal, which led 
to the incarceration of the portion of gut. Up to a certain moment 
the symptoms depended merely on one cause; after that period, 
strangulation took place—an occurrence which could not be easily 
diagnosed, as vomiting, one of the most striking symptoms, had 
previously existed. 
LECTURE XX. 
Influenza continued—History of the symptoms—Stethoscopic phenomena—Post- 
mortem appearances—Extent to which the nervous system is implicated—Character 
of the sputa—Appearances of the urine—Cerebral affections—Bleeding only to be 
employed at the onset—Opiates in conjunction with antimony or nitre—Blisters 
generally inefficient—Warm fomentations beneficial. 
In my last lecture I alluded to the affection of the intestinal canal 
in influenza, and stated that in many cases there is derangement of 
the digestive tube—as manifested by thirst, anorexia, nausea, or 
even vomiting, and a tendency to diarrhoea. When diarrhoea 
occurs, it is generally at the commencement of the disease; and INFLUENZA. 
395 
it is remarkable that this state is frequently exchanged, rather sud- 
denly, for one of an opposite character. Thus, when you have 
succeeded in checking the diarrhoea with chalk mixture and opium, 
a state of costiveness will frequently ensue, requiring the daily use 
of purgatives and enemata. I have now witnessed several cases 
in which the moderate use of opiates and astringents brought on 
constipation, requiring the use of strong purgatives and enemata, 
thrown up with Read’s syringe. 
In influenza, as in many other febrile affections, the lungs become 
considerably engaged; the disease first attacks the nose and throat, 
then the larynx and trachea, and, finally, the ultimate ramifications 
of the bronchi. There are several other affections which com- 
mence in a similar way—as ordinary catarrh, bronchitis, and 
measles. In influenza, most persons have the nose and throat 
affected in the beginning; the inflammation creeps gradually along 
the lining membrane of the air-passages, until it involves the 
greater part, or the whole, of the bronchial mucous membrane. 
The progress of the inflammation is extremely rapid, and in the 
course of twenty-four, or even twelve, hours the lungs become 
engaged. There is, however, much difference as to the extent to 
which this inflammation proceeds. In many cases, it is limited to 
the nose and throat; the patients complain of coryza, hoarseness, 
and slight cough. In others, the trachea also is more or less 
affected, and the cough is more troublesome; but, generally speak- 
ing, the latter as well as the former cases are unattended with 
fever. The patients cat and drink as usual, go about their ordinary 
business, and sleep tolerably well at night. This appears to be the 
general course of the disease when the inflammation is limited to 
the nose, throat, and upper part of the air-passages ; when it spreads 
farther, and attacks the first ramifications of the bronchi, there is 
some dyspnoea and tightness of chest, the cough is much more 
troublesome, and the appetite and digestion are somewhat impaired; 
but persons in this state, although resting badly and eating but 
little, will continue to go about—constantly, however, complaining 
that they are very ill. AVhen the smaller divisions and ultimate 
ramifications of the bronchi are engaged, there is soreness of chest, 
remarkable dyspnoea, and constant harassing cough; the headache 
is also aggravated, the patient loses all inclination for food, sleeps 
badly at night, and is confined to the bed or house. First, then, 
you have the mucous membrane of the eyes, nose and throat 
affected; then the larynx and trachea; then the larger bronchi; 
and, finally, the smaller and more minute ramifications. When 
the latter state has continued for some time, more or less serous 
engorgement of the lung takes place, and this adds to the dyspnosa 
and cough. On applying the stethoscope over various parts of the 
lung, you will hear at various parts a moist crepitus, indicating the 
existence of serous infiltration. The smaller bronchial tubes and 
air-vesicles are congested and filled with mucus ; the blood cannot 
pass freely through the lung, and consequently must be imperfectly 
aerated; the secreting and absorbing functions of the lung are 396 
graves’s clinical lectures. 
deranged, and hence arises a state in which the pulmonary capil- 
laries become congested, and permit the more fluid part of the blood 
to exude into the parenchyma of the lung, giving rise to what is 
termed serous infiltration. Something similar to this occurs also 
in general bronchitis, particularly in fever, but we very seldom 
have hepatisation resulting from such causes. In hepatisation, the 
capillaries pour out, not serum, but lymph, which glues together 
the cells of the pulmonary tissue, and forms a dense solid mass. 
Hence, in influenza or bronchitis, you seldom have true pneumonic 
inflammation. You will have extensive and dangerous engorge- 
ment, but when you examine the lung after death you do not find 
any real solidification, and you can restore the lung almost to its 
original permeability and buoyancy by squeezing out the infiltrated 
fluid. Yet I must admit that this is not always the case, and that 
in influenza, as well as in bronchitis, you may have true pneumo- 
nia superadded to the original affection of the lining membrane. 
This occurred in the case of a lady whom I attended in Capel street, 
and who was attacked with influenza shortly before delivery. On 
the day of her accouchement, pneumonia was superadded to the 
bronchial inflammation, and she died with extensive hepatisation 
of the right lung. This also occurred in the case of a man of 
middle age, residing in Suffolk street, who had been labouring for 
some days under excessive engorgement of the lung. I have also 
observed the same occurrence in a gentleman whom I attended 
with Mr. Colies, in Exchequer street; and in another case which I 
saw in Whitefriar street. 
One of the most singular features in the history of the present 
influenza is the extraordinary degree of dyspnoea witnessed in most 
cases where the lung is extensively engaged, but particularly where 
the patients had been previously subject to pulmonary affections; 
and even in many cases where the bronchial mucous membrane is 
but slightly engaged, the amount of dyspnoea is remarkably great. 
Indeed, it might be said with much truth, that the dyspnoea was by 
no means proportioned to the extent of pulmonary inflammation. 
There is at present in the hospital a woman labouring under influ- 
enza, whose chest sounds clear on percussion, and in whom every 
part of the lung is permeable, who presents nothing more than a 
few sonorous rales in the course of the larger bronchial tubes, and 
yet she is suffering from considerable dyspnoea, and the respirations 
amount to forty-six in a minute. We cannot, therefore, attribute 
the difficulty of breathing to mere bronchitic lesion, for it is not in 
proportion to this lesion. Another patient admitted into Sir P. 
Dun’s Hospital exhibited a similar train of symptoms. He was a 
negro sailor, a native of New Brunswick, and was seized with the 
epidemic a few days after his ship arrived in Dublin; he was a 
man of Herculean form and finely developed chest, and in the 
prime of life. His suffering from dyspnoea was intense ; his chest 
heaved, he tossed about in bed in a constant state of agitation and 
restlessness, and yet the respiratory murmur was every where dis- 
tinctly audible through the lung, and no rale could he heard, except INFLUENZA. 
397 
here and there a few bronchitic wheezings. He also laboured under 
insomnia, and, though he had but little fever, his debility was ex- 
treme. Indeed, his pulse was so weak from the commencement, 
that I could not venture to treat him antiphlogistically; and I 
accordingly ordered extensive vesication over the chest, with the 
use of wine, stimulants, and narcotics. This man subsequently 
recovered—an event which could scarcely have occurred under 
the plan of treatment adopted, had his dyspnoea depended on mere 
bronchitis. It should be also borne in mind, that in many bad 
cases of influenza the dyspnoea is intermittent, or at least undergoes 
remarkable exacerbations and remissions at certain hours of the 
day and night. It would appear that the respiratory derangement 
depends on the same general cause which produces the whole train 
of symptoms, and that it might exist even where there was no 
bronchial inflammation at all. It is true, that where the bronchitis 
is present, it adds to the distress of respiration, but the dyspnoea 
appears to be chiefly attributable to some impression made on the 
vital activity of the lung. That the lungs are endowed with an 
inherent vitality necessary to the aeration of the blood has been 
long acknowledged by the Germans, who have described a dyspnoea 
from paralysis of the lungs ; and this opinion is now generally 
adopted in Great Britain, since the results of the experiments on 
the eighth pair of nerves have been duly appreciated. We have 
abundant illustrations of this truth in asthma, in which the greatest 
dyspnoea is often present, without any appreciable lesion of the 
lung. And it would be a fortunate circumstance for the patients 
in influenza, if this were not the case; for we could then treat the 
affection of the lung as ordinary bronchitis, and should expect to 
find it amenable to the ordinary remedies. You are aware that 
the mortality in cases of ordinary bronchitis is extremely small, if 
we except very young children and persons advanced in life. In 
adults, when met by prompt and appropriate treatment, it is in 
general a very manageable disease, and seldom proves fatal unless 
combined with other unfavourable conditions. This, however, is 
not the case in influenza, nor is the pulmonary affection so easily 
treated, or the dyspnoea so readily controlled. I saw, some time 
ago, a fine young woman, servant to a gentleman in Fitzwilliam 
street, for whom every thing had been done which the best and 
most skilful practice could devise; but her condition, when I saw 
her, was desperate, and she died the following day : yet her chest 
sounded well on percussion, and we could hear nothing over the 
whole lung except a few sonorous and sibilous rales, and the respi- 
ratory murmur seemed every where nearly as loud as natural. Of 
course, such a lesion of the nervous influence could not last long 
without necessarily inducing pulmonary congestion—an inevitable 
consequence of imperfect aeration of the blood. When the eighth 
pair of nerves is divided, the animal is slowly suffocated ; and, on 
dissection, the lungs are found engorged, and the bronchial mucous 
membrane congested and inflamed. May not the affection of these 
parts in influenza be sometimes induced by lesions of nervous 398 
GRAVES’S CLINICAL LECTURES. 
power in the lungs? I am indebted to my friend. Dr. George 
Green, for the following results of his very numerous post-mortem 
examinations in this disease, and I feel great pleasure in being able 
to give them—as such examinations, at least in this country, are 
very rare. Dr. Green observes :— 
“ The cases which proved fatal at the House of Industry, during 
the late epidemic influenza, occurred principally among the aged 
inmates of both sexes. I had an opportunity of examining several 
of these cases, and the following were the principal post-mortem 
appearances observed. 
“ The bronchial mucous membrane was found, in every case, 
more or less congested and inflamed. The colour varied consider- 
ably—being in some of a dull red, and in others of a much darker 
hue. The inflammation, in most cases, was found to occupy both 
the trachea and the bronchial tubes of both lungs; in other in- 
stances, it was confined to one lung alone. A sanguinolent frothy 
mucus occupied the area of the tubes, and increased in quantity as 
they were traced to their minuter divisions. The parenchymatous 
tissue of the lung was invariably discoloured, being generally of a 
dark or violet colour ; its specific gravity was increased, and it did 
not crepitate, or at least very feebly, when pressed between the 
fingers. The surface of its section was not rough to the touch, and 
when pressed in the hand a quantity of the mucus described above 
was driven out. In some cases, the postero-inferior portions of one 
or both lungs were very dark coloured, and the finger could be 
passed easily through its substance. When the surface thus torn 
was examined, it did not appear to be granular; it resembled more 
a portion of gangrenous lung, except that there was an absence of 
fetor. This last appearance was found principally in very aged 
persons. It was rare to find any traces of the second and third 
stages of ordinary pneumonia in these patients; but in the young 
and robust, who were received into the Hardwick Fever Hospital 
from the neighbouring streets, these degenerations of the structure 
of the lung were observed, together with the same inflammation of 
the bronchial mucous membrane. 
In most of the aged patients, the blood was found dark coloured 
and fluid in both cavities of the heart, and in every vessel where it 
was examined. The cases in which fibrinous concretions in the 
cavities of the heart were found, were very few, and these inva- 
riably in the young or middle aged. In the former class of patients, 
also, the lung occasionally appeared to be oedematous; and, in one 
or two cases, a considerable effusion of serum had taken place into 
the pleural cavities. The signs of recent pleuritis were very rare, 
but old adhesions, as might be expected in such subjects, were very 
commonly found between the pulmonary and costal pleurae. In 
one case of a lunatic, who survived the immediate attack of influ- 
enza, tubercles appeared to have been rapidly developed in both 
lungs. In another lunatic, two tubercular cavities were found in 
addition to the state of the lung and air-tubes already adverted to. 
With respect to the nature and duration of the symptoms of 399 
those cases which came under my own management, I have little 
to say in addition to what is already so familiarly known. The 
physical signs afforded by percussion and auscultation were almost 
universally as follows:—Dulness, more or less decidedly marked, 
in the postero-inferior portions of the lungs ; sonorous or some 
form of the bronchial rales throughout the chest, or, what was more 
common, a mixed sonorous and crepitating rale, or, in the latter 
stages, a muco-crepeating rale. The sputa were seldom rusty- 
coloured or tenacious, but rather resembled those of bronchitis. In 
many cases, the want of power to excrete them appeared to be the 
immediate cause of death ; but in others, the morbid cause, what- 
ever it might be, appeared to have affected the entire respiratory 
and circulating systems, producing great congestion of the venous 
system, and a state not unlike asphyxia. The latter cases were 
almost all among the aged inmates of the House of Industry. 
The appearances of the other viscera were not such as could in 
any way account for the result, so often speedily fatal; so that, so 
far as one could hazard a conjecture, the morbid cause appeared to 
have made its primary impression on the respiratory mucous sur- 
face, thereby interfering with the proper aeration of the blood, and 
inducing the changes in that fluid and in the structure of the lungs 
above detailed.” 
INFLUENZA. 
Such are the appearances observed by Dr. Green in his nume- 
rous dissections of persons who died of influenza. They may be 
relied on as perfectly accurate, for no one is better acquainted with 
pathological phenomena than Dr. Green, and consequently no one 
better able to furnish valuable evidence with respect to the appre- 
ciable changes produced by influenza in the pulmonary and other 
tissues. 
I have already advanced the opinion, that we should not hastily 
assume that influenza consists essentially in the morbid changes 
which dissection reveals; we should examine every side of the 
question, and consider whether it is not possible that the alterations 
in the pulmonary tissue may not be, to some extent at least, the 
consequences of the disease. Let us consider for a moment the 
method we pursue in reasoning about the progress and causes of 
the symptoms in ordinary bronchitis. Here a patient is seized with 
a pectoral affection, attended by cough, dyspnoea, and more or less 
fever. We find certain rales, and the expectoration is altered in 
quality and quantity. Further, observing a number of such cases, 
we remark that the danger is proportioned to the degree of dyspnoea, 
and the dyspnoea to the extent and nature of the rales, together 
with the quantity and quality of the expectoration. To these the 
general constitutional affection, and the probable results of the dis- 
ease, have certain definite relations, a knowledge of which is soon 
obtained by experience. But these rales, and this state of the 
respiration and expectoration, we have reason to believe, arise from 
the presence of bronchial inflammation ; and to this we refer all 
the symptoms observed. On this supposition, too, we proceed in 
our treatment, and the result most commonly justifies its correct- 400 
graves’s clinical lectures. 
ness; and we have additional evidence of its truth furnished by 
post-mortem examinations. Now, in such instances, the chain of 
inductive evidence is complete, and we feel a conviction that our 
practice is founded on correct notions of the nature of the disease. 
But how different is the case when we assume that influenza is 
caused by bronchial inflammation ! In influenza, the dyspnoea is 
not always proportioned to the bronchitic affection—nay, in some 
cases we have seen that difficulty of breathing was most urgent in 
cases where the air entered into all parts of the lung with facility, 
and where few and unimportant rales existed. Again, although 
the presence of a copious viscid secretion in the bronchial tubes 
was sure to aggravate dyspnoea, yet it often occurred in patients 
whose air-passages were very little, or not at all, obstructed in this 
way. The effects, too, of remedies, antiphlogistic, expectorant, and 
derivative, were very different from what they would have been 
had the disease depended on a mere bronchitis. I have already 
stated my conviction, that the poison which produced influenza 
acted on the nervous system in general, and on the pulmonary 
nerves in particular, in such a way as to produce symptoms of 
bronchial irritation and dyspnoea, to which bronchial congestion 
and inflammation were often superadded. 
In this view of the subject I am not singular, for I find that it 
has been advocated by Dr. Peyton Blakiston, in a short treatise on 
influenza, as it occurred at Birmingham. He states that his re- 
searches have led him to the conclusion, “that influenza is an 
affection of the nervous system, with its concomitant derangements 
in the organs of digestion, circulation, &c., commonly known under 
the name of nervous fever, accompanied throughout its whole 
course by irritation of the pulmonary mucous membrane, which 
not unfrequently amounts to congestion, and even to inflammation.” 
This distinction between influenza and feverish cold with bron- 
chitis, is, in a practical point of view, of great importance, and 
should never be lost sight of in the treatment of influenza—for it 
prevents us from placing our sole confidence in remedies adapted 
to mere bronchitic inflammation. Thus, Dr. Blakiston asserts, and 
most physicians will agree with him in this point at least, that it 
was often necessary to have recourse to diffusible stimulants at the 
commencement, and to administer tonic medicines in an early stage 
of the disease. 
In some cases, even where great dyspnoea exists, the cough is 
hard and dry, and the expectoration scanty; in others, the expec- 
toration is copious, so as to cause constant efforts to cough it up; 
and, indeed, it is melancholy to look at the distress which patients 
suffer in this respect. You will hear the wheezing of the phlegm 
in the throat and air-passages before you enter the room, and you 
will see the patient exhausted by successive paroxysms of cough, 
and ineffectual attempts to expectorate. In other cases, where the 
vitality of the lung is less injured, and the general tone of the sys- 
tem less deranged, the sputa, although copious, are expectorated 
with considerable facility. The sputa bear considerable analogy to INFLUENZA. 
401 
those observed in ordinary bronchitis; they consist at first of a 
grayish mucus, which, as the disease proceeds, exhibits a globular 
appearance, or assumes a puriform character, and does not coalesce; 
in other cases they are extremely viscid and ropy, like solutions of 
gum or isinglass. A remarkable fact with respect to the sputa in 
influenza is, that they are very seldom mixed with air-bubbles. On 
mentioning this to-day to some persons attending my class, I was 
shown some sputa discharged by a patient labouring under influ- 
enza, in which there were some air-bubbles ; this, however, is 
extremely rare. In a lecture which was delivered here some time 
ago, I took occasion to allude to the secretions of the bronchial 
mucous membrane, and stated my conviction that this subject had 
not received as yet the attention which its acknowledged import- 
ance demands. There is one point, in particular, of which no ade- 
quate explanation has been as yet given—namely, why it is that in 
some cases of pulmonary inflammation the sputa are filled with 
air-bubbles, while in other instances there is no appearance of air- 
bubbles from the beginning to the end of the disease. The presence 
of air-bubbles in the sputa has been explained, by supposing that 
air becomes incorporated with the mucus while it is driven up and 
down in the bronchial tubes during the acts of respiration and 
coughing; just as if you shake a solution of soap or any other 
viscid fluid in a half-empty bottle, it becomes impregnated with 
air-bubbles. There may be some truth in this, but I think it does 
not sufficiently explain the presence and intimate incorporation of 
air with the sputa in certain affections of the lung; and it appears 
to me that we can scarcely understand this, unless we suppose that 
the air and mucus are secreted together. You are aware that air 
is secreted by the bronchial mucous membrane, and that in some 
cases this secretion is morbidly increased, in others morbidly dimi- 
nished. Now, it is not very unreasonable to suppose that the 
mucous membrane may secrete air and mucus together in abnormal 
quantity; and that this, rather than any mechanical agitation, may 
be the cause of the intimate combination of air with the expecto- 
rated fluids. 
I need scarcely make any observation on the cough in influenza. 
It is in general very troublesome, particularly at night. Many 
persons are not much annoyed by it during the day, but at night it 
becomes very harassing, and prevents them from sleeping. When 
severe, it continues both night and day; and even when persons 
have recovered from the fever and dyspnoea, and are able to go 
about, the cough will continue extremely troublesome: this I have 
observed in the majority of cases. In this state medicines prove of 
very little service, and one of the best remedies is to change to a 
mild country air. Cases of cough, in which I bad tried every 
remedy without success, and which had resisted every form of 
treatment in the city, yielded in a few days to the salubrious influ- 
ence of change of air. 
In influenza, the urine is generally much loaded with lithates and 
super-1 ithates, and contains a large quantity of erythric or purpuric 402 
acid. It is red when voided, deposits a good deal of sediment, and 
tinges the vessel in which it lies with a pink film. It bears some 
resemblance to the urine which accompanies arthritic and gouty 
affections. In very bad cases, this state of the urine continues up 
to the period of death. You recollect what I stated with regard to 
the-condition of the blood ; it is generally buffed, even where there 
is scarcely any febrile excitement in the system, and thus affords a 
very fallacious indication. The same observation holds good with 
respect to the state of the urine and the temperature of the skin. 1 
may observe here that the heat of skin is very variable: it is some- 
times very high, sometimes natural; in fact, like the pulse, it falls 
and rises in a very remarkable manner, at certain times in the day. 
I have already spoken of the affection of the mucous membrane 
of the bowels. I may observe, that in some cases of influenza the 
morbid influence is translated to the brain, and symptoms of deli- 
rium or coma supervene. Thus, in two instances communicated 
to me by the surgeon-general, the patients fell into a state resem- 
bling coma, during the course of the disease. In three cases wit- 
nessed by Mr. Swift, the attack of influenza terminated in a train 
of symptoms bearing a close analogy to delirium tremens, and 
requiring the use of blisters to the head and nucha, full doses of 
opium, purgative enemala, wine, and the occasional use of mercu- 
rials. The patients complained of great headache, noise in the 
ears, some intolerance of light, and more or less sleeplessness from 
the commencement, along with the usual pulmonary symptoms. 
After five or six days, they became excessively nervous, lost all 
sleep, had continued subsultus and tremors, and talked very inco- 
herently, particularly at night. During the prevalence of the 
cerebral symptoms, the pulmonary affection partially or wholly 
disappeared, but returned again in some degree after the subsidence 
of the delirium. All these cases terminated favourably. 
I believe I have already remarked, that many persons who have 
laboured under very severe pulmonary symptoms will struggle 
through the disease; and 1 may mention here that I have seen 
persons recover, who have suffered from continued orthopnoea for 
three weeks. Still the mortality, particularly among the aged, is 
very great; and I fear that we shall shortly have but few octogena- 
rians to tell the occurrences of the last century. Indeed, the mor- 
tality has not been confined exclusively to the aged, for many 
persons in the vigour of life have sunk under the attack. There 
have been several deaths among the soldiers in our garrisons, not- 
withstanding the excellent state of health which our troops gene- 
rally enjoy, and the skilful and judicious treatment of our present 
army surgeons. The results of the medical treatment and necro- 
scopic observations in the different regiments in London, Dublin, 
and Edinburgh, will form a most valuable document, and I hope it 
will be made public for the benefit of the whole profession. 
It now remains for me to say a few words concerning treatment. 
First, as to bleeding. A great deal was expected from general 
bleeding, because the disease was sudden and violent in its onset, 
GRAVES’S CLINICAL LECTURES. 403 
and accompanied by symptoms which seemed to require active 
measures—such as an inflammatory state of the bronchial mucous 
membrane, accompanied by quick pulse, hot skin, and high-coloured 
urine. This led persons to expect much benefit from venesection. 
The results, however, of its employment are, generally speaking, 
unsatisfactory. Where venesection was employed promptly and in 
the beginning of the disease, and where it seemed to be strongly 
indicated by the buffed and cupped state of the blood, even in such 
cases it has failed to afford any thing like material or permanent 
benefit, or to produce a decided amelioration of the existing symp- 
toms. The general impression among practitioners in Dublin at 
present seems to be, that bleeding is doubtful in its effects, if not 
altogether improper. I am much inclined to think that bleeding, 
unless employed within the first twelve or twenty-four hours, will 
be likely to do as much or more harm than good. Bleeding on the 
second or third day, except to relieve congestion of the lungs, seems 
inadmissible. The same observation holds good with reference to 
other diseases. Thus, in scarlatina, if you happen to be called in 
when the rigor commences, and while the disease is beginning to 
form, you will often accomplish much good by bleeding your 
patient; but after eighteen or twenty-four hours, when the disease 
is fully formed, venesection will not do. On this point I can speak 
from experience. In scarlatina, the difference of a few hours ren- 
ders venesection inapplicable, and even injurious. It is the same 
thing with respect to influenza ; general bleeding is useful only in 
the commencement, and, where the symptoms seem to demand it, 
it should be employed at least within the first twenty-four hours. 
Where I have been fortunate enough to find the disease just com- 
mencing, I bleed to the amount of twelve or fourteen ounces, order 
the patient to remain in bed and take some aperient, followed by 
the use of nitre. In this way, by timely bleeding, aperients, sudo- 
rifics, and confinement to bed, the attack generally passes over in 
two or three days. I could mention many instances of the success 
of this plan of treatment. In one family I treated all the indivi- 
duals attacked in this way, and I have done the same thing in 
many cases of persons somewhat advanced in life. In the case of 
an old gentleman, who was very severely attacked, I succeeded by 
these means in checking the disease at once. My experience, there- 
fore, is, that bleeding is of service in the very commencement of 
the disease; but as it seldom happens that a physician is called in 
at this period, I would qualify my statement by saying, that, as a 
general measure, bleeding in influenza is seldom admissible. When 
you are called on to attend cases, you will most generally find that 
the patients have been ill for two or three days or more ; and then 
the only mode of abstracting blood, which you can have recourse 
to with safety, is by leeching. About eight or ten leeches applied 
over the hollow of the neck, just above the sternum, and allowed 
to bleed pretty freely, will prove very serviceable; and if you apply 
them in the evening, you will often secure to your patient a good 
night’s rest. This plan of leeching the hollow of the neck, in 
INFLUENZA. 404 
graves’s clinical lectures. 
cases of tracheo-bronchial inflammation, is an excellent one: the 
leeches are applied at a spot which lies close to the trachea, and 
particularly to that point to which the irritation accompanying 
bronchitic affections is chiefly referred. 
By the aid of leeching, the use of aperients, if necessary, and 
confinement to bed, with sudorifics, you will frequently succeed in 
removing the fever and bronchial inflammation. You will derive 
much benefit, particularly in the early stage of influenza, from tar- 
tar emetic and nitre; but I must say, that neither leeching nor 
tartar emetic and nitre prove as valuable and as efficacious, in 
influenza, as they do in ordinary bronchitis. Some of my friends, 
who used tartar emetic as a nauseant in the commencement of the 
disease, inform me that they have derived benefit from its use; 
and others have told me that they have used tartar emetic and 
opium in the commencement and during the course of the disease, 
with advantage. I have not employed the first of these, but I have 
the latter, and with favourable results. You may, therefore, after 
using antiphlogistics for a day or two, proceed to the use of opiates, 
in combination with tartar emetic or nitre. In some cases, the 
camphorated tincture of opium will answer very well; in others, 
you will find the acetate or muriate of morphia better. A mixture, 
composed of six ounces of almond emulsion, a dram of nitre, and 
half a dram or more of the liquor muriatis morphias, will be found 
very useful. The muriate of morphia, which possesses many of 
the valuable properties of opium without its defects, will serve to 
tranquillise the system and produce sleep—two most important 
points in a disease like influenza connected with increased nervous 
irritability. A gentleman, on whom I place much'reliance, tells 
me that he has treated many bad cases successfully with camphor 
mixture, tincture of opium, and tartar emetic. I need not mention 
the various remedies which have been recommended in this dis- 
ease—as Mindererus’ spirit, Hoffman’s anodyne, ipecacuanha, alone 
or combined with extract of conium and blue pill, and many other 
remedies belonging to the class of diaphoretics or expectorants. 
They are all more or less serviceable, but they have all the common 
defect of producing less relief than they usually do in cases where 
the pulmonary affection is simple and idiopathic. Towards the end 
of the disease, you find it necessary to give stimulant expectorants 
and light tonics—as decoction of polygala senega, infusion of 
calumba, &c. &c.x 
One word about blisters, before I conclude. They are useful in 
some cases, but in many of the severe ones they do little or no 
good, and only add to the patient’s sufferings. They do not relieve 
the pulmonary symptoms, and particularly the dyspnoea, in the 
manner you would be prepared to expect. I do not know a more 
1 Doctor Blakiston strongly recommends the etherial tincture of lobelia, 
in large doses, repeated at short intervals, in influenza where bronchitis was 
present. As I had not the advantage of perusing his book during the preva- 
lence of the epidemic, (it was not published till May,) I had no opportunity 
of trying this medicine in the way he suggests. INFLUENZA. 
405 
remarkable circumstance, in the present disease, than the failure of 
blisters; and in many cases I do not employ them at all. Foment- 
ing the trachea and chest with very hot water appears to be much 
more serviceable. This has proved extremely valuable in many 
cases of this as well as other affections of the air-passages; and on 
referring to the late American journals, I find that the plan of treat- 
ing croup in its onset, by means of very hot water applied with a 
sponge to the throat—a plan which I recommended some time ago 
in the Dublin Medical Journal—has been extensively employed in 
America, and with the most happy results. Sponging the throat 
and chest with water, as hot as it can be borne, has been found, in 
many instances, capable of arresting all the threatening symptoms 
of croup at once. Several cases are mentioned in the American 
journals, in which the lives of the little patients were evidently 
saved by this application. I may state, also, that not long since a 
child was saved in Dublin by the same means. By the advice of 
Mr. Smyly, who suspected the threatened attack, the child’s mother 
had every thing prepared, and by her promptitude and care arrested 
the disease before it had sufficient time to form. 
I have nothing more at present to add on the subject of influ- 
enza ; we are still much in the dark as to the best mode of giving 
relief—and this is the more singular, as in general the disease 
allows full time for the trial and operation of medical agents. PATHOLOGICAL INDEX. 
TAGE 
Abscess of the heart, . . . 225 
Ague cake, .... 168 
Alvine evacuation, peculiarities in the, 382 
Amaurosis, 153 
Anasarca with bronchitis, case of, 178 
Anatomy, morbid, connection of with 
practical medicine, ... 3 
Aneurism, abdominal, . . .311 
thoracic, suspected, . 48 
Aphonia, 149 
Arthritis, 66 
and urticaria, with jaundice, 105 
Asthma with bronchitis, . . 54 
Bright, disease of, . . . . 376 
•« Bronchitis, .... 97 
chronic, . . 11,55 
mercury in, . . 348 
with anasarca, case of, . 178 
with asthma, . . 54 
Button-farcy in the human subject, 293 
Cancrum oris, .... 166 
Carditis, 224 
Cholera 157 
acetate of lead and opium in, 158 
Chorea, 174 
Constitution, gastric, . . . 197 
inflammatory, . 197 
Coup de soleil, .... 327 
Cough, chronic, sarsaparilla and ni- 
tric acid in, ... 354 
Cutaneous affections after fever, . 373 
Delirium and sleeplessness, . 32 
Diabetes, 179 
case of, ... 317 
Diarrhoea, chronic, . . . 128 
Dropsy, case of, . . . 57, 187< 
following scarlatina, . . 376 
with albuminous urine, . ib. 
Dysentery, 140 
chronic, . . . 128 
Enteritis, cured by opium, . . 124 
and peritonitis, case of, 95- 
Erysipelas, case of, 46, 136, 245, 369 
epidemic, . . . 259 
Evacuations, alvine, peculiarities in, 382 
Expectoration in pneumonia, . 44 
PAGE 
Farcy, button, in the human subject, 293 
,Fever, bed-sores in, ... 109 
blisters, &c. in, . . 185 
blueness of the fingers and 
toes in, ... 1S1 
maculated, . . 118,253 
nervous, . . . 142, 172 
scarlet, . 182, 193,201,281 
spotted, . . . 118,253 
supervention of other diseases 
on 367 
tartar emetic and opium in, 360 
treatment of, 
110, 211, 219, 259, 285, 303, 319 
typhoid, .... 253 
typhus, .... 253 
with cerebral irritation, . 356 
with tympanitis, &c. . 231 
yellow, .... 133 
Gangrene and pleuritis, . . 38 
Gastric constitution, . . . 197 
Glanders in the human subject, . 293 
Gout, 328 
affecting the spinal marrow, 345 
Gouty degeneration of the spinal cord, 337 
inflammation, mercury in, . 347 
Heart, abscess of the, . . 225 
Hepatic diseases, .... 238 
Hepatitis, chronic, . . . 241 
Hoarseness, . . , . .151 
(Inflammation, constitutional, . 328 
gouty, mercury in, . 347 
neuralgic, after fever, 367 
scrofulous, of the lung, 349 
Inflammatory constitution, . 197 
(Influenza, 385 
Iritis, syphilitic, ... 68 
Jaundice, with arthritis and urticaria, 105 
.Kidney, diseased, . . . 376 
■Laryngitis, chronic, . . . 226 
Liniment of St. John Long, . 55 
Liver, diseases of the, . . . 238 
Lungs, scrofulous inflammation of 
the, mercury in, 349 PATHOLOGICAL INDEX. 
PAGE 
Lung, solidification of the, percus- 
sion in, ... 355 
Metritis, case of, ... 381 
Nervous system, pathology of the, . 70 
Neuralgia of the face, . . 103( 
Neuralgic inflammation after fever, 367 
(Esophagitis, case of, 127 
Opium, poisoning by, flagellation in, 265 
Paralysis, ... 70,336 
agitans, . . . .176 
Paraplegia, .... 70 
Percussion in solidification of the 
lung, 355: 
Pericarditis, .... 223 
Peritonitis and enteritis, case of, . 95 
Phlebitis, case of, . . 162, 369 
Phlegmasia dolens, . 165, 369,379 
Phthisis, percussion in, . . . 356 
scrofulous, prevention of, 351 
Physiology, importance of, . . 1 
Pleuritis and gangrene, . . 38 
*Pleuro-pneumonia, . . . 145 
► Pneumonia, .... 44 
complicated with pleuritis, 144 
double, .... 221 
Poisoning by opium, flagellation in, 265 
Poisons, animal, remarks on, . 301 
Prurigo, 229 
Psoriasis, diffused, . . . 139 
Pulmonary diseases, blisters in, . 289 
Pulsations of the heart in disease, 52 
Pulse, remarks on the, . . 126 
PAGE 
Pustules of Colles, . . . 372 
»Rheumatism, acute, . . . 66 
chronic, ... 64 
hydriodate of potass, in, 353 
►Scarlatina, . . 182,193,201,281 
dropsy following, . 376 
Scrofula, mercury in, 349 
Sleeplessness, .... 25 
and delirium, . . 32 
Sores, bed, in fever, . . . 109 
Spinal cord, gouty degeneration of 
the, . . . 337 
gout in the, . . 245 
Spleen, organic derangement of the, 243 
Syphilis, eruption in, 61 
iritis of, ... 68 
secondary, ... 59 
Thyroid gland, affection of the, . 135 
Tic douloureux, simulation of, . 103 
Tympanitis with fever, . . 231 
Typhoid fever, .... 253 
Typhus, 253 
spotted or eruptive, . . 358 
tartar emetic and opium in, 360 
Urine, albuminous, . . . 376 
retention of, ... 213 
Urticaria, 107 
and arthritis with jaundice, 105 
Uterus, inflammation of the, . . 382 
Vesicles of Colies, . . 372, 375 
Voice, loss of, .... 149 
THE END.