HXOOO 17833 
 
 ^ 
 
 mm-: 
 
 JMniii I ' ' 
 
 If") ' *'< 
 
 
 

 ^ 
 
 CoUege of 3^f)vsitim^ aniJ ^urgeonss 
 Hibrarp 
 
p. 
 
 % 
 
 t^ 
 
DISEASES OF TROPICAL CLIMATES 
 

 
To old " Netley men," wherever they are serving their 
 country, this brief summary of the Lectures on Tropical 
 Medicine, " once delivered " to them during the brief season 
 of their probation, is dedicated with a renewed expression 
 of the warm interest and goodwill of their friend and former 
 teacher. 
 
 "QUI MONET AMAT, AVE ET CAVE." 
 
Digitized by tine Internet Arciiive 
 
 in 2010 witii funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/diseasesoftropicOOmacl 
 
CONTENTS 
 
 PAGE 
 
 Introductory Lecture . . . . i 
 
 LECTURE II 
 
 Malaria . . . . . . .22 
 
 LECTURE III 
 Intermittent Fever ..... 40 
 
 LECTURE IV 
 Remittent Fever . . . . . .58 
 
 LECTURE V 
 Enteric Fever 74 
 
 LECTURE VI 
 Febricula and Relapsing Fever . . .102 
 Dengue ........ 109 
 
Vlll CONTENTS 
 
 
 LECTURE VII 
 
 PAGE 
 
 Yellow Fever 
 
 LECTURE VIII 
 
 . 119 
 
 Insolation 
 
 LECTURE IX 
 
 . 142 
 
 DiARRHCEA 
 
 LECTURE X 
 
 • 157 
 
 Dysentery 
 
 
 • 174 
 
 LECTURE XI 
 
 Dysentery {Continued) . . . . .193 
 
 LECTURE XII 
 Cholera . . . . . . .212 
 
 LECTURE XIII 
 
 Cholera {^Conti7iued) . . . . .236 
 
CONTENTS 
 
 LECTURE XIV 
 
 PAGE 
 
 Diseases of the Liver. .... 262 
 
 LECTURE XV 
 Beriberi ....... 308 
 
 LECTURE XVI 
 
 Guinea- Worm . . . . . .321 
 
 The Climate of India . . . . .326 
 Farewell Address . . . . -329 
 
 APPENDIX 
 
 Dr. Warburg's Tincture . . . -339 
 
 Martin's Acid Bath 340 
 
 Formula for the Diarrhcea Mixture in the 
 
 "Field Companion" .... 340 
 
DISEASES OF TROPICAL CLIMATES 
 
 INTRODUCTORY LECTURE 
 
 Gentlemen — Meeting you here for the first time, it is 
 necessary for me to give you some explanation of the 
 nature and scope of the course of instruction on which 
 you are about to enter. The chair I have the honour 
 to fill in this school is that of Military Medicine. It is 
 my business to deal with the diseases apart from the 
 battle and other injuries to which soldiers are liable in 
 the course of their service. 
 
 The subject of military medicine is a very wide one, 
 so much so, that with the time at my disposal it is im- 
 possible for me to deal with it in its entirety. Fortu- 
 nately the scheme of study here has been so arranged 
 as in a great measure to meet this difficulty. 
 
 One course supplements another ; some subjects that 
 might with propriety be dealt with from this chair, fall 
 as naturally into the course of Military Hygiene, and are 
 taken up by my colleague, the professor of that branch. 
 The Professor of Pathology, in like manner, is able to 
 deal with the morbid anatomy of some diseases more 
 minutely than the time allotted to me enables me to do. 
 
 B 
 
2 DISEASES OF TROPICAL CLIMATES lect. 
 
 The part of the course on which we enter to-day is 
 entirely devoted to Tropical Medicine. 
 
 Let me first invite your attention to two important 
 aids to the study on which you are about to enter. The 
 great hospital in which we are assembled is intended 
 for the reception of invalids from every part of the 
 world where the British soldier serves, whether suffer- 
 ing from disease or wounds; opportunities are thus 
 offered to you to study the effects of various climates 
 and diseases, as yet foreign to your experience, on the 
 persons of those who, under due supervision, will be 
 committed to your care in the wards. This was the 
 chief motive that governed the senate of the Army 
 Medical School, acting in this, as in all other matters, 
 with the sanction of the Minister for War, in selecting 
 the Royal Victoria Hospital, Netley, as the home of 
 the school, in the face of objections to such a selection 
 of considerable weight, viz. its distance from London, 
 cutting the professors off from the great centres of 
 medical education, and profitable intercourse with 
 metropolitan teachers and scientific societies. 
 
 The next is the Pathological Museum of the Medical 
 Staff of the Army, which has found a permanent home 
 in this hospital. It is not too much to say of this 
 collection that, as an aid to the study of military medi- 
 cine and surgery, there is no museum in this country 
 like it. The teachers here find on its shelves material 
 to illustrate every disease and injury to which the 
 soldier is liable, and its doors are open to you during 
 all working hours for private study. 
 
INTRODUCTORY LECTURE 
 
 If you, as many have done, ask what is the neces- 
 sity for special instruction in the diseases of hot 
 cHmates ? I answer, that the subject is not taught 
 in the civil schools, partly for want of time and the 
 needful opportunities for the study of such diseases on 
 the part of the teachers, and the necessary material 
 for bedside illustration so abundantly supplied here ; 
 but, above all, because 60,000 British soldiers are 
 always serving in India, requiring a large staff of care- 
 fully instructed and trained medical officers for their 
 care. Nor is this all. Side by side with those who 
 devote their lives to the service of the British army sit 
 a body of gentlemen, for whose benefit, no less than 
 for theirs, this school was established. For them the 
 study of tropical medicine is of vital importance. All 
 their professional lives will be spent in India ; on them 
 the medical charge of a large native army will devolve, 
 without the aid of which it would be impossible to hold 
 India as a British possession, except at a sacrifice which 
 England has neither the means nor the inclination to 
 make. To them will in the future be committed the 
 care of the valuable lives of those charged with the civil 
 administration of India, and from the ablest of them the 
 selection of teachers will be made to fill the chairs of 
 the medical and allied sciences in the colleges estab- 
 lished by an enlightened Government, and to be its 
 advisers on all questions affecting the health of the 
 200,000,000 of people of the various races of the 
 Queen's empire of Hindostan. 
 
 Before entering on the study of the diseases which 
 
4 DISEASES OF TROPICAL CLIMATES lect. 
 
 are the chief factors of mortality and invaliding in 
 India, it will not be out of place to take a retrospective 
 glance at the causes which, in past times, were most 
 active in conducing to the immense mortality and in- 
 validing which were first brought to light by the statis- 
 tical inquiries of Sir Alexander TuUoch and Dr. Balfour, 
 and subsequently by the Royal Commission appointed 
 to report on the health of the army of India. 
 
 According to the Commissioners the death-rate of 
 the British soldier from the first occupation of the 
 country, down to the time immediately preceding the 
 appointment of the Royal Commission, i860, oscillated 
 round 69 per 1000. They did not say that this number 
 died every year, still less that men died at this rate at all the 
 stations where they were quartered ; during the Mahratta 
 war it was as high as 134 per 1000, and in 1852 it was 
 as low as 40 per 1000. 
 
 In India, as at home in the pre-sanitary age, the great 
 aim of the local authorities was to confine the efforts of 
 medical officers as much as possible to the cu?-e of 
 disease. Military men in all ages and in all countries 
 have been impatient of medical "interference" in matters 
 affecting the health of those under their command. 
 " Medical advice " (by which was meant advice on the 
 prevention of disease), said a General, whose army was 
 melting away from preventable causes, " is a very good 
 thing when it is asked for," which it never was by this 
 commander, whose army in Burma lost 113, 106, and 
 130 per 1000 in the three years 1824-26. Authorities, 
 civil and military alike, were of opinion that the diseases 
 
INTRODUCTORY LECTURE 
 
 of India arose from causes beyond human control; as 
 they could not be " cured " they were to be " endured," 
 and as little said about them as possible. 
 
 In time, however, a change was gradually brought 
 about. The sanitary movement in England had a great 
 effect ; slowly the dawn of a better day appeared ; the 
 exhaustive and fruitful inquiry into the health of the 
 British army, followed by a like measure for the army 
 of India, in both cases conducted by Royal Commis- 
 sioners, gave an impetus to the sanitary movement. The 
 Government of India was at last roused to action, and 
 entered on the work of sanitary reform under the 
 guidance of sanitary commissioners selected from their 
 own service, with intelligence and zeal, and with results 
 which will be developed in this course of lectures. Sir 
 Ranald Martin, formerly a medical officer of the Bengal 
 army, was an active member of both commissions, as he 
 was of the commission to which England owes the 
 Health of Towns' Act, the Magna Charta of British 
 Sanitary Reform ; and both armies owe a debt of grati- 
 tude to the labours of this distinguished and large- 
 hearted man, in a small degree commemorated by his 
 personal and professional friends, who knew him well 
 and loved him much, in the memorial gold medal 
 competed for by those in this school who, animated by 
 his example, seek to follow in his footsteps. 
 
 Let us look more closely at this part of our subject. 
 Going back many years we find it was the custom to 
 send troops to India in a class of ships ill-adapted and 
 fitted for such a purpose ; very inferior in point of 
 
6 DISEASES OF TROPICAL CLIMATES lect. 
 
 speed, the voyage, often extending over six months, 
 sometimes reached nine in duration. Overcrowding was 
 the rule, the ration was ill-suited for so long a voyage, 
 and often deficient in anti- scorbutic elements. The 
 mortality in these prolonged voyages was always con- 
 siderable, sometimes shocking. We read of 170 men 
 dying in the Hoogly in one ship, after such a voyage, 
 between the months of August and January. Of two 
 companies losing 75 men during a voyage of eleven 
 months, 40 of them from "fever," probably typhus, 
 18 from dysentery, and the remainder from scurvy and 
 cachexy. The Second Battalion of the 42d Regiment 
 suffered a loss of 5 officers, and 116 men between 
 England and Calcutta. Let the above examples, out 
 of many, suffice. It is well that we should occasion- 
 ally look back on such facts and figures, and compare 
 them with those of our own time : they serve to mark 
 progress, and should stimulate us to fresh exertion. By 
 way of contrast then let me invite your attention to the 
 fact that when the mutiny of the Bengal Sepoys called 
 for the presence of a large European force to suppress 
 it, regiment after regiment was landed in Calcutta, in 
 by far the majority of instances, without a death by 
 the way. 
 
 After voyages such as I have indicated, in duration 
 so extended, and under sanitation so defective, it will 
 not surprise you to learn that the soldier was too often 
 landed in a deteriorated state of health — in a more or 
 less scorbutic condition, and consequently ill able to re- 
 sist the disease -producing agents to which he was at 
 
INTRODUCTORY LECTURE 
 
 once subjected. Arrived in India he was too often 
 quartered in stations of proved insalubrity — stations 
 selected, in most cases, without reference to questions 
 of health ; military and political considerations of real, 
 often of merely supposed urgency, alone governing the 
 selection. The barracks were placed with a like disre- 
 gard to the health of the inmates, in unsuitable places, 
 on unsuitable soil, in a word, with total disregard to all 
 that we comprise under the word climate. The build- 
 ings themselves were often ill -contrived, ill -ventilated, 
 almost always overcrowded. I have seen 1200 men 
 quartered in barracks originally intended for 700. The 
 latrines were almost invariably in the wrong place, im- 
 perfectly flushed, a privy atmosphere often prevailing in 
 certain ranges, invariably giving a much larger propor- 
 tion of cases of diarrhoea, dysentery, cholera, and what 
 is now recognised, but was not then, enteric fever. 
 Surface drainage in the neighbourhood of the barracks 
 was usually most imperfect ; subsoil drainage mostly 
 never thought of The water supply, to this day a 
 great difficulty in India, was in the olden time hardly 
 recognised as a source of disease at all, and was often, 
 indeed almost always, to put it mildly, bad. The food 
 of the soldier was ill-suited to the climate, monotonous, 
 excessive in nitrogenous ingredients, ill-cooked, greasy 
 curries being the most common form — a fertile source ot 
 diarrhoea, particularly in young soldiers, and of hepatic 
 disorders among those of all ages. It is impossible 
 to exaggerate the extent to which intemperance prevailed, 
 or the amount of disease to which, directly and indirectly, 
 
8 DISEASES OF TROPICAL CLIMATES lect. 
 
 it led ; the liquor consumed being often of a peculiarly 
 pernicious kind. It is needless to add that sexual 
 excesses contributed, then as now, with all that impurity 
 brings in its train, to swell the amount of sickness, 
 mortality, and invaliding. Until a comparatively recent 
 time in the history of the European army in India, the 
 system of dressing and accoutreing the English soldier 
 was opposed to the plainest dictates of common sense.; 
 within my own recollection he mounted guard in the 
 hottest weather dressed very much as if he had been 
 doing duty in a Canadian winter, less, of course, his 
 greatcoat, and as for his head-gear, I have, as I have 
 elsewhere said, seen at least half a dozen different forms 
 of chako " dance into the light and die into the shade," 
 the last more ingeniously contrived even than the 
 first, to concentrate the sun's rays on the crown of the 
 head, as if the intention of the inventor had been to 
 promote insolation, too often followed by a successful 
 result. I cannot resist pausing for a moment to notice, 
 what you must often have done as you passed, in your 
 walks through London, some of our official buildings, 
 particularly those belonging to the military departments. 
 There, in the bitterest days of our winter, are to be seen 
 men shivering on sentry duty in their tunics, while their 
 comrades off duty are walking about comfortably in their 
 greatcoats. Or, what is still more curious, we can any 
 day see some of the finest-looking soldiers the world can 
 show, sitting motionless on their horses, in the same 
 weather, alike unprotected, with a brightly polished 
 cuirass on their chests to carry off briskly into space 
 
INTRODUCTORY LECTURE 
 
 what of animal heat the winter wind has left, while, 
 perhaps, a mounted trooper on ordinary duty of some 
 kind, duly protected, is to be seen trotting comfortably 
 past. Yet I often hear people wonder why the house- 
 hold troops suffer with exceptional severity from destruc- 
 tive lung diseases? It is not in India only that some 
 lessons are wanted on this subject ; " smartness " in 
 Avinter weather should surely give place on so vital a 
 point as this. 
 
 Returning to what concerns us here to-day, I have to 
 show you that it is only in recent years, say within the 
 last thirty, that attention was paid to season in the 
 movement of troops, which often took place during the 
 rainy season, or in the fervent heat of the Indian dog- 
 days. It is hard to say which was the most destructive 
 or caused the greatest amount of suffering. Let me 
 give you an example, more likely to impress you than a 
 vague general statement, sure to " go in at one ear, and 
 out at the other." Within my own recollection the fol- 
 lowing tragical occurrence took place. A distinguished 
 General officer arrived in Madras to take the command 
 of the army of that Presidency. It so happened that 
 the regiment he commanded in Spain, under Wellington, 
 and with whose history his own was imperishably as- 
 sociated, was shortly expected to arrive within the limits 
 of his command. Not unnaturally he was anxious to 
 secure for his old regiment the best station in the 
 Presidency. Having ascertained this, he gave orders 
 that the regiment, then occupying the station reputed 
 the best, should, on the arrival of his own, be marched 
 
10 DISEASES OF TROPICAL CLIMATES lect. 
 
 to one in a distant part of the Presidency. The officers 
 of the local staff pointed out that to carry out this order 
 would doom the regiment to destruction, as the monsoon 
 was on the point of bursting. To this the commander- 
 in-chief would not listen ; he had never served in India, 
 knew nothing of its climate, and thought that British 
 soldiers should be ready to go anywhere and do anything. 
 The march took place. At the end of it the regiment 
 was inspected by Inspector-General Donald Macleod (an 
 old Peninsular companion of the commander-in-chief), 
 who reported that barely loo men were fit to bear 
 arms. Transport ships were taken up, and the miser- 
 able remains of this once fine regiment was sent to 
 cruise in the Bay of Bengal, to " recover " their health. 
 It was my fortune to see this regiment in Lower Burma 
 soon after it had been made up to its former strength by 
 drafts from England. The late Dr. Parkes saw it 
 also, and very well knew the sad episode in its history I 
 have just related. Drills and military exercises were 
 often carried on in like manner in defiance of climatic 
 conditions, and sometimes in the face of terrible examples 
 of evil consequences resulting. Just before my arrival 
 in India, a General officer met with a fatal accident. 
 What took place on the occasion of that officer's funeral 
 is a tradition in that part of India to this day. The 
 parade took place in heavy marching order, the men 
 having as head-gear one of the ray-traps already referred 
 to, made after the pattern of the one I now show you. 
 Before the sun rose next day seventeen men were in the 
 dead-house struck down by insolation. Can we wonder 
 
INTRODUCTORY LECTURE 
 
 that the death-rate and terrible amount of invaliding 
 revealed by the Royal Commission in the European 
 part of the army of India, startled the conscience of the 
 nation, and roused the authorities to the necessity of 
 sanitary reform in the widest sense of the term, I 
 must not pass from this painful part of my subject 
 without touching on another point. In the pre-sanitary 
 age little was done, at all events in a general and 
 systematic way, to raise the moral tone of the soldier by 
 the establishment of reading and recreation rooms, and 
 to wean him from vice and debauchery by other means 
 than a harsh and unsympathetic discipline. It is 
 unpleasant to recall the frequency and severity with 
 which the lash was used to punish " crimes " and 
 breaches of military discipline, that would, in the present 
 day, be thought adequately punished by some days' con- 
 finement to barracks, or at most to the solitary cells. 
 
 The financial aspect of this state of matters did not 
 escape the attention of the Royal Commissioners, and 
 it is well you should have it brought before you, to 
 deepen the impression it is my object to make on your 
 minds on your first entry on the study of military 
 medicine. The cost of a regiment in India, when every 
 item has been brought into the account, they reckoned at 
 the great sum of ;^ 100,000, and the money value of a 
 man at ;^ioo. Without going into details, I may say 
 that they calculated the cost of sickness to the State, at 
 the rate they make out in their Report, to be ;^5 88,000 
 annually. Deducting ;^2 00,000 for sickness assumed 
 to be inevitable, and ;^3 88,000 remain. 
 
12 DISEASES OF TROPICAL CLIMATES lect. 
 
 Turning now for a brief time to the first effects of the 
 great sanitary movement to which I have just referred. 
 This is often spoken of as if it was entirely due to the 
 labours of the Royal Commission to w^hich I have so 
 often referred. If you wdll turn to the evidence taken 
 before this commission, you will find abundant proof 
 that their recommendations, which have been so fruitful, 
 were for the most part based on knowledge supplied by 
 the medical and other officers of both armies — knowledge 
 which had been for many years available if those in 
 power had sufficiently appreciated its value and carried 
 it into practice. This statement, which does no injustice 
 to the Royal Commissioners, is due to those who were 
 long the unheeded promoters of sanitary reform. The 
 splendid results which have followed this reform were 
 brought about in the main by a reversal of the system 
 it has been my duty to explain to you. 
 
 Troops are now sent to India at proper seasons of 
 the year in steamships expressly built and fitted for the 
 purpose. They are housed in better barracks, without 
 overcrowding, and properly ventilated ; and health con- 
 siderations in most cases are ahowed due weight in the 
 selection of site. As already said, a proper water supply 
 is one of the greatest obstacles in the way of health in 
 India. It is very difficult to obtain it, particularly when 
 troops are quartered in or near the great centres of 
 population, where the soil has become sodden with faecal 
 impurities. As a rule no pains are spared by engineer 
 and medical officers to secure the best available, and to 
 use the best known means for its purification. There is 
 
INTRODUCTORY LECTURE 
 
 no part of a medical officer's duty of more importance 
 than to keep a watchful eye over the water supply for 
 the men committed to his care. The latrines, already 
 shown to have been in the olden time such fertile sources 
 of disease, are now better placed, and the dry-earth 
 system has everywhere superseded that of imperfect flush- 
 ing. It has, however, been lately established that the 
 good effects of this system may be vitiated if the vessels 
 in use for the solid deposits are unglazed. Such vessels 
 become in time saturated with decomposed matter, 
 give out an abominable odour, and become sources of 
 disease. The point, trifling as it may appear, is worth 
 your attention. The diet of the soldier in India is 
 better attended to ; is less monotonous, of better quality, 
 and better cooked. His clothing is now infinitely 
 better adapted to the climate, and his head is protected 
 by a helmet better suited for the purpose. I cannot 
 refrain from mentioning a fact recently brought to my 
 notice by a medical brother officer. In one of the 
 actions with the mutineers a cavalry soldier, whose hard 
 fate it was to wear a huge brass helmet, was brought to the 
 field-operating tent with one leg below the knee smashed 
 by grape-shot. In reply to a question as to the pain of 
 a wound so serious as to demand immediate amputation, 
 he replied, "Yes, sir, it is painful, very painful, but 
 nothing to the horrible pain in my head from that thing," 
 pointing to his brass helmet beside him.^ The modern 
 
 1 The present regulation helmet, although a great improvement 
 on the old chako, is far from perfection ; it gives no protection to 
 the temples, is badly shaped, and not properly ventilated. Many 
 
14 DISEASES OF TROPICAL CLIMATES lect. 
 
 system of accoutreing the soldier has been extended to 
 India, to his immense comfort : an improvement mainly 
 due to my late colleague, Professor Parkes, with which 
 his name ought to be more associated than it ever has 
 been. The temperance movement has made great pro- 
 gress in India. Total abstainers are now reckoned 
 among our men by thousands ; and although I am far 
 from saying that soldiers have ceased to carry with them 
 to the East their national vice, as compared with what 
 it was in my day, the improvement is very notable, and 
 has been a powerful factor in diminishing disease and 
 mortality. No better evidence of this gratifying fact can 
 be adduced than this, which I give you on the authority 
 of the paymaster of this hospital, that the money brought 
 home from India by the invalids and time-expired men 
 who pass through it, often amounts to between forty and 
 fifty thousand pounds in an invaliding season. Much is 
 now done to find wholesome recreation and employment 
 for them by the establishment sometimes of workshops, 
 and always of reading and other recreation rooms. Hill 
 stations now exist where formerly unknown ; and as 
 facilities for rapid movement and the concentration of 
 troops, when required, become more and more estab- 
 lished, it is probable that a longer part of the British 
 soldier's service in India will be passed away from the 
 
 officers wear a small white skull-cap under their cork helmets, 
 which, slight as it may appear as a protection, is found very 
 effectual. The nearer the military authorities can be induced to 
 approximate the head-gear of soldiers to that worn by sportsmen 
 in India, the fewer will be the cases of sunstroke on service. 
 
I INTRODUCTORY LECTURE 15 
 
 hot and malarious plains than is as yet possible. To 
 the young soldier fresh from Europe this will be a great 
 boon, and tend to diminish the sickness and death-rate 
 from enteric fever, which is the scourge of the young and 
 newly-arrived. 
 
 When climate-struck, the facilities for a return to their 
 native land, for the non-commissioned officers and privates 
 of the army, have been enormously extended. The 
 same "first-class" transports that brought them to India 
 take them home again, and on arrival they are received 
 and cared for in the noble hospital in which we are 
 assembled. 
 
 Of late years the death-rate among officers in India 
 has been about 13 per 1000, closely approximating to 
 that of the Civil Service. The mortality of the wives 
 and children of soldiers has always been high. As a 
 class the women are ignorant, slow to accommodate 
 themselves to the new climatic conditions in which they 
 are placed, and in the pre-sanitary age they were not 
 so well cared for and instructed as they might have 
 been. In 187 1 the death-rate was 18.53 per 1000, 
 including 2.45 per 1000 from cholera. In Madras it 
 was 18.30 per 1000 from all causes. In Bombay it 
 was 17.93 PS^ 1000, no cholera in that year. As with 
 the wives so with the children of British soldiers, the 
 mortality has always been high, sometimes enormous ; 
 it has been recorded as reaching 83 per 1000, 94 per 
 cent being under five years of age ; the chief causes 
 of mortality being convulsions, dentition anaemia, and 
 atrophy, diseases for the most part due to the ignorance of 
 
i6 DISEASES OF TROPICAL CLIMATES lect, 
 
 the mothers, more particularly in the all-important matter 
 of diet. That this enormous mortality is not due merely 
 to climate is conclusively proved by the statistics of the 
 civil, military, and medical funds, which show that up to 
 the age of seven years the mortality of European child- 
 ren in the class represented is much less than among 
 children of the same class in Europe. And Sir Joseph 
 Fayrer has shown, that although the Female Orphan 
 Asylum in Calcutta is not very favourably placed 
 as regards its sanitary surroundings, the mortality 
 among its inmates is less than in similar institutions in 
 Europe. 
 
 Let us now see the effect in the reduction of mortality, 
 the outcome of the improvement in sanitation I have 
 briefly summarised. I take the year 187 1, about ten 
 years after the introduction of measures of sanitary 
 reform on a large scale, and because it was the first year 
 in which the sanitary commissioner, with the Govern- 
 ment of India, was able to include in his annual report 
 the statistics for all India. The death-rate for all 
 India in that year was 17.53 per 1000, the lowest, up 
 to that date, ever attained. In the Bengal Presidency 
 it was 17.83 per 1000, "just a trifle above that of the 
 native army," which was 17.81 per 1000. Deducting a 
 small mortality from cholera among British troops, the 
 death-rate from all causes was 17.12 per 1000. Follow- 
 ing the same authentic record, we find that the strength 
 of the British army in India in that year was 56,806, 
 the deaths amounted to 996, the invalids for discharge 
 and change of air 23S1, including those who died on 
 
I INTRODUCTORY LECTURE 17 
 
 the homeward voyage, and in this hospital, the total 
 loss by death and by discharge was 34.71 per 1000, 
 just one -half of the loss by death alone in the pre- 
 sanitary age. This was not all : in the year under notice 
 the number of men "constantly sick" fell from 10 per 
 cent to 5 1 per cent of strength. 
 
 What are the diseases which injure the health and 
 destroy the life of the British soldier in India ? They 
 are chiefly fevers, bowel complaints, diseases of the liver, 
 and epidemic cholera. Turning again to the year 187 1, 
 the strength of the army being, as already mentioned, 
 56,806, and the total deaths 996, we find that 62 died 
 from cholera, 99 from malarial fevers, 92 from enteric 
 fever, 87 from phthisis, 39 from insolation, 96 from 
 diseases of the heart and blood-vessels, 21 from pneu- 
 monia, 155 from liver diseases, and 76 from dysentery. 
 The sanitary commissioner compares this death-rate with 
 that of the same class at home, and the result is that 
 respiratory diseases are less fatal in India ; the mortality 
 from heart disease is nearly the same in both countries ; 
 but the febrile group is sixfold more fatal in India than 
 at home, while dysentery is 47, and hepatitis 227 times 
 more fatal than at home. 
 
 The startling fact that enteric fever is the disease 
 most fatal to young soldiers in India was brought to 
 light by the late Dr. Bryden, statistical officer to the 
 Government of India, an officer of whom it is not too 
 much to say that he was one of the ablest vital statists 
 the medical profession has ever produced. Until a com- 
 paratively recent time this disease was not clinically 
 
 c 
 
i8 DISEASES OF TROPICAL CLIMATES lect. 
 
 dififerentiated in India. Just as in Europe it was con- 
 founded with typhus, until Jenner and Stewart estabhshed 
 the diagnosis, so in India, cases of enteric fever were 
 constantly mistaken for the adynamic form of remittent 
 fever, and registered accordingly. 
 
 It was first diagnosed by Dr. Scriven of the Bengal 
 army, by myself, and the late Dr. Barclay, then sur- 
 geon of the 43d Regiment, in Madras, about the same 
 time ; but it is mainly to the researches of Dr. Bryden 
 that its great prevalence and fatality was placed on a sure 
 statistical basis. The thread of malaria, with more or 
 less of the type of periodicity it always induces, obscuring 
 the diagnosis ; the fact also that men dying of this 
 disease, when their bodies were brought to the post- 
 mortem table, almost invariably presented the well-known 
 morbid appearances due to malarial poisoning, tended to 
 mislead observers, and even to cause some to deny 
 stoutly the existence of enteric fever at all in India. 
 Has it ever been imported into that country from 
 Europe ? Surgeon-General Munro has placed on record 
 an instructive example of this. His regiment, the 9 2d, 
 took the disease on board ship when it embarked for 
 India, suffered from it on the voyage, carried it up the 
 Indus to its destination — the station of JuUundur, where 
 it prevailed for some time. But, as already mentioned, 
 it is mainly to Bryden we owe the fact that enteric fever 
 is the scourge of young soldiers in the first year of their 
 Indian service, and that it is mainly in the hot weather 
 that they are prone to be attacked. Bryden was of 
 opinion that the disease can arise spontaneously, without 
 
I INTRODUCTORY LECTURE 19 
 
 the application to the system of a poison elaborated in 
 the persons of men previously affected; although he 
 admits that a zymotic element is generated when enteric 
 fever is so developed. 
 
 In 187 1, the year, under the guidance of the sanitary 
 commissioner, we are passing in review, the admissions 
 for intermittent fever were 21,174, for remittent 1648, 
 for continued and ephemeral fevers, under which head 
 I suspect many sUght cases of undiagnosed enteric were 
 included, 7230, and recognised enteric 207. In all, 
 from this class, 30,259 admissions out of a total number 
 of 82,345, 460 men being constantly in hospital from 
 fevers. 
 
 It is impossible to give in figures any adequate notion 
 of the extent to which the abuse of alcohol in India has 
 tended, directly and indirectly, to swell the amount of 
 sickness, mortality, and invaliding. It will throw little 
 light on this painful subject to say, that in the year under 
 notice there were 125 admissions and 9 deaths from 
 delirium tremens. No figures can show the effects of 
 this potent disease factor. My experience leads me to 
 point to the fact that in 187 1 3700 men were admitted 
 into hospital under the head of hepatitis, with 155 
 deaths, as strong evidence of the baneful influence of 
 strong drink in a hot climate. In India, as at home, 
 venereal diseases swell the sick returns; 458 men were 
 constantly in hospital from this cause. It is needless to 
 remind you that out of the total admissions, 11,179, a cer- 
 tain proportion from the secondary forms of this disease 
 must inevitably have become permanently inefiicient. 
 
20 DISEASES OF TROPICAL CLIMATES lect. 
 
 I have thus, gentlemen, as far as the time at my dis- 
 posal for the purpose admitted, given you, as it were, 
 a bird's-eye view of this part of the subject. Before I 
 conclude I wish you to understand that the unfortunate 
 antagonism to which I referred in the early part of this 
 lecture, as existing between military and medical authority 
 on questions of health has been almost entirely removed. 
 In accordance with a wise recommendation of the Royal 
 Commissioners, medical officers are no longer restricted 
 to the cure of disease. They are not only allowed but 
 are enjoined to advise on its prevention, as perhaps the 
 most important part of their duty. But you must under- 
 stand that commanding officers are not, by the rules of 
 the service, obliged to follow the advice given. When a 
 senior medical officer tenders advice on an important 
 point of sanitation, if the officer in command does not 
 see fit to comply with the advice given, if that advice 
 does not commend itself to his judgment, or cannot for 
 good military reasons be carried out, the authorities 
 direct him to place his reasons in writing for his refusal, 
 and the responsibility of the medical officer ceases. 
 
 And here, gentlemen, let me at this, the very outset 
 of your military life, advise you to be most circumspect 
 in this matter of advice, at all times, but more particu- 
 larly in the early years of your career, when as yet your 
 personal experience is small. Let me urge you to apply 
 your minds during your brief stay here to learn " how to 
 advise." That is one of the reasons why you are sent 
 here. Some would-be advisers of young army medical 
 men try to persuade them that when they leave the civil 
 
INTRODUCTORY LECTURE 
 
 schools they are fully equipped for all that is before them 
 in military hfe. Gentlemen, believe me, this is a mis- 
 take ; if with such a notion in your heads you enter on 
 your duties despising what is taught here, your first 
 interview with a commanding officer of knowledge and 
 experience when you appear before him as an adviser 
 on a matter of health, will painfully undeceive you. 
 Modern soldiers are not all ignorant, as many of those 
 of the old school were, of the elements of sanitary 
 science, and some, you wall find, have Parkes' Elements 
 of Hygiene at their finger ends, as ignorant and pre- 
 sumptuous advisers will soon find out to their confusion. 
 This, gentlemen, is a word to the wise. Above all, let 
 me urge you, when you approach those who have the 
 responsibility of miUtary command on their shoulders, 
 particularly in the early days of your service, not to do 
 so (excuse the familiar but expressive word) '"'■bump- 
 tiously^' but rather modestly, and only after you have 
 carefully considered the subject in all its bearings. 
 When you have to put your advice in writing be doubly 
 circumspect, '■'■ lit era script a manet." Remember, it has 
 to be submitted to a man of education, of experience, of 
 knowledge of his work, and of the world ; and be assured, 
 if your letter, memorandum, or whatever shape it may 
 have, is not so written as to carry on its face evidence 
 that it proceeds from the pen of an educated gentleman, 
 it will count for little in the estimation of the officials 
 into whose hands it may pass. 
 
LECTURE II 
 
 MALARIA 
 
 Before entering on the subject of the class of fevers 
 known as malarial, it is necessary to say a few words on 
 the poison to which they are supposed to owe their 
 origin, and from which they take their name. To this 
 agent the name of malaria has long been given — in the 
 present state of knowledge a sufficiently convenient 
 term, although it implies an hypothesis. 
 
 Let me first deal with the latest opinion put forth by 
 men of science as to the real nature of the supposed 
 cause of the class of fevers known as malarial. Accord- 
 ing to Professors Tommasi Crudeli of Rome, and 
 Klebs of Prague, these fevers are not due to a malaria 
 or fever-generating agent proceeding from marshes. In 
 the year 1870 they examined the lower strata of the 
 atmosphere in the Agro Ro7jiano, as well as the soil and 
 water of that region so notorious for fevers of the inter- 
 mittent and remittent type. In the two former they dis- 
 covered " a microscopic fungus, consisting of numerous 
 movable shining spores of a longish oval shape, and 
 nine micromillimetres in diameter. This fungus was 
 
MALARIA 23 
 
 artificially generated in various kinds of soil ; the fluid 
 matter thus obtained was filtered and washed, and the 
 residuuip left after filtration was introduced under the 
 skin of healthy dogs. The same thing was done with 
 the firm microscopical particles obtained by washing large 
 quantities of the surface soil." According to the learned 
 authors the animals so treated went through all 
 the phenomena of a typical case of intermittent fever ; 
 showing precisely the same acute enlargement of the 
 spleen as human patients who have caught the disease 
 in the ordinary way, and in their spleens the charac- 
 teristic form of fungus was found. As this fungus grows 
 in the shape of small rods, the discoverers gave it the 
 name of Bacillus ?nalaricB, and declared their belief that 
 the class of fevers hitherto supposed to be due to a bad 
 air soil- produced, was due to this bacillus. Two 
 physicians, practising in Rome, viz. Drs. Marchiafava, 
 and Valenti, announce that they have detected this 
 bacillus in human patients in a more advanced stage 
 than in the animals experimented on by Tommasi 
 Crudeli and Klebs. In the article " Malaria," contributed 
 by me to Dr. Richard Qvizixis Dictionary of Medicine, in 
 addition to the above particulars, given in greater detail, 
 you will find the following passage : " Dr. Crudeli still 
 more recently states, as the result of further pathological 
 investigations, that the bacilli may always be found in 
 the blood during the period of invasion of the fever ; 
 but that during the acme they disappear, and spores 
 only can be discovered. The bacilli have been found 
 chiefly in the spleen of tne human subject, and in the 
 
24 DISEASES OF TROPICAL CLIMATES lect. 
 
 marrow of bones in animals experimented on. The 
 bacillus has not yet been found in India. According to 
 the researches of Laveran, extended and corrected by 
 Richard, the blood in malarial fever contains, during 
 the accession, spherical organisms, developed in con- 
 nection with the red corpuscles, and furnished with 
 filaments; also certain curved and pointed bodies, 
 which are only infected and deformed corpuscles. The 
 pigment granules of malarial blood are produced in the 
 red corpuscles during the growth of the organisms" 
 {^Lancet, 1882, vol. i. p. 993). Should future observa- 
 tions by independent observers in other malarial regions 
 confirm these conclusions, it would be difficult to over- 
 rate their importance. 
 
 In the years that have elapsed since the existence of 
 the Bacillus malartcs was brought to notice, this much- 
 needed confirmation by independent observers in 
 malarious regions has not been forthcoming. Very 
 competent observers have looked for it in vain in the 
 most malarious districts of Bengal. I do not doubt that 
 a fungus exists such as the eminent men found in the 
 soil of the Agro Romatio, and in the spleens of men 
 who have died from the pernicious form of fever there 
 generated \ but the question. Is it the cause of the fever ? 
 is not yet answered. It must be kept in mind that 
 malarial fevers prevail in regions where the soil is 
 widely different from that of the Agro Romano, in arid 
 sandy districts, where it is difficult to believe that such 
 a bacillus could find the conditions needful for its ex- 
 istence. As to its presence in the organs of those 
 
H MALARIA 25 
 
 dying of malarial fevers contracted in the regions where 
 Drs. Tommasi Crudeli and Klebs made their observa- 
 tions, we must bear in mind that Professor Salisbury 
 of the Medical College, Ohio, when he put forward the 
 theory that malarial fevers were due to the introduc- 
 tion into the system of cells or spores emanating from 
 certain species of algoid plants called Palmellce, which 
 are among the lowest known vegetable organisms, sup- 
 ported his opinion in the same way, by demonstrating 
 the presence of these low vegetable forms in the urine 
 and other secretions, and even in the organs of men 
 who have died from ague. It is not disputed that he 
 may have found what he describes, but the fatal fact 
 remains, malarial fevers abound where no such vegetable 
 forms are to be found. 
 
 In the present state of knowledge we must turn in 
 another direction for an answer to the question, What is 
 malaria? We cannot isolate this poison by direct 
 experiment, it is too subtle for demonstration by the 
 means known to chemistry ; but the peculiar phenomena 
 it induces on the living organism we do know. I have 
 elsewhere defined the term to mean an earthborn 
 poison, for the most part generated in soils the energies 
 of which are not expended in the growth and sustenance 
 of healthy vegetation. By almost universal consent it 
 is the cause of all the types of intermittent and remittent 
 fevers, and of the degeneration of the blood and tissues 
 from long residence in regions where it is generated. The 
 term malaria is preferable to that of marsh miasm, which 
 implies that the poison is only produced in marshes. 
 
26 DISEASES OF TROPICAL CLIMATES lect. 
 
 This poison is almost everywhere present in India. 
 Dr. Parkes has well said that when a climate is said to 
 be unhealthy, it means that it is malarious. It is every- 
 where most intense in its action in low, warm, and moist 
 places, where there is rank vegetation and water. As I 
 have already indicated, it also sometimes shows its pre- 
 sence in warm climates at certain seasons, when some 
 of the above conditions are absent. In such cases 
 either organic matter will be found to exist in the 
 youngest strata of the soil, or, where water in the sub- 
 soil is detained by a bed of clay, both conditions may 
 and sometimes do coexist. It is an old observation 
 that marshes are not, as a rule, dangerous when 
 abundantly covered with water, but when the water 
 level is lowered, and the soil is exposed to the sun, 
 malaria is given off in abundance. 
 
 One of the best examples I can give you of the 
 genesis of malaria on a large scale is what occurred in 
 the district of Burdwan some years ago. This district 
 is reputed to be more healthy than the central or 
 eastern districts of the Gangetic delta. The soil is 
 alluvial, but dry. The drainage of the district was 
 obstructed by the silting up of its natural outlets, the 
 soil became waterlogged, with the result of an immense 
 development of malaria, and an alarming increase of 
 sickness and mortality from fever. The way in which 
 malaria is generated in a destructive form under different 
 conditions can best be shown by the experience of 
 Wellington's army when operating in Estremadura. 
 The country was so arid and dry from want of rain that 
 
MALARIA 27 
 
 the river-beds and water-courses were reduced to mere 
 lines of widely-separated pools ; yet, as Dr. Ferguson 
 records, the army suffered from a remittent fever of 
 such malignancy as to threaten its destruction. The 
 same thing happened to the army in the bare open 
 country by which Ciudad Rodrigo is approached from 
 the side of Portugal, at a time when the country re- 
 sembled a brick-field. The explanation is to be found 
 in the fact that both districts are in the rainy season 
 flooded with water, the malaria being given off only 
 when the drying process begins under the action of a 
 powerful sun. 
 
 The natives of India, not without good reason, believe 
 that the poison of malaria is often conveyed into the 
 system by water ; being generated by the decomposition 
 of vegetable matter in ill- kept and neglected wells. 
 We send our patients from one place to another for 
 " change of air," they do this to " change the water." 
 There is no place in the world with a worse reputation 
 for malaria and all that it brings in its train than the 
 Roman Campagna. To all appearance it is free from 
 the commonly recognised sources of malaria ; but the 
 cultivating hand of man has long been withheld from its 
 rich soil, the energies of which, no longer turned to food- 
 producing ends, are given up to the development of 
 malaria. Recent discoveries have disclosed the inter- 
 esting fact that the Romans were not ignorant of the 
 importance of subsoil drainage as a corrective of malaria; 
 the remains of a regular system of pipes for the purpose 
 having been brought to light. In the absence of this 
 
28 DISEASES OF TROPICAL CLIMATES lect. 
 
 system, the indispensable factor, viz. stagnant subsoil 
 water is again there in abundance, hence the malaria, 
 disease, and death for which the Campagna has such 
 an evil reputation. 
 
 Some rocks in a state of disintegration, when freely 
 exposed to the drying action of the sun and air, are 
 often in hot climates highly malarious. The best 
 example of this that has come under my observation is 
 a most instructive one. Before the island of Hong-Kong 
 was ceded to the British Government, it was temporarily 
 occupied by the troops then operating against China in 
 our first war with that country, on the site on which now 
 stands the city of Victoria. They enjoyed good health. 
 Immediately after the cession excavations on an extensive 
 scale for building purposes began. At once it became 
 frightfully unhealthy, from a form of remittent fever of 
 great malignancy. The soil was composed of granite in 
 such a state of disintegration that it crumbled under the 
 fingers ; it contained about 2 per cent of water, and 
 according to Friedell, quoted by Parkes, was permeated 
 by a fungus. I well remember the following painful 
 occurrence. A small house was occupied by some 
 artillery officers ; one of them, a young and inexperienced 
 subaltern, impatient of the want of space behind the 
 house, had the side of the hill scarped away, exposing 
 a considerable surface of the soil. The result was that 
 all the inmates of the house were at once struck down 
 by the prevailing fever, and the young ofiicer, the uncon- 
 scious author of the mischief, fell a victim to it. Even 
 in Europe, soil long left fallow often gives off malaria 
 
MALARIA 29 
 
 when disturbed. Thus in 181 1, when the S. Martin 
 Canal in Paris was being excavated, an epidemic of 
 intermittent fever prevailed in the quarters of the 
 Temple, and others in the line of the excavations. 
 Again in 1840, when the fortifications of the city were 
 being erected, the same thing took place ; and so late as 
 the second empire, when the new streets and boulevards 
 were constructed under the regime of Baron Hauseman, 
 intermittent fever again appeared among those exposed 
 to emanations from the soil. It is needless to add that 
 in tropical climates this is a common occurrence. 
 
 Malarial fevers are sometimes seen on board ships at 
 sea, and as I have elsewhere shown (article " Malaria " 
 in Quain's Dictionary of Medicine) can be thus explained: 
 {a) the sufferers may have had their systems charged 
 with malaria before embarkation ; {h) they may have 
 used water on board drawn from a malarious locality ; 
 (c) the source of the malaria may be in the ship, from 
 decayed vegetable matter mingling with the bilge water, 
 in ships under a bad sanitary regime; or {d) it may arise 
 from malarious mud, as in the case of H.M. ship Power- 
 ful, returning from India, when a severe outbreak of 
 fever was traced to this cause. I am indebted to the 
 late Dr. Mansfield, R.N., for an instructive exam. pie of 
 a fatal form of yellow malarial fever on board H.M. ship 
 Egmont, long used as a store-ship at Rio. The ship 
 was found to be in a state of decay, and the timbers 
 were permeated by fungi of large size, of a white or 
 cream colour, giving off a sickening and offensive odour. 
 
 Temperature exercises a powerful influence on the 
 
30 DISEASES OF TROPICAL CLIMATES lect. 
 
 development of malaria. Many places are safe in winter 
 which give off the poison freely in summer. Wenzel 
 has investigated the effects of temperature by exact 
 observations for a period of twelve years, made during 
 the construction of the fortified port of Jahde, a very 
 malarious locality. He shows that the increase in the 
 number of malarial attacks was coincident with a rise in 
 the temperature. In the diagrams of temperature and 
 sickness constructed by him, there is a constant pre- 
 cedence of the temperature curve by 20 or 25 days 
 to the sickness curve of attacks ; so that three weeks 
 of increased temperature appeared to be the period 
 necessary for the production of the malarial poison and 
 an outbreak of sickness. These observations were rnade 
 in a temperate climate. In regions where a high tem- 
 perature is more quickly developed the poison would be 
 sooner given off and its effects would be more rapidly 
 seen. In any year when the medium summer tem- 
 perature did not reach 12° R. (59° F.) the sickness 
 remained at its minimum. 
 
 Malaria abounds at the base of all mountain ranges 
 in India. That belt of country at the base of the 
 Himalayas, known as the Terrai, is notorious at certain 
 seasons for its insalubrity. The soil consists of a vast 
 accumulation of organic matter, the subsoil being charged 
 with water from the mountain streams. 
 
 As has been already said, chemistry has not thrown 
 much light on the nature of malaria, certainly not on its 
 power to act deleteriously on the human system. The 
 air of marshes contains watery vapour and carbonic acid 
 
11 MALARIA 31 
 
 in excess, and, under certain conditions, sulphuretted 
 hydrogen ; carbonated hydrogen is also present, and 
 occasionally free hydrogen and ammonia, and, it is said, 
 phosphuretted hydrogen and the debris of animal and 
 vegetable life (Parkes). It is capable of drifting along 
 plains to a considerable distance from its source, 
 particularly in the direction of the prevailing ^Yind. 
 Italian writers constantly refer to an example of this 
 recorded by Lancisi. Thirty inhabitants of Rome were 
 walking towards the mouth of the Tiber ; suddenly the 
 wind arose, blowing towards them from the swamps of 
 that region. Twenty-nine of them were attacked with 
 intermittent fever. Examples of this kind could be 
 multiplied indefinitely; the fact is notorious in all 
 malarious regions. It ascends mountains when favoured 
 by ravines and currents of heated air, a point of great 
 importance. I could give you many examples of the 
 ill effects of placing human habitations near the edge of 
 such ravines on mountain ranges of great elevation, 
 where the inmates have suffered severely from malarial 
 fevers. The height to which malaria can ascend from 
 its source is a matter of dispute. Parkes thought that 
 500 feet is the limit in temperate climates, and 1000 to 
 5000 in warmer regions. I have, however, known men 
 to suffer malarial fevers at a height of more than 5000 
 feet above the heated plains, whose habitations, were 
 placed as above stated on the edge of ravines up 
 which malaria ascended with the currents of warm_ 
 air from below. M. Leon Colin, a French military 
 physician of great eminence, who studied this sub- 
 
32 DISEASES OF TROPICAL CLIMATES lect. 
 
 ject with care during the French occupation of Rome, 
 does not use the term malaria to express the poison 
 that generates periodic fevers. He prefers the term 
 telluric poison {intoxication telluric) proceeding from 
 the vegetative energy of the soil, when that energy is not 
 taken up by its natural consumers, crops or plants, in a 
 word, healthy vegetation. This " telluric poison " is 
 only, after all, a malaria, a bad or poisonous air generated 
 in the soil, under another name. AVhat M. Leon Colin 
 is most anxious to insist on is the point I have already 
 pressed on your attention, viz. that merely marshy vapour 
 is not the only source of so-called malarial fevers, for 
 they are found in the Sahara and in Algeria, where there 
 are no marshes to exhale nor surface vegetation to 
 putresce. This is indisputably true in India, where soils 
 long left uncultivated and far from marshes are often 
 unhealthy, and invariably so when freshly exposed to 
 the air, until their vegetative energy is turned to the 
 growth of crops under the cultivating hand of 
 man. 
 
 We must not forget that this powerful poison was 
 once nearly as prevalent in Great Britain as it is at this 
 day in Bengal, and was the prolific mother of the same 
 class of fevers which prevail where it exercises sway. It 
 is banished from our soil by ages of cultivation, drainage, 
 and more particularly subsoil drainage, but it still lingers 
 in places where these measures are imperfectly carried 
 out Historians tell us that when from political causes 
 extensive tracts of country in England have been thrown 
 out of cultivation in the then undrained condition of the 
 
u MALARTA 33 
 
 subsoil, malarial fevers raged in an epidemic form and 
 caused great mortality. 
 
 In India a progressive increase in the death-rate 
 from this class of fevers extending over years is occasion- 
 ally noted by the sanitary commissioners. Thus Dr. 
 Cornish records that since the year 1868 there was 
 a progressive increase in the death-rate from fevers in 
 the Madras Presidency, rising from 105,692 in that 
 year to 192,469 in 1871. And the same careful sani- 
 tary authority noted a well-marked movement south- 
 wards in the same Presidency of what he terms a 
 " malarial wave," proceeding from the northern districts 
 of Ganjam, Vizagapatam, and Godavery, towards Salem 
 in the south. In the last-named district the death-rate 
 from fevers in 1868 was 105,692, in 1871 it rose to 
 19,501. Mr. Cornish has placed on record a fact to 
 which I have often referred in this lecture-room, and 
 which I mention once more to impress on your minds 
 the importance of the subject to which this lecture has 
 been devoted. It is this : the year 1869 was a year of 
 severe cholera in an epidemic form, causing a heavy 
 mortality, yet for every death from that disease 23 
 took place from malarial fevers. 
 
 Of course there are numbers of our profession who 
 do not accept the doctrine of the existence of such a 
 poison as malaria at all ; as I have said in the article 
 to which I have more than once referred, " Those who 
 deny its existence have a difficult thesis to maintain." 
 To Dr. Oldham "chill," to Dr. Munro "certain electrical 
 conditions," explain the grave effects commonly attributed 
 
 D 
 
34 DISEASES OF TROPICAL CLIMATES lect. 
 
 to malaria. Once more to quote my own words, "If 
 chill will account for the loss of 10,000 men at Wal- 
 cheren, for the frightful disaster of a like kind at Car- 
 thagena, for the terrible mortality from paroxysmal fevers 
 at the Mauritius, and countless examples of the same 
 kind elsewhere, and for the yearly loss of life in India 
 from fevers — the country in which Dr. Oldham serves, 
 why, seeing that mankind are exposed to ' chill ' every- 
 where, are not such fevers with their sequels universal in 
 their prevalence, instead of being confined to places 
 under one or other of the conditions described in this 
 article ? Why, above all, in a country like Great 
 Britain, where vast multitudes of the population are 
 hourly exposed to every variety of atmospheric change, 
 have paroxysmal fevers, once endemic there, disappeared, 
 save in such exceptional places as are still under one or 
 other of the conditions described above?" No satis- 
 factory answer has been given to this question. As for 
 " the electrical conditions " of the other hypothesis, 
 when its author can explain what these conditions are, 
 and why they no longer exist in the British Islands, or 
 do not produce their usual effects, we shall be prepared 
 to discuss their value from a pathological point of view. 
 There is no fact in pathology more familiar to those 
 who have practised in malarial climates than this, that 
 the human constitution can be silently undermined by 
 malaria, without the manifestations of febrile phenomena 
 sufficiently marked to attract the attention of the suff"erer. 
 In such regions the children of those affected by the 
 malarial cachexy are often born with the peculiar tint of 
 
MALARIA 35 
 
 skin characteristic of the affection, and also with en- 
 largements of the liver and spleen ; changes brought 
 about in the womb, as we see in the children of syphilitic 
 parents. . Trousseau has observed this to occur in some 
 of the malarious parts of France. It is capable of 
 giving a type of periodicity to almost all diseases, even 
 to such affections as pneumonia and pleurisy, and the 
 irritative fever succeeding surgical operations and severe 
 injuries. Practitioners in the Southern States of America 
 have noted this, and it is yearly seen in this hospital 
 among our invalids from India. It is doubtful whether 
 the human system once saturated with this poison ever 
 really gets rid of it. Certain it is that those who have 
 long been victims to ague are liable to suffer from their 
 old enemy, years after they have been removed from 
 fresh exposure to the cause of their ailment. Agues are 
 not always developed at the time and in the country 
 where the poison was taken into the system. Men 
 coming here from malarious countries sometimes have 
 their first attack of intermittent fever in this house. 
 Examine such men, and you will see that they bear in 
 their bodies evidence of the malarial cachexy in the 
 tinge of their skins, and their enlarged livers and 
 spleens. 
 
 In all true malarial fevers there is from the first great 
 disturbance of the stomach, and in severe remittents 
 this is generally the most troublesome symptom. In 
 that fatal form of the disease to which Continental 
 writers give the name "pernicious," morbid appearances in 
 the stomach are invariably found to be the chief lesion. 
 
36 DISEASES OF TROPICAL CLIMA TES lect. 
 
 Of all the structural changes brought about by this 
 poison the most common is enlargement of the spleen, 
 the " ague cake " of the Fens. You have specimens on the 
 table showing this enlargement in every degree. I invite 
 your attention in particular to the enormous example of 
 this enlargement in this jar. It was taken from the 
 body of a small drummer-boy, the greater part of whose 
 short life was spent in the Pesha^^oir Valley. Its weight 
 was 10 lbs. 15 ounces, its length is 14 inches, breadth 
 7^ inches, and 4^^ inches in thickness. Its in- 
 crease was due to connective tissue. In men dying 
 from the more acute forms of fever the spleen is often 
 found to present the appearance of a mere bag of blood. 
 In India fatal occurrences are often the subject of 
 judicial inquiry from blows thoughtlessly inflicted on 
 natives whose spleens are in this condition. The spleen 
 swells and enlarges not only under the stimulus of the 
 malarial poison, but also in enteric fever, and in most 
 other affections in which noxious matters have been 
 taken into the blood. In fact, as Vichow long since 
 demonstrated, even,' considerable irritation of a gland 
 results in an increased formation of cells in it, and in 
 proportion to the extent of such irritation we see the 
 colourless elements of the blood also increase. Under 
 the influence of the malarial poison the organ undergoes 
 also changes in colour. Sometimes it becomes of the 
 colour of port wine lees ; again we find it of a slate 
 colour, and on section almost invariably deeply pig- 
 mented. 
 
 The liver also enlarsjes, being congested with dark 
 
MALARIA 37 
 
 coloured and tenacious blood. The colour varies 
 according to the degree of this congestion, and to the 
 length of time from which the patient has suffered from 
 the poison and the fevers it causes ; the tint varies from 
 different shades of red to a slatish colour, the tissue 
 being soft, easily torn, and always pigmented. 
 
 The result of these visceral enlargements, when exces- 
 sive, is obstruction of the portal circulation and the 
 passage of blood through the venu cava, with effusion 
 into the peritoneal cavity. 
 
 Of all the morbid effects of malaria the most common 
 is pigmentation, derived from the colouring matter of 
 the blood, which escapes and infiltrates the liver, spleen, 
 and sometimes the brain. The hsemoglobin becoming 
 converted into haematodin ; anaemia is a common sequel 
 of malarious poisoning ; you see it among our invalids 
 here in every degree. The suddenness with which this 
 takes place is often quite startling ; this was observed by 
 our army medical officers to be a notable feature in an 
 outbreak of malarious fever in the Mauritius some 
 fifteen years ago. The skin becomes of a dirty pale 
 brownish hue. This change is not icteric in its orgin ; 
 it is the outcome of the spleen and liver changes already 
 described. The number of red globules diminishes 
 sometimes to the extent of 75 per cent, they lose much 
 of their red colour and their spherical shape, are slow to 
 gather into rouleaus, and their edges become serrated. 
 
 Professor Kelsch, of the military hospital Val-de- 
 Grace, has made blood changes in malarious fevers the 
 subject of special study ; following for this purpose the 
 
38 DISEASES OF TROPICAL CLIMA TES lect. 
 
 method of Malassez, by which the blood globules in a 
 given quantity of blood can be counted under the 
 microscope. By this method, Professor Kelsch, in a 
 case of ague carefully observed, satisfied himself that 
 in 24 hours his patient lost more than a million 
 of globules per millimetre cube. In prolonged fever 
 and in cachectic cases, the loss, according to the same 
 author, is much greater. In less than a month the 
 globules fall from five millions to a million and a half 
 or less per millimetre cube {Edinburgh Medical Journal). 
 Neuralgias are common sequels of malaria, brow-ache 
 and hemicrania are familiar examples. 
 
 When the condition of the blood is as above de- 
 scribed palpitation of the heart is rarely absent. Al- 
 buminuria is a symptom that often gives rise to much 
 needless alarm. In former years I have sent officers 
 home with the gravest possible prognosis, on account of 
 the presence of albumen in the urine, with a dropsical 
 condition of the lower extremities. This condition of 
 things rarely alarms me now. We see it often here, and 
 as a rule it passes away under the improved condition 
 of the patient's blood and general health, brought about 
 by judicious treatment, good food, and pure air. 
 
 Diarrhcea is easily excited in malaria-struck men, and 
 it is needless to add that scurvy is a formidable com- 
 plication of this cachexy. 
 
 The late Mr. Cutchliff, of the Bengal army, brought 
 forward some evidence to prove that in some low 
 swampy malarious districts in India, impotency pre- 
 vailed, which is an additional reason why in places 
 
MALARIA 39 
 
 much scourged by this poison population becomes 
 sparse. 
 
 I have said much to you on the subject of malaria, 
 more perhaps than some of you may think necessary ; 
 but before passing from a subject of such paramount 
 importance let me clinch what I have said. In 1804 
 this country sent an army of 36,481 rank and file to 
 Walcheren. Fifty days after landing nearly 10,000 men 
 were in hospital with malarial fever — from 25 to 80 
 men died daily. At this rate, if the force had remained 
 250 days on the island, it would have been exterminated. 
 Even after it was evacuated 36,000 men went into 
 hospital with disease, the seeds of which were planted 
 there. I have already asked the question, Will Dr. 
 Oldham's theory of " chill " account for this horrible 
 destruction? Once more, the Italian War Office has 
 looked into the financial aspect of malaria, as it con- 
 cerns the army of Italy, the charge amounts yearly to 
 ;^4oo,ooo. " No part of Italy can be traversed with- 
 out the signs of this destructive agency to take the 
 sweetness out of life, and to bring continually near the 
 shadow of death. Not merely does it here and there 
 peremptorily curtail the field of industry; everywhere 
 it threatens the labourer and saddens his life." 
 
LECTURE III 
 
 INTERMITTENT FEVER 
 
 We have now to consider the remarkable forms of fever 
 to which the poison of malaria gives rise. This fever 
 then is one of malarial origin, characterised by the 
 sudden rise of temperature during the paroxysm ; by 
 the equally sudden fall at its termination, and by the 
 regularity of the times of accession and apyrexia. 
 
 In the preceding lecture the morbid effects of the 
 action of malaria on the solids and fluids have been so 
 fully described that repetition is not needed. 
 
 Premonitory Sympto7ns. — As in other fevers so in 
 this, the febrile attack is preceded by symptoms which 
 herald the coming paroxysm. These are pain in the 
 back and lower limbs, loss of appetite, languor, lassitude, 
 gastric irritation, with nausea, and sometimes vomiting, 
 particularly if the stomach is at the time loaded by a 
 full meal, and sometimes urinary irritation, with frequent 
 calls to micturate ; the sufferer passing small quantities 
 at a time of pale coloured and highly acid urine, giving 
 rise to much distress. Then follow in succession the 
 well-known phenomena : first, of the so-called cold or 
 
LECT. Ill INTERMITTENT FEVER 41 
 
 shivering stage, succeeded by the hot, which in its turn 
 gives way to the last or sweating stage. When this 
 passes away a period of apyrexia succeeds, which lasts 
 for 24, 48, or 72 hours, when the same phenomena 
 recur. The first is the quotidian, the second the 
 tertian, and the last the quartan type of the fever. The 
 quotidian is the most common, the quartan the rarest 
 of all. The statistics for the three Presidencies ot 
 India show this, and the same rule seems to hold 
 everywhere ; thus, in the army of the United States in 
 their great war, out of 98,237 cases of intermittent 
 fever, 51,602 were quotidian, 44,875 were tertian, and 
 only 1757 were of the quartan type. 
 
 All the world over a quartan ague has been noted 
 as the most obstinate. It is certain that in India the 
 first attacks are almost invariably quotidian. What is it 
 that determines the difference? I do not pretend to 
 know. It may be, as has been suggested, that the 
 difference depends on the extent to which the system 
 is charged with the poison, the quotidian indicating the 
 highest degree of saturation, exciting a more frequent 
 disturbance of the system. During the apyrexial in- 
 terval patients are said to be "well;" this, however, is 
 true only in a comparative degree, for there is often, 
 and in first attacks almost always, a certain amount of 
 malaise and general discomfort, indicative of the ex- 
 istence in the system of a poison which previous 
 paroxysms have failed to eliminate or destroy. 
 
 Let us look more closely at the phenomena of the 
 different stages. We find that after a longer or shorter 
 
42 DISEASES OF TROPICAL CLIMATES lect 
 
 continuance of the premonitory symptoms, the patient 
 experiences a sense of coldness in the back and limbs, 
 gradually felt all over the body, soon he shivers, rigors 
 rapidly succeed each other ; the skin shrivels, the nails 
 become blue, and in the warmest climate he desires to 
 be warmly covered, and is in a state of extreme dis- 
 comfort. This feeling of cold is only a "subjective 
 symptom." The skin, from contraction of the super- 
 ficial vessels, is indeed colder than natural, but the 
 clinical thermometer, in the mouth or rectum, will at 
 once indicate a rise in the temperature of from two to 
 three degrees, and this even before rigors set in. The 
 phenomena of the cold stage then are gastric irritation, 
 a foul tongue, nausea, a rapid pulse, quickened respira- 
 tion, and a sensation of extreme coldness, not confirmed 
 by the thermometer. The characteristic of the tem- 
 perature curve in intermittent fever is its sudden rise to 
 a high pyrexial degree, and an equally rapid fall to the 
 normal or rather a little below it, as soon as the sweat- 
 ing stage begins. This temperature curve is very 
 characteristic. It has been shown by Wunderlich to 
 occur in few diseases. This high authority on tem- 
 perature in disease notes only the relapse into fever 
 during convalescence from typhoid fever, the paroxysms 
 of acute tuberculosis, and those of pysemia. The cold 
 stage varies in duration from half an hour to two hours. 
 If protracted beyond this the case is one of severity. I 
 have sometimes seen a prolonged cold stage caused by 
 a load of indigestible food on the stomach, at once 
 brought to an end by an emetic. 
 
Ill INTERMITTENT FE VER 43 
 
 After a space of time varying in different cases the 
 hot stage sets in, or, as it has been called, " the stage 
 of equalisation of the circulation and chemical action." 
 The patient feels warm all over, the bed-clothes are 
 thrown aside, the face flushes, the pulse rises in 
 volume, strength, and frequency, the skin becomes hot, 
 the patient grows restless and complains of headache, 
 with pain in back and limbs ; the tongue is usually 
 dry and bile-tinted, and the bowels are constipated. 
 The temperature rises to 105°, 106°, and even to 107°, 
 and so remains until the sweating begins. 
 
 Some American writers, familiar with the severer 
 forms of the disease, dilate on the advantages of a 
 "good hot stage," regarding powerful reaction as con- 
 ducive to the patient's safety, whereas a quick and feeble 
 pulse, with rapid thoracic respiration, and a low tem- 
 perature, they justly regard as dangerous. This is the 
 condition commonly seen in the victims to this fever in 
 the most malarious parts of Italy, whose constitutions 
 have been broken down by innumerable attacks ; those 
 who have had to treat the disease in the persons of 
 Asiatics, under like conditions, are only too familiar 
 with the description. 
 
 The paroxysm at last ends in the sweating stage, to 
 the infinite relief of the sufferer. Beads of perspira- 
 tion appear on the brow, and soon the patient sweats 
 profusely — the pulse falls in frequency, the respiration 
 becomes tranquil, the temperature steadily falls until it 
 reaches some points of a degree below the normal. 
 The average duration of a paroxysm is about six hours, 
 
44 DISEASES OF TROPICAL CLIMATES lect. 
 
 but it may extend to twelve. In first attacks the 
 tongue is generally furred, and some degree of this will 
 be noticed with the recurrence of the paroxysm. The 
 saliva is invariably acid. 
 
 Urine. — As already stated, it contains a large amount 
 of free acid, and it retains this acidity for some days 
 even in the hottest weather. During the interval it is 
 generally alkaline. When the paroxysms cease, the 
 watery part of the urine diminishes. It assumes a 
 deep orange colour, depositing urate of ammonia. 
 Intelligent patients learn the significance of this sign, 
 and often intimate to the physician that more quinine is 
 not required. At the first elevation of temperature the 
 urea increases (Parkes) ; this lasts during the cold and 
 hot stages, then it decreases, falling below the healthy 
 average. Colin and other French military authors note 
 the enormous excretion of urea in malarial fevers both 
 in Italy and Algeria. 
 
 Fevers of this type differ from others in an important 
 particular : they are not communicable from person to 
 person ; the cause is not reproduced in the bodies of 
 those affected. It is important to note with reference 
 to the period of recurrence of the paroxysm, that in 
 what may be called a waxhig ague, that is before the 
 person has been brought under the influence of remedies 
 which break the regularity of the hour of attack, the 
 cold stage on successive days will appear an appreciable 
 time before the hour of first accession. The reverse is 
 the case when the fever is wanmg, or when the patient 
 has been to some extent brought under the influence of 
 
Ill INTERMITTENT FE VER 45 
 
 quinine, the recurring paroxysm will appear perhaps an 
 hour or more later. 
 
 Treatment. 
 
 There is no part of the duty of military and naval 
 medical officers of more importance than the careful 
 and conscientious management of young soldiers when 
 first they are brought under the influence of malaria 
 It is a point of immense importance to their future 
 health and efficiency that no pains should be spared 
 to break the recurrence of the paroxysms as soon as 
 possible. There is a tendency in the human system 
 to repeat morbid phenomena by what, for want of a 
 better name, we may call the force of habit. It may 
 be, as some suppose, that a febrile paroxysm is the 
 means by which the system is relieved of a certain part 
 of the poison or ferment that is acting deleteriously on 
 the red corpuscles throughout the whole extent of the 
 circulatory system ; but even so, few can doubt that 
 every succeeding attack of fever is a step, long or short, 
 towards those organic changes on which so much was 
 said in a previous lecture, ending in that cachexy which 
 finally unfits its victim for the active duties of life. 
 The plan I have for years past urged on the attention 
 of those who have preceded you on these benches, is 
 not to lose sight of a young officer or soldier who 
 returns to duty after a first attack of intermittent fever. 
 I advise that such men should be kept on a special 
 fist, and that within a lunar month from the period 
 of cure, they should be required to present them- 
 
46 DISEASES OF TROPICAL CLIMATES lect. 
 
 selves to have their systems fortified against another 
 attack by being kept for some days under the in- 
 fluence either of quinine or arsenic. This last is 
 one of the oldest known remedies against malarial 
 fevers. Its power as a prophylactic is much insisted 
 on by Professor CrudelL Being slower in its action 
 than quinine, it is less suited for the treatment of 
 fever when actually present ; but if judiciously used its 
 power of strengthening the system against malaria can- 
 not be doubted, and it has the advantage of being a 
 cheap remedy, and what to most people is of more con- 
 sequence, it is absolutely tasteless. To bring and keep 
 the systems of young soldiers for some time after an 
 attack of malarial fever, under the influence of arsenic, 
 is a simple proceeding, which by a little trouble and 
 arrangement can easily be carried out ; by so doing I 
 beheve the power of resistance of the human organism 
 to the assaults of malaria will be strengthened, to the 
 advantage alike of the man and the State, whose costly 
 serv'ant he is. So much for medicinal prophylaxis, not 
 the least important part of deaUng successfully with the 
 class of fevers under consideration. 
 
 There is no drug capable of arresting the stages of 
 an intermittent fever once it has entered on the first or 
 cold stage. As I have elsewhere put it (Quain's Diction- 
 ary), there is little to be said as to the treatment of the 
 stages of ague, they must take their course ; the only 
 interference called for is to supply the patient with the 
 covering he so much desires during the cold stage ; and 
 if this be protracted unduly, to give him draughts of 
 
Ill INTERMITTENT FEVER 47 
 
 warm tea, and should symptoms of collapse appear, more 
 particularly in men debilitated by disease, and in Asiatics, 
 to administer such restoratives and stimulants as the 
 case may demand. It is needless to say that the time- 
 honoured practice of administering an emetic at the 
 onset of the cold stage, is more " honoured in the breach 
 than the observance"; an exception should be made 
 when the stomach is loaded with a hea\'^^ meal. Diges- 
 tion is arrested during the pyrexial period, and the 
 system is relieved and the cold stage shortened by the 
 action of a simple mustard emetic, aided by copious 
 draughts of warm water. The great traveller Livingstone, 
 who added medical knowledge to his qualifications as a 
 missionary and explorer, and whose experience in malarial 
 fevers was immense, began the treatment of all severe 
 cases with the following combination : Resin of jalapand 
 of rhubarb from 6 to 8 grains, with 4 grains of calomel, and 
 a like quantity of quinine. According to the great 
 traveller, and his hardly less experienced companion, the 
 Rev. Horace Waller, this combination was found a ver}' 
 effective beginning of the treatment in cases both of 
 intermittent and remittent fever. In Livingstone's camp 
 the above pills were known as his ■' rousers," and were at 
 once administered to men who from premonitory sjTup- 
 toms were observed to be " idle and lethargic." In about 
 five hours copious dark coloured motions followed. If 
 these were delayed, a brisk purgative enema was given. 
 Quinine was then given in 4-grain doses every four 
 hours until 12 grains were administered in the twelve 
 hours succeeding the purgative medicine. Linngstone 
 
48 DISEASES OF TROPICAL CLIMATES lect. 
 
 and his followers deemed any other mode of dealing with 
 
 the fevers of Africa to be "mere trifling." Common 
 sense points to the necessity of caution in the use of such 
 active purging in men debilitated by disease or climate, 
 or both, or when the patients are delicate women, or 
 Asiatics, often calling for as delicate handling. This 
 sharp treatment is not appUcable to those who are or 
 have recently been suffering under any form of bowel- 
 complaint. The effect of this purgation is not only to 
 unload the bowels, but also to relieve the liver gorged 
 with blood and bile. A very efficient purgative com- 
 bination is from 3 to 5 grains each of calomel, extract of 
 colocynth, and scammony, with a few drops of some 
 aromatic oil, and 4 or 5 grains of quinine. The 
 "inter^^al" must be turned to the best account with the 
 view to prevent the recurrence of a paroxysm. With 
 this view, as soon as the sweating is over, 10 grains of 
 quinine should be given, and repeated in five or six 
 hovu-s. I believe this to be the most effective and 
 economical method of using the remedy. If the quinine 
 is rejected and nausea and vomiting interfere with its use 
 by the mouth, it can be given by enema in 4 ounces 
 of beef tea, or in water, and in this way it is quite 
 efficacious. It is not always that a paroxysm is prevented, 
 but if not, it will certainly be observed to be less severe. 
 And the above method must be persevered in until the 
 desired result is obtained, and until the thermometer no 
 longer indicates a rise in temperature at the time of 
 expected attack. In cases where complications arise, it 
 is in a high degree dangerous to pause in the adminis- 
 
Ill INTERMITTEXT FEVER 49 
 
 tration of quinine, or to use depressing remedies for this 
 or that set of symptoms. Those who so act, in the 
 graver forms of malarial fever, will have little success in 
 dealing with them. Epilepsy, low forms of pneumonia, 
 asthma, and bronchitis, may have to be met aided by 
 support from proper food, and stimulants when called 
 for. For years I have urged this point on the attention 
 of those who have preceded you in this school, and I 
 am glad to be able to enforce this lesson with the high 
 authorit}^ of Trousseau. He says, " If, mistaking the 
 nature of the phenomena, the physician is eager to com- 
 bat the symptoms, the coma, convulsions, or delirium, 
 by local or general bleeding, or by any other measure 
 which is at least useless if it be not dangerous, he will, 
 from the moment that calm begins to show itself, take 
 credit for having obtained a fortunate result, which his 
 ill-judged intervention has only not prevented; at the 
 very time he is congratulating himself upon having 
 achieved a success, the patient may be carried off by a 
 paroxysm which might have been averted by appropriate 
 treatment." What this great physician has said of the 
 gravest forms of " pernicious " intermittent fever, is a 
 hundred times more true of the remittent form, where 
 such treatment as he has thus impressively condemned 
 is fraught with danger. Surgeon-General Cornish, late 
 Sanitary Commissioner of Madras, has shown how 
 terribly the mortality among the natives of Southern 
 India is aggravated by the system of starvation to which 
 they invariably subject themselves when suffering from 
 malarial fevers. Of all the complications to which I 
 
 E 
 
50 DISEASES OF TROPICAL CLIMATES lect. 
 
 have referred, the most common among Asiatics is a low 
 form of pneumonia, and this is what is so fatal to them 
 everywhere, but more particularly when serving in 
 malarial climates, where the temperature is liable to 
 greater diurnal variations than that of their own country. 
 Surgeon-General Home, V.C., has done good service by 
 the urgency with which he has directed the attention of 
 medical men in India to scorbutus as a complication of 
 this and other diseases ; it should always be looked for 
 and counteracted by appropriate treatment. 
 
 It ' is hardly necessary, after what has been said, to 
 insist on support by nutritious diet, and, when called 
 for, by the judicious use of stimulants of the best quality 
 procurable. Livingstone and his followers used bitter 
 ale in preference to all others, after the liver had been 
 well acted on by the " rousers " of their leader. Other 
 intelligent travellers in malarious countries are no less 
 explicit on this point. Burton, than whom few men 
 have faced more dangers from climate, advises "ye 
 best wine in ye cellar," and poking a little fun at the 
 dog-Latin of some of our prescriptions, he slily adds, 
 '^ non sine tobacco if that can be enjoyed !" 
 
 Treatment of Malarial Cachexia. — On the first signs 
 of this sad condition appearing, the patient should be 
 sent to a non-malarial climate. Fortunately, in the 
 present day a long sea-voyage is not necessary. Before 
 it became the practice to send our invalided soldiers 
 from India through the Suez Canal, few of them were 
 landed at Netley free from scurvy. Even now it is a 
 condition to be carefully looked for and treated when 
 
Ill INTERMITTENT FEVER 51 
 
 discovered. A ration into which salt meat enters is 
 poison to a malaria-struck man. Another point of 
 supreme importance is the necessity of warm clothing. 
 Mere "chill" will not originate an ague, but to a man 
 saturated with malaria and whose abdominal organs are 
 in the morbid condition I have described, chill may 
 be fatal, not only by bringing on attacks of his old 
 enemy, but something infinitely worse, viz. pneumonia 
 of a fatal form. Some years ago an attempt was made 
 to lessen the pressure on our space in this hospital 
 during the summer time (which is often excessive, when, 
 as often happens, five, and even seven, hundred invaUds 
 are admitted in one day) by sending invalids from India, 
 so timed as to arrive here in the winter season, or, what 
 is just as bad, in our ungenial spring. The result was 
 most unfortunate. I have seen as many as five men 
 landed with double pneumonia with which they were 
 attacked on coming under the influence of our damp and 
 cold climate. Not only was this the case, but men who 
 had convalesced from dysentery on the voyage home, 
 were again attacked by it, in a sub-acute form, and landed 
 in a pitiable condition. . 
 
 Sir Ranald Martin long ago called attention to 
 the importance of proper clothing on return to a cold 
 climate, but the lesson to this day is little acted on, and 
 many suffer in consequence. 
 
 To a man charged with malaria pure country air in 
 a healthy situation is the first requisite. Some late 
 experience on the point has led me to think highly of a 
 well-regulated system of massage, by a well-trained hand; 
 
52 DISEASES OF TROPICAL CLIMATES lect. 
 
 the effect of this, if steadily and skilfully done by an 
 expert, is to diminish congestion of the abdominal organs, 
 and to distribute the blood more equally through the 
 system (a powerful aid to its depuration) ; to regulate 
 the action of the bowels, without the need for aperient 
 medicine ; to remove the oppressive feeling of languor 
 and lassitude ; to promote cheerfulness and healthy 
 action of the skin. I am aware, of the difficulty of 
 carrying out such a system as this in such an hospital as 
 this, where our invalids are numbered by hundreds ; but 
 even here something of this kind could be done with 
 advantage, if some of our orderlies were trained for the 
 purpose. The various preparations of iron are clearly 
 indicated. An excellent form is that known as Easton's 
 Syrup, Syrupus quinicz et strychnice phosphatis, in doses 
 of from one-half to a drachm, in a little glycerine and water. 
 Each drachm contains one grain of the phosphate of 
 iron, about one of the phosphate of quinine, and -gL of 
 the phosphate of strychnia. My colleague. Professor 
 Aitken, published the formula for this preparation in 
 the second volume of his great work, and the value of it 
 is now, in consequence, well known to the profession. 
 It is almost needless to add that great care is required 
 in its preparation. I have met with specimens so ill- 
 prepared that the strychnia was unsafely in excess. 
 There is an old preparation of iron, formerly in the 
 Dublin Pharmacopeia, which I regret is not in the British 
 Pharmacopma. I refer to the tincture of the acetate, one 
 of the lightest and most agreeable forms of giving this 
 remedy. The following is an excellent formula for pre- 
 
in INTERMITTENT FEVER 53 
 
 scribing iron for delicate and fastidious patients of both 
 sexes : — 
 
 Ferri et quin. citrat. 5ij., acid citric. 5i., spirit, chloro- 
 formi 3ij., syrup, simp. 3vi., tinct. aurant. oiv. V\_. The 
 dose is a teaspoonful twice a-day in water. To those 
 with time and means at their disposal, I urgently advise 
 a course of the waters of Karlsbad or Homburg, of 
 course to be used under local medical advice. I sup- 
 pose I must in the last twenty years have sent at least 
 a hundred sufferers to one or other of the places named. 
 I can hardly call to mind a single instance in which 
 benefit was not derived from the use of the waters 
 named. In most cases this has been signal. I do not 
 care to speak much of my personal experience, but I 
 may be allowed to say that I never fairly got rid of 
 malaria out of my system until, under the care of my 
 kind friend, Dr. Deetz of Homburg, I went through two 
 courses of the baths and waters there. I add one word 
 of caution : the mineral waters there and elsewhere, 
 prepared as they are in nature's own laboratory, are 
 more powerful and subtle in their action than the world 
 supposes ; and at such places the maxim " every man his 
 own doctor," is a dangerous one. I have seen conse- 
 quences little short of disastrous from their use without 
 the necessary guidance as to selection of spring, quantity, 
 and dietetic regimen. When a visit to one or other of 
 the spas named is impossible, the water of Karlsbad, in 
 combination with that of Friedrichsall, taken morning 
 and evening in moderate quantities, will be found most 
 useful in removing congestion of the liver, aided by local 
 
54 DISEASES OF TROPICAL CLIMATES lect. 
 
 fnassage over the organ. Where the spleen remains 
 enlarged and resists the means above detailed, the oint- 
 ment of the biniodide of mercury locally applied often 
 reduces the size of the organ with surprising quickness. 
 I have used this remedy in this house for twenty years ; 
 but I believe it was Mr. Macnamara, formerly of the 
 Bengal army, who, knowing that this ointment is almost 
 specific in reducing goitres, first applied it to the reduc- 
 tion of enlarged spleens in India. The strength of the 
 ointment is 15 grains to an ounce of lard or vaseline. 
 A portion about the size of a large nutmeg should be 
 gently rubbed in with a smooth paper-cutter or spatula 
 over the swelling, before a fire, and, if needful, cautiously 
 repeated in about ten days. I say cautiously, as no 
 good but much harm may result from bringing the con- 
 stitution of the patient unduly under the influence of 
 one or other of the constituents of this active drug. 
 
 Dr. Lauder Brunton has pointed out that patients 
 sometimes suffer from sharp pain in the rectum just as 
 the shivering fit is coming on ; he attributes this to some 
 obstruction to the flow of blood through the hsemor- 
 rhoidal veins. The local pain is quickly relieved by 10 
 grains of quinine, or the application of warmth over the 
 hepatic region and gentle rubbing. 
 
 This is the proper place to bring to your notice some 
 of the substitutes for quinine. In the military hospitals 
 of India quinine is now little used. Since the successful 
 introduction of cinchona on some of the spurs of the 
 Himalayas, and the beautiful " Blue Mountains " of 
 Southern India, a cheaper drug is suppHed by the Govern- 
 
Ill INTERMITTENT FEVER 55 
 
 ment chemists, known as cinchona alkaloid I have not 
 had much experience in its use, but although more apt 
 to disagree with men of delicate stomachs, it is found, as a 
 rule, to answer well for general purposes. To be equally 
 effective it must be given in fuller doses than quinine. 
 Of arsenic I have already spoken, and repeat, that in 
 my opinion it is better adapted to strengthen the system 
 against the assaults of malaria than for the treatment of 
 the fevers it causes ; for some of the sequels, such as 
 malarial neuralgias, it is often more useful than quinine, 
 and may sometimes be combined with that drug with 
 advantage. In the French army it is much used, for 
 economical reasons, in the treatment of malarial fevers, 
 when it is given with greater freedom and in much larger 
 doses than are usually prescribed with us ; the object 
 being, as Boudin expressed it in a valuable communi- 
 cation to the late Dr. Morehead, to substitute an arsenical 
 for a malarial diathesis. 
 
 The sulphate of cinchona is reported by Dr. Paul 
 Turner, an American physician, to be efficacious to the 
 extent of a scruple during the intermission, succeeding 
 in 79 per cent of his cases. Salicine per se is not a 
 reliable remedy, but the salicylate of quinine is now 
 much used as a remedy in India after the regularity of 
 the paroxysms has been broken ; and it is very useful in 
 the malarial neuralgias already spoken of. Professor 
 PoUi of Milan has written strongly in favour of the 
 alkaline sulphites. Tried by our army medical officers 
 in an epidemic of malarial fever in the IMauritius, they 
 were of no avail. Much has been written lately in favour 
 
56 DISEASES OF TROPICAL CLIMATES lect. 
 
 of the Eucalyptus globulus, the so-called " fever tree " of 
 Australia. It has been much vaunted in Germany. My 
 trials of it in this hospital were unsatisfactory ; I cannot 
 deny it some power in mild cases, but in the severer 
 forms of intermittent fever it is of little or no value. 
 The preparation I used was a strong tincture made from 
 the leaf, which when fresh gives out a strong camphor- 
 aceous odour. To this its supposed virtue as an antidote 
 to malaria has been attributed. A belt of trees inter- 
 posed between a source of malaria and human habitations 
 has long been believed to intercept at least a portion of 
 the poison, and the Eucalyptus globulus has been sup- 
 posed to be peculiarly efficacious in this way. Although 
 a hard-wooded tree, it grows with great rapidity ; it is 
 very greedy of moisture, and where planted in sufficient 
 numbers, may act favourably as a consumer of moisture 
 in the subsoil. Carbolic acid has been tried by Drs. 
 Declat, Barrant, and others, and by them supposed to 
 be an infallible remedy against malarial fevers ; but 
 more extensive experiments made by Dr. H. Curschman 
 of Berhn (1873), proved the supposed remedy to be 
 utterly valueless. 
 
 I fear I must leave the interesting therapeutic question, 
 " How does quinine act?" to those who devote them- 
 selves specially to this important branch of medical 
 science. Herepath long ago showed that not much of 
 it taken into the system is excreted from it ; it is either 
 assimilated or destroyed in its transit through the 
 vascular system. Binz has shown -its wonderful power 
 in preventing and arresting putrescence and fermentation. 
 
Ill INTERMITTENT FE VER 57 
 
 The high price of this invaluable drug has been a 
 temptation to a few manufacturers to adulterate it ; 
 some years ago it was discovered that the hospitals in 
 Paris were supplied with " quinine " adulterated " to 
 nearly the extent of one-half with an inert substance." 
 There is too much reason to believe that the supply of 
 this adulterated drug was not confined to the Paris 
 hospitals, and the fact will explain the unmerited dis- 
 repute into which quinine has sometimes fallen. 
 
LECTURE IV 
 
 REMITTENT FEVER 
 
 Definition. — A paroxysmal fever of malarial origin, in 
 which the paroxysms do not intermit, but only, as the 
 term denotes, remit. 
 
 It is the gravest form of the class to which it belongs. 
 It is a more acute affection than intermittent fever, to 
 which it is closely allied; one form often passing into 
 the other. It is more pronounced in its symptoms, 
 more rapid in its course, and the direct mortality from 
 it is much higher. It has many synonyms, such as 
 bilious-remittent, jungle fever ; and it often gets local 
 names from the place or district where it prevails to an 
 exceptional extent — a bad practice, leading to confusion 
 and misapprehension. The most objectionable name is 
 inflammatory remittent, productive of mistakes as to its 
 true nature, and sure to lead to treatment of a mis- 
 chievous kind, based on false pathology. By the French 
 it is known as Fievre remitte7ife, in Germany as Bosurtigus 
 endemisches fieber. 
 
 Remittent fever is seen in all climates where malaria 
 is found in sufficient concentration to generate it. It 
 
LECT. IV REMITTENT FEVER 59 
 
 was at one time not uncommon in Britain, and our 
 armies have suffered from it almost wherever they have 
 served, very notably at Walcheren and Carthagena — two 
 of the saddest episodes in our military history ; in the 
 East and West Indies, in the Mediterranean, and with 
 extreme intensity, in the west coast of Africa. In India 
 we meet with it in the deltas of rivers, in terrais, in 
 jungles at certain seasons, with great intensity at the 
 base of mountain ranges, and not unfrequently in barren 
 plains from which the cultivating hand of man has been 
 withheld. 
 
 A remittent fever does not present in its course a 
 distinct interval or period of complete apyrexia ; the 
 symptoms abate^ they do not cease ; the fever partakes 
 more of the continued type ; and the more this is the 
 case the greater is the danger. 
 
 It is a common disease in Italy, and the French army 
 has suffered severely from it in Algeria. In unhealthy 
 countries it is often the first form of fever that attacks 
 newcomers ; but survivors in second attacks are more 
 prone to suffer from the intermittent type. The medical 
 officers of our army in Spain observed that men on first 
 entering a malarial locality generally suffered from the 
 remittent form, while the inhabitants were only affected 
 by the intermittent type ; if they continued to serve in 
 the place they became liable, like the inhabitants, only 
 to the milder form of the disease. The French army 
 surgeons had a like experience in Algeria; out of 3199 
 cases of remittent fever only 359 had second attacks ; 
 while out of 15,080 cases of intermittent no less 
 
6o DISEASES OF TROPICAL CLIMATES lect. 
 
 than 4295 were readmitted with the same type of 
 fever. 
 
 The anatomical characters are much the same as in 
 the intermittent form, the difference is one of degree; this 
 being so, it must suffice to refer to the description given 
 in previous lectures. The mucous coat of the stomach 
 and duodenum is more congested, and the tissues are 
 more softened than in milder forms of malarial fever, 
 and Briiner's glands are more enlarged. The blood 
 changes also are more intense, and the consequent 
 pigmentation of liver, brain, and spleen are more 
 marked. 
 
 The pre7nojiitory symptoms are much the same as in 
 other forms of malarial fever, perhaps more marked. 
 
 Cold Stage. — This is by no means so intense or so 
 prolonged as in intermittents ; often it is little more 
 than a passing feeling of chilliness without distinct 
 rigors. The thermometer shows a temperature two or 
 three degrees above the normal, which rapidly rises, 
 as the hot stage develops, to 5°, and sometimes even 
 10° above normal. 
 
 Hot Stage. — With this high temperature the whole 
 system is disturbed into what Robert Jackson termed 
 "a tempest of the frame." The skin is pungently hot, 
 the face is flushed, headache is intense, the pulse rises 
 to 120 or more, there is dorsal pain, the tongue is foul, 
 dry, and bile-tinted. There is a sensation of oppression 
 at the epigastrium, which becomes full and tense ; 
 vomiting now sets in, which brings no relief to the 
 epigastric uneasiness ; soon it becomes distressing, the 
 
IV REMITTENT FEVER 6i 
 
 quantity of fluid ejected far exceeding what is taken 
 by the patient. At first the vomit is colourless, then 
 bilious, and sometimes even bloody, in so-called " per- 
 nicious " fevers even resembling the " black vomit " of 
 yellow fever ; the respiration is hurried, and the patient 
 tosses in search of relief from change of position. Jn 
 this state he remains for a time varying from six to 
 twelve hours, then the symptoms abate, the skin becomes 
 moist, far short of the profuse sweating of an inter- 
 mittent, the temperature falls several degrees, never 
 reaching the complete apyrexia of the milder type ; 
 the vomiting ceases, the headache lessens, and the 
 epigastric fulness and tension decrease. This, in 
 technical language, is the remission. Mark it well. It 
 is not only an unspeakable relief to the patient, but 
 a precious time for treatment. Even in the severest 
 cases when the general symptoms abate so slightly as 
 to escape the attention of an inexperienced observer, 
 the thermometer will indicate the remission. In from 
 two to twelve hours a sensation of chilliness will recur, 
 soon followed by a rise in temperature and the other 
 symptoms of the hot stage. This is termed the 
 exacerbation, which in its turn again gives way as before 
 to the remission. The longer the exacerbation, in other 
 words, the nearer the fever comes to the continued type, 
 the more dangerous it is. In this fever a morning re- 
 mission is almost invariable, hence the old rule among 
 military physicians in the West Indies, to pay an early 
 morning visit to turn the hours of remission to the best 
 account. The exacerbation usually returns at noon, and 
 
62 DISEASES OF TROPICAL CLIMATES lect. 
 
 often lasts till midnight. In the worst forms the skin 
 assumes a yellow tint, to which the term yellow remittent 
 is given. This has sometimes led inexperienced observers 
 into mistaking the disease for specific yellow fever. 
 
 Hiccough is a troublesome symptom, and if it 
 appears late in the disease and continues during the 
 remission, is not a favourable one. 
 
 The bowels are usually constipated, but are some- 
 times loose. If the motions are bloody and offensive, 
 a condition of evil omen is threatened. 
 
 Jaundice is rare ; the yellowish tinge of the skin 
 already described is not icteric, but depends on the escape 
 of the colouring matter of the blood into the tissues, 
 and is an unfavourable symptom. Completely developed 
 jaundice only occurred in 28 out of 114 of Dr. More- 
 head's carefully observed clinical cases. 
 
 Hepatitis, at least in India, is rare, very rare in the 
 course of this fever, although the gastro-duodenal tender- 
 ness, always more or less present, often leads to an error 
 in diagnosis. It was not until I had an opportunity of 
 seeing cases of this fever brought to Netley from the 
 west coast of Africa that I saw genuine suppurative 
 inflammation of the liver running its course in men 
 suffering from unmistakable malarial remittent fever. 
 In the cases referred to, and in many others from the 
 same region, under observation at the same time, a 
 distinct and most offensive odour proceeded from the 
 patients in the sweating stage, compared by the sufferers 
 themselves to that of the pestiferous swamps from 
 whence came the malaria that poisoned them. This 
 
IV REMITTENT FEVER 63 
 
 odour was quite perceptible on the towels with which 
 they dried their bodies, and on their bedding. 
 
 The urine is acid, scanty, and high-coloured, very 
 rarely albuminous. During the hot stage the secretion of 
 urea is much increased, but lessened during the remis- 
 sion. In some cases of this fever recorded by me, 
 there was profuse secretion of bloody urine, which 
 lasted until convalescence set in. 
 
 The adynamic form of remittent fever is one of great 
 gravity. It is characterised from an early stage by prostra- 
 tion, brief and uncertain remissions, a quick and com- 
 pressible pulse, a black and dry tongue, the teeth 
 being covered with sordes, rapid respiration, epigastric 
 tension and oppression, with vomiting, often bloody ; 
 loose, offensive, and bloody motions, with a disposition 
 to hsemorrhage from the mucous surfaces generally. 
 This is a form of fever common in the most malarious 
 regions of Italy, occurring in men debilitated by long 
 exposure to the poison, and this is the form to which 
 Continental writers apply the term "pernicious." It is 
 a fatal form, and post-mortem examination often reveals 
 ulceration of the small intestines, as well as the usual 
 morbid appearances of malarial fevers. 
 
 The duration is from five to fourteen days. In the 
 worst forms death is rare before the eighth day. But, 
 as in all malarial fevers, the duration is much affected 
 by treatment. 
 
 Diagnosis. — In the article "Remittent Fever," in 
 Quain's Dictionary, I have given the diagnosis between 
 this and specific yellow fever in the following words : — 
 
64 DISEASES OF TROPICAL CLIMATES lect. 
 
 Remittent is paroxysmal; yellow fever is continued. 
 Remittent has a morning remission ; yellow fever has 
 not. Haemorrhage from any source is exceptional in 
 remittent ; in yellow fever it proceeds from mouth, 
 nose, eyes, ears, bowels, the urinary passages, and from 
 any broken surface or scratch on the skin. Over 
 remittent fever the power of quinine is beyond question ; 
 the drug is powerless in yellow fever. Death in the 
 worst remittents is uncommon before the eighth day ; 
 in specific yellow fever it is common on the third day. 
 The mortality -rate in yellow fever is often 40 per 
 cent; that of remittent in the present day does not 
 in India exceed 4 or 5 per cent, and is often 
 much less. Yellow fever is portable and contagious ; 
 remittent is neither. Yellow fever has a special habitat 
 of its own, and can only exist as an endemic disease 
 in countries where the mean temperature does not fall 
 below 72° F. Lastly, specific yellow fever is not a 
 disease of India, where every form of malarial fever 
 exists as an endemic disease. It will be more convenient 
 and save repetition if I postpone what I have to say 
 on the more difficult question of the diagnosis of malarial 
 from tropical enteric fever, until I come to the descrip- 
 tion of that disease. 
 
 Prognosis. — This is favourable when the remissions 
 are distinct, when the interval between them and the 
 exacerbations is prolonged, when the skin acts freely, 
 and when the urine deposits a sediment like that in 
 intermittent fever. 
 
 Faint and uncertain remissions, a tendency to collapse 
 
TV REMITTENT FEVER 65 
 
 as the fever progresses ; in a word, when symptoms 
 generally recognised as typhoid appear, and when there 
 is a tendency to haemorrhages from the mucous surfaces, 
 all point to an unfavourable termination, and indicate 
 the necessity of energetic conservative treatment to 
 rescue the patient from a perilous condition. 
 
 Treatment. — It has been my fortune to have to treat 
 this disease in some of the most unhealthy climates in 
 India and China, and in the persons of invalids who 
 have had a recurrence of it on their return from the 
 west coast of Africa. When I first went to India the 
 treatment left as a bad legacy to Indian practitioners by 
 Dr. James Johnson was still in vogue among some of 
 my older brethren. Johnson was a naval surgeon whose 
 experience of tropical diseases was confined to the sea- 
 board of India ; he had for patients seamen whose 
 constitutions were not deteriorated by long residence in 
 malarial climates ; he was a man who " had the courage 
 of his opinions," and never failed to convey them to 
 others with some literary ability, and with a dogmatism 
 very satisfying to young and inexperienced men in 
 search of guidance under difficulties. Johnson, in a 
 word, mistook the disturbance of the system, the 
 "tempest of the frame," for inflammatory action; and 
 taught that this was to be met by energetic " anti- 
 phlogistic treatment," carried out with a high hand, and 
 with unflinching faith. He bled, he leeched, he bled 
 again, he purged, he salivated. What success he met 
 with at sea, it is not for me to say, I do not in fact 
 know ; but this I do know, his disciples on shore, of 
 
 F 
 
66 DISEASES OF TROPICAL CLIMATES lect. 
 
 whom some, a select few, survived to my day, a 
 " survival " not perhaps of the " fittest," were faithful to 
 the teaching of their master. The result was not satis- 
 factory ; I put it mildly when I say the mortality was ten 
 times what it is to-day. Happy, I sometimes thought, 
 were those who succumbed in comparison with others 
 who came out of the unequal battle, blanched, maimed, 
 almost toothless, and mercurialised. Enough, let us 
 turn from the contemplation of this picture, not, how- 
 ever, before I add that the system was a departure from 
 an older and better one, under which the predecessors 
 of the Johnsonian school successfully treated this formid- 
 able fever, with no better weapon than crude " Jesuits' 
 Bark," which, to use their own phrase, they "threw in" 
 with generous hands. 
 
 The indications of rational treatment are plain and 
 simple, viz. to prevent the recurrence of the exacerba- 
 tions by means that do not injure the constitution, and 
 to sustain the system until it throws off the poison that 
 oppresses it. 
 
 No question of the use of emetics comes in here ; 
 nature solves that even too energetically. It is, how- 
 ever, a matter of real importance that the bowels should 
 be unloaded; it is certain that this is essential to the due 
 action of quinine. Under the head of intermittent 
 fever I have given }'ou Livingstone's effectual method of 
 doing this, and also a formula that I have found to 
 answer the purpose equally well. Can we do anything 
 to mitigate the severity of the stage of exacerbation and 
 to shorten it? We have in aconite a remedy at once 
 
IV REMITTENT FEVER 67 
 
 safe and effective, if judiciously used, and which has 
 the inestimable advantage of leaving no sting behind it. 
 I advise you to administer it in the mode advised by 
 Professor Ringer, in drop doses every ten minutes for 
 an hour, and then every hour or half-hour until the 
 temperature begins to fall and the skin to act. If you 
 use Fleming's Tincture, remember that it is five times 
 more powerful than the ofi:icial preparation, and use it 
 with the necessary caution. Aconite used in this way 
 acts as a calmative, depressent and diaphoretic, and given 
 as advised in a teaspoonful of water, it tends rather to 
 restrain than to provoke vomiting. As soon as the first 
 sign of remission is given by the thermometer, quinine 
 should be administered in a full and effective dose of 
 not less than 10, and not more than 20 grains; it 
 is, I think, more effective given in solution. Some 
 patients dislike the bitterness of the remedy so much, 
 and the condition of irritability of the stomach is so 
 great, that pains should be taken to lessen this — the 
 addition of some such corrective as syrup of orange, or 
 where available, the quinine may be given in capsules, 
 which are now elegantly prepared by French and 
 American pharmacologists, who take more pains to 
 make physic palatable than is done in our country. 
 The dose should be repeated during the remission so as 
 to ensure the patient being under the influence of the 
 drug before the time of expected return of the exacerba- 
 tion. The surest indications of sufficient cinchonism is 
 some degree of ringing in the ears. I am no advocate 
 for " pushing " quinine to excess by the use of doses to 
 
68 DISEASES OF TROPICAL CLIMATES lect. 
 
 the extent of half a drachm or a drachm, which not 
 only induce deafness, but even temporary blindness. 
 This, to my mind, is to abuse and to bring into dis- 
 repute an invaluable remedy. I have already shown 
 you how a patient may be brought under the influence 
 of quinine by injection into the bowel, a method which 
 is often called for when the stomach rebels against its 
 use by the mouth. Remembering that quinine acts 
 powerfully in reducing temperature, it may be given in 
 this way even in the hot stage, to the extent of a scruple 
 with advantage, when, if given by the mouth, it would 
 be at once rejected. Like many other drugs, quinine is 
 more than twice as effective when given hypodermically. 
 There is no doubt that remittent fever has in this way 
 been very effectually treated ; but if the quinine is 
 dissolved, as it usually is, with the aid of a mineral acid, 
 it is apt to cause troublesome ulceration. When this 
 method was in vogue in India some years ago, many of 
 our invalids coming to Netley carried on their arms and 
 other parts of their persons cicatrices of pretty deep 
 ulcers caused in this way. This led me to make trial of 
 the more soluble so-called neutral-sulphate of quinine 
 for this purpose, which answered equally well ; 5 or 6 
 grains will dissolve in much less than a fluid drachm of 
 water with a little heat, and this injected into the skin 
 did not, in my trials, cause ulceration or even irritation. 
 The syringe for this operation should be larger than that 
 used for the injection of morphia, and the needle should 
 be made of platinum. 
 
 I must not, however, fail to bring to your notice a 
 
IV REMITTENT FEVER 69 
 
 very grave objection to the use of quinine in this way. 
 Some years ago tetanus followed this operation in six 
 cases in India. The late Sir William Muir, when 
 director-general, was kind enough to send me the 
 details of the cases, so there can be no doubt of the 
 fact. I cannot tell you the proportion of cases in which 
 so disastrous an effect followed, whether or not any 
 considerable branch of a nerve had been wounded, or 
 whether the instrument had or had not been properly 
 cleansed in a disinfecting fluid after use ; but with the 
 knowledge of the fact I have just given you, I think 
 you will not be very ready to subject your patients to 
 such a grave risk as this, when other means of effecting 
 your purpose are open to you. There is, to my mind 
 something revolting in a death brought about, directly 
 or indirectly, by a remedy intended to cure. 
 
 There is yet another way in which this fever may be 
 dealt with. I have, in the lecture on intermittent fever, 
 brought to your notice some of the substitutes for 
 quinine. I have reserved until now one which can 
 hardly be called a substitute, inasmuch as that drug 
 enters into the formula for the remedy. This is War- 
 burg's Tincture, the composition of which is shown on 
 the board behind me ; ■*■ it will strike you as a mere 
 farrago of drugs, some of them obsolete. The quantity 
 of quinine in each ounce of the tincture hardly ex- 
 ceeds 9 grains ; yet, thus combined, it acts on the 
 system with great energy. The tincture is in fact the 
 
 1 The formula for the preparation of this tincture will be found 
 in the Appendix. 
 
70 DISEASES OF TROPICAL CLIMATES lect. 
 
 most powerful diaphoretic known to me. It is sold in 
 small bottles, each containing one ounce. It can be 
 given in the hot stage after the bowels have been freely 
 relieved. Half an ounce is given undiluted, the remain- 
 ing half ounce in about from two and a half to three 
 hours, as little fluid as possible should be taken im- 
 mediately after it ; the result is almost certainly a 
 marked reduction of temperature, and profuse action of 
 the skin, with a proportionate relief of all the symptoms. 
 The remedy should always be given to the patient in 
 bed, when it is more effective. It often happens that 
 one administration of the tincture suffices to bring the 
 fever to an end without another. 
 
 I cannot refrain from mentioning the first case that 
 came under my notice in which a valuable life was saved 
 by this remedy. When attached to the Political Resi- 
 dency of Hyderabad in the Deccan, information was 
 brought to the Resident that his son-in-law, an 
 intimate friend and brother officer of my own service, 
 then acting as statistical surveyor of the Deccan, had 
 been brought into a station about 80 miles away, in a 
 hopeless state, from remittent fever, and delirious. I 
 hastened to his assistance. Arrived at the station, I 
 approached the house where my friend was from the 
 rear ; I observed a quantity of bedding and night-clothes 
 exposed to the sun, and concluded that I had arrived 
 too late to be of use to my friend. On entering the 
 house by the front, I was joyfully surprised to find him 
 sitting in the hall, not only free from fever, but well and 
 in excellent spirits. I then heard that an officer, be- 
 
IV REMITTENT FEVER 71 
 
 longing to the Mysore Commission who was passing 
 through the station, had persuaded the medical officer in 
 charge to give Warburg's Tincture, which, acting in the 
 manner I have described, brought the attack to an end 
 with profuse action of the skin, which explained the 
 drying process that alarmed me. This officer had no 
 return of fever, and soon returned to duty. I was 
 assured by the medical officer of the station that nothing 
 could be more alarming than the condition of his 
 patient when brought under his care. Encouraged by 
 this trial I have since used it in a great number of 
 cases, and I can truly say it has rarely disappointed me. 
 I admit that in very adynamic cases the free diaphoresis 
 it causes will need caution in its use, and liberal support 
 during its action. 
 
 This remedy was first introduced into India by 
 the late General Sir Mark Cubbon, K.C.B., when 
 that eminent administrator was commissioner of the 
 Mysore province. It was largely and successfully 
 used by the medical officers of the Mysore Com- 
 mission, and such was the confidence it inspired in 
 the administrative officers of the commission, that the 
 most malarious parts of the province were visited by 
 them without fear. By my advice the late lamented 
 General Gordon took a supply of the tincture with him 
 to the Soudan, and on several occasions, as he more 
 than once assured me, his own valuable life and that of 
 others was saved by it. This remedy is better known 
 and more used in Southern India than in Bengal. Its 
 reputation was much injured by a spurious imitation of 
 
72 DISEASES OF TROPICAL CLIMATES lect. 
 
 it, which was unfortunately on one occasion suppHed to 
 the Government of Madras. I must frankly tell you 
 that some odium fell on me for using and recommend- 
 ing •' a secret remedy " before its composition was 
 made public. I am as much opposed as any one in 
 our profession to the use of secret remedies, which nine 
 times out of ten are either useless or dangerous ; but 
 there are exceptions to most rules, and this, it appeared 
 to me, was one of them ; of this I am certain, I have 
 saved many valuable lives with it. In Rome, or its 
 neighbourhood, I was unlucky enough to recharge my 
 system with malaria, a charge which exploded in Flor- 
 ence in a most severe attack of remittent fever ; when 
 the thermometer gave in the early morning the first 
 indication of a coming remission, I had recourse to this 
 febrifuge ; shortly I was bathed in a perspiration so 
 profuse as to saturate bed and bedding, to my unspeak- 
 able relief; no exacerbation followed, and in twenty-four 
 hours I was in the famous picture galleries free from 
 every trace of fever. 
 
 My friend Dr. W. S. Playfair has used this tincture 
 in some bad cases of puerperal fever with good effects, 
 and its therapeutic action has also been investigated in 
 an interesting communication to The Practitioner by 
 Dr. Broadbent. It is quite possible that the action of 
 quinine may be in like manner assisted by combination 
 with other aromatic stimulants. 
 
 Once more I must insist on the necessity of due 
 support by suitable diet during the remission, and 
 stimulants on the first sign of failure of the heart's 
 
IV REMITTENT FEVER 73 
 
 action. Treated in this way, the death-rate from even 
 the worst forms of malarial fever among Europeans in 
 India ought to be, and in point of fact is now, remark- 
 ably small. In the year 1884 the latest statistics that 
 came under my observation, the total mortality from 
 malarial fevers in the European part of the army of 
 India, was only 0.02 (representing the death of one 
 man), a mortality nearly seven times less than the 
 average mortality of the last decade. There was no 
 diminution in the number of admissions from fevers of 
 this class in the year in question, which amounted to 
 1350 per 1000. 
 
 I closed the article on "Remittent Fever" in Quain's 
 Dictionary of Medicine by a quotation from the writ- 
 ings of an intelligent friend and fellow - traveller of 
 Livingstone, which I repeat here : " One thing, how- 
 ever, must be strongly urged, it is that all notions about 
 not being able to ' stand quinine,' that it ' flies to the 
 head,' and so forth, must be banished as utter nonsense. 
 In Africa every one can stand quinine ; there is scarcely 
 a disorder there in which it is not positively required." 
 I add, from my own experience, that this observation is 
 as true of malarial regions in other parts of the world as 
 it is in Africa. 
 
LECTURE V 
 
 ENTERIC FEVER 
 
 In tlie introductory lecture to this course, I mentioned 
 that it was the late Dr. Bryden, of the Bengal army, 
 who first seriously awakened the attention of the pro- 
 fession in India to the widespread distribution of enteric 
 fever in that country, and brought out the fact that 
 youth and recent arrival there are intimately related as 
 predisposing causes of this fever. It is not in the army 
 of India only that this disease proves destructive ; the 
 French army, serving in Algeria, has suffered in liko 
 manner. As in India, so in Algeria, the young and the 
 newly-arrived are the victims. When the Pontifical 
 States were occupied by the French army, the mortality 
 from this fever reached in one year the high figure of 
 20.3 per 1000 effectives. The reports of the sanitary 
 commissioners in the three Presidencies conclusively 
 show " that the disease attacks soldiers of short residence 
 in India in much greater proportion than others ; and 
 further, that the greater the proportion of young unac- 
 climatised men in the army of short residence in India, 
 the greater is its liability to loss from this disease." 
 
 The following table shows the mortality from enteric 
 
ENTERIC FEVER 
 
 fever, and ratio of liability to it at different ages. From 
 Twentieth Annual Report of Sanitary Commissioners with 
 the Government of India : — 
 
 Year. 
 
 Under 25. 
 
 25 
 
 to 29. 
 
 30 tc 
 
 34- 
 
 Deaths 
 
 Percent- 
 
 Deaths 
 
 1 Percent- 
 
 Deaths 
 
 Percent- 
 
 
 per 
 Mille. 
 
 age of 
 Liability. 
 
 per 
 
 Mille. 
 
 1 age of 
 i Liability. 
 
 per 
 Mille. 
 
 age of 
 Liability. 
 
 1S77 
 
 2.45 
 
 44.2 
 
 1-55 
 
 27.9 
 
 0.C9 
 
 17.8 
 
 1878 
 
 6.04 
 
 53-0 
 
 3-55 
 
 ! 3I-I 
 
 1.04 
 
 91 
 
 1879 
 
 6.17 
 
 54-1 
 
 2-73 
 
 23.9 
 
 1.78 
 
 15.6 
 
 1880 
 
 6.25 
 
 56.26 
 
 3-15 
 
 28.35 
 
 1.09 
 
 9.81 
 
 1881 
 
 4-56 
 
 59- S4 
 
 1-57 
 
 20.60 
 
 0.79 
 
 10.37 
 
 1882 
 
 4-32 
 
 56.18 
 
 1-55 
 
 20.16 
 
 O.7S 
 
 10.14 
 
 1883 
 
 4-34 
 
 66.36 
 
 1.50 
 
 22.94 
 
 0.70 
 
 10.70 
 
 In further illustration of the fact so well brought out 
 by the table showing the influence of youth, the follow- 
 ing facts may be given from the same Report : — At 
 Lucknow 44 cases of enteric fever occurred in one year 
 (1883); of these no less than 35 belonged to the Derby- 
 shire Regiment, recently arrived from Egypt, principally 
 composed of young soldiers. Of the 44 cases, 33 
 occurred in men between 20 and 24 years of age, and 
 9 in men from 25 to 29 ; 33 had been less than a year in 
 India, and 5 over one, but less than two years. Evidence 
 to the same effect could be multiplied indefinitely.-"- 
 
 1' There is nothing peculiar to hot climates in all this, for the 
 enteric fever age is about the same in all climates. 
 
76 DrSEASES OF TROPICAL CLIMATES lect. 
 
 Until the year 1861 enteric fever never appeared in 
 the medical statistics of the army of India, European 
 or native. Fevers were registered under three heads — 
 Intermittent, Remittent, and Continued. The two first 
 were regarded as without question due to malaria. 
 Under the heading Febt-is communis continiia were 
 classed all fevers not distinctly paroxysmal. I do not 
 doubt that hundreds of cases formerly regarded as the 
 adynamic form of remittent with imperfect remissions, 
 were in fact cases of enteric fever, and would now be so 
 diagnosed and classed ; and that a large proportion of 
 those entered in the returns as common continued fever, 
 more particularly those with a history of " bowel compli- 
 cation," as the diarrhoea of such cases was often phrased, 
 were enteric, as we now understand the term. 
 
 After what has been said, I need hardly add, I do 
 not admit that enteric fever is a new disease in India. 
 In the Madras General Hospital, as far back as the year 
 1838, the year of my first connection with India, at 
 Secunderabad, in the Deccan ; in China, as far north as 
 Nankin, I saw and treated cases of continued fever, 
 extending over twenty days in duration, with the " bowel 
 complications " above referred to ; if I saw such cases 
 now I would unhesitatingly diagnose them as enteric 
 fever. The symptoms were the same, the mortality 
 exceeded that of fevers distinctly malarial, they were not 
 amenable to quinine, intestinal haemorrhage was not 
 uncommon, and the intestinal lesions were what we now 
 recognise as characteristic of enteric fever. It must be 
 kept in mind that clinical thermometry only came into 
 
V ENTERIC FEVER 77 
 
 general use in India in 1861, or thereabouts, as an aid 
 in the diagnosis of disease. It was on my return to 
 India in 1857, after two years' residence in Europe, that 
 I satisfied myself that fevers such as I have described 
 were none other than enteric. I then saw, treated, and 
 dissected cases of fever as distinctly enteric in symptoms, 
 progress, and post-mortem lesions, as any to be seen in 
 the London Fever Hospital. No attentive student ot 
 Indian medical literature can doubt that Clark, Annesley, 
 Twining, and others treated and dissected cases of 
 enteric fever ; reading the accounts they have left in the 
 light of modern science. There are more Europeans now 
 in India of the enteric fever liability age than in their day. 
 No one dreams of dating the existence of enteric fever in 
 Great Britain from the researches of Dr. A. P. Stewart and 
 Sir William Jenner. Like them, we study disease from 
 better standpoints, with more light, with better means 
 of research, and as a natural result our diagnosis is better. 
 What is the cause of enteric fever as we meet with it 
 in tropical and sub-tropical climates ? Here we get on 
 controversial ground. I am not here to dogmatise, to 
 assert that enteric fever has no other factors than those 
 with which we are familiar at home ; but this I do say, 
 those who assert that the fever so fatal to young soldiers 
 in India cannot in any case be traced to a pythogenic 
 origin, have a difficult thesis to maintain. Few, if any, 
 in this country doubt that this fever, in the language of 
 Professor Aitkin, is generated by a specific ^ morbid 
 
 '^Professor Aitkin now (1836) disavows his old belief in the 
 uniform origin of specific diseases. He holds that such an opinion 
 
7S DISEASES OF TROPICAL CLIMATES lect. 
 
 cause, fostered by, if not actually born of, decomposing 
 nitrogenous matter. I ask is there any country in the 
 world where decomposing nitrogenous matter is more 
 abundant than in India ? If so, what is there in the 
 nature of the climate or in the soil to hinder the genesis 
 of the contagium of a disease that elsewhere owns decom- 
 posing nitrogenous matter for its parent ? It is said, 
 and truly said, that the present sanitary condition of our 
 barracks in India and their surroundings is such as to 
 forbid the origin of such a contagium in or about them : 
 that there is no such thing as sewer air in them. On 
 this point I remark that this improvement is, compara- 
 tively speaking, a thing of yesterday. I have seen, and 
 very notably in the barracks of Fort St. George in 
 Madras, and the old infantry barracks of Secunderabad, 
 of dysenteric notoriety, the latrines so placed and their 
 conservancy so bad, that a privy atmosphere pervaded 
 certain dormitories near them, and I long ago placed it 
 on record that the majority of cases brought into hospital 
 of dysentery, diarrhoea, fever, and cholera, came from 
 the barrack rooms under this influence ; and Surgeon- 
 General Cornish, when sanitary commissioner of Madras. 
 noted, in one of his reports that when the dry-earth 
 system of conservancy was substituted for the old latrines, 
 and when the sea-wall of the fortress was thrown down, 
 admitting free perflation of air, an immediate diminu- 
 tion in the number of fevers took place. 
 
 The same high authority records that when typhoid 
 
 is now inconsistent with the light thrown on pathology by the 
 Darwinian hypothesis of evolution. 
 
V ENTERIC FEVER 79 
 
 fever prevailed in the artillery barracks at St. Thomas' 
 Mount, near Madras, "local nuisances were abundant in 
 the shape of foul drains and cesspools in the neighbour- 
 hood of barracks and hospitals." As for the old privies 
 of the Secunderabad barracks — I quote from the official 
 report of Superintending-Surgeon Cole — " They were 
 positively pestiferous, the buildings and their neigh- 
 bourhood were sodden and saturated with the foul 
 imbibitions of a long series of years, and emitted most 
 offensive odours." When this description was written, 
 the regiment then in barracks was suffering from a non- 
 malarious fever of a continued type, and extremely fatal, 
 and Mr. Cole was of opinion that the disease was 
 propagated by a direct contagium from the morbid alvine 
 discharges. I pray you to note this significant fact. 
 The 17th Lancers occupied these barracks after these 
 dreadful latrines were abolished and the dry-earth 
 system substituted, and the result was that the regiment, 
 with an average strength of 576, in three years lost only 
 37 men from all causes; a death-rate which, at the 
 period in question, was a mere flea-bite when compared 
 with the mortality of previous years in the same barracks, 
 such, for example, as that which the Royal Scots suffered, 
 when in one year, out of a strength of 1098 men, the^ 
 regiment lost 104 men from dysentery alone. 
 
 I admit the immense improvement in the sanitary 
 condition of the barracks in India ; but, I ask, are our 
 soldiers confined to barracks ? Notoriously they are 
 not. The native bazaars and villages within easy distance 
 of most of our cantonments stand on soil for aiies sodden 
 
8o DISEASES OF TROPICAL CLIMATES lect 
 
 with excremental matter, and the tanks and wells of such 
 places are befouled with all manner of impurities. This 
 being so, we naturally turn to the media by which such 
 impurities may be conveyed into the system. Are these 
 not the same there as here ? " Organic-laden air, water, 
 milk, or other beverages," articles of food, all freely used 
 by young soldiers in such places, and even, as Dr. Kerr 
 Innes has suggested, clothes washed in tainted water. 
 
 I am well aware that pains are taken to supply our 
 barracks with the purest water obtainable ; we know too 
 well that even in this country this desirable end is far 
 from being always attained, and it is notorious that in 
 India a pure water supply is one of the greatest difficulties 
 for the sanitary engineer. The simple fact is, and must 
 be, that when soldiers leave their barracks they drink 
 when they are thirsty, without curiously inquiring about 
 the source of the water supply. In the barracks at Rawul 
 Pindi some years ago an outbreak of enteric fever 
 occurred, and several men died. One of the wells of 
 supply was found to contain more than 12 grains of 
 organic matter per gallon, and the water was thick and 
 offensive, and Dr. Gillespie noted the significant fact, 
 that after that well was closed no more cases of enteric 
 fever presented themselves. Surgeon-General Sir Anthony 
 D. Home, V.C., K.C.B., in a report addressed to the 
 Government of Madras, states the following facts : 
 " During the third quarter of the year under report there 
 occurred in the 2d Battalion 13th Regiment at Kamptee 
 twenty-three cases of fever, of which eight were returned 
 as enteric, and the rest as simple continued fever." 
 
ENTERIC FE VER 
 
 Regarding the latter, it has to be observed that from the 
 description given, they appear to have been also cases of 
 enteric fever of a mild type. The twenty-seven men 
 attacked belonged to various blocks in the barracks, and 
 no room seemed to be more obnoxious to the disease 
 than another. The latrines were all in fair order, and 
 no suspicion attached to them. The drinking water 
 supplied to the barrack rooms was taken from a well 
 specially conserved for the supply of drinking water, and 
 after being drawn from the well, it was passed through a 
 filtering tank, and again filtered in barracks. The milk 
 was also above suspicion. 
 
 After a time it was noticed that nearly the whole of 
 those attacked were total abstainers from intoxicating 
 drinks. Further inquiry elicited the fact that the total 
 abstainers had a recreation room, where tea, coffee, and 
 aerated waters were supplied, and that the water used in 
 their preparation was taken, not from the well set apart 
 for drinking, but from another close at hand, considered 
 fit to furnish water for cooking only. This well wa 
 situated close to the site of former latrines, the surface 
 drain from the wash-house passed within 4 feet of it, 
 and, on closer examination, signs of percolation from 
 the drain into the well were discovered. On analysis 
 the water of this well contained an excess of organic 
 matter. The well was closed, and the fever ceased. In 
 this case it was possible to trace the disease to its 
 source, just as we see done constantly by experts in this 
 country. It is clear to my mind that if outbreaks of 
 enteric fever in India could be subjected to such an 
 
 G 
 
82 DISEASES OF TROPICAL CLIMATES lect. 
 
 exhaustive inquiry as the one under notice, the result in 
 many, perhaps in most, cases, would be the same. 
 
 The station of Bangalore, in the Mysore province, in 
 the Presidency of Madras, is the most coveted station in 
 Southern India. Its water supply has always been most 
 unsatisfactory. In 1883 40 cases of enteric fever were 
 reported as having occurred among the British troops 
 serving there. The medical officer's views on this 
 outbreak were as follows : — " No insanitary defects could 
 be discovered within the barracks. The water supply 
 — mixed with water from the Ulsoor tank and dhobies' 
 (washermen) works (as usual) — was impure from con- 
 tamination by excrement and filth of every description. 
 There is not only the immediate danger from the 
 pollution of the water supply tank, but as a portion only 
 of the filth washed into it becomes oxidised and 
 innocuous, the remainder is deposited on the bed of the 
 tank ready to give forth in the dry season, when the 
 water is low and the bed of the tank (125 acres in 
 extent) is exposed to the sun, the noxious vapour which, 
 in conjunction with the use of the water, predisposes to, 
 if they do not directly cause, this fatal form of fever." 
 To this report the surgeon-general adds : — " The con- 
 ditions referred to in these extracts are, in my opinion, 
 sufficient to account for the prevalence of enteric fever 
 in Bangalore." 
 
 I could, from the mass of material at my command, 
 multiply examples of this kind ; the above must suffice.^ 
 
 ^ Because I have insisted so much on the fact that enteric fever 
 has in India a filth origin in many cases as much as in Europe, I 
 
V ENTERIC FEVER 83 
 
 I must not omit to bring to your notice a notable 
 fact that cannot be easily made to fit in with the pytho- 
 genic theory. I refer to the number of cases of this 
 disease reported as having occurred among young officers 
 and soldiers while campaigning in Southern Africa and 
 in the deserts of the Soudan ; a subject of melancholy 
 interest to us in this school, for it is with pain I record 
 the fact that some of your almost immediate predeces- 
 sors on the benches you occupy, succumbed to the 
 disease in Egypt since our troubles and military opera- 
 tions in that country began in 1882, all of them within 
 the enteric fever age ; for I observe the fact " that no 
 medical officer of the rank of surgeon-major died of the 
 disease." What has been said on the pythogenic origin 
 of the fever in the examples given cannot be gainsaid, 
 unless you follow the simple and easy process of throw- 
 ing overboard the evidence, a small part of which only 
 I have had time to place before you, which has been 
 accumulated by trustworthy observers. We can without 
 difficulty account for the cases which occurred among 
 our young officers and soldiers when quartered in in- 
 sanitary and uncleanly cities like Cairo and such places as 
 
 may possibly be thought open to the charge of entertaining opinions 
 too exclusive on this point. I believe, however, that in my teaching 
 here I have shown myself alive to the modifying influence of malaria 
 and climate on the symptoms, course, and lesions of the disease. I 
 cannot be blind to the fact that, due allowance being made for the 
 modifying influences named, we do see in India a large number of 
 cases of true enteric fever with a filth history ; and I avow my 
 belief that in many others where the filth factor is denied, it is 
 because its existence has not been traced. 
 
84 DISEASES OF TROPICAL CLIMATES lect. 
 
 Suakim ; but how are we to explain the fact that some 
 officers and men suffered from the disease in the desert, 
 far from human habitations and the filth invariably to be 
 found near them in such regions ? I can conceive it 
 possible that in an uncertain proportion of cases the suf- 
 ferers contracted the disease in one or other of the 
 places named, although it did not develop itself until 
 they were far from the spot where the contagium w^as 
 taken into the system.^ Again, knowing as I do the 
 rapidity with which even in desert places insanitary con- 
 ditions are established in camps that occupy a fixed 
 position for even a short time, I can conceive it possible, 
 and even probable, that some cases might be traced to a 
 cause generated in this way, and once a zymotic element 
 is introduced into a camp, even by a few cases, it is not 
 difficult to account for the spread of the disease. I do 
 not, however, wish to dogmatise on this, I admit, diffi- 
 cult question ; we must await the result of more light 
 and careful study and experience. I have always held 
 that enteric fever can arise de novo, and the examples 
 given strongly support the hypothesis ; and while it will 
 be seen that I am much impressed by the part filth plays 
 in the genesis of enteric fever in tropical climates as well 
 as at home, I admit to the fullest extent the influence of 
 climate, malaria, and it may be other as yet unknown 
 factors in modifying the] symptoms, temperature curve, 
 course, and duration of the fever, as well as the lesions 
 
 i In considering the possibility of such an occurrence the long 
 period of incubation must be kept in mind, extending as it does 
 sometimes over twenty days. 
 
V ENTERIC FEVER S5 
 
 found after death. Above all, I warn you that while 
 purely typical cases of enteric fever will be seen in 
 tropical and malarial climates, many will present more or 
 less of that mixed character on which American physicians 
 have insisted so much. I must not omit to mention 
 that a specific typhoid bacillus existing in the lym];^atics, 
 blood, and tissues, is said by Klebs to be the cause of 
 this fever. That this eminent observer found a bacillus 
 such as he describes, we need not doubt. On the other 
 point let us reserve our judgment, and, as in other cases 
 of a like kind, await the result of further investigation. 
 
 Anatomical Characters. — The structural lesions ob- 
 served in a typical case of enteric fever are described in 
 all the text-books in your hands, with so much care and 
 minuteness that it would be a waste of time to repeat the 
 description. The most characteristic are found in the 
 small intestine and mesenteric glands ; the part most 
 affected being that portion of the ileum near the caecum, 
 where Peyers' patches present changes which are recog- 
 nised in Europe as pathognomonic of enteric fever. 
 
 I hand round some drawings made in the dead- 
 house of an Indian military hospital, by Surgeon-Major 
 Gillespie. I particularly ask your attention to the draw- 
 ing marked No. I. ; it represents a portion of the 
 ileum near the caecum ; note the swollen and congested 
 state of the mucous membrane, the enlargement of the 
 solitary glands, some of them having evidently burst and 
 discharged their contents, and passed into the stage of 
 ulceration ; above all, observe the condition of the 
 agminated glands which constitute Peyers' patches. One 
 
86 DISEASES OF TROPICAL CLIMATES lect. 
 
 Stands out throughout its entire length, many lines above 
 the level of the surrounding mucous membrane ; note 
 how the glands are swollen and distended with exudative 
 matter, having the " tawny " or fawn colour described by 
 Professor Aitkin, Dr. Broadbent, and other authors. In 
 other parts you will notice that the process of softening is 
 more advanced, the distended glands having burst and dis- 
 charged their contents, leaving behind the " reticulated," 
 "pitted," or "sieve-like" appearance, so named by many 
 pathologists. In the drawing marked No. II., the patches 
 are represented in a more advanced stage still, that of ulcer- 
 ation, with detached circular ulcers of various sizes, scat- 
 tered overthe mucous membrane. In the notes of the cases 
 sent to me with these drawings, the spleens are reported as 
 having been "enlarged, soft, the tissue easily broken down." 
 The drawings were taken from men who died at 
 Rawul Pindi, already referred to, with all the symptoms 
 of enteric fever. One of the barrack wells was found on 
 examination to contain water described as " thick and 
 offensive, " with 1 2 grains of organic matter to the gallon. 
 The use of this water was forbidden, and no more cases 
 of enteric fever appeared. The medical officer advised 
 that the well should be permanently closed, as others 
 gave an abundant supply of water of good quality. This 
 was not done. The reason is thus given in the report 
 from which I quote : " The authorities do not yet suffi- 
 ciently believe in the possible effects of bad water." Per- 
 haps, if the " authorities " could be persuaded to drink 
 this "thick and offensive water" for a month, it might 
 carry conviction, if not to their minds, to that part of 
 
V ENTERIC FEVER S7 
 
 their organisation depicted in the drawings we have been 
 studying. 
 
 The morbid appearances in the mesenteric glands 
 are pretty nearly as constant as those in the glandular 
 structures in the ileum ; they are enlarged and filled 
 with exudative matter of the same appearance and 
 colour as that found in Peyers' patches. The heart, in 
 prolonged cases, is found soft and flabby, the muscular 
 fibres being in a state of degeneration. This condition 
 is common to other fevers of long duration attended 
 with high temperature, and failure of its action from 
 this condition is often the cause of sudden death, one 
 of the many contingencies of this fatal fever. The 
 structural changes of the liver and kidneys is due to the 
 same cause — long-continued high temperature. 
 
 The malarial element enters so largely into all febrile 
 conditions in India and other malarial countries, that the 
 usual organic lesions caused by that agent are rarely 
 absent. 
 
 The symptoms of enteric fever as seen in Europe 
 are to be found in the text-books in your hands. I 
 cannot hope to add a single word to the description 
 given by Murchison, by Dr. Broadbent, and by my 
 colleague Professor Aitkin, in his great work, now in 
 all your hands ; to repeat what they have written would 
 be "wasteful and ridiculous excess," to compress would 
 be to spoil. My business here is to describe to you 
 how this disease presents itself to us in malarial climates, 
 modified as it almost always is by the action of that 
 ever-present poison. No easy task. Doubtless in the 
 
88 DISEASES OF TROPICAL CLIMATES lect. 
 
 persons of late arrivals, before their systems have been 
 much affected by malaria, the diagnosis is not more 
 difficult than at home. I now show you the temperature 
 chart of a case of this kind, for which I am indebted to 
 my friend, Surgeon - General Sir Anthony Home, and 
 with it, for the sake of comparison, I place one from 
 Wunderhch ; you will see that they correspond in all 
 essential particulars. There is the same gradual rise 
 in the temperature, which did not attain its maximum 
 until the fifth day, when it reached 105° F. ; there is 
 the usual evening rise and morning fall. In the Indian 
 chart the temperature was much affected by the cold 
 bath, the dotted line showing the fall after each emersion. 
 Towards the last days of the attack the oscillations, if 
 not so marked as in Wunderlich's typical chart, are 
 sufficiently evident, and towards the end we observe 
 the characteristic lengthening of the morning remission. 
 The chart gives also the pulse and respiration rates, the 
 nature of the stools, and the date on which the rose 
 spots appeared. The pulse rate never exceeded 84 ; 
 the stools throughout were " bilious," and do not 
 appear to have presented the pale brownish -yellow 
 colour with flocculi, so characteristic of enteric fever, and 
 the average number throughout was 3.3 daily, but they 
 were foetid. The rose spots appeared on the seventeenth 
 day, and were present until the twenty-first day. The 
 condition of the spleen is not noted on the chart.^ 
 
 1 The characteristic eruption of enteric fever is not so common 
 in India as at home ; and, as in this case, the crops of rose- 
 coloured spots appear later in the disease. Some care is necessary 
 to differentiate them from the bites of insects. 
 
m 
 
 se/ 3 
 
 oohNo 783 
 
 FoUo 
 
 36-50. 
 
 
 
 
 
 14 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
 7 
 
 8 
 
 9 
 
 10 
 
 .4 
 
 23 
 
 24 
 
 25 
 
 26 
 
 
 
 
 
 
 lime 
 > 9 
 
 M. P.K 
 
 T!UT16 
 
 9 9 
 
 A.W. P.M. 
 
 Tinu. 
 9 9 
 
 A.M. P.M. 
 
 Tirrve, 
 9 9 
 
 A.M. P VI. 
 
 A.M. P.M 
 
 lime' 
 9 3 
 
 A.M. P.M. 
 
 Time 
 ^ 9 
 
 A.M. P.M 
 
 Tim& 
 9 9 
 
 A.M. P.M. 
 
 Time' 
 
 9 9 
 
 A.M. P.M. 
 
 9 9 
 
 A.M. P.M. 
 
 7^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 - 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 L 
 
 
 
 : 
 
 
 
 
 
 
 ^ 
 
 ^ 
 
 . 
 
 ■9 
 
 
 
 
 _ 
 
 
 
 •wr ^ 
 
 / 
 
 
 
 
 
 
 
 
 y 
 
 \/ 
 
 ■ 
 
 • 
 
 
 
 
 
 
 "1 ■■^' 
 
 
 ^^ 
 
 
 
 
 
 
 
 - =0 
 
 $;S 
 
 
 ^.^ 
 
 
 
 • 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 : 
 
 
 
 
 % ]_■ 
 
 3 % 
 
 Z j 
 
 1 ■ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
RECORD OF TEMPERATURE. PULSE AND RESPIRATION 
 
 Corps. C.E. Chaplaav. Heffiviental N? - Rank 
 Disease/ ETderix/ Texer . BcUe/ of Attach IT^ of 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Age, 37. 5e7^i:ce' 70^2. StcOwn). Suhaihw. 
 Case, Booh Mo YSS Folio. 35-50. 
 
 Awfust/ 1884. ResulO - Date' ofJtesuU 18 
 
 OBs"rV.T°L. 
 
 AUGT 
 
 II 
 
 IZ 
 
 13 
 
 14 
 
 15 
 
 16 
 
 17 
 
 18 
 
 19 
 
 20 
 
 21 
 
 22 
 
 23 
 
 24 
 
 25 
 
 26 
 
 27 
 
 28 
 
 29 
 
 30 
 
 31 
 
 SEPTI 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
 7 
 
 8 
 
 9 
 
 10 
 
 o.vsoro,3»3.. 
 
 
 / 
 
 2 
 
 3 
 
 .4 
 
 5 
 
 6 
 
 7 
 
 8 
 
 9 
 
 /O 
 
 fl 
 
 72 
 
 13 
 
 n 
 
 15 
 
 76 
 
 17 
 
 7S 
 
 73 
 
 20 
 
 27 
 
 22 
 
 23 
 
 24 
 
 25 
 
 26 
 
 
 
 
 
 
 'Ar;;:.-;." 
 
 Tone 
 9 S 
 
 Time 
 3 d 
 
 Time, 
 3 9 
 
 Time 
 
 9 a 
 
 2i>TK 
 
 3 3 
 
 77>ne 
 9 a 
 
 JXme, 
 
 d d 
 
 nine 
 3 9 
 
 7&7U> 
 
 A7m. 
 
 Time 
 
 S 3 
 
 lime 
 3 9 
 
 5 5 
 
 Time, 
 3 3 
 
 Tune' 
 3 9 
 
 Time 
 3 9 
 
 9 3 
 
 Time 
 3 9 
 
 3 3 
 
 9 3 
 
 » 9 
 
 Tmc 
 3 .3 
 
 Tiinfi 
 3 9 
 
 TYme 
 fl S 
 
 » 3 
 
 3 3 
 
 9 9 
 
 Tim*- 
 B 3 
 
 .9 9 
 
 9 9 
 
 
 Time' 
 
 ^^ 107* 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — lOG' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — 105' • 
 
 
 
 
 \ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — 104* -1 
 
 
 
 
 
 
 
 
 
 
 '■•■ 
 
 
 
 
 
 
 
 '.fis 
 
 iljr 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — -i 
 
 — 103" 2 
 
 
 
 
 
 • 
 
 
 V 
 
 
 r 
 
 •>/ 
 
 >; 
 
 fore,Ba 
 
 WShe 
 
 Lf 
 
 \^, 
 
 •■■3o'- 
 
 /♦a 
 
 .^ 
 
 12 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — 102* 1 
 
 
 
 
 - • 
 
 
 
 ^ 
 
 J 
 
 
 1 
 
 .\ 
 
 / 
 
 4': 
 
 1 \\ 
 
 / 
 
 [ Ik 
 
 i^ 
 
 70 
 
 1 ' Ei: 
 
 9— A 
 
 .-» EJ r. 
 
 
 
 
 
 
 
 
 
 
 
 
 — 101" 
 
 
 
 ■ / 
 
 ^ ■ 
 
 
 
 
 • 
 
 
 iV(. 
 
 rBMh 
 
 
 • 
 
 
 f 
 
 s< 
 
 « 
 
 -I^ 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 100" 
 
 
 ^ 
 
 • 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Ha 
 
 
 
 
 M?^ 
 
 
 -7 
 
 
 
 
 
 
 
 
 
 
 — S9" -l 
 
 
 A^ 
 
 
 
 
 
 
 
 
 
 : 
 
 
 
 
 
 
 
 
 -§; 
 
 • '^■/ 
 
 ir.M 
 
 .^ 
 
 
 
 
 
 
 
 
 
 
 -6 
 
 / 
 
 
 
 
 
 
 
 
 
 
 ■ 
 
 
 
 
 
 
 
 
 
 xj 
 
 |: 
 
 v> 
 
 J 
 
 iv^ 
 
 ^ 
 
 — -m- 
 
 _* 
 
 
 
 
 
 
 — 37" 2 
 
 
 
 
 
 h--,~ 
 
 
 
 
 
 J- 
 
 
 
 
 
 
 
 ^.. 
 
 f^- ■ 
 
 1 :,^. |; 
 
 J ■ g 
 
 
 
 ^: 
 
 
 WJt 
 
 / 
 
 ^ 
 
 
 
 
 
 . 
 
 — 9fi" ' 
 
 
 
 
 
 
 
 
 
 
 . * °* 
 
 
 «■■- 
 
 
 
 
 |:S 
 
 I.| 
 
 
 1 : 1 1 . 
 
 
 .S:fi 
 
 |;| 
 
 Pi ■.'*: ■ 
 
 :«" ■i'*' 
 
 'rPii 
 
 [^•:^ 
 
 .■^ ,-^ 
 
 
 
 
 
 
 — ■ 
 
 
 
 
 
 ■ t- 
 
 S $ 
 
 § 
 
 S 
 
 «;§ 
 
 s s 
 
 s;^ 
 
 §:$ 
 
 s's 
 
 S-8 
 
 S K 
 
 §■> 
 
 S^g 
 
 
 s ;^ 
 
 §■$ 
 
 si§s 
 
 $-g 
 
 s ■§ 
 
 R :^ 
 
 $ R 
 
 S -s 
 
 ^.^ 
 
 R S 
 
 
 
 
 
 
 RE8P6RATP0MS PER 
 
 
 
 
 
 .H 
 
 -JVa 
 
 tLvrcdj 
 
 --- 
 
 h;-°i 
 
 press 
 1/ tiiru 
 
 
 -], 
 
 (- 
 
 -_■_. 
 
 — - 
 
 — 
 
 --- 
 
 -.- 
 
 '-1 '^aiiirc h :— - 
 
 --;- 
 
 
 
 
 
 ■ 
 
 
 
 
 
 
 
 
 
 
 
 MOTIONS 
 
 
 
 
 
 / 2 
 Bilious 
 
 
 
 1 3 
 
 z 
 
 2 
 
 2 2 
 
 ! z 
 
 2 1 
 
 2 2 
 
 2 3 
 
 
 
 3 7 
 
 2 8 
 
 7 i 
 
 Z 3 
 
 muous 
 
 2 4 
 Idtmv 
 
 5 
 
 3 7 
 BUious 
 
 3 7 
 
 
 
 2 7_ 
 
 3 2 
 
 2 
 
 
 
 
 
 
 Tepid, BaOv mv 
 
 a^dwj 
 
 Web SI 
 
 wet on 
 
 IZ'^dj 
 
 ly.^Tu 
 
 spots 
 
 or 
 
 oA 
 
 doTnin. 
 
 aZ' ££n 
 
 dernA. 
 
 s.mSj 
 
 ^ots 
 
 
 
 
 
 
 
 fcetub. 
 
 Id£m,. 
 
 
 
 
 
 
 
 
 
 
 
 
 
ENTERIC FEVER 
 
 In his report for 1883 the sanitary commissioner, 
 with the Government of India, remarks : " The reports 
 by medical officers on cases of enteric fever occurring 
 under their care show, as usual, how indefinite are the 
 symptoms which are often presented by cases of this 
 kind. In numerous instances the patients were ad- 
 mitted as suffering primarily from ordinary remittent 
 fever, and even febricula. Thus one medical officer 
 writes : many of the cases were admitted for febricula, 
 and after a few days changed to enteric fever. Another 
 writes : the eruption of enteric fever is more often absent 
 than present ; diarrhoea invariably absent until the dis- 
 ease is far advanced ; pulmonary complications are 
 severe, congestion of the lungs setting in early." 
 
 The most distinctive diagnostic symptoms between 
 enteric fever, pure and simple, and malarial remittent 
 are as follows : — 
 
 Entei'ic. Malarial Remittent. 
 
 Onset gradual, no rigors, only sense Onset more sudden, rigors 
 
 of chilliness. not distinct. 
 
 Rise of temperature gradual ; maxi- Rise much quicker, attaining 
 
 mum not attained for days. maximum in a few hours. 
 
 Evening rise of temperature and Morning fall of temperature 
 
 morning remission ; difference amounting to 3 or 4 de- 
 
 between morning and evening grees. 
 
 temperature not more than a 
 
 degree or one and a half, at a 
 
 later period as much as two and 
 
 more. 
 Heat of skin not distinct to hand Skin hot and pungent to 
 
 even when thermometer indicates hand. 
 
 that the blood is many degrees 
 
 above normal. 
 
90 
 
 DISEASES OF TROPICAL CLIMATES lect. 
 
 Enteric. 
 
 Headache moderate, face slightly 
 
 flushed. 
 Tongue coated in centre, red at tip 
 
 and edges, redness increasing as 
 
 case advances. 
 
 Abdomen tumid and splenic dul- 
 ness earl)'. 
 
 Tenderness and gurgling in right 
 iliac fossa not always present. 
 
 Diarrhcea the rule ; motions some- 
 times bilious, sometimes pale 
 brown with flocculi ; rose spots 
 occasional. 
 
 Pulse and temperature do not al- 
 ways correspond ; pulse may not 
 exceed 90 when temperature may 
 be 105° ; often dicrotous. 
 
 Relapses common. 
 
 Duration from 17 to 24 days. 
 
 Death not common before end of 
 second week. 
 
 Complications. — Haemorrhage fro m 
 bowels, perforation, diarrhoea, 
 albuminuria, thrombosis, embol- 
 ism, congestion of lungs, pneu- 
 monia. 
 
 Enteric fever not much if at all 
 under control of remedies as to 
 duration. 
 
 Malarial Re7?iittent. 
 
 Headache severe, face 
 
 flushed. 
 Tongue foul throughout. 
 
 Abdomen not so tumid, epi- 
 gastric oppression marked, 
 spleen also enlarged. 
 
 Absent. 
 
 Constipation the rule ; no 
 eruption. 
 
 Pulse and temperature more 
 nearly correspond ; with a 
 temperature at or above 
 105° pulse would gener- 
 ally be over 100, iio- 
 120. 
 
 Not often seen, although re- 
 mittent may pass into in- 
 termittent form. 
 
 Does not usually exceed 10 
 or 14 days. 
 
 Death sometimes as early as 
 eighth day. 
 
 Haemorrhage rare, albumin- 
 uria very rare ; pulmonary 
 complications common. 
 
 Remittent fever can be cut 
 short by remedies at an 
 early period. 
 
V ENTERIC FEVER 91 
 
 The cases of enteric fever admitted into Netley 
 Hospital from Egypt differed in no particular from 
 cases of the same disease contracted in this country. 
 Relapses were common to them all. In one case, that 
 of a young officer, the first relapse followed a full meal 
 taken at Malta. Up to the arrival of the transport at 
 Malta he was considered convalescent, and his diet had 
 been strictly regulated; he broke through the rule of 
 diet ordered, a relapse with profuse diarrhoea followed 
 immediately, and he was admitted to the sick officers' 
 quarters at Netley in a state of great prostration ; three 
 other relapses followed, with, on two occasions, haemor- 
 rhage from the bowels ; he was more than once rescued 
 from impending death by the watchful promptness of 
 the night-nurse in attendance. 
 
 Treatment. — The principles of treatment are much 
 the same everywhere, the most essential points being 
 a well-ventilated room or ward, good nursing day and 
 night ; a careful record being kept frotn first, not from 
 memory afterwards, of temperature, pulse, excretions, 
 food, and medicine. Every evacuation should be 
 powerfully disinfected and so disposed of as not to 
 risk the contamination of the water supply. From an 
 early part of the treatment the bed-pan should be used 
 — late in the disease this is imperative; cases of sudden 
 death from non-observance of this rule have been fre- 
 quent. The patient's linen should be frequently changed 
 as well as his sheets, with as little disturbance and fatigue 
 as possible. For this purpose it is well to have his 
 night-dress made Hke a child's pinafore, which the 
 
92 DISEASES OF TROPICAL CLIMATES lect. 
 
 attendant can remove and replace without much dis- 
 turbance of his person. Where possible two beds 
 should be used, one for night and the other for the 
 day ; the bedding of the one not [in use to be well 
 aired. Sponging of the body with tepid water, to which 
 permanganate of potash may be added (Broadbent), is 
 most refreshing : it promotes sleep and calms restlessness ; 
 if the temperature is high, the water may be used some 
 degrees lower than the temperature of the bod}'. Milk 
 should be the chief article of diet, to which, if any of it 
 is passed in a curdled state, some lime water should be 
 added, lest diarrhoea be provoked. Bread should be 
 sparingly given, if at all; it is apt to ferment, and is 
 better omitted from the diet altogether. From two to 
 three pints will be required ever}- twenty-four hours, 
 supplemented by a pint or a pint and a half of beef or 
 chicken tea. Patients soon get weary of beef tea. I 
 have often found that the addition of a teaspoonful of 
 Valentine's essence of beef makes it more palatable. 
 This can also be given cold in a little water, and is 
 sometimes much relished. Food should be given 
 regularly every three hours, day and night ; a little 
 hydrochloric or phosphoric acid may from time to time 
 be given as an aid to digestion. If the liquid stools 
 exceed three in twenty -four hours, they should be 
 restrained; an enema of 20 or 25 '\ of tincture of 
 opium in a little starch repeated if necessary two or 
 three times in twenty-four hours will usually sufifice. A 
 large proportion of cases will do well under this simple 
 treatment without further medication. 
 
ENTERIC FE VER 
 
 93 
 
 In India the question will often arise, Is quinine 
 useful or necessary ? I think that in mild cases in 
 young patients newly arrived, and who have not suffered 
 from malaria, it is not called for, particularly if the 
 temperature is not high. When the opposite conditions 
 prevail, more particularly when the rise in temperature 
 begins at or about i p.m., I believe it should be used ; 
 it unquestionably distinctly lowers the temperature, a 
 point of unspeakable importance. The long-continued 
 high temperature of this fever, continued as it is for 
 weeks, from its effect on the nervous system, and, above 
 all, on the muscular structure of the heart, is in itself 
 a great danger, and a frequent cause of death. Any 
 means, therefore, which, without aggravating other symp- 
 toms, tend to lower temperature, are not to be lightly 
 esteemed. If you will look once more at the tem- 
 perature chart of the case from India, you will see that 
 from day to day the temperature was much reduced by 
 the cold bath. Cold effusion was, as you know, much 
 used by the famous Dr. Currie, of Liverpool, in the 
 fever which prevailed in his day, no doubt typhus — a 
 fever so contagious that Currie, in taking the temperature 
 of his patients, contrived a thermometer curved in such 
 a way that he could read the index standing behind his 
 patients without the danger of their breath. Jackson 
 too, the prince of army surgeons, used cold water, 
 particularly the cold douche, in the camp fevers of his 
 time, and with great success. 
 
 In Germany and in France the treatment by the bath 
 has been revived, and the effect has been, according to 
 
94 DISEASES OF TROPICAL CLIMATES lect. 
 
 Brand. Liebermeister, Jiingensen, and others, to reduce 
 the mortalit}- from 15.4 per cent to 3.1. 
 
 According to Broadbent, it has not been so successful 
 in England. Perhaps it has not been found practicable 
 to carry it out either in public or private practice in the 
 face of a prejudice against it on the part of the people, 
 and no doubt also on account of the sacrifice of time 
 it demands. 
 
 With the cold bath some of the Continental phy- 
 sicians combine very full doses of quinine. Different 
 authorities take different temperatures as their standard 
 for the use of the bath — from 10 2.1 F. to 103°. The 
 patient by some is placed in a bath at a temperature 
 ranging from 65' to 70' F., kept in it for ten minutes, and 
 the emersion is repeated when the temperature rises again, 
 perhaps three times in twenty-fouj hours. A little 
 brandy is recommended before and after the bath ; the 
 patient is dried and carefulh" but lightly covered. 
 
 The method which finds most favour with British 
 practitioners, and is the one strongly advised by Broad- 
 bent, is to place the patient in the bath at a temperature 
 of from 80° to 90° F., and to cool rapidly down to 
 70' or 65'; if the patient's temperature is high, the 
 cold water should be poured over the head. It is 
 immediately after the bath that the administration 
 of quinine is ad-^ised, in full doses of not less than 
 10 or 12 grains at short intervals, until 30 or . 40 
 grains are taken. If there is irritability of the stomach, 
 20 grains with a few TIL of laudanum may be given by 
 enema. I have already mentioned that in this way it 
 
V ENTERIC FEVER 95- 
 
 acts effectively. Broadbent adds a word of significant 
 caution on the combination of quinine and the bath, 
 viz. that he has twice seen tetanus follow their use, 
 although both patients recovered. 
 
 In my lectures on the treatment of malarial fevers 
 I have pointed out that quinine is often abused by being 
 given in excessive doses ; this may have been the cause 
 of the formidable symptoms mentioned. I feel con- 
 vinced that the same good end may be obtained by 
 smaller doses.^ 
 
 1 M. Bouchard uses tepid baths which gradually grow cold ; 
 he keeps the patient's shirt on, and uses as much water as will 
 cover his shoulders ; so arranging that hot or cold water can be 
 easily added, and surplus water allowed to run off. The rectal 
 temperature is to be ascertained before the bath is given. The 
 water is lowered two degrees in temperature every ten minutes, 
 until it has fallen to 86° F. ; the patient is kept in the bath at this 
 temperature for ten minutes ; he is then well dried, a dry shirt is 
 put on him, and he is wrapped up in a warm blanket. These baths 
 are given as soon as the diagnosis is made, and are continued until 
 the rectal temperature is maintained at 37.5 cent. (98.6 F.) 
 Eight baths should be given in twenty-four hours, until towards the 
 end of the fever, when three or four are found sufficient. It is 
 claimed for this method that it is agreeable to the patient, that the 
 temperature is effectually lowered, that it generally prevents stupor. 
 Delirium, ataxy, and headache are greatly modified ; dryness of 
 the mouth and tongue is relieved. When temperature is not 
 sufficiently relieved, Bouchard adds quinine to the treatment. It 
 is admitted that the frequency of the baths and their duration are 
 very trying, and that when quinine is given with the baths, certain 
 "slightly disagreeable results are apt to follow." If syncope 
 happens in or after the baths, they are to be discontinued. In 
 pulmonary complications they should not be given. — British Medical 
 Journal, No. 1319, loth April 1886. 
 
96 DISEASES OF TROPICAL CLIMATES lbct. 
 
 There is £i:::::tr raethod of treating enteric fever, 
 which has been very strongly advocated by the late 
 Surgeon-Major MofStt, the brother-in-law and companion 
 of Chinese Gordon in the campaigns that made that 
 lamented officer so fcimous. Dr. Moffitt had a large 
 experience of this disease, both in China and India, 
 more particularly at Mount Aboo. Not satisfied with 
 the results of the usual treatment of enteric fever, he 
 made an extensive trial of turpentine, given, from the 
 onset of the disease, not merely as a remedy against 
 hemorrhage, for which purpose its value has long been 
 acknowledged. Dr. Moffitt claimed for this remedy, 
 used in this way, that it prevented meteorism, checked 
 diarrhoea, and prevented hsemorrhage. I have looked 
 carefully through the record of his cases, kindly 
 placed at my disposal, and think the treatment was 
 very successful, the mortality less than under the old 
 method, and that it is worth a more extensive trial in 
 India. 
 
 It is after the end of the second week that we have 
 to expect one or more of the complications mentioned. 
 Lung complications wiU evidence themselves by a rise 
 in temperature and a quickening of the respiration ; a 
 sudden fall of temperature indicates haemorrhage. The 
 favourite remedy for this complication in this hospital 
 is ergotin hypodermically ; from 2 to 6 minims of a 
 solution of eigotin of the strength of a grain in 2 
 minims of distilled water, or the liquid extract may be 
 given internally in dos^ of 60 minims, and repeated 
 in half an hour several times, until some effect is pro- 
 
V ENTERIC FEVER 97 
 
 duced. Of turpentine for this purpose I have already 
 spoken, the dose is 10 to 15 minims. 
 
 From 20 minims to 5SS. of tincture of opium will 
 control the peristaltic action of the bowels, and for this 
 purpose is strongly advised by Broadbent and others 
 as a powerful means of aiding the above measures. 
 
 Should symptoms of perforation or peritonitis set in, 
 opium in full doses is the only remedy that can relieve 
 or afford the smallest chance of recover}'. Tympanitis, 
 if at all excessive, is a source, not only of discomfort to 
 the patient, but of danger by provoking haemorrhage, 
 and must be met in like manner by opium and small 
 doses of turpentine. 
 
 Diarrhoea, when the motions exceed three a day, 
 is best restrained by the same invaluable remedy given, 
 as already mentioned by enemita. 
 
 Lung complications, congestion or pneumonia, are 
 best met by turpentine stupes — turpentine internally and 
 stimulants. As in all fevers, the condition of the 
 bladder requires attention, particularly if there be a 
 tendency to stupor, and bed-sores should be guarded 
 against by constant watchfulness. The return to the 
 use of solid food should be very gradual, and not 
 attempted until convalescence is far advanced ; no 
 more fatal error can be committed than to neglect 
 this cardinal rule of treatment. 
 
 The rules for the use of stimulants in enteric fever 
 have been much disputed. It is a fact that many cases 
 do well without wine or spirits from first to last ; but 
 to insist, as some do, that they should never be used, 
 
 H 
 
DISEASES OF TROPICAL CLIMATES lect. 
 
 is, in my opinion, a grave mistake, and one that if acted 
 on in military practice, particularly in men who have 
 indulged in spirits freely, would in many cases be fatal. 
 In drunkards they may be required from the first, in others 
 only when signs of weakness set in. When the heart's 
 action becomes weak, the first sound indistinct, and 
 the pulse flutters, they are urgently needed ; again, a 
 dry tongue with sordes in mouth and teeth are signs 
 in this as in other fevers which loudly call for them ; 
 a high temperature added to the above symptoms 
 is an additional reason for their use. A careful 
 physician will watch the effects closely, and will find 
 in the improved aspect of the patient, the better action 
 of the heart, a pulse increasing in strength and 
 diminishing in frequency, with a fall in the tempera- 
 ture, the justification for their use. It is impossible to 
 give a hard and fast rule as to quantity — this must 
 vary with the requirements of each case ; but whatever 
 the stimulant be, whether brandy or whisky, it should 
 be given after food. 
 
 Enteric fever "is the most treacherous of all dis- 
 eases" (Aitken). Keeping this continually in mind, a 
 prudent practitioner will be guarded in his prognosis, 
 remembering the many complications which may arise 
 in its course, and at any time give a grave aspect 
 to a case, when, to all appearance, it may have been 
 progressing favourably ; it leaves those who have 
 emerged from it in a state of mental childishness, 
 which often lasts for a considerable time after ap- 
 parent restoration to health (Jenner), and Professor 
 
V ENTERIC FE VER 99 
 
 Aitken adds a maxim which from a pretty large 
 experience I can confirm, and which I commend to 
 your attention; it is this: "No man can be considered 
 as fit for Work, or for General Military Service, for 
 three or four Months after an attack of severe Enteric 
 Fever,"' 
 
 Before I pass from this important subject, let us see 
 whether anything can be done in the way of prevention 
 to guard our young soldiers from this destructive disease. 
 Climatic causes are without the range of preventive 
 medicine, except in so far as we can modify the effects 
 of such causes by attention to the general laws of health 
 applied to the peculiar nature of the climate with which 
 we have to deal. We can by attention to such laws 
 construct the houses in which we live, the clothing we 
 wear, the food we eat, the water we drink, so as to pro- 
 tect ourselves against influences which tend either 
 directly to cause disease, or indirectly to predispose to 
 it ; and we can by such means as drainage, both surface 
 and subsoil, in the neighbourhood of our dweUings, do 
 much to banish well-known causes which either create 
 or aggravate disease, and still more by the careful 
 removal of every kind of filth and decomposing animal 
 and vegetable matter. We can attend to the due regu- 
 lation of barrack latrines, to the purity of the water 
 supply, to the sources from which milk and other articles 
 of consumption are obtained. We can by every channel 
 open to us, by wise and reasonable representation, keep 
 before the minds of the authorities the health conservancy 
 of the native towns, bazaars, and neighbouring villages 
 
loo DISEASES OF TROPICAL CLIMATES lect. 
 
 frequented by our men. Gentlemen, it often astonishes 
 me to hear this last item of prevention sneered at and 
 undervalued, not only by men outside the profession, but 
 by sensible men within it. I can tell you of a city in 
 England, " no mean city," but one of much historical 
 interest, where, until very recent times, the carriage ways 
 within its walls could not be disturbed to mend a gas- 
 pipe without the almost immediate appearance of cases 
 of scarlatina, sometimes of a malignant type, in the 
 houses near the opening. For ages this city had been 
 riddled with cesspools, and when some attempt was 
 made to drain it, the work was so carried out as to 
 aggravate the evil : the death-rate in this city was within 
 living memory one of the highest in the kingdom. When, 
 therefore, we are sneered at for teaching by pen and 
 speech that the soil in and about Indian cities, bazaars, 
 and villages, is sodden with excrementitious matters, the 
 accumulation of ages, and that such a condition of 
 things is a fertile source of disease, we must bear the 
 reproach of ignorance with patience. 
 
 In my evidence before the Royal Commission that 
 inquired into the health of the army of India, I pressed 
 on the Commissioners the importance of making a 
 greater use of hill stations for young soldiers than was 
 then the practice ; that the proper use of such stations 
 was to preserve health, not to cure disease. It un- 
 fortunately happened that when hill cantonments were 
 first established, sanitary precautions were neglected. It 
 was thought that elevation above the heated plains, 
 mountain air, and so on, would be enough ; and that 
 
ENTERIC FEVER 
 
 hygienic measures, the necessity for which on the 
 plains was not denied, at least in words, might with 
 safety be neglected. A fatal error, as now acknowledged. 
 I do not say that hill stations alone, however well 
 selected and cared for, will suffice entirely to protect 
 our young soldiers in the first years of their Indian 
 service from the disease that is so destructive to them ; 
 but I do say, that if, on first arrival, they are quartered 
 on hill stations properly selected, lodged in suitable 
 houses, constructed on hygienic principles, and clothed 
 in accordance with the demands of the climate, and 
 healthfully occupied, we may see a marked diminution 
 in the prevalence of a disease that more than any other 
 to which the human race is liable, may be classed among 
 those that are distinctly preventable. 
 
LECTURE VI 
 
 FEBRICULA AND RELAPSING FEVER 
 
 This form of fever is more aptly designated by the term 
 Ephemeral than that of Febricula in general use. 
 Systematic writers are puzzled how to classify it, as it 
 cannot be traced to the action of any specific poison. 
 In hot climates it is commonly regarded as a kind of 
 " seasoning fever," chiefly attacking young persons of 
 both sexes on first arrival after imprudent exposure to a 
 hot sun. Young officers and recruits kept too long at 
 morning drill are prone to suffer from it ; the latter 
 more especially, after many hot and sleepless nights in 
 barracks, swarming with mosquitoes and other insects, 
 and indulgence in hot curries, to which they are not 
 accustomed, with perhaps some of the pernicious drinks 
 to be found in every bazaar. Although of short dura- 
 tion the fever is often very severe, particularly in young 
 men of a sanguine temperament, the temperature rising 
 with great rapidity to 103° or 104° F., with a full, 
 frequent pulse, a foul tongue, severe headache, lumbar 
 pains, hot and dry skin, great thirst, and scanty high- 
 coloured urine. Defervescence sets in from 12 to 24 
 
LECT. VI FEBRICULA AND RELAPSING FEVER 103 
 
 hours, the febrile condition rarely lasting more than 30 
 hours. In no febrile affection does the urine diminish 
 so quickly as in this (Parkes): "it presents the very type 
 of the so-called febrile urine." The specific gravity is 
 very high (103 5- 1037); it is never albuminous. With 
 the fall of temperature the quantity of urine increases. 
 I have occasionally seen cases in delicate young men in 
 which the defervescence has not been so sudden, the 
 temperature remaining several degrees above normal for 
 several days, with slow convalescence, requiring a change 
 to sea or to a mountain station before return to duty. 
 
 The diagnosis is not difficult. The rapidity with 
 whicb. the temperature attains its maximum, the brief 
 duration of the febrile state, and the absence of the 
 progressive weakness preceding the rise of temperature, 
 mark it off from enteric fever. With any malarial fever 
 it cannot be confounded, as beyond a slight difference 
 between morning and evening temperature; there is no 
 periodicity in the symptoms. The treatment is simple: 
 confinement to bed, the exhibition of a mild purgative ; 
 a solution of the citrate or acetate of ammonium, with 
 acetate of potassium (2 drachms of each, with 4 drachms 
 of spirit of nitre and camphor water, with a little syrup 
 to 8 ounces, make a pleasant diaphonetic mixture). Great 
 relief is obtained from tepid sponging, and the use of ice 
 to the head, the free use of diluents, and low diet. 
 
 The German equivalent for our relapsing fever, viz. 
 Typhus Recur?'ens, better expresses the phenomenon 
 from which this fever takes its name than the one by 
 which it is known with us. 
 
104 DISEASES OF TROPICAL CLIMATES lect. 
 
 I may preface what I have to say on the subject of 
 this fever with the remark, that I never saw an example 
 of it in India in the person of a European, civil or 
 military. British soldiers there are exposed to many 
 causes of disease, but are not in the condition of those 
 who are the usual victims to relapsing fever; they cannot 
 be classed with those who are " poor and ill-fed, who 
 live miserably " ; and when the disease prevails among 
 the native population as an epidemic, they are rarely 
 brought into contact with the sufferers. 
 
 The cause of this disease is not known. From the 
 often observed fact that it treads in the footsteps of 
 famine, it takes the name by which it is generally known 
 in Ireland, viz. Famine Fever. It is beyond doubt that 
 scarcity of food, overcrowding, and want of cleanliness 
 of place and person are at least predisposing causes ; 
 these being the conditions most favourable to the 
 genesis and spread of typhus fever, it is not surprising 
 that they are sometimes, as in Ireland, found together, 
 although they are said by Parkes, to be "altogether 
 distinct." 
 
 Being a distinctly contagious disease, overcrowding, 
 the usual concomitant of famine, favours its spread. 
 
 It has been seen in an epidemic form in the Punjab, 
 and in 1877 it prevailed extensively in the Bombay 
 Presidency.^ 
 
 ^ My friend and successor, Deputy Surgeon-General David B. 
 Smith, informs me that he had to do with a fatal outburst of this 
 fever, attended with great mortality, in the Delhi Prison. It was 
 distinctly traceable to an insufficient dietaiy in the prison. Many 
 
VI FEBRICULA AND RELAPSING FEVER 105 
 
 Anatomical Characters. — Enlargement and softening of 
 the liver and spleen are the most constant of the morbid 
 changes; the spleen attains to a size nearly as great as in 
 malarial fevers ; the blood is often found in a fluid 
 state after death ; no other organ seems to present any 
 notable morbid change. 
 
 In 1872 Obermeier detected a spirillum in the blood 
 of those affected, which now goes by his name, Spirillum 
 Obermeieri, seen always in the stage of pyrexia, dis- 
 appearing with that stage, and again reappearing at the 
 period of recurrence of the fever. This spirillum was 
 also carefully observed by Dr. Vandyke Carter during 
 the Bombay epidemic of 1877, already referred to. Is 
 this spirillum the cause of the fever ? Murchison and 
 Bastian do not admit that it is. Professor Aitken is of 
 opinion that the weight of evidence seems in favour of the 
 belief that the spirillum found in the blood in this fever 
 is non-essential, and merely an epiphenomenon ; or as 
 Murchison has put it, the soil is suitable for its develop- 
 ment during the febrile process, and unsuitable when 
 that process is complete. Carter himself, having failed 
 many times to transmit the disease by innoculation in 
 monkeys, allows that the point is doubtful. Certain it 
 is that the curious appearance and disappearance of this 
 spirillum may be accepted as an infallible diagnostic 
 mark of relapsing fever. 
 
 We have relapses in many diseases, very notably in 
 typhoid fever ; excluding malarial fevers which recur 
 
 of the prisoners had previously suffered from scarcity of food. 
 Numerous examples of the same kind could be quoted. 
 
io5 DISEASES OF TROPICAL CLIMATES lect. 
 
 with clock-like regularity, to which the term Relapse is 
 not applicable, there is no other disease in which 
 convalescence having to all appearance not only set in, 
 but being complete, after 5, 6, or 8 days of ardent 
 pyrexia, with an apyretic period lasting from 5 to 7 days, 
 recurs again and goes through the same phenomena as 
 in the first attack, except the fever under notice ; hence 
 its name, Relapsing or Recurrent Fever. And this not 
 only once or twice, but it may be many times. 
 
 The symptoms are well marked. Those of invasion 
 are much the same as in other fevers, viz. prostration, 
 headache, pains in back and limbs, becoming more 
 severe as the fever develops, lassitude, nausea, sometimes 
 vomiting. The prostration increases, rigors set in with 
 severe headache and giddiness, driving the patient to 
 bed ; the skin becomes intensely hot, the temperature 
 rises to 105° F., and sometimes a degree or two more 
 the face is flushed and anxious ; the tongue at first mois' 
 with a thick yellowish-white fur, later on becomes dry 
 and even black ; thirst is intense, and the pulse ranges 
 from no to 140; the epigastric tenderness and fulness 
 are often as well marked as in severe remittent fever, 
 and the vomiting as urgent ; the patient is restless and 
 complains bitterly of rheumatic-like pains in his limbs 
 and joints, a condition of things like acute rheumatism, 
 all the more that the patient sweats without relief; the 
 temperature curve is peculiar, while the ascent is not so 
 quick as in malarial fevers, it soon attains its maximum, 
 the fall to the normal or below it at the period of 
 defervescence taking place very rapidly. When the 
 
VI FEBRICULA AND RELAPSING FEVER 107 
 
 fever recurs the ascent to the maximum is again rapid, 
 and the fall equally so. Jaundice is generally present, 
 but bile is abundant in the stools. The bowels are 
 sometimes confined, but diarrhoea is common, and in 
 Asiatics almost invariable. 
 
 On the fifth, seventh, or eighth day a crisis sets in, 
 usually suddenly, ushered in with profuse sweating, with 
 diarrhoea, and often epistaxis and haemorrhage from the 
 bowels, and a rapid fall in the temperature and relief of 
 all the distressing symptoms ; almost invariably this 
 condition of apparent convalescence is maintained until 
 the fourteenth day, reckoning from the first onset, when 
 the pyrexia and other symptoms recur, and this second 
 paroxysm goes through the same phenomena as the first. 
 The relapse seldom exceeds 5 days, and its duration 
 may be a day or two less, and in some it may not exceed 
 24 hours. As a rule patients have seldom more than 
 one relapse, but two or more are not uncommon. 
 
 There is a tendency in relapsing fever to sudden 
 death (Aitken) ; this is not an infrequent event in 
 Asiatics who have been reduced by scarcity of food, and 
 patients so reduced frequently succumb to the copious 
 diarrhoea of the crisis. The mortality among Asiatics 
 reduced by famine who are attacked by this disease is 
 increased by the almost impossibility of supporting them 
 by the most careful diet. Nutrition is in fact impossible 
 from the fatty degeneration of the lacteals, as shown by 
 the researches of Dr, David Cunningham in the last 
 famine in the south of India. Even in Europeans, 
 under the most favourable conditions, convalescence is 
 
loS DISEASES OF TROPICAL CLIMATES lect. 
 
 very slow, and in Asiatics it is much protracted. The 
 sufferers remain long in a weak state, and often suffer 
 from severe pains in the limbs. Dr. Aitken refers to 
 a form of opthalmitis, described by Drs. Mackenzie and 
 Anderson of Glasgow, as seen in that city during the 
 prevalence of relapsing fever, occurring sometimes during 
 the fever, but more frequently after it, hence named by 
 Mackenzie "post-febrile opthalmia"; seen in two forms, 
 an active inflammation of the shell of the eyeball and 
 iris, or an amaurotic state, due to congestion of the 
 chonoid and iris. In Asiatics sloughing of the cornea 
 is not uncommon as a sequel of this fever as well as of 
 cholera, apparently from a mere failure of nutrition. 
 
 Treatment. — There is no specific treatment for this 
 fever. In the form in which the disease is seen in India, 
 it resolves itself into careful dieting of the sick. For 
 the reason given above this in the native races, reduced 
 by starvation, is always a difficult, often an impossible 
 thing to accomplish ; diarrhoea, with them almost always 
 present, is aggravated by the presence of food which is 
 not digested and absorbed, and this easily passes into 
 intractable dysentery. Milk in small quantities often 
 repeated, thin arrowroot gruel, which I have found to 
 be the safest and most easily assimilated diet for patients 
 emerging from the collapse of cholera, is equally suitable 
 for nourishing the sick in the condition of which I am 
 speaking ; with chicken-tea, soft-boiled eggs, and white 
 wine whey. In robust Europeans little medication is 
 required. The bowels should be relieved if constipated. 
 Vomiting is best combated by the use of ice, and the 
 
DENGUE 
 
 109 
 
 external use of mustard to the epigastrium. Aitken 
 advises 5 grains of calomel and i of opium in severe 
 cases. Headache is relieved in those who can bear the 
 remedy, by the application of a few leeches ; and in 
 the more weakly by blisters to the nape, a remedy not 
 applicable, for fear of sloughing, in half-starved Asiatics. 
 The action of the kidneys is promoted, and the risk of 
 ursemic poisoning lessened by the use of nitre, given 
 from the first (Murchison), whose formula is i or 2 
 drachms of nitre dissolved in 2 pints of barley-water, 
 acidulated with a drachm of dilute nitric acid, and 
 sweetened ; this can be taken in 24 hours. If sup- 
 pression of urine takes place, the hot air-bath and 
 saline diuretics must be used, and active purgation with 
 compound jalap is urgently called for. For the jaundice, 
 which sometimes is present, Murchison recommends the 
 addition of hydrochloric acid to the nitre mixture given 
 above. Anything like active purgation at any stage of 
 the disease would be fatal to sufferers among the native 
 races; in their case the chief difficulty is to control 
 diarrhoea or dysentery, as the case may be. Our chief 
 reliance must be placed in some of the preparations 
 of opium. 
 
 Dengue. 
 
 The term Dengue, in universal use to designate the 
 form of fever I am about to describe, seems to have 
 originated in the West Indies. Many derivations have 
 been assigned to it, most of them fanciful. It is certain 
 that among the negroes there, Dandy Fever was a common 
 
no DISEASES OF TROPICAL CLIMATES lect. 
 
 name for it, supposed to refer to the peculiar gait of 
 those affected, suggesting to the negro mind the idea of 
 affectation or conceit. Dengue is supposed to be a 
 Spanish corruption of this whimsical term. Dr. 
 M'William, R,N., tells us that a fever known by the 
 name of Dandy Fever prevailed throughout the West 
 Indian Islands in 1830, and preceded an epidemic of 
 yellow fever ; and the same author mentions that a 
 similar fever appeared at Rio de Janeiro, at Pernambuco, 
 and Bahia, and went by the trivial name of the Polka ; 
 its appearance being nearly coincident with the intro- 
 duction of the well-known dance of that name. This 
 polka fever, in like manner, preceded an outburst of 
 yellow fever. The term Dandy Fever, however, was in 
 use among the negroes of the West India Islands long 
 before the occasion referred to by Dr. M'William. 
 
 The College of Physicians have sanctioned the term 
 Dengue, by admitting it into the nomenclature of diseases. 
 In some parts of the United States it became popularly 
 known as Break-bone Fever, with reference, no doubt, to 
 one of its most painful symptoms. Scaj'latma rheumatica 
 (Copeland) is another name derived from the peculiar 
 rash which appears in the course of the affection, and the 
 pains in the limbs above referred to ; in Calcutta it is 
 often spoken of as " Goodeve's red fever," that physician 
 having described the disease as he saw it there in 1844. 
 
 It seems impossible now to trace the origin of this 
 fever ; many believe that it first appeared within the 
 yellow fever zone. The fact that outbursts of this fever 
 sometimes are the precursors of an epidemic of yellow 
 
VI DENGUE III 
 
 fever, within the Hmits of that zone, gives some colour to 
 this behef. Be this as it may, the disease has prevailed 
 far outside the limits of that zone. Without giving you 
 in detail a list of the recorded epidemics which have 
 appeared in various parts of the world, I may mention 
 that it was seen in Philadelphia in 1780, and described 
 by Dr. Rush of that city. It was then it appears to 
 have gained its popular name of Break-bone Fever. So 
 far as can now be ascertained, India was first visited by 
 it in an epidemic form, 1824. It raged in Burma among 
 the troops engaged there under Sir Archibald Campbell, 
 from there it passed to Calcutta, and thence over a 
 wide area. It was seen and described in the second 
 volume of the Transactions of the Medical and Physical 
 Society of Calcutta, by Drs. Twining, Cavell, and Mouat. 
 The last-named physician saw it at Berhampore, and 
 described it under the name of Epidemic Fever. His 
 description leaves us in no doubt that the fever was 
 Dengue and no other ; he noted the suddenness of the 
 attack, the redness and watering of the eyes, the acute 
 pain in the joints, rendered excruciating on the slightest 
 touch, the scarlet or crimson efflorescence on the 
 surface; its ephemeral duration; its not requiring blood- 
 letting ; its sparing neither age, sex, nor habit of body ; 
 its seizing the acclimated as well as those recently 
 arrived, symptoms, which, in his opinion, stamped it at 
 once a different disease from the remittent or endemic 
 fever of Lower India. 
 
 Dengue was again seen in Calcutta in 1844, when it 
 was described by Dr. Goodeve in the ninth volume of the 
 
112 DISEASES OF TROPICAL CLIMATES lect. 
 
 same Transactions, under the name of a Peculiar Form of 
 Eruptive Fever. Dr. Goodeve evidently was not aware 
 at the time he wrote that the affection had ever been 
 seen in India before. It is, however, to be noted that 
 this careful observer makes no mention of the articular 
 pain which is characteristic of true Dengue. 
 
 The disease appeared at Zanzibar in 1870, following 
 an epidemic of cholera, frotn thence it Avas introduced 
 into Aden, and was carried to Western India, spreading 
 over a wide area, and in 1872 was once more epidemic 
 in Calcutta, where it affected a large part of the popula- 
 tion of all races and ages. Dr. Charles, then one of the 
 professors in the Calcutta Medical College, made it a 
 subject of careful study, and his Treatise on the disease 
 you will find in the Library here. It will be seen that 
 Dengue has travelled widely, and so far as I have been 
 able to gather from the sources of information open to 
 me, its symiptoms and behaviour have been much the 
 same in all places of its visitation. 
 
 Dengue is usually seen in an epidemic form, and may 
 be defined as a contagious febrile affection which im- 
 partially attacks all races, both sexes, and all ages. Its 
 invasion is sudden, attended with headache, red and 
 watery eyes, some redness of the fauces, without pain or 
 difficulty in swallowing, severe muscular and articular pain, 
 wdth much suffering, general distress, prostration, sleep- 
 lessness and restlessness; with pyrexia, the temperature 
 rising from 100° to 103°, and in exceptional cases to 
 105° F., with a scarlatina-like rash ; generally attacking 
 once, a rule subject to many exceptions, the fever having a 
 
VI DENGUE 113 
 
 remittent tendency, with a liability to relapse. The 
 mortality trifling. 
 
 Sympto7ns. — The period of incubation is uncertain ; 
 it may be only a few hours, or five or six days. When 
 a disease is epidemic there must always be doubt and 
 uncertainty on this point. Early in the course of an 
 epidemic the invasion is observed to be almost always 
 sudden ; later on the symptoms which usually precede 
 an attack of fever are noticed, languor, lassitude, loss of 
 appetite, nausea, and such like famihar symptoms. The 
 attack is often in the night ; the patient awakes with 
 headache, pain in one or more joints, in the back, flying 
 from one joint to another, now in the fingers or toes, 
 then in the thighs, or in the arms, wrists, or ankles ;. 
 often the whole body aches in an intolerable manner, 
 and he tosses in the. vain effort to find an easy position ; 
 the eyes smart, are red and watery, the face is flushed 
 and swollen, there is thirst, the skin is hot, the tongue 
 varies, generally with a white fur, always red at tip and 
 edges, the papillae prominent, showing through the fur 
 strawberry-like. Prostration appears early ; the pulse is 
 quick, always compressible, the urine usually normal in 
 quantity, colour, and specific gravity, without albumen, 
 or deposit on cooling ; some observers, notably Cavell 
 and Mouat, speak of it as scanty and high coloured, 
 probably in the cases where the temperature was high. 
 The bowels are usually costive ; vomiting is not uncom- 
 mon, and if the invasion quickly follows a meal, almost 
 invariable. The restlessness, " universal soreness," and 
 general distress often amount to anguish. 
 
114 DISEASES OF TROPICAL CLIMATES lect. 
 
 As already said, the temperature soon reaches ioo°, 
 103°, and it has been seen as high as 106° F. — a tempera- 
 ture indicative of danger, particularly in the hot season. 
 
 The rash appears generally on the second or third day ; 
 Mouat has • noticed it " from the first." I observe that 
 neither Twining, Cavell, or Mouat, the physicians who saw 
 and studied the disease in 1824, speak of the appearance 
 of a rash twice in the course of the fever ; while Charles 
 describes two, viz. what he calls the " initial rash " of a 
 scarlatina-like character, appearing on the second day or 
 thereabouts, and a " terminal rash " of a measly appear- 
 ance, showing itself about the fourth or fifth day. This 
 initial rash was far from being invariable in Dr. Charles' 
 cases ; indeed, he says it was absent in fully one-third of 
 his patients. It is difficult, at this distance of time, to 
 determine whether this double rash was a peculiar 
 feature in the epidemic of 1872, or whether, from its 
 transient nature, it escaped observation in that of 1824. 
 This initial rash sometimes covers the entire surface of 
 the body, at others only the face, or some other part of 
 the person ; it may be of a bright vivid red colour, or of 
 a duller red ; it disappears on pressure with the finger, 
 and is attended with itching which materially adds to the 
 discomfort and restlessness of the sufferers. 
 
 In children the rash cannot always be distinguished 
 from urticaria. The initial rash when present usually 
 disappears entirely in about twenty-four hours, and some- 
 times fades away in half that time. Still, some hours 
 may elapse before the temperature falls, and the rheu- 
 matic-like pains and discomfort survive the fall in temper- 
 
vr DENGUE 115 
 
 ature for some days. According to Charles, the terminal 
 rash appears usually on the fourth day, other observers 
 have seen it on the fifth and sixth day ; this terminal 
 rash is very evanescent, and consequently it escapes 
 observation. There is no fever during the eruptive 
 period as a rule, although Mouat in some of his cases 
 observed " a secondary fever " of short duration at the 
 period of efflorescence ; the rash rarely lasts more than 
 forty or forty-eight hours. As already said, this eruption 
 resembles measles, but even in the same epidemic it may 
 differ in different persons ; sometimes it resembles that 
 of scarlatina, or urticaria, in others lichen, and the same 
 observation was made by Mouat. 
 
 The duration of the disease is about eight days, but 
 the convalescence is slow, extending in many cases over 
 months before health is restored. 
 
 Relapses both of the fever and rheumatic pains occur, 
 with prostration. These relapses may sometimes be 
 traced to imprudence on the part of the patient, errors 
 in diet, or too early attempts to resume work. Twining 
 mentions a severe relapse which followed a cold bath, 
 before convalescence was complete. 
 
 The complications are catarrh, epistaxis, swelling of 
 the lymphatic glands, ptyalism (easily provoked by mer- 
 cury), of which Twining gives an example — orchitis, which 
 is very rare. 
 
 Diagnosis. — Little need be said on this point. There 
 are only two diseases with which it can be confounded, 
 and these only by the careless or the ignorant, viz. scar- 
 latina and acute rheumatism. I never saw a case of 
 
ii6 DISEASES OF TROPICAL CLIMATES lect. 
 
 genuine scarlatina in India. I have heard that cases of 
 it have been seen at some of the hill stations of Upper 
 India ; if so, they were probably imported from Eng- 
 land. Certainly no epidemic of scarlet fever has ever 
 been seen in India. Dengue, when seen there, is 
 always epidemic. In scarlatina the throat symptoms are 
 among the first to attract notice ; the redness spreads 
 from the tonsils to the palate, uvula, pharynx, and epi- 
 glottis, and ulceration is common, which is not confined 
 to the tonsils. The throat symptoms in dengue seldom 
 go beyond a slight degree of redness, with little or no 
 pain or difficulty in swallowing. In scarlatina the urine 
 from first gives evidence of much nitrogenous waste, and 
 as desquamation begins albumen is usually present ; in 
 dengue the urine is normal. The rheumatism of scarlet 
 fever is rarely seen before the end of the first week ; in 
 dengue it is one of the earliest and most marked of the 
 symptoms. The rash of scarlatina appearing on the 
 second day lasts for five or six days, that of dengue only 
 a few hours. 
 
 Dengue can hardly be mistaken for acute rheumatism, 
 which is never epidemic ; the latter is usually preceded 
 by signs of deranged health ; the pyrexia is more intense ; 
 the acid sweats and the long duration of the disease 
 mark it off with sufficient distinctness from dengue. 
 
 Treatment. — If we look to the record of the effects of 
 what is called active treatment, in other words, bleeding, 
 leeching, and purging, left us by the authors to whom 
 I have referred, viz. Twining, Cavell, and Mouat, you 
 will not find much to encourage you to revert to a 
 
VI DENGUE 117 
 
 system of which it is not too much to say that it was 
 worse than the disease. The simple truth is, dengue 
 has a certain more or less definite course to run ; we 
 cannot by any known means cut this course short, but 
 we may do much to mitigate the patient's sufiferings, to 
 shorten the period of convalescence, and restore him to 
 health. 
 
 If the attack comes on shortly after a meal, a mustard 
 emetic will give relief, and spare the patient much nausea 
 and efforts to rid the stomach of an undigested meal. 
 Active purgation does no good, the movement of the 
 affected parts adds to the patient's sufferings, and free 
 purging only promotes prostration without any compen- 
 sation. Aconite, in drop doses of the tincture given every 
 ten minutes, until a full medicinal dose has been taken, 
 will do much to lessen headache, to calm restlessness, and 
 to promote action of the skin. Dr. Charles' favourite 
 remedy is belladonna, which may be given according to 
 his formula, viz. a drachm of the tincture, and 5 drachms 
 of syrup of orange, of which a sixth part should be taken 
 every hour by an adult until three doses have been given. 
 In severe cases the dose may be doubled, the effects being 
 watched. The affected joints should be smeared with 
 a liniment composed of one part of chloroform to seven 
 of belladonna Hniment, and wrapped up in cotton wool. 
 When the temperature is high, sponging of the surface 
 first with tepid water, and then with w^ater 15° below the 
 temperature of the surface will be grateful to the patient ; 
 and when headache is intense ice may be applied to the 
 head. When the temperature rises, as it may in rare 
 
iiS DISEASES OF TROPICAL CLIMATES lect. vi 
 
 cases, to io6°, the question of the use of the cold bath 
 may arise. The safest course is to place the patient in 
 a bath at 90'', and to cool it down to a temperature 15° 
 below that of the surface when the patient was placed in 
 it, ice at the same time being applied to the head. 
 Solid food should not be given until ever)' trace of 
 pjTexia has disappeared. Quinine and tonics, such as 
 the citrate of iron and quinine, are then useful ■ and the 
 s}Tup known as Easton's {the Syfupus Ferri^ Qui/iice, et 
 StryclmicB Fhosphatis) is particularly applicable. 
 
LECTURE VII 
 
 YELLOW FEVER 
 
 Synonyms. — Hczmogasti-ic Pestilence — Typhus Icterodes — 
 Synochus Icterodes — Causus — Fierore Jaune^ French j 
 Galbus Fieber, German. 
 
 The literature of the subject is immense. Owing to 
 the ravages it has caused it has not only long engaged 
 the attention of the medical world, but also of the 
 various governments whose fleets and armies have 
 suffered from it. 
 
 Yellow fever was unknown before the discovery of 
 the New World. It is said to have a habitat of its own, 
 viz. the shores of the Gulf of Mexico, the northern and 
 eastern shores of South x^merica, and the islands in the 
 Caribbean Sea. Its ravages have not been confined to 
 this habitat ; it has visited many regions outside its 
 limits, although incapable of establishing itself for any 
 length of time as an endemic disease. Many places 
 which, in the early part of this century, were scourged 
 by it are now free from its ravages ; towards the close of 
 last century it often prevailed in the northern cities of 
 the Atlantic coast of the United States, where it is now 
 
120 DISEASES OF TROPICAL CLIMATES lect. 
 
 never seen. In 1797-98 New York, Boston, Phila- 
 delphia, and Charleston suffered. In 1800 it again 
 ravaged Boston, Baltimore, and other parts of the Union. 
 Cadiz suffered from it in the same year, and various 
 parts of Spain throughout 1804. Gibraltar had no less 
 than four epidemics between the years 1810 and 1828 ; 
 it was towards the end of the epidemic of this last- 
 named year that the famous military surgeon Hennen 
 perished. Lisbon, an uncleanly city, has had two 
 visitations, the last in 1857. Vera Cruz and the 
 Havana rarely escape an annual visit ; at both places 
 the disease is endemic in the strictest sense of the term. 
 Memphis, Tennessee, in lat. 35 N., has suffered three 
 times. Like many other cities, it grew up without the 
 guidance of a sanitary engineer, with the usual result ; 
 every house sat on its own cesspool, until the terrible 
 discipline of three epidemics of yellow fever aroused the 
 inhabitants to a sense of their danger, and led to a 
 thorough measure of sanitary reform. 
 
 Yellow fever and the West India Islands are insepar- 
 ably associated in men's minds, and not without reason, 
 for the graveyards of most of them, have been fed fat 
 with its victims. Yet it is equally true that individual 
 towns and islands have enjoyed long intervals of freedom 
 from its attack. Thus at St. Domingo there was no 
 yellow fever between 1775 and 1785 ; none at Grenada 
 between 1763 and 1793. The islands of St. Kitts, St. 
 Vincent, and Barbados were so healthy previous to 
 1793 "that soldiers fresh from Europe, notwithstand- 
 ing their debauched lives, enjoyed good health." The 
 
YELLOW FEVER 
 
 principal medical officer in the West Indies for the time 
 has placed it on record "that between 1785 and 1792 
 only one officer died out of four regiments quartered in 
 Barbados." The first recorded outbreak of the disease 
 in the West Indies was in 1647. It was in the year 
 1793 that the pestilence reappeared after a long interval 
 of freedom ; always endemic there, it breaks out 
 occasionally in an epidemic form with much violence, 
 and generally betw^een the months of May and August. 
 
 It is a disease of tropical and sub-tropical climates. 
 Within such limits it finds the conditions most suitable 
 for its action in maritime cities slightly above the level 
 of the sea. 
 
 Humboldt's dictum that yellow fever cannot exist at 
 an elevation of 3000 feet above the level of the sea has 
 not stood the test of experience. On three occasions it 
 has been introduced and been fatal at the military post 
 of Newcastle, in Jamaica, which is 4000 feet above that 
 level. This post is situated on a spur of land falling 
 rapidly from the Blue Mountains under St. Catherine's 
 Peak, southwards to the villages and ravines which 
 connect it with the low country. The cantonment was 
 not well planned, and, until warned by the visitations of 
 yellow fever I have mentioned, the sanitary arrangements 
 were defective, and the disease, once introduced, found, 
 in a limited area, crowded with buildings, under bad 
 conservancy, the conditions most suitable for its destruc- 
 tive action. Under better arrangements this important 
 post has not suffered from the disease since i860. 
 
 In the United States the highest level to which the 
 
122 DISEASES OF TROPICAL CLIMATES lect. 
 
 disease has attained is 262 feet. I have already men- 
 tioned Vera Cruz as a place which is the very home of 
 yellow fever ; it has never prevailed at Xalapa, which is 
 in the same latitude as Vera Cruz, but 4350 feet above 
 the sea. 
 
 What is the cause of yellow fever? Dr. Parkes has 
 classed it among faecal diseases. I have been in the 
 habit for years past of placing before those who have 
 preceded you much evidence, gathered from many 
 sources, in support of this opinion. I am now able to 
 compress into much smaller space evidence which, to 
 my mind, is very convincing on the point. My col- 
 league, Professor Aitken, in an introductory address to 
 the surgeons on probation in the Army Medical School, 
 afterwards expanded and published under the title of The 
 Doctrine of Evolution in its Application to Pathology^ in the 
 course of his instructive and interesting argument quotes 
 largely from what Dr. Charles Creighton has written on 
 the de novo origin of some specific fevers. After some 
 observations illustrating the fact that yellow fever appeared 
 in the seventeenth century as a new disease, and showing 
 that for more than a century after the Spanish conquest 
 of America, and for many years after the English and 
 French colonisation of the West India islands there 
 was no yellow fever, and that when it did come it was 
 something different from the ever present malarial fever ; 
 and some remarks on its peculiar geographical distribu- 
 tion \ still quoting Dr. Creighton, Professor Aitken goes 
 on to say, " There is only one thing that covers its (yellow 
 fever) history, geography, and the remarkable changes 
 
YELLOW FEVER 
 
 in its distribution, and that is the slave trade. The 
 localities where it is, or has been endemic or repeatedly 
 epidemic, are those found to be the creeks, wharves, 
 and low shipping quarters of the ports of debarka- 
 tion of the slave trade, together with a few much less 
 endemic but not less significant spots in Spain, and on 
 the west coast of Africa — the places to which vessels 
 engaged in the contraband slave trade had gone on their 
 return voyage. After showing that Peru offers only an 
 apparent exception to this rule, inasmuch as the coolie 
 trade across the Pacific has many points of resemblance 
 to the old African slave trade, reference is made to the 
 fact that after the disastrous outbreak of yellow fever at 
 Barcelona in 182 1, the French Government caused an 
 inquiry to be made which gave the first clue to the con- 
 nection between yellow fever and the slave trade. Dr. 
 Auduard, who conducted the investigation, came to the 
 conclusion ' that it was a peculiar form of typhus due to 
 the emanations from the putrid dysenteric discharges of 
 the negro ; and the fever owed its well-marked specific 
 type to the fact that the matters which excited it could 
 be traced to the negro body.' It was Auduard's opinion 
 that it was when the discharges were fermented that they 
 produced in others a typhus of a peculiar type. The 
 slaves themselves did not suffer from yellow fever, but 
 they suffered much from dysentery and from the ' horrors 
 of the middle passage,' so that a slave ship would arrive 
 at her destination with no contagious fever aboard but 
 saturated with the filth of her human cargo, out of which 
 the specific yellow fever '■came i?tto being.'' These con- 
 
124 DISEASES OF TROPICAL CLIMATES lect. 
 
 ditions must have arisen often at all the Spanish ports 
 where yellow fever was almost a yearly occurrence ; and 
 the whole history and geographical distribution of yellow 
 fever in America are of the same description, so that sea- 
 ports where cargoes of slaves had been landed year after 
 year became so saturated with the peculiar filth of the 
 trade, that the wharves, landing-places, and shipping 
 quarters of these ports became foci of infection. In 
 some places, such as Vera Cruz, the poison seems to 
 have become peculiarly fixed in the soil, so as to defy 
 all attempts to get rid of it ; but in the great cities on 
 the Atlantic seaboard of the United States the fever was 
 practically eradicated soon after the importation of 
 negroes ceased. During the sixteen years after that 
 date (1808) yellow fever appeared only seven times in 
 the different parts of the Union, whereas in the sixteen 
 years preceding the abolition of the traffic in slaves it 
 had broken out fifty-eight times. In the Spanish sea- 
 ports also the great epidemics of yellow fever are an 
 almost forgotten tradition." 
 
 Brazil is then shown to illustrate the same facts. 
 There epidemics of recent date, the first in 1849, pre- 
 vailed, because for some time it was the only market 
 open to the trade except Cuba. The disease has also 
 been established in the seaports of Peru, under like 
 conditions, viz. by ship-loads of sickly, ill-fed, ill-cared- 
 for Chinese. Like the negroes, the Chinese did not 
 themselves suffer from yellow fever, but they suffered 
 from these dysenteric and non-contagious ailments from 
 which the yellow fever "came into being." 
 
YELL W FE VER 125 
 
 The case is thus summed up : " If, then, we put to- 
 gether the facts of this remarkable disease ; when we 
 consider that its advent into the world coincided with 
 the rise of the slave trade ; that its habitat is or has been 
 the ports of debarkation of the slave trade, and those 
 places in Spain and the west coast of Africa to which 
 slave ships went on their return voyage ; that its exacer- 
 bations have coincided with the most lawless period of 
 the negro traffic ; that it gained a footing in the ports 
 of Brazil in 1849, when the slave trade flowed into that 
 channel \ and that it has become endemic subsequent to 
 1853 on the Pacific coast of South America, in those 
 parts of Peru which were the seat of an infamous coolie 
 trafific, we cannot but see in all this concurrence of 
 testimony a proof that Auduard was right in describing 
 yellow fever as a peculiar form of typhus, originating at 
 all its endemic centres in the filth of slave ships, just as he 
 showed that it had so originated as a matter of fact in two 
 of the Spajiish outbreaks. But if that evidence should 
 not be enough, we have only to add the fact that the 
 negro cannot take the disease, although it rages most in 
 the very quarters where negroes live. The yellow fever 
 still lurks about the wharves and shipping quarters of 
 towns where cargoes of negroes used to be landed ; and 
 every few years, when the weather is at its hottest, it rises 
 into a pestilence." 
 
 This is a long extract, but its importance cannot be 
 overestimated ; to my mind it sheds a flood of light on 
 a subject which has hitherto been one of profound ob- 
 scurity. It does more, it holds out a hope in which we 
 
126 DISEASES OF TROPICAL CLIMATES lect. 
 
 may indulge that in time this terrible pestilence, the 
 punishment inflicted on mankind for this accursed traffic, 
 may disappear. 
 
 I have now as briefly as possible to give you some 
 evidence of its portability and introduction into places 
 far from the spots — '"the wharves, landing-places, and 
 shipping quarters, the foci of infection." 
 
 Yellow fever has twice been introduced into Oporto, 
 on the first occasion by a ship which entered the Douro 
 from Rio de Janeiro, where the disease was raging. 
 Five of the crew died of the disease on the passage ; 
 immediately after her arrival it broke out in Oporto. 
 It is a notable fact that the custom-house officers, the 
 first to board the infected ship, were the first attacked. 
 In 1856 the disease was again brought to Oporto in the 
 same manner. As already mentioned, yellow fever has 
 twice been imported into Lisbon, on the last occasion 
 from Rio de Janeiro. In this epidemic 5652 inhabitants 
 perished. 
 
 One of the most authentic examples of the portability 
 of yellow fever by human intercourse is the famous case 
 of its introduction into St. Nazaire in 1861 by the 
 Anne Marie. The disease was raging at the Havana, 
 from whence the vessel sailed ; several of the crew 
 died of it on the passage ; the ship arrived at St. 
 Nazaire on the 25th of July, having left Havana on 
 the 13th of June. On the 5th of August the labourers 
 employed in unloading the vessel were seized with the 
 disease, from them it spread to the town, causing 44 
 cases and 26 deaths. 
 
YELL OW FEVER 127 
 
 The Swansea case is an equally good example. A 
 ship, named the Hcda, with cases of yellow fever on 
 board, left Cuba on the 26th of July 1S65 ) fresh cases 
 occurred on the passage. The Hecla entered Swansea 
 harbour on the 19th of September, with one of her 
 crew affected with yellow fever, and two others con- 
 valescing from the disease. The ship was moored 
 alongside of the wharf, landed her sick, discharged her 
 cargo, and remained in that position until the 28th, 
 when, in consequence of representations, the vessel was 
 removed from the dock. Between the 15 th of Sep- 
 tember and the 4th of October 20 inhabitants of 
 the town were attacked with distinct yellow fever. It 
 was clearly established that the first sufferers were those 
 who had intercourse with the crew, and that those sub- 
 sequently attacked had intercourse with them. A ship 
 which lay alongside the Hecla was affected, three of her 
 crew having taken the disease i^ide Eighth Report of the 
 Medical Officer to the Privy Council). On several 
 occasions the disease has been brought from one or 
 other of the West India Islands into Southampton, and 
 I had an opportunity of seeing one case of it in one 
 of the hotels of that town, with my friends Drs. Lake 
 and Keele ; in like manner it was imported in one of 
 the royal mail steamers. 
 
 I must now invite your attention to some important 
 facts, the outcome of the labours of many observers 
 who have studied this pestilence : (i) The inhabitants 
 of northern climates suffer more from yellow fever than 
 those bred in warm latitudes. Thus in Blair's ex- 
 
128 DISEASES OF TROPICAL CLIMATES lect. 
 
 perience in the Demerara epidemic of 1837, while the 
 percentage among West India islanders was 6.9, that of 
 French and Italians was 17.1, that of English, Irish, and 
 Scotch was 19.3, that of Germans and Dutch was 20, 
 that of Swedes, Norwegians, and Russians was 27.7 ; 
 (2) Those recently arrived within the sphere of its 
 activity are most prone to suffer ; the strong and robust 
 are more liable to the disease than those of a feeble 
 constitution ; (3) Females are less liable to be attacked 
 than males, and the mortality among them is less ; (4) 
 The disease, so to speak, spares those at the extremes 
 of life, the very old and the very young — the age of 
 vigour between 35 and 40 is the age most prone to 
 suffer ; (5) The pure-blooded negro enjoys an exemp- 
 tion from attack which admits of no doubt; Creighton 
 however remarks " that this immunity is perhaps not so 
 striking now, when the negro blood is not so pure"; 
 (6) It occurs once during life, to this the exceptions 
 are few; (7) Outbursts of yellow fever within the so- 
 called yellow fever zone are sometimes preceded by a 
 prevailing mild form of fever, rarely, if ever, proving 
 fatal, never attacking the same person twice, but giving 
 no protection against an attack of its fatal successor; 
 (8) Yellow fever, when once introduced into any city, 
 evinces a disposition to confine its ravages within a limited 
 area, "a tainted district," always the most uncleanly. 
 This is a point of cardinal importance, as regards the 
 safety of troops, pointing as it does to immediate 
 removal from the vicinity of the "tainted district." 
 Want of attention to this peculiarity of the disease has 
 
YELL OW FE VER 1 29 
 
 caused the death of thousands ; (9) Yellow fever re- 
 quires a temperature of 70° F. for its existence j 
 " however violent it may be at any place, yellow fever 
 is arrested from the day on which the earth is frozen " 
 (Jones); (10) The period of incubation is uncertain, 
 and appears different in different epidemics : it may 
 extend from twenty-four hours to weeks, some say 
 months — a doubtful statement. 
 
 Anatomical Characters. 
 
 Blood. — In the days when bleeding was practised, 
 physicians had an opportunity of observing the condition 
 of this fluid, and describe it as being in the first stage 
 red, coagulating quickly ; twenty -four hours later to 
 be much darker in colour, more liquid, less disposed to 
 coagulate, the serum yellowish, clot soft ; finally, fluid 
 and black. 
 
 Nervous System. — In most of the dissections made at 
 the Havana by Bellot the younger, the solar and semi- 
 lunar plexus were found red, at some points even black, 
 and easily torn. 
 
 The heart is invariably found in a state of true 
 fatty degeneration, more marked than in any other 
 disease; the cavities are distended with dark fluid 
 blood. 
 
 The lungs usually present few changes beyond some 
 congestion at the lower portions. 
 
 Liver.- — I invite your attention to the drawings sus- 
 pended behind me ; they were made in the hospital at 
 
 K 
 
I30 DISEASES OF TROPICAL CLIMATES lect. 
 
 Demerara, under the direction of Blair, during the epi- 
 demic of yellow fever at that place, which he has de- 
 scribed so well. Observe the yellow colour and blood- 
 less appearance of the cut surface. It is said that in 
 uncomplicated yellow fever there is in this organ an ab- 
 sence of the pigmentation observed in malarial fever. In 
 some of the specimens before you distinct pigmentation 
 is visible; whether this was the result of previous attacks 
 of malarial fever, or of a malarial element in this 
 epidemic, I cannot say ; but when you examine with 
 the microscope the sections of organs prepared at the 
 same time by Blair, and which are on the table for your 
 inspection, you will observe in many of them evidence 
 to the same effect. The liver cells you will notice are 
 filled with fatty material, the organ, except in those who 
 die at a very early stage, being always in a state of fatty 
 degeneration. The gall bladder is usually empty. 
 
 The spleen is generally normal in size and appear- 
 ance, thus presenting a marked difference from what is 
 seen in malarial fevers. 
 
 The kidneys are of a brownish-yellow colour, and the 
 malpighian corpuscles and tubuli uriniferl are filled with 
 granular albuminoid and fatty matter, detached epithelial 
 cells, and oil globules (J. Jones). 
 
 In Blair's drawings you will observe the messentery 
 is depicted of a pale yellowish or citron colour, not 
 mentioned by any of the many authors who have de- 
 scribed this disease. 
 
 The stomach is represented in the drawings to be 
 intensely congested ; it usually contains black vomit, the 
 
YELL W FE VER 1 3 1 
 
 orifices of the tubular glands are sometimes filled with 
 a dark-coloured material, and the mucous membrane is 
 sofi:, sometimes eroded. The intestines have externally 
 a pale yellowish tint, as in the drawings before you, not 
 a constant appearance, for other authors describe them 
 as dark coloured, generally distended with gas, contain- 
 ing altered blood ; according to Jones, one of the latest 
 American authorities, " intussusception of the bowels is 
 not unfrequent." 
 
 Symptoms. — The disease generally attacks in the 
 night, and, like other fevers, is preceded by malaise ; 
 chills soon follow, sometimes passing into severe rigors, 
 if violent they last a short time, if slight they may 
 persist for twenty-four hours (Bellot). Frontal headache 
 is hardly ever absent from the first, and is seen in every 
 degree of severity; it lasts three or four days, with 
 this there is lumbar pain, a symptom rarely absent, and 
 " very urgent " when urine is suppressed (Donnet). Epi- 
 gastric tenderness, with, in severe cases, a sensation of 
 oppression of a most distressing nature, is a constant 
 symptom ; the organs connected with the semilunar 
 plexus suffer most ; this epigastric tenderness is one of 
 the last symptoms to disappear. The eyes are con- 
 gested and yellowish, the tongue is coated, the pulse 
 is sometimes soft and compressible, at others hard. In 
 the West Indies Jackson has seen it as high as 130. 
 Dr. Lyons, in the Lisbon epidemic, noted that whenever 
 it reached 115 the case was apt suddenly to assume a 
 typhoid type ; the same author has seen it as low as 
 60, without the other pyrexial symptoms in the least 
 
132 DISEASES OF TROPICAL CLIMATES lect. 
 
 abating; in such cases, however, it always maintained its 
 force and tension. " Thus a strange combination is ex- 
 hibited, a pulse at 60, and a temperature over 100° F." 
 The temperature ranges from 100° to 107" F., the 
 face is congested, thirst is intense, with nausea and 
 vomiting first of ingesta, then bile, and finally, black 
 vomit. The bowels are usually constipated, the urine 
 is albuminous, and hcemorrhage in a more or less degree 
 from all the mucous orifices appears. The heat of skin 
 is pungent to the hand, and it displays the colour from 
 which the fever takes its name, varying, as you see in 
 the drawings exhibited, taken from nature, from light 
 citron to the deepest saffron. This yellow colour often 
 deepens after death. In some fatal cases it has hardly 
 been observed ; its appearance is irregular, sometimes it 
 comes out early, and again not until the day of death. 
 This yellow colour is not a true icterus, but depends 
 rather upon the escape of certain colouring matters 
 from the blood. Opinions vary as to the prognostic 
 value of this symptom, some attaching little importance 
 to it ; on the other hand Charles Bellot, whose 
 experience in Cuba has been great, deemed a yellow 
 skin on the third day a bad prognostic, but after the 
 fifth or sixth not unfavourable. Some of the older 
 writers dwell much on certain marks, "marblings and 
 wheals " on the skin, more particularly those who were 
 most free in the use of lowering treatment. These 
 patches are described as yellow, brownish, or livid, 
 and sprinkled with petechise. With these appearances 
 generally come the hEemorrhages from nose, mouth, 
 
YELL O W FE VER 1 3 3 
 
 ears, and vagina, and the black vomit, and also a 
 peculiar odour from the person, due doubtless to the 
 diseased condition of the blood. To the above symp- 
 toms add insomnia, jactitation, hiccough, subsultus ten- 
 dinum, delirium, and coma. 
 
 Let us look at some of the symptoms more closely. 
 
 I. Vomiting is early seen, first, as I have said, of 
 ingesta, then of a quantity of fluid out of all proportion 
 to that taken, specks are then seen in it like particles of 
 snuff, then the whole becomes black ; this is the black 
 vomit, the cafe fioir of the French. As I have shown 
 you, vomiting in malarial remittents is a distressing 
 symptom ; it does not appear to be so in yellow fever. 
 Blair tells us that a patient may be conversing with you, 
 suddenly he ejects a large quantity of black vomit, and 
 then resumes the conversation as if nothing had 
 happened. Vomiting may appear at any stage, some- 
 times only at the point of death. What is black vomit ? 
 It is decomposed blood, mixed, it may be, with acid 
 secretions from the stomach. Solution of nitrate of 
 silver throws down a white precipitate from it ; it has 
 an acid reaction, and effervesces with alkaline carbon- 
 ates ; it presents under the microscope epithelial 
 scales, nuclei, and variously altered blood discs, which 
 are generally broken down, some few remain entire, 
 invariably segregated, milled at the edges, with distinct 
 central depressions. Dr. Wilson, R.N., who made the 
 above microscopic observations at Bermuda, in 1864, 
 noticed also another microscopic appearance; "a 
 number of small circular cells, much smaller than 
 
134 DISEASES OF TROPICAL CLIMATES lect. 
 
 blood-corpuscles, were seen ; these were generally 
 clear, sometimes opalescent, and they moved about 
 freely in every direction. These cells were observed to 
 elongate, then to assume an hour-glass contraction, and 
 ultimately to divide into two cells." Dr. John Davy 
 incinerated black vomit, and always found peroxide of 
 iron in the ashes. 
 
 2. Constipatio7i is the rule. 
 
 3. Albiniimous Uiine. — Within the yellow fever 
 zone albumen is constant in the urine. In 62 cases 
 treated by Dr. Donnet at Port Royal it was observed 
 in all of them. It is not so constant out of this zone. 
 Lyons found it in the Lisbon epidemic only in excep- 
 tional cases, but always in connection with a depres- 
 sed condition of the system. Bile is often present. 
 Hellier found albumen in the urine in something of 
 an inverse proportion to the chlorides. In Donnet's 
 Port Royal cases where albumen was abundant, there the 
 chlorides were absent, and with the disappearance of 
 the albumen, chlorides again made their appearance. 
 
 4. Suppression of urine is a fatal symptom, chiefly 
 from retention of urine in the system. It is a good 
 rule to use the catheter, as urine may be retained. 
 
 5. The range of hccmorrhages in this disease is 
 unexampled. The blood transudes through the tissues 
 with the greatest facility ; the gums are always soft 
 and spongy, and blood pours out from them in large 
 quantity. There is a form of the disease which merits 
 the term hemorrhagic par excellence. In this form 
 blood escapes from the vagina, nose, mouth, gums. 
 
YELLOW FE VER 135 
 
 throat, eyes, and eyelids, and the cutaneous surface. 
 Lyons saw this form at Lisbon, chiefly among obese 
 women, and generally those of both sexes remarkably 
 plethoric and in the most vigorous years of life. It is a 
 fatal form, death generally taking place in from five to 
 seven days. If not then cut off, the same author observed 
 that they are apt to sink into a low typhoid state. I 
 have spoken of the peculiar smell given off by yellow fever 
 patients ; this is most notable in the hcemorrhagic form. 
 
 6. Lisomnia is a common symptom, attended with 
 restlessness, impatience of clothing, and a desire to 
 leave bed and walk about. The old authors gave the 
 name of " walking cases " to this form. 
 
 7. Deliriuffi is an occasional symptom, followed by 
 coma. But Blair tells us that patients often die with 
 their faculties unimpaired — dying with an assurance of 
 rapid recovery trembling on their lips. 
 
 Diagnosis. — The only disease with which yellow fever 
 is hkely to be confounded is yellow malarial fever. 
 
 Malarial fever is a paroxysmal Yellow fever is continuous. 
 
 disease. 
 
 Has a morning remission. Yellow fever has none. 
 
 Albuminous urine. Very rare. In yellow fever the rule. 
 
 Spleen always enlarged. Unaffected. 
 
 Liver merely congested. Profoundly affected. 
 Haemorrhages extremely rare. ■ An unexampled range of haemor- 
 rhages. 
 
 Attacks again and again. Only one attack. 
 
 Black races as subject to attack Negro race not affected. 
 
 as whites. 
 
 Not contagious. Highly contagious. 
 
 Amenable to quinine. Quinine has no effect. 
 
136 DISEASES OF TROPICAL CLIMATES lect. 
 
 The difference between the mortaUty of the two 
 diseases is most striking; thus, as Dr. Macdonald, 
 Inspector-General, R.N., has recorded, out of 292 cases 
 of malarial fevers in the West Indies, only 4 proved 
 fatal ; while out of 183 cases of yellow fever 72 died — a 
 difference in the relative mortality of the two diseases, 
 which, even if there were no other evidence, sufficiently 
 stamps the one as specifically different from the 
 other. 
 
 Prevention. — This to medical officers of the army 
 and navy is a matter of cardinal importance. It is true 
 that since the abohtion of slavery the number of British 
 troops in the yellow fever zone has been greatly reduced, 
 still, it is my duty to inform you that the very first 
 service five or six of your predecessors of one term 
 had to perform was to face a severe epidemic of this 
 disease at Bermuda. As for naval medical officers, they 
 are frequently employed within that zone, and in the 
 course of their service will often have to advise their 
 captains on the subject. Remember that remarkable 
 peculiarity of yellow fever to which I have already called 
 your attention, viz. the disposition it always evinces to 
 confine its ravages within a narrow area, "a tainted 
 district." Immediate removal of the troops out of this 
 " district " is the first and most important thing to be 
 done ; it should be done at once, on the very first sign 
 of an epidemic visitation. To wait until the men 
 become "tainted" is an act of culpable folly, without 
 excuse in the present state of knowledge. This fatal 
 mistake was made at Bermuda in 1864, and was 
 
YELL W FE VER 1 3 7 
 
 immediately followed by a lamentable loss of life. 
 Fourteen officers out of thirty, nearly 50 per cent, died, 
 and out of 250 men attacked, 107 lost their lives. 
 Warning of the coming danger was given by competent 
 medical authority ; it was unfortunately neglected until 
 the day of grace was past. Remember also that 
 epidemics of yellow fever within its zone are occasion- 
 ally preceded by outbursts of other non-fatal forms of 
 fever (Dengue for example). On any such occasion 
 be on the outlook for its fatal successor, and be ready 
 to move on its first appearance. Another point of 
 immense importance is this : The history of nearly 
 all the epidemics of yellow fever with which I am 
 acquainted points to defective hygiene in the places that 
 have suffered. It is notorious that in past days our 
 barracks in the West Indies were generally placed in 
 bad positions, and the conservancy arrangements were 
 often very defective ; there was no drainage, they 
 were surrounded by offensive cesspools ; so placed as to 
 be acted upon by the sun, and to send their foetid emana- 
 tions into the buildings occupied by the troops. Into 
 these pits, as the late Dr. Bone and many other army 
 medical officers have recorded, the evacuations even of 
 men suffering from yellow fever were cast. In Bermuda, 
 so late as 1864, things were not much better. Gibraltar, 
 in its days of visitation, was in no better case \ and 
 Lisbon to this day has the reputation of being an 
 uncleanly city. In an age of sanitation, it is not 
 necessary to add more on this point. Naval officers 
 are no doubt, by the regulations of their own service, 
 
138 DISEASES OF TROPICAL CLIMATES lect. 
 
 instructed that when yellow fever breaks out at sea 
 flight to higher latitudes is essential for the safety of 
 the crew. The sick should not be treated between 
 decks, but under some temporary shelter on the upper 
 deck ; and the utmost pains should be taken to prevent 
 the excretions of the sick from finding their way into 
 any part of the frame of the ship ; any wooden 
 receptacles, such as buckets, that may have been used 
 to receive such should be destroyed. There is evidence 
 to show that yellow fever has on many occasions been 
 brought both into men-of-war and merchant ships with 
 coals saturated with the excreta of yellow fever 
 patients. The protection of coal depots from the risk 
 of such contamination is worth the attention of the 
 naval and mercantile authorities within the yellow fever 
 zone. 
 
 T?-eatment. — Although yellow fever is a specific 
 disease, there is no specific treatment for it. Dr. 
 Parkes has reminded us of the teaching of Lind on 
 an important point of treatment. Here is the passage : 
 " I have often observed the poor seamen," says Lind, 
 " in the merchant service, to recover from yellow fever 
 solely by having the benefit of a free and constant 
 admission of the cool sea air into a ship anchored at a 
 distance from the shore, where they lay utterly destitute 
 of every assistance in sickness, and even of common 
 necessaries, having nothing but cold water to drink, and 
 not so much as a bed to lie upon ; while gentlemen 
 newly arrived from England, by being shut up in small, 
 close, suffocating chambers at Kingston or Port Royal, 
 
YELL OW FEVER 139 
 
 expired, with their whole mass of blood dissolved, flow- 
 ing from every pore — the stifling heat of their room 
 having produced a state of universal putrefaction in the 
 body, even before death." In the Bermuda epidemic, 
 already referred to, the yellow fever patients were 
 crowded into a building in the very centre of the 
 "tainted district," where "they lay on the floor ejecting 
 black vomit over one another." Surely Lind's teaching 
 was loudly called for there. The smallest allowance of 
 cubic space should be 2000 feet per man. 
 
 The indications of treatment are: (i) to clear out the 
 whole intestinal tract, without depressing the system ; 
 (2) to lower the temperature, to lessen headache, to 
 calm restlessness, and to moderate the heart's action and 
 relieve dyspnoea ; (3) to promote free action of the skin 
 and kidneys ; (4) to combat the typhoid state and to 
 restrain haemorrhage; (5) to moderate secondary fever, 
 should it arise. 
 
 The bowels should be relieved by a full dose of calo- 
 mel in combination with quinine, followed by castor 
 oil. What answers the purpose equally well is a com- 
 bination of calomel, extract of colocynth, and scammony ; 
 5 grains of each, with a few drops of some aromatic oil. 
 To attain the second indication, tincture of aconite in 
 drop doses every ten minutes or quarter of an hour, 
 until a full medicinal dose has been given ; the eff'ect 
 being kept up, if need be, by repeating the same dose 
 at intervals of longer duration, watching the effect ; or 
 from 2 to 4 drops of tincture of veratria viridis, or 2 to 4 
 drops of gelsemii every two or four hours (Jones). When 
 
r40 DISEASES OF TROPICAL CLIMATES lect. 
 
 the temperature, in spite of the above means, keeps as 
 high as 105° or upwards, ice-cold water may be thrown 
 into the bowels, and the vomiting should be restrained by 
 giving the patient ice to suck, applying mustard to the 
 epigastrium, or ice in a bladder or bag. Bellot has 
 found drop doses of liquor arseniculis, up to 6 or 8 
 drops, at short intervals, effectual in controlling the 
 vomiting. Great relief to the violent frontal headache 
 is obtained by friction with a liniment of camphorated 
 spirit and belladonna. There is no part of the treat- 
 ment so essential as the promotion of free action of the 
 skin and kidneys by hot mustard foot-baths, and the 
 use of diluents, barley water, lemonade, iced water. 
 Some years ago I met with a little work written by the 
 master of a ship trading to the Havana, whose name 
 has escaped me. All his life had been spent within the 
 yellow fever zone. This old " salt " well knew the im- 
 portance of stimulating the action of the skin ; he 
 invariably plunged his affected seamen into a tub of hot 
 water and mustard " up to the waist," and he writes 
 with enthusiasm of the good effects of this treatment. 
 You will take this irregular bit of evidence as to this 
 point quantum valeat, remembering, however, that some 
 of the highest authorities recommend it quite as strongly. 
 The greatest care should be taken to protect the patient 
 from draughts of cold air on coming out of the bath. On 
 the first signs of suppression of urine dry cupping over 
 the loins should be used with hot stimulating applica- 
 tions, and cerebral excitement should be met with 
 bromide of potassium. 
 
YELL W FE VER 1 4 1 
 
 When the state of febrile excitement has subsided 
 and the patient passes into a typhoid state, iced cham- 
 pagne and beef-tea should be given. Blair preferred 
 Rhenish wine to all others. Tympanites is often a 
 distressing symptom; assafoetida enemeta with turpentine 
 are useful, not only by expelling flatus, but in stimulating 
 the kidneys. The diet should at first consist only of 
 the mildest articles. Barley water, water arrowroot, iced 
 milk in soda water ; and the return to more nutritious 
 food should be gradual. Rest in the recumbent position 
 is essential, not only during the active stage of the 
 disease but until convalescence is well established. Over 
 the haemorrhages, so characteristic of the worst forms of 
 yellow fever, medicine has little control. Jones advises 
 scruple doses of sulpho-carbolate of soda to counteract 
 the risk of septic poisoning which has been known to 
 follow decomposition of the blood effused into the 
 gastro-intestinal tract. 
 
 Quinine has no effect in controlling this fever, but it 
 is useful in moderate doses in the secondary fever which 
 sometimes occurs. Opium is condemned by all the 
 best authorities in all stages of the disease. Treatment 
 conducted on the conservative principles I have in- 
 dicated is much more successful than when it was of a 
 more "active" kind. Out of 256 cases treated much 
 on the lines I have sketched for your guidance in this 
 lecture, Dr. Joseph Jones, one of the best and latest 
 authorities in the United States, had only 18 deaths. 
 
LECTURE VIII 
 
 INSOLATION 
 
 This serious affection has many synonyms — -sunstroke, 
 sun fever, coup de soleil, calenture, heat-apoplexy, detus 
 soils, erytliismus tropicus. Insolation is the term by 
 which it is designated in the official classification in use 
 in the British army. The most inappropriate and mis- 
 leading is that of heat -apoplexy. It is much to be 
 desired that this term should disappear ; it is based on 
 false pathology, and has led to mischievous treatment. 
 
 Definition. — • An affection of the nervous system 
 induced by heat, solar or artificial, profoundly affecting 
 the functions of circulation and respiration, with, in 
 some of its forms, extreme pyrexia, unexampled con- 
 gestion of the lungs, and a high mortality. 
 
 This formidable affection is one of great interest and 
 importance to army medical officers everywhere, but 
 more especially to those charged with the care of troops 
 in hot climates. As I have elsewhere shown, it is a 
 notable fact that in the statistics of the Indian army, 
 before the date of the mutiny of the Bengal native 
 regiments, this affection seldom appears ; some forms 
 
XECT. VIII IXSOLATION 143 
 
 of it were included under the heading Ardent Continued 
 Fever, while those proving quickly fatal with insensibility, 
 convulsions, stertorous breathing, and such-like symptoms, 
 were considered to be cases of cerebral apoplexy, and 
 registered accordingly. Thus, in the example recorded 
 by Martin, H.M. 13th Regiment, which marched from 
 Nuddea to Berhampore in the midst of the hot weather, 
 63 men were struck down, of whom 18 died. All the 
 cases were entered as " apoplexy." In my introductory 
 lecture I referred to the case of the 68th Regiment, 
 quartered in Fort St. George, Madras, in May 1834. 
 The regiment paraded in full dress at an early hour in 
 the afternoon for a funeral, and marched for several 
 miles ; one man died before the funeral was over, two 
 more shortly afterwards, and men suffering from insola- 
 tion in varying degrees were brought into hospital 
 throughout the night, of whom many died. The 63d 
 Regiment suffered in the same way at the same place, 
 and under circumstances precisely similar. 
 
 I was an eye-witness to the terrible sufferings of the 
 98th Regiment on the occasion of the capture of Chin- 
 kiang-foo, the last military operation of the war in 
 China, under Sir Hugh, afterwards Lord Gough. The 
 regiment arrived at the scene of operations only the day 
 before, having come out from England in an over- 
 crowded transport, under the command of an officer at 
 that time without experience in tropical war. The men 
 paraded for action in one of the hottest days of a hot 
 season, dressed as if for a show parade in Hyde Park ; 
 they had, on landing, to take possession of a steep hill 
 
144 DISEASES OF TROPICAL CLIMATES lect. 
 
 of moderate height ; before they reached the summit 
 1 5 men died on the spot from insolation, " they gave 
 a few convulsive gasps, and died before anything could 
 be done for their relief;" many others were struck 
 down, and not a few perished during the night from the 
 same cause acting in a less rapid way. 
 
 The 43d Regiment made during the Indian mutiny a 
 march of iioo miles from Bangalore to Central India; 
 part of this long march having been made in the hot 
 season, the men were exposed to a very high tempera- 
 ture by night as well as by day, and before it was com- 
 pleted they were in a state of extreme exhaustion. 
 While in a valley at the foot of the Bisrangunge Ghat, 
 the thermometer in the largest tents stood at 118° and 
 in the smallest 127° F. during the day, and at 105° 
 at midnight. In this position cases of insolation were 
 brought to the hospital tents at every hour of the day 
 and night, and although a large proportion of them 
 recovered, 2 officers and 1 1 men were buried under one 
 tree in the neighbourhood of the camp (Barclay). 
 
 It is not on the line of march only that men suffer 
 from insolation in hot climates ; they are liable to it 
 during the hot weather in India in barracks where the 
 sanitary arrangements are bad ; in other words, when 
 overcrowding and imperfect ventilation are added to 
 high temperature : of this I could give you many ex- 
 amples. Insolation may occur also on board ship 
 under conditions similar to those in barracks. It is, for 
 example, a common occurrence on board the mail 
 steamers in the Red Sea, in the hot months of August 
 
INSOLATION 145 
 
 and September, the sufferers being generally affected 
 when in the horizontal position in ill-ventilated cabins. 
 
 French men-of-war carry larger crews in proportion 
 to the size of the ships than in the British navy. M. 
 Bassier, surgeon in the French navy, reports in his 
 Dissertatio?t sur la Calenture, that in the month of 
 August 1823 the man-of-war brig Le Lynx, cruising off 
 Cadiz, had 18 cases of insolation out of a crew of 
 78 men. The heat was excessive (33° to 35° Cent.), 
 and much aggravated by calms. In this case the 
 ship was overcrowded ; " le batement, tres petit, ojjrait 
 peu d'espace pour le coucher de Vequipage^ Boudin 
 {Statistiques Medicales) records that the French man-of- 
 war Dugesne, while at Rio Janeiro, had 100 cases of 
 insolation, out of a crew of 600 men. Most of the 
 men were attacked, not when exposed to the direct 
 rays of the sun, but at night, when in the recumbent 
 position — that is, when breathing not only a hot and 
 suffocating, but also an impure air. 
 
 Do not, however, suppose that this affection is con- 
 fined to hot chmates. The records of European war- 
 fare abound with examples of the effects of insolation on 
 troops in the field. Let me give you a very striking 
 one, the full details of which you will find recorded by 
 Carlyle, in his rugged but graphic style, in the sixth 
 volume of his Life of Frederick the Great, On the 6th 
 of September 1760 that great commander made a 
 forced march from Kloster Marienstern to the Spree, 
 with the object of intercepting Marshal Dawn, the 
 Austrian general. This was such a march for heat and 
 
 L 
 
146 DISEASES OF TROPICAL CLIMATES lect. 
 
 difficulty as the king never had before. 105 Prussian 
 soldiers were struck down never to rise again. Mar- 
 shal Dawn fared still worse in the heat of that terrible 
 race; 200 of his men died on the road, and 310 more 
 were invalided for life.-*- 
 
 Men will bear a high temperature in the open air 
 with comparative impunity, provided (a) it is not too 
 long continued ; (b) that exertion be not pushed to the 
 limit of human endurance, as in some of the marches 
 given above ; {c) that the free movement of the chest 
 be not interfered with by dress and ill-contrived ac- 
 coutrements ; and (c/) that strict temperance be ob- 
 served. British sportsmen in India often pursue their 
 exciting amusement in the hottest weather under the 
 above conditions, and seldom suffer from sunstroke ; 
 they are of course careful to protect their heads and 
 the upper part of their spines from the direct rays of 
 the sun. It is needless to add that the conditions 
 under which soldiers have to do their duty in war are 
 very different, more particularly at a time when little 
 attention was paid to suit the clothing and accoutre- 
 ments to the nature of the climate. 
 
 The case of the 43d Regiment, as related by Dr. 
 Barclay, and referred to above, brings out another pre- 
 
 ^ It is to be noted that, in accordance with the prevailing notions 
 on the subject at the time, the hot, parched, and thirsty soldiers 
 were forbidden to drink a drop of water. Carlyle describes how 
 the poor men, as they crossed the water-brooks on the line of 
 march, disregarding the cudgels of the sergeants, freely used, 
 "pounced down irrepressible, and drank from the brim of 
 the hat." 
 
INSOLATION 147 
 
 disposing cause which exercises a powerful influence, 
 viz. the effects of prolonged exertion. 
 
 First, there is a great waste of tissue ; so long as 
 the functions of the skin, bowels, and kidneys are 
 maintained in tolerable activity, the blood remains pure ; 
 but as the exertion continues under a high temperature, 
 the function of the skin first diminishes and then ceases, 
 the cooling effect of evaporation is lost, the temperature 
 of the blood rises, and is loaded with effete matters, 
 no longer excreted. Obstinate constipation, a constant 
 condition, follows \ the activity of the kidneys is lessened, 
 still further promoting blood impurity. In this state of 
 the system the appetite fails, nausea succeeds, and the 
 sight of food excites loathing. 
 
 From the above it is evident that while extreme heat 
 is the real exciting cause, the restriction of the free 
 movements of the chest by tight clothing and accoutre- 
 ments, excessive fatigue with all its consequences, the 
 impure air of« ill-ventilated barracks and ships, are 
 powerful predisposing causes of insolation. 
 
 A hot and moist condition of the air is most favour- 
 able to the production of insolation in crowded and ill- 
 ventilated rooms, as it not only hinders the cooling effect 
 of evaporation, but interferes also with the artificial 
 means used to reduce the temperature of the overheated 
 dormitories. 
 
 Morbid Anatomy. — The blood is invariably fluid, as 
 in men killed by lightning, with extreme engorgement of 
 the venous system. 
 
 The brain has been obser\-ed by Professor Arndt 
 
I4S DISEASES OF TROPICAL CLIMATES lect. 
 
 to be moist ; in some dissections made by him seven 
 hours after death, the ventricles were distended with 
 fluid, the convolutions flattened, and sulci obliterated, 
 yet the veins and sinuses of its membranes were without 
 blood. 
 
 The nervous substance is always ansemic. I have 
 never seen a single example of hsemorrhage into the sub- 
 stance or ventricles of the brain ; so far from this, the 
 capillaries are empty, or nearly so. 
 
 The heart is, as a rule, from which I have seen no 
 exceptions, contracted, and the colour a dull red, the 
 tissue dry and fragile ; the general muscular system 
 presenting the same appearance. 
 
 The lungs are in a state of hyperaemia without example 
 in any other disease. 
 
 The liver is usually enlarged, has a doughy feeling, 
 and when impressed by the finger the marks remain; 
 the acini are distinct, and its substance dry. 
 
 The kidneys are enlarged, the capsule easily separ- 
 able, the cortical substance pale, the medullary injected 
 with blood, the tissue charged with albuminous and 
 fatty molecules. Arndt found the blood loaded with 
 excreted material, an observation confirmatory of the 
 effects of high temperature and fatigue hindering its 
 depuration, pointed out in the course of this lecture. 
 Arndt's dissections were made on the bodies of soldiers 
 who died suddenh', as in some of the examples I 
 have given you. The blood is rich in carbonate of 
 ammonia, and extremely dark in colour ; there is thus 
 a strong analogy between the blood of men dying from 
 
INSOLATION 149 
 
 the effects of high temperature and in cases of septic 
 disease. 
 
 Insolation is seen in three forms, which the late Dr. 
 Morehead described as the cardiac, the cerebro-spinal, 
 and the mixed — terms which are sufficiently convenient. 
 The cardiac or syncopal variety is the one usually seen 
 to occur at night when men are in -the recumbent posi- 
 tion under the conditions I have described ; and also 
 when making excessive exertion in a hot sun, as in the 
 case of the 98th Regiment, death taking place from 
 failure of the heart's action suddenly, before the sufferer 
 has time to give warning of his distressed condition, and 
 often before anything can be done for his relief If 
 death does not take place at once the patient will be 
 found in a state of extreme prostration, the skin pale 
 and moist, with a weak and fluttering pulse. 
 
 In the so-called cerebro-spinal variety there are pre- 
 monitory symptoms. Heat of skin, which is ardent and 
 stinging, with extreme dryness ; giddiness, congestion of 
 the eyes, debility, nausea, and frequent micturition. This 
 last symptom was first noted by my colleague Professor 
 Longmore, and also by Dr. Barclay, the constant cry of 
 whose men was, "I cannot hold my water." Headache 
 is extremely rare ; sometimes a wild shout of terror 
 followed by an attempt to escape from an imaginary 
 enemy gives the first warning to bystanders of what is 
 impending. When men in barracks are sensible of the 
 above premonitory symptoms, or some of them, they 
 assume the recumbent position, and in that state pass 
 into coma, the attention of their comrades being first 
 
ISO DISEASES OF TROPICAL CLIMATES lect. 
 
 called to their condition by their stertorous breathing. 
 The respiration is hurried, the pupils contract and are 
 insensible to light, the conjunctivee become of a pink 
 colour, the heart's action is irregular, with a quick, 
 irregular, and fast failing pulse. Convulsions, always of 
 an epileptiform character, may or may not be present ; 
 patients sometimes dying without moving a limb. The 
 temperature reaches 107°, 108°, and sometimes iio°F., 
 within three degrees of the temperature at which the 
 myosin of the blood coagulates. It sometimes happens 
 that the cerebro-spinal nerve centres are so profoundly 
 affected by the high temperature in weakly subjects, that 
 asphyxia and apncea come on before there is time for 
 the development of the above symptoms, in such cases 
 death takes place with great rapidity. 
 
 In the so-called mixed form the symptoms, as we 
 might expect, present some of those of both varieties. 
 It is not necessary to overload the description by 
 attempting to define them. Morehead was of opinion 
 that the cerebro-spinal variety of insolation was the one 
 most frequently seen in the sthenic constitution of the 
 newly -arrived European ; yet it is certain that in the 
 case of the men of the 43d Regiment, worn out by 
 excessive fatigue in their long march, this was the form 
 of the affection which most prevailed amongst them ; 
 while the men of the 98th Regiment, fresh from Europe, 
 suffered from the cardiac variety. 
 
 Sequels. — The most common is epilepsy in various 
 degrees of severity, from slight epileptiform convulsions 
 to the severest forms of the disease. I have seen an 
 
INSOLATIOA 151 
 
 immense number of soldiers invalided from India for 
 this affection following sunstroke ; in a large proportion 
 of the cases the attacks had disappeared before arrival 
 at Netley, particularly in the long voyage round the 
 Cape of Good Hope; in others, as a rule, we found the 
 disease amenable to treatment ; so that the prognosis 
 is on the whole favourable. S. much more formidable 
 sequel is persistent headache depending probably on 
 chronic meningitis, with some thickening of the mem- 
 branes. This is often a cause of much suffering, some- 
 times extending over years. Not unfrequently there is 
 more deep-seated cerebral mischief, giving rise to mental 
 weakness and a long train of distressing symptoms, often 
 of a hopeless kind. I have seen a few examples of 
 chorea-like movements of the muscles of the forearm 
 and hands, probably due to nerve irritation, kept up by 
 the impure condition of the blood already described. 
 
 Diagnosis. — The diseases with which in former years 
 sunstroke was most often confounded appear to have 
 been cerebral apoplexy and ardent fever ; with the 
 former it has no pathological relations. In both 
 apoplexy and insolation we have coma ; the pulse in 
 the former is slow, generally full, often intermitting. In 
 sunstroke it is usually quick and sharp. In apoplexy 
 the breathing is slow, irregular, and explosive in expira- 
 tion. In sunstroke it is rapid and noisy, but not 
 explosive. In apoplexy the pupils are, as a rule, dilated, 
 or one is more so than the other. In sunstroke in every 
 case seen by me they were contracted ; the skin in 
 apoplexy is not hot, is indeed often cold and moist ; in 
 
152 DISEASES OF TROPICAL CLIMATES lect. 
 
 sunstroke, except in the cardiac variety, it is very hot 
 and excessively dry. 
 
 Hemiplegia is the almost invariable result of cerebral 
 haemorrhage; I never saw it follow directly on sunstroke. 
 
 Prognosis. — The most unfavourable signs are pro- 
 longed and complete insensibility, without movement, a 
 much more alarming condition than occasional convul- 
 sions, intense heat of skin resisting the use of the douche 
 and other means of applying cold, increasing congestion 
 of the eyes, tumultuous action of the heart, failing pulse, 
 and lividity of hands and feet. 
 
 The mortality from sunstroke has always been high, 
 as high as 45 or 50 per cent; it is now, under a more 
 rational treatment, much diminished ; but it must be 
 kept in mind in estimating the death-rate that in our 
 military statistics it is only the direct mortality that is 
 recorded. Many men are invalided for the sequels of 
 the disease, some of whom, after lingering for a longer or 
 shorter time in civil life after discharge, ultimately die 
 from chronic cerebral diseases induced by it.^ 
 
 ^ During 1868 no less than 241 admissions for insolation 
 occurred in the Bengal army. All but 14 were admitted in the 
 months of June, July, August, and September. The maximum in 
 one month (114) occurred in August. With a minimum of 2.41 
 per 1 000 in Bengal proper, they rose to a maximum of 1 1 in the 
 Punjab. In this last province 144 cases were treated, occurring 
 mostly among troops marching to the frontier campaign in August. 
 Of these all but 13 were successfully treated. The ages of those 
 who died present a remarkable contrast to those who died of 
 typhoid fever. Of the 92 deaths from sunstroke returned in the 
 age statement only 16 vi^ere under 25 years of age. The ratio of 
 mortality was nearly double among the older men. The mortality 
 
INSOLATION 153 
 
 Prophylaxis. — The immense improvement that has 
 taken place in barrack accommodation in India has 
 done much to lessen the number of cases of barrack insol- 
 ation, and the danger of overcrowding is well understood. 
 It is a good rule even now, when the night temperature 
 is exceptionally high, to have tents pitched, so as to 
 diminish the number of men in the barrack dormitories. 
 
 In future troops are not likely to be drilled in a hot 
 sun or made to attend funeral parades at 3 p.m., or 
 marched in hot weather, except under a pressing military 
 necessity. When such a cruel necessity exists, an 
 abundant supply of water for drinking and douching 
 purposes should be provided, the pace should be easy, 
 the halts frequent, and as much as possible open 
 order should be observed ; a point much insisted 
 on by Marshal Ney; alcohohc drinks should be 
 forbidden, tea and coffee being, where practicable, 
 substituted. During the military operations of the last 
 war in China, an officer in command of a battery of 
 artillery, when the troops were called out for duty on a 
 hot day, willing to do his men a " kindness," opened the 
 canteen, and allowed every man a spirit ration. That 
 battery had more cases of sunstroke on that day than 
 all the rest of the force engaged. 
 
 As is well known, since the days of the Indian 
 Mutiny the dress of the British army in India has 
 undergone an immense improvement, and instead of the 
 
 of the cases treated, all round, was 35.68 per 1000 {Vide Report 
 of the Sanitary Commissioner with the Government of India for 
 i! 
 
154 DISEASES OF TROPICAL CLIMATES lect. 
 
 head-dresses in use before that time, the head, neck, and 
 spine are now better protected by means adapted to the 
 purpose. 
 
 Treaime?it. — It is hardly necessary to dwell long on 
 the fact now well established, that bleeding is not only not 
 required, but is in this affection, in all its forms, a fatal 
 proceeding. In the article Sunstroke, communicated 
 by me to Russell Reynolds' System of Medicine, I have 
 given examples of the bad effects of this measure. 
 These examples are written for your learning. I have 
 reason to know that their publication contributed to the 
 extinction of the practice. 
 
 In the slighter forms of mere exhaustion from heat, 
 without the formidable symptoms of developed insolation, 
 mere removal into the shade, rest in the recumbent 
 position, opening up of the clothes, a mild and not too 
 long prolonged douche over head, nape, and chest, stimula- 
 tion by means of ammonia to the nostrils will suffice, a 
 watchful eye being kept on men in this condition lest 
 more formidable symptoms should supervene. 
 
 In real sunstroke,when a man falls, more energetic means 
 are required. The patient should be removed into the 
 shade and stripped, and the douche should be used with 
 energy to head, nape, and chest, and repeated again and 
 again, until the function of respiration is restored. A 
 large mustard -plaster should be applied to the chest, 
 and he should be still further roused by flicking with a 
 wet towel, or flagellation with an extemporised "rod"; 
 a turpentine enema should be given, and he should be 
 encouraged to drink freely of cold water. 
 
INSOLATION 1 55 
 
 In those cases where the temperature is high the 
 above means Avill require to be repeated from time to 
 time ; he should be enveloped in a wet sheet, and an 
 enema of ice-cold water should be given — one of the 
 most powerful means at our disposal. Even after the 
 temperature has been reduced there is always a tendency 
 to a dangerous recurrence of it ; on the first thermo- 
 metric indications of this the above means must be used 
 persistently until this thermic condition is removed. 
 On the first appearance of convulsions the cautious 
 inhalation of chloroform will often calm them, and con- 
 tinued insensibility must be met by a blister to the nape 
 or to the shaven scalp, which is often most effective ; 
 the bowels should be freely evacuated. 
 
 On the appearance of any of the sequels I have 
 described removal to a cold climate at the earliest 
 possible period is essential. This often effectually cures 
 the epileptiform convulsions. Bromide of potassium, 
 the use of a mild shower-bath, sea-bathing, and attention 
 to the general health will generally effect a cure in the 
 more obstinate cases. 
 
 The persistent headache is best dealt with by iodide 
 of potassium. I have tried counter-irritation in various 
 ways without much effect. The daily use of an ice-cup 
 for an hour or two is often a great relief On the other 
 hand it sometimes aggravates suffering. In men of 
 a robust constitution a carefully regulated course of 
 mercury is sometimes effectual, promoting, we may 
 reasonably suppose, the absorption of effused lymph. 
 
 In all cases of sunstroke return to a hot climate 
 
156 DISEASES OF TROPICAL CLIMATES lect. viii 
 
 should not be thought of until every trace of the effects 
 of the attack have disappeared for at least a year. In 
 some of the more severe cases return is not admissible 
 at all. Every case must be judged on its merits, and 
 not settled by applying one rule to all. 
 
 To the above measures I would add a well regulated 
 course of massage as highly conducive to recovery. 
 
LECTURE IX 
 
 DIARRHCEA 
 
 " Bowel complaints " have always been conspicuous 
 in the statistics of tropical diseases. Sir Ranald Martin, 
 in a memorandum prepared for the Royal Commission 
 that inquired into the health of the army of India, 
 showed that next to malarious fevers bowel complaints 
 are the most prevalent ; while the dangers to health and 
 to life from these last are even greater than from fevers. 
 In the Presidency of Madras, out of an aggregate 
 British force of 82,342 men serving there from 1842 to 
 1848, there occurred 10,531 cases of dysentery, and 
 9189 cases of diarrhoea, making a total of 19,720 cases 
 of bowel complaints, exclusive of cholera. 
 
 My long experience at Netley enables me to say with 
 confidence that probably more than a half of the cases 
 in the above statement entered as diarrhoea were in 
 reality cases of chronic dysentery. 
 
 A definition of diarrhoea is hardly necessary. By 
 this term is understood a flux from the small intestine, 
 the result of local or constitutional causes, the stools 
 passed without tenesmus, and presenting much variety 
 
158 DISEASES OF TROPICAL CLIMATES lect. 
 
 in consistence, colour, and odour. The more serous 
 the evacuations are, and the more rapidly the blood is 
 deprived of its watery constituents, the greater is the 
 effect on the system and the danger to life. 
 
 Diarrhoea may be regarded from two points of view : 
 as a disease in itself, or as a symptom and complication 
 of many diseases. It is the first that concerns us here. 
 
 Many causes contribute to set up this affection ; such 
 as sudden alternations of temperature from heat to cold, 
 affecting the function of the skin, determining hepatic 
 congestion, with functional derangement of the liver ; 
 errors in diet, particularly on first arrival in a hot climate, 
 the use of food, more especially fish or shell-fish, in the 
 stage of decomposition ; impure water, breathing a privy 
 atmosphere ; mental emotion, acting on the mucous 
 membrane or muscular coat of the intestine, by impres- 
 sions conveyed through the nervous system. This cause 
 is well illustrated in military life by the number of men 
 seen to "go to the rear " under the influence of emotions 
 excited by the near prospect of battle, which quickly 
 pass away under the fierce excitement of combat. 
 
 Observation has convinced me that the worst idiosyn- 
 crasy a person can take with him to a hot climate is the 
 disposition to relaxation of the bowels from slight causes. 
 Such people are not only liable to frequent attacks of 
 diarrhoea, but are among the first to suffer from dysentery 
 and cholera when exposed to the contagium of those 
 affections. 
 
 Diarrhoea is often the means by which injurious 
 matters, solid or gaseous, that have been taken into 
 
IX DIARRHCEA 159 
 
 the system are quickly thrown out. Two friends of 
 mine, driving in an open carriage, puUed up for a few 
 minutes near a Hvery stable in a country town ; close 
 to the carriage was a grating for ventilating the main 
 sewer ; a quantity of boiling water was poured into the 
 sewer from the neighbouring stable ; in a moment the 
 carriage and its inmates were enveloped in a cloud of 
 watery vapour, carrying with it a putrid and intolerable 
 stench. To this my friends were exposed only for a few 
 seconds, as the coachman instantly drove quickly away. 
 All three were soon attacked by nausea, had to hasten 
 home, and were smartly purged, the evacuations having 
 the same offensive odour as the sewer air that so quickly 
 affected them. 
 
 When the Wellington Barracks, near Conoor, on the 
 Neilgherry Hills in the south of India, were first occupied 
 by a battalion of the Rifle Brigade, diarrhoea prevailed 
 to a great extent among the men, which was at first, as 
 usual, set down to "climatic causes." The real cause 
 was a privy atmosphere. During the construction of 
 the buildings the native workmen were under no police 
 conservancy, with the natural result, the ground was left 
 in a condition of extreme filth ; when this was remedied 
 the diarrhoea disappeared. 
 
 In the lecture on Enteric Fever I have given evidence 
 in abundance of the evil consequences of establishing 
 a privy atmosphere in and about buildings where many 
 men are congregated. 
 
 Among the causes of diarrhoea I have mentioned 
 shell-fish. At certain seasons rock-oysters are supplied 
 
i6o DISEASES OF TROPICAL CLIMATES lect. 
 
 in the market at Madras. Out of every hundred an 
 uncertain number of them are distinctly poisonous, 
 whether from decomposition or some other cause I can- 
 not tell. I have been called twice in one night to see 
 new arrivals from " up country " in one or other of the 
 hotels, suffering from diarrhoea of an alarming kind after 
 partaking of rock-oysters, esteemed a great delicacy by 
 those who have been long quartered away from the sea- 
 coast. The symptoms were nausea, vomiting, profuse 
 watery purging, extreme weakness, a cold and clammy 
 skin, with a weak and fluttering pulse ; in a word, a 
 condition hardly to be distinguished from the collapse of 
 cholera. To one case that proved fatal I was called in 
 consultation. The patient, who by the way was a noted 
 gourmet, had made a long journey to the coast during 
 the oyster season, to " enjoy his favourite dish." This 
 gentleman, who was known to his medical attendant to 
 be prone to diarrhoea, was warned in vain to abstain 
 from his "favourite dish," died with the symptoms I 
 have just described. Ashamed of his weakness he did 
 not send for his doctor until it was too late to save him. 
 Among the predisposing causes of tropical diarrhoea 
 must be placed malaria. A malaria -struck man is 
 extremely sensitive to alternations of temperature ; his 
 heat-generating powers are impaired, and he suffers from 
 chills brought on by sudden variations of which healthy 
 men take no notice. We see this in the persons of 
 invalids brought home from India at improper seasons. 
 Unless they are carefully protected by suitable warm 
 clothing, when they are exposed to the damp cold of our 
 
DIARRHGEA 
 
 high latitudes, they are almost certain to suffer from 
 diarrhoea, more particularly if they have had the disease 
 in India. 
 
 Young persons on first arrival in a hot climate are 
 liable to have an attack of so-called bilious diarrhoea ; 
 under the stimulus of unwonted heat the biliary secretion 
 is increased to such an extent as to provoke it, or what 
 is perhaps a more common cause, over-indulgence in 
 highly-spiced food sets up relaxation, and the irritation 
 of the mucous membrane by reflex action promotes a 
 profuse biliary discharge which aggravates the diarrhoea. 
 In the introductory lecture I adverted to the great 
 mortality among the children of European soldiers from 
 the diarrhoea of dentition, aggravated by unsuitable 
 food. 
 
 On the hill stations on the spurs of the Himalaya 
 Mountains there prevails at certain seasons, usually the 
 setting in of the rains, a "white flux," which, more than 
 twenty years ago, was first carefully described by my 
 friend Dr. Alexander Grant of the Bengal army, in the 
 Indian Anrials. The sanitation of Indian hill stations, 
 when first occupied, was too often left to chance. But 
 hill stations, any more than other places of equal salubrity, 
 do not prosper under such a system ; soon the seeds of 
 disease, carelessly planted, grow to maturity, and produce 
 their invariable fruit. So it was in the early days of our 
 hill stations. Enormous quantities of night soil were 
 allowed to be cast down the slopes of the hills leading 
 to the ravines below; the rains in due time dissolve 
 such accumulations, and two things result : the sources 
 
 M 
 
1 62 DISEASES OF TROPICAL CLIMATES lect. 
 
 of water supply are polluted, and the air carried up from 
 the hot steaming ravines and valleys is charged with foul 
 matters. No doubt, also, the change from the hot 
 plains to the cool atmosphere of these elevated regions, 
 more particularly the damp and cold nights, provokes 
 there, as elsewhere, the hepatic congestion and functional 
 derangement of which Dr. Grant writes ; more par- 
 ticularly when acting on the systems of men and women 
 charged more or less with malaria from residence in 
 malarial climates on the plains below. 
 
 Dr. Grant describes the stools as pale drab or 
 muddy gray in colour ; frothy and feculent in the 
 early stages, later on becoming gray and pultaceous, or 
 lienteric ; giving off an odour described as " peculiar 
 and unnatural," but not offensive. They are often quite 
 white. This affection, if not successfully dealt with at 
 first, is apt to become chronic, reducing the patient to 
 an aneemic and exhausted condition, and at this stage 
 is a danger to life. Although originating on the hills 
 it is apt on return to the plains to break out again, 
 necessitating removal to Europe. Both Dr. Grant and 
 Dr. Goodeve refer to this, the latter instancing the 
 case of H.M. 29th Regiment, the 2d Bengal Europeans, 
 and the Bengal Artillery, who suffered in the plains 
 after having, previous to joining the army of the Punjab 
 in 1848-49, being subject to the disease on the hills. 
 
 White flux is not confined to the hill stations of 
 India ; a very obstinate form of diarrhoea in which, after 
 a time, the stools present the pale drab or whitish colour 
 described above, is seen on the malarial plains, and 
 
IX DIARRHCEA 163 
 
 when neglected and allowed to become chronic it is a 
 tedious and dangerous affection, reducing the sufferers 
 to an emaciated and anaemic condition under which they 
 ultimately succumb. The disease begins in an insidious 
 way, at first exciting little attention and no alarm. The 
 motions may not exceed two or three in twenty-four 
 hours ; are not in the first instance either pale coloured 
 or fluid, only assuming their characteristic appearance at 
 a later stage. If not checked by appropriate treatment, 
 symptoms of grave constitutional derangement appear ; 
 the patient becomes dyspeptic, suffers from flatulent 
 colic j the tongue becomes red, smooth, and glazed ; the 
 mouth is covered with apthous sores, which extend to 
 the edges of the tongue ; the appetite fails, nutrition 
 becomes daily more imperfect, and the stools, having 
 now assumed their characteristic appearance, become 
 more frequent and copious, and are voided with violence, 
 an invariable symptom of the scorbutic condition, which 
 is now fully established. This white flux should, in 
 my opinion, be designated Scorbutic Diarrhoea. I have 
 at this time under my care a gentleman of our own pro- 
 fession, from Ceylon ; after suffering much in that island 
 from malarial fever, some attacks of dysentery, and rather 
 acute hepatic derangement, he returned to his native 
 country. After attempting the practice of his profession 
 in a cold and exposed district, he fell into a condition 
 closely resembling that described above. Kept for a 
 long time before he came under my care without 
 vegetable food in any shape, the scorbutic condition, 
 more or less present from first in Ceylon, became fully 
 
i64 DISEASES OF TROPICAL CLIMATES lect, 
 
 developed ; he had daily from three to four large, 
 pale, yeasty-looking, very offensive motions, passed with 
 force, and sometimes nearly filling the pan of the close 
 stool ; he suffered severely from flatulent colic ; his 
 gums were red, soft, and spongy, and from them thin 
 watery blood flowed almost incessantly, particularly 
 at night, his pillow in the morning having invariably a 
 large bloody stain, and his teeth covered with loose 
 clots. On his legs were several scorbutic patches. 
 The treatment in the first instance was entirely directed 
 to the cure of the scurvy, all attempts to control the 
 diarrhoea by means of astringents were given up, his diet 
 was regulated so as to give his blood what it so much 
 needed, an abundant supply of vegetable elements. In 
 a surprisingly short time a great improvement took 
 place in this gentleman's condition ; his gums ceased 
 to bleed and became firm, the scorbutic patches dis- 
 appeared from his legs, the stools were reduced to one 
 or two in twenty-four hours, diminished in quantity, and 
 improved in colour and consistence, and were no longer 
 voided with force. His appetite improved, he was not 
 troubled with the daily attacks of flatulent colic which 
 had caused so much suffering ; he gained flesh visibly, 
 and he is now able to take long drives and to spend 
 much of his time in the open air. I must not omit to 
 mention that when I first examined his urine it presented 
 much to alarm, and to give an additional aspect of 
 gravity to the case ; it was of low specific gravity, 
 contained a large quantity of pus, albumen, mucous, and 
 blood. He has now been a month and' a {^^m days 
 
IX DIARRHCEA 165 
 
 under treatment, and only a very small quantity of 
 albumen remains, which is day by day diminishing. 
 The patient had also a tight stricture in the mem- 
 branous part of the urethra ; when he first came under 
 treatment in the scorbutic condition described, it was 
 impossible to attempt dilatation, for the moment the 
 softest catheter was introduced into the orifice of the 
 urethra, blood flowed out to such an extent that it was 
 impossible to proceed. As soon as the scorbutic symp- 
 toms disappeared this complication was dealt with at my 
 request by my friend Dr. Bullar, without much difficulty. 
 
 I have given you the details of this case at length, 
 because it illustrates a point I wish much to insist on, 
 viz. the part that scurvy plays in either causing or 
 complicating the bowel complaints of India. When a 
 batch of invalids are brought into this hospital, the first 
 thing done is to see to what extent they are scorbutic. 
 Long experience has taught me that all treatment for 
 the relief of diarrhoea or dysentery will fail unless this 
 complication is removed. 
 
 I frankly tell you I never thoroughly appreciated 
 the importance of scurvy in tropical medicine until I 
 came to Netley ; it is not in bowel diseases only that it 
 acts as a grave complication, but in many other diseases, 
 as has been much insisted on by my friend Sir Anthony 
 Home, V.C. This able and experienced medical officer 
 has even found a not inconsiderable number of men 
 in the ranks of regiments, inspected by him, giving evi- 
 dence of the presence of this cachexy. I commend this 
 point to your serious attention and future watchfulness. 
 
1 56 DISEASES OF TROPICAL CLIMATES lect. 
 
 All trustworthy authorities on tropical medicine have 
 called attention to hepatic derangements in the diarrhoea 
 of hot climates, both as a cause and a complication. 
 I have elsewhere pointed out that persistent diarrhoea 
 is often in India a significant symptom of hepatic 
 abscess, and is one of the most powerful factors in 
 lowering the system in that dangerous disease. 
 
 The Morbid Anatoiny of diarrhoea will of course 
 depend on the cause that has excited it, the duration 
 of the disease and its complications. As I have before 
 remarked, many, I should say more than a half, of the 
 cases sent from India to Netley as " chronic diarrhoea," 
 are, in reality, cases of chronic dysentery. When such 
 terminate fatally the lesions are almost entirely confined 
 to the large intestine, unless there has been a scorbutic 
 complication, when they will be found to extend beyond 
 the caecum into the ileum. But, as my colleague. 
 Professor Aitken, has shown, it is a mistake to suppose 
 that the lesions in fatal cases of diarrhoea are confined 
 entirely to the small intestine. " There seems," he says, 
 "to be conclusive evidence to show that much of the 
 intestinal catarrh described by the common name of 
 diarrhoea is associated with an erythematotis congestion of 
 the mucous surface of the intestine, extending in patches 
 of a few inches to several feet in extent in all parts of 
 the canal, and rarely attended by increased vascularity of 
 the submucous tissue. They are more common in the 
 ileum than the jejunum, and still more frequent in the 
 colon." Goodeve, who has examined the intestines in 
 some fatal cases of white flux, was surprised to find, in 
 
DIARRHEA 167 
 
 spite of the long duration of the disease, few changes of 
 importance in the mucous surface ; but he noticed an 
 appearance with which at Netley we are very famiUar, 
 viz. thinning of all the coats of the intestine, until they 
 are quite diaphanous. Enlargement of the solitary 
 follicles of the bowel to the size of pin-heads, sur- 
 rounded by a little ring of vascularity, tumefaction, and 
 Iiypertrophy of villi, and pigmentary deposits in Peyer's 
 patches (Aitken) are the most common lesions. In 
 some cases of white flux observed by me in India and 
 at Netley, I have been able during life to make out 
 atrophy of the liver, and post-moi-tem have found the 
 organ to be so closely embraced by an adhering capsule 
 as obviously to interfere with the circulation of the 
 gland. In some this was to all appearance the result 
 of perihepatitis. At this time I have under my obser- 
 vation a tropical patient suffering from chronic diarrhoea 
 of long standing, in whom atrophy of the liver is only 
 too evident, under percussion ; in this case the patient 
 gives a history of an attack of acute pain in the liver 
 resembling that of pleurisy, which, in all probability, 
 was due to inflammation of the capsule. 
 
 Diagnosis. — The only disease with which diarrhoea 
 can well be confounded is dysentery, when that affection 
 has passed into a chronic stage, and when the stools 
 have become copious, fluid, and of a brownish colour. 
 Here the past history of the case, if carefully inquired 
 into, ought to guide to a correct diagnosis ; the odour 
 of the dysenteric motions so peculiar, characteristic, 
 persistent, and offensive, remains sufficiently distinct 
 
i68 DISEASES OF TROPICAL CLIMATES lect. 
 
 to the last to be at once recognised by an experienced 
 physician. 
 
 In diarrhoea, pure and simple, there is often severe 
 griping, but there is no tenesmus. 
 
 Treatment. — To treat tropical diarrhoea with success, 
 it is above all things necessary that treatment should be 
 early, that is, before the disease gets into a hopelessly 
 chronic stage. Careful medical officers in India invoke, 
 for this purpose, the aid of regimental officers in com- 
 mand, to ensure that men seen, in barrack language, " to 
 be going often to the rear," are duly reported. 
 
 The next point is that treatment should be based on 
 a careful consideration of the cause that has excited the 
 disease ; in other words, that it should not be carried 
 out as a matter of routine, astringents being resorted to 
 merely to counteract the looseness of the bowels, with- 
 out reference to the nature and cause of the looseness. 
 
 In that form of diarrhoea, due to over-indulgence in 
 too stimulating food, so common in the case of fresh 
 arrivals, with nausea, foul tongue, griping, and copious 
 feculent stools, an antacid draught composed of a 
 moderate dose of rhubarb in combination with the 
 compound chalk powder in a little aromatic water, rest 
 in the recumbent position, and a hot fomentation to the 
 abdomen, will give immediate relief. If the griping 
 continues, a few drops of the " mixture against diarrhoea," 
 to be found in the Field Companion, with a few 
 drops of tincture of opium, will soon allay the irritation. 
 A restricted diet will be necessary for some days, and 
 much benefit will be derived from a few grains of 
 
IX DIARRHCEA 169 
 
 rhubarb with powder of calumba, four of each, with 
 12 grains of bicarbonate of potassium in some aro- 
 matic water. The formula for the aromatic mixture 
 will be found in the Appendix. It is often most useful 
 in allaying the griping to which young and unseasoned 
 soldiers are liable when marching in the early morning, 
 and which often alarms them with a groundless fear of 
 cholera. If cholera prevails, diarrhoea is certain to 
 prevail also, as will be shown in the lecture devoted 
 to that disease. Prompt suppression of this diarrhoea 
 is a point of preventive practice of the first im- 
 portance. The aromatic mixture to the extent of 10 
 or 20 drops, with 15 or 20 of the tincture of opium, 
 should be given at once, the patient being confined 
 to the recumbent position ; the aromatic mixture in 5 
 drop doses being repeated from time to time as 
 occasion demands. If the patient shows a tendency 
 to faintness, warm brandy and water should be given at 
 once. 
 
 Dr. Goodeve gives a therapeutic caution on the use 
 of chalk mixtures in hot weather in India, which I 
 commend to your attention. " Chalk and other 
 mixtures should never be made up with sugar and 
 mucilage in the hot and rainy seasons, or they should 
 be made up for the day only. In less than twenty-four 
 hours the mixture runs into fermentation, and is hurtful 
 in diarrhoea ; " and he adds, " the chalk mixture of the 
 London Pharmacopoeia is always useless in India." 
 Mixtures containing chalk should be sweetened only 
 when taken. 
 
lyo DISEASES OF TROPICAL CLIMATES lect. 
 
 In the form of diarrhoea which follows the sudden 
 application of cold to the surface, in which the stools 
 are serous, with shreddy feculent matter suspended in 
 them, presenting various shades of colour from dark or 
 greenish-brown to gray or white, there is generally some 
 vascular excitement preceded by rigors, more or less 
 severe. In such cases the stools soon lose their feculent 
 nature, and unless treatment be early and judicious, the 
 " white flux " is apt to be established, which, as already 
 shown, is a form of diarrhoea extremely difticult to cure. 
 
 Obviously here the first indication is to restore the 
 suspended function of the skin and liver. For this 
 purpose a hot bath taken at the bedside, and followed 
 by placing the patient between blankets, instead of 
 sheets, is a measure often followed by the best results, 
 provided care be taken not to expose the hot surface to 
 cold air. The action of the skin may be still further 
 promoted by Doner's powder, 8 to lo grains, with 
 the addition of i grain of ipecacuanha, and the 
 application of a sinapism over the region of the liver. 
 If the motions continue to show want of bile, it will be 
 advisable to give a few small doses of blue pill, or of 
 gray powder with soda. If the stools continue after 
 the above treatment to be copious and serous or watery. 
 Dr. Harkin's method of blistering the skin over the 
 course of the vagus may be tried ; it has sometimes been 
 followed both in acute and chronic diarrhcea with 
 surprising effects. 
 
 In the hill diarrhcea, so often the outcome of damp- 
 cold, the same attention should be paid from the first 
 
IX DIARRHCEA 171 
 
 to restore the action of the skin, and by the same means 
 diligently persevered in, every effort being made to pre- 
 vent this troublesome affection establishing itself in a 
 chronic form, which it is almost certain to do unless 
 successfully dealt with in the early stages. The use of 
 astringents in the early stage of this form of diarrhoea 
 seems only to aggravate and confirm it. In addition 
 to the above means the nitro- muriatic acid bath of 
 Scott and Martin should be used ; or a compress soaked 
 in this acid, of the strength used in the bath, may be 
 applied over the belly. It is often most successful in 
 promoting free biliary secretion. The formula for this 
 bath will be found in the iVppendix. I strongly advise 
 the use of what is called the hydropathic belt in this 
 and many other forms of chronic diarrhoea ; it acts in 
 two ways ; by the firm support it gives it seems to dimi- 
 nish the chronic congestion of the abdominal organs, 
 and to act as a perpetual fomentation of the most 
 soothing kind. It is easily extemporised. A piece of 
 stout calico is shaped so as to fit closely to the abdomen, 
 with long ends to fasten behind ; a double or treble 
 fold of calico wrung out of the acidulated or even 
 simple cold water, is retained in situ next the skin by 
 means of a few tapes stitched on at right angles to the 
 length of the belt, and over the wet calico (that is be- 
 hind it) a piece of waterproof material ; this can be 
 worn day and night as long as it is required, being only 
 removed for an hour or two during digestion. Salicin, 
 to the extent of 5 or 6 grains, with i of ipeca- 
 cuanha three or four times a day, is an excellent 
 
172 DISEASES OF TROPICAL CLIMATES lect. 
 
 remedy. Attention to the general health is of course 
 important ; above all, the diet should be so regulated 
 as not to superadd a scorbutic element to the disease, 
 which is too often done by confining the diet exclusively 
 to farinaceous articles. Where Bael fruit is useful, I am 
 sure it is in counteracting this tendency to scurvy. 
 The pernitrate of iron with glycerine is the best remedy 
 against the anaemia of diarrhoea. When patients are 
 sent from India to their native land for chronic 
 diarrhoea, attention should be paid to provide warm 
 clothing, and to the season of arrival. The diarrhoea 
 of infancy in India requires careful treatment, more 
 particularly during dentition. The stools then often 
 present an appearance nearly resembling chopped 
 spinach, the colour being often of a more vivid green, 
 due, almost always, not as is commonly supposed, to 
 depraved biliary secretion, but to an excess of free acid 
 in the stomach and bowels. No treatment is more 
 pernicious in such cases than the administration of 
 mercurials, with a view to correct this faulty action of 
 the liver ; they invariably aggravate what they are 
 intended to correct. In such cases small doses, a grain 
 or two according to age, with twice or three times as 
 much bicarbonate of soda, often acts like a charm, and 
 is always useful. In plethoric children, whose gums 
 are hot, tense, and swollen over the advancing tooth, 
 the gum-lancet is required, and often not only helps to 
 check diarrhoea but wards off convulsions, or Avith the 
 aid of a few whiffs of chloroform, as recommended by 
 Sir James Simpson, relieves them when present. In 
 
IX DIARRHCEA 173 
 
 anaemic children, whose blood is thin and watery, the 
 gum-lancet is not a safe remedy ; the difficulty of sup- 
 pressing haemorrhage from the scarified gum being 
 always great, sometimes impossible. Children in this 
 condition are often saved by a change of diet ; the 
 juice of a half-raw beef-steak, extracted by a lime- 
 squeezer, has in my hands rescued many children of 
 tender age from extreme peril. It is an old and w^ell- 
 known remedy, or rather means of sustaining life, and 
 if to it is added, when the lamp burns low, a few drops 
 of brandy, it will be all the better. I frankly tell you 
 that I have sometimes had to regret my timidity in the 
 use of support of this kind in tiding young children in 
 India over critical hours, not in bowel complaints only, 
 but in other diseases also, but have never once had to 
 reproach myself with too great freedom in the use of 
 such means. 
 
LECTURE X 
 
 DYSENTERY 
 
 The Royal Commissioners, in their famous Report on 
 the Health of the Army of India, remark under the 
 head of Dysentery, next to fevers in frequency, but more 
 fatal, comes the dysentery of India. In its causes it is 
 intimately associated with tropical fevers, remittent and 
 intermittent, so much so that where fevers are present 
 dysentery is never far off. Out of an aggregate British 
 force of 25,433 men of her ^Majesty's army, serving in 
 periods of eight and ten years respectively in the stations 
 of Calcutta, Chinsurah, and Berhampore, all in Bengal 
 Proper, there occurred 8499 cases of dysentery and 
 diarrhoea, an amount of sickness under this one head 
 they truly characterise as " enormous."' On the autho- 
 rity of Sir Ranald ]Martin, the Commissioners go on to 
 say that amongst British soldiers eleven cases of dysentery 
 occur to one amongst the native soldiery. In acute 
 dysentery there is much present danger and suffering, 
 and when the disease is not arrested at once, chronic 
 suffering, extending over years, or the prospect of death 
 more or less distant in the hospitals, is all that remains 
 
DYSENTERY 175 
 
 to the soldier. The case is described by the older 
 army surgeons as presenting " a spectacle of distress of 
 as pitiable a kind as can be found in the history of 
 human suffering." Invaliding and death are the last 
 events, and most of the deaths which occur amongst 
 sick soldiers on the voyage homewards from India are 
 from chronic dysentery. 
 
 This is a gloomy picture. I place it before your 
 eyes at the outset of our study of this disease, for the 
 express purpose of awakening your minds to the im- 
 portance of the subject on which we enter to-day. I 
 am thankful to say that while it must be admitted the 
 colours are not too dark and the picture only too true 
 to nature, it depicts a scene of the past, of that pre- 
 sanitary age of which I have had so much to say in 
 the course of my lessons in this school on other 
 branches of military medicine, as well as that devoted to 
 the diseases of hot cHmates. It is not in India only 
 that dysentery has been one of the chief causes of 
 mortality and invaliding ; it has prevailed in all climates, 
 and has been the scourge of armies in all ages. 
 
 I regard the enormous diminution that has taken 
 place in the death-rate and invaliding from this disease 
 as the most notable example of the triumph of improved 
 sanitation and successful treatment of which modern 
 tropical medicine can boast, and it always gives me 
 great satisfaction, year after year, to associate the name 
 of Dr. Docker, formerly of the 2d Battahon of the 7th 
 Royal FusiUers, with a method of treating this disease, 
 which, although not original, for it is a revival of an old 
 
176 DISEASES OF TROPICAL CLIMATES lect. 
 
 method, has done more to lessen human suffering wher- 
 ever this disease prevails than any other plan of treat- 
 ment our art has been able- to suggest; and I rejoice 
 that at last the State has, although late in the day, 
 acknowledged this great service to suffering humanity. 
 As I have elsewhere shown, in the year 1883, out of 
 a force of 13,000 men 500 cases of dysentery were 
 treated with only two deaths. In the pre-sanitary age 
 I have known one regiment, with an average strength 
 of 1098 men, have 2497 admissions and 104 deaths in 
 one year ; the deaths mostly from two diseases : dysen- 
 tery and its common sequel, tropical abscess of the 
 liver. 
 
 It is tropical dysentery with which we have to do 
 here ; a reference to any of the text-books in your 
 hands will give you particulars of the universal pre- 
 valence of this disease in various forms, more particu- 
 larly that great storehouse of medical literature, the 
 magnum opus of my colleague Professor Aitken. 
 
 Pathology. — I have always believed and always 
 taught that the dysentery of India is a specific disease — 
 that is, that there is something specific in the poison 
 that causes it, although there are many ways in which 
 this poison can be, so to speak, brought into active 
 operation. In the quotation from the Report of the 
 Royal Commission with which I opened this lecture, the 
 intimate relation between tropical dysentery and malarial 
 fevers is brought out ; not only must we regard malaria 
 as predisposing to dysentery by its action in undermin- 
 ing the general health, but it seems impossible to resist 
 
DYSENTERY 177 
 
 the evidence that it is in itself a direct cause. Nothing 
 is more certain than this, when malarial fevers were 
 endemic in England over -large parts of the kingdom, 
 dysentery was also a prevailing disease. The cultivat- 
 ing hand of man, except in a few corners where the 
 old conditions in a small degree are imchanged, has 
 banished malaria from the soil, and with this poison 
 malarial fevers and dysentery have disappeared. There 
 is no more familiar fact than this : a party of men go 
 into unhealthy jungles at a dangerous season, some will 
 return with a remittent or an intermittent fever, others 
 with an attack of dysentery. Not many years ago a 
 young coffee planter was placed under my care in the 
 neighbouring town of Southampton ; he was one of five 
 men about his own age, and of his own calling, who 
 committed this act of folly : two contracted severe 
 remittent fever, of which one died ; two others, of 
 whom my patient was one, were punished with dysen- 
 tery, in his case with the formidable sequel of a pysemic 
 abscess of the liver; the fifth escaping uninjured. Naval 
 officers employed on the coast of Africa relate similar 
 examples in the case of boats' crews, going inshore at 
 night, watching the mouths of malarious rivers for slave- 
 ships seeking to evade the blockading men-of-war. 
 Dysentery in hot climates can often be traced to ex- 
 posure to relatively cold air, particularly when blowing 
 from malarial quarters. In the article Dysentery, in 
 Russell Reynold's System of Medicine, I have given the 
 case related by the late Dr. Mackay, R.N., of seamen 
 in ships serving in the malarious rivers of China sleep- 
 
 N 
 
178 DISEASES OF TROPICAL CLIMATES lect. 
 
 ing on deck, rolling up their jerseys on account of the 
 heat in the early part of the night, thus exposing their 
 naked bodies to the cold morning air, blowing from 
 the rice-swamps, with, in many cases, dysentery as the 
 consequence. We have seen that water charged with 
 decomposing vegetable matter can carry malarial poison 
 into the system and develop fever j there is abundant 
 evidence that dysentery can be caused in the same way, 
 more particularly when faecal impurities are added, as 
 in the tanks in the native quarters of Calcutta, so often 
 referred to by the sanitary officers of that city as sources 
 both of dysentery and cholera. 
 
 Dr. Chevers has pointed out that much of the 
 cholera and dysentery that prevailed in Calcutta in his 
 time on board the vessels frequenting the Hooghly was 
 caused by drinking the always muddy and filthy, and 
 often brackish water, taken up in buckets over the ship's 
 side. Nearly every person in his time, native or 
 European, who came to Calcutta, suffered more or less 
 from some kind of bowel complaint, but none so much 
 as seafaring men. Opposite to Calcutta, where the 
 shipping anchor, 40 tons of excreta were in those 
 days discharged into the river daily. Things are a good 
 deal changed now. Much, if not the whole, of this 
 enormous amount of impurity is, under the new system 
 of drainage, carried and discharged elsewhere. And 
 the better quarters of this great city are now supplied 
 with comparatively pure water : two measures which have 
 exercised a vast influence in diminishing sickness and 
 mortality from bowel complaints and cholera. 
 
DYSENTERY 179 
 
 As if to prove the accuracy of Dr. Chevers' account, 
 the municipal authorities supplied hydrants along the 
 river-bank, for supplying the shipping with purer water 
 from the new source of supply ; immediately a marked 
 diminution in the amount of sickness among the ships' 
 crews took place. The new supply falling short, the 
 river-bank hydrants were cut off, the shipping had to fall 
 back on the old source of supply alongside ; at once the 
 sanitary officer had to record a large increase in sickness 
 among the class affected by this unintentional experiment. 
 
 Very memorable to me is my first introduction to 
 what, without hyperbole, I may call the home and head- 
 quarters of dysentery, viz. the barracks of infamous 
 notoriety known as the old infantry barracks of Secun- 
 derabad in the Deccan. They stood on low ground, 
 swampy on one side, overshadowed by rocks on the 
 other ; exposed to the malarious influence of the marsh 
 during the south-west monsoon, the rocks on the other 
 side cutting off the invigorating wind from the opposite 
 quarter. A crowded graveyard close to the buildings on 
 a higher level, drained in the direction of what for many 
 years was the source of the water supply. In the near 
 vicinity of the barracks were ravines much frequented by 
 camp followers for purposes of nature. When I first 
 did duty with H.M. 55th Regiment, which then occupied 
 them, an average strength of from 1000 to 1200 men 
 were quartered in blocks that, according to modern 
 sanitary requirements, were only fit to accommodate 
 700. I have already, in the lecture on Enteric Fever, 
 quoted Superintending Surgeon Cole's terrible description 
 
7.83 DISEASES OF TROPICAL CLIMATES lect. 
 
 of the barrack latrines, and their effect on the health of 
 the inmates. It is not too much to say in the course 
 of the many years these ill-placed, badly-constructed, 
 and always overcrowded buildings were occupied, their 
 very walls became saturated with the contagium of the 
 most deadly form of dysentery to be found in all India. 
 I need not repeat in detail the loss of life they directly 
 and indirectly caused. The mortality was seldom less 
 than one in every five attacked, and has often been as 
 high as one in three, and large numbers who did not die 
 had a worse fate, sinking into the miserable condition 
 quoted from the Report of the Royal Commissioners in 
 the opening sentences of this lecture.-*- 
 
 The evil did not stop there ; the regimental hospital 
 in which the cases originating from the causes explained 
 were treated, became, like the barracks, a source of 
 infection ; it could not well be otherwise, for it seldom 
 contained less than 50 cases in the various stages of 
 dysentery. Disinfection of stools was then never thought 
 of, and, as the excellent medical officer under whom I 
 served made it a point of conscience to see every 
 evacuation passed between one visit and another, you 
 can understand that a " privy atmosphere " too fre- 
 quently pervaded the wards, the penetrating and per- 
 sistent nature of those excretions, justly styled by Parkes 
 
 1 Dr. Clouston records in the Medical Times of 3d June 1865 
 an outbreak of dysentery in the Cumberland and Westmoreland 
 Asylum, due to the effluvia from a field irrigated with sewage. 
 The diet of the inmates seems to have been entirely deficient in 
 fresh vegetables ; the disease excited, as above mentioned, assumed, 
 as we might expect, the scorbutic form. 
 
DYSENTERY 
 
 " the most offensive of the organic effluvia," was every- 
 where present at certain hours ; and I am convinced 
 that it was from this source the disease spread, as I 
 often knew it to do, to patients who were in hospital for 
 trivial ailments. In short, I believe that the infective 
 property was everywhere in that building; in the walls, 
 the wooden bedsteads, the bedding, and above all in 
 ,the utensils in hourly use by the sick. Let me say 
 before I pass from this subject that these vile buildings 
 died hard. The medical officers of the many regiments 
 quartered in them had one and all condemned them, 
 and inspecting officers had supported this conderhnation 
 through every channel open to them; but they held their 
 ground, until at last their terrible history was made the 
 subject of parliamentary discussion ; then, and not till 
 then, a Commission was appointed to make a final report 
 on the subject. Of this Commission I had the satis- 
 faction to be a member (1859); judgment went against 
 them, and before my connection with that part of India 
 ceased, I stood beside Mr. Bushby, the Resident at the 
 Court of Hyderabad, and saw the first stone of the 
 palatial barracks of Timulghery " well and truly " laid. 
 Before they were completed, the mutiny of the native 
 army of Bengal broke out, which delayed the final 
 abandonment of that dysenteric pest-house for some 
 time. If you want proof that the disease had its origin 
 in the place I have assigned to it, you have it in the fact 
 that, with few and rare exceptions, it was confined to the 
 men quartered in the barracks ; the ofificers did not 
 suffer from it. 
 
i82 DISEASES OF TROPICAL CLIMATES lect. 
 
 As I have more than once remarked to you, bowel 
 complaints tread in the footsteps of war ; more especially 
 when war is waged, as in the pre-sanitary age it always 
 was, regardless of common sense on matters of health. 
 Deeply engraved on my mind is the terrible first occu- 
 pation of the island of Chusan in China, in the war of 
 1840 with that empire. 
 
 In the month of July in that year I saw the 26th 
 Regiment (Cameronians) disembark on that island 900 
 strong, in high health and efficiency ; they had the 
 misfortune to lose their commander some weeks before : 
 a war-bred man of great experience, who was a " father " 
 to his men. The 26th came on this service direct from 
 Bengal. In the midst of the hot weather the meat for 
 their use was killed and salted. As might have been 
 expected at such a season the process was, unavoidably 
 perhaps, very imperfectly effected. It was most of it, 
 in fact, half- putrid when the regiment disembarked. 
 Common sense dictated its immediate destruction. This 
 was not the opinion of the general who, in virtue of his 
 seniority, now assumed the command of the whole force. 
 This officer thought the waste of so much " human 
 food " bad economy, so it was decreed that the Camer- 
 onians should eat it. The regiment was quartered in 
 the small town of Tientsin, the capital of the island, 
 without the ceremony of any previous cleansing. The 
 result soon appeared : fever and scorbutic dysentery for 
 all war purposes destroyed that regiment in two months : 
 not 200 of the men at the end of that thne remained 
 fit to bear arms. 
 
DYSENTERY 183 
 
 Do not suppose I take any pleasure in recalling such 
 miserable episodes in our military history as the one I 
 have just related. I am sent here to teach you military 
 medicine, and I must teach you, not by precept only, 
 but by examples, which are written for your learning. 
 The survivors of the first occupation of Chusan are few, 
 the remembrance of what they saw can only pass away 
 with themselves; it was indeed " a spectacle of distress of 
 as pitiable a kind as can be found in the history of 
 human suffering." I have often thought if what hap- 
 pened then could have been as vividly presented to the 
 public at home as was afterwards done on the larger field 
 of the Crimea, the advent of sanitary reform in war 
 might have been hastened by many years, and our 
 annals might have been spared that sad record of 
 ineptitude and suffering. War at the best is a terrible 
 thing, but such scenes as those I have slightly touched 
 on — indicated rather than described, are not unavoidable. 
 Let us rejoice that we are now not only allowed but 
 enjoined to mitigate its horrors, which your predecessors 
 were not. 
 
 The above, then, are the chief factors in the causation 
 of this disease in hot climates, so far as I know them. 
 To recapitulate, they are, malaria and, what that poison 
 brings in its train, febrile disturbance, with hepatic con- 
 gestion and impaired digestion, irritation of the mucous 
 membrane, and inflammation of the solitary glands of 
 the large intestine. Impure drinking-water, the effect 
 of chills in malarial regions, the massing of men in over- 
 crowded, badly-situated barracks, pervaded by a faecal 
 
1 84 DISEASES OF TROPICAL CLIMATES lect. 
 
 atmosphere ; more particularly proceeding from ill-kept 
 latrines, into which the secretions of dysenteric patients 
 have been cast, unsuitable food acting as an exciting 
 cause in aid of the above, acting also as a putrid or 
 scorbutic element on complication. 
 
 Morbid Anatomy. — Opportunities of observing the 
 first anatomical signs of dysentery are only afforded 
 when patients in the first stage of the disease die from 
 other causes, when hyperemia — that is, retention of blood 
 in the mucous and submucous tissues probably present 
 the only morbid appearance. The lesions in dysentery 
 are, as a rule, confined to the large intestine ; the excep- 
 tion is in scorbutic dysentery, when they pass beyond 
 the caecum and extend into the small intestine ; the 
 parts most affected are the descending colon and 
 rectum, but often the whole extent of the great gut is 
 implicated. 
 
 It is now a well-established fact that the morbid 
 anatomy of tropical dysentery is essentially the same as is 
 observed wherever the disease prevails, that the differ- 
 ence, where a difference exists, is one of degree only. 
 Much of the confusion that undoubtedly is to be found 
 in the descriptions given by authors appears to arise 
 from the different stages of the affection in which the 
 morbid appearances have been seen and described. It 
 is to Parkes the discovery is due that the solitary glands 
 are the commencing seats and centres of ulceration in 
 dysentery ; these structures, distributed over the surface 
 of the colon, " present the appearance of round opaque 
 bodies, without apparent orifice, embedded in the mucous 
 
D YSENTER Y 
 
 membrane, and even apparently attached to the sub- 
 mucous cehular tissue." It is in and around these 
 glands that ulceration mostly begins. In the beginning 
 of the process they are enlarged, distended with a 
 whitish material, compared by Parkes to a mixture of 
 flour and water, sometimes bearing on their summits "a 
 small black point"; as the disease advances these glands 
 become prominent and surrounded by a vascular ring, 
 and ulceration begins either at the apex or around the 
 glands, the mucous membrane pressed upon by the 
 hypertrophied gland has its vitality destroyed and 
 ulcerates, or the ulceration may commence " by effu- 
 sion of fluid beneath the mucous membrane." This 
 effused matter is of a white or yellowish colour, rais- 
 ing a portion of the mucous membrane softened in its 
 texture easily rubbed off" exposing an ulcer. In acute 
 dysentery proving rapidly fatal, the following is the usual 
 condition observed : The Ccecum and colon thickened 
 throughout by exudation between the tunics, the solitary 
 glands will be seen standing out with their white con- 
 tents and black points ; the intervening membrane 
 crowded with ulcers in various stages and of all sizes — 
 some not larger than a pin's head, with raised edges, 
 others in a more advanced stage, the edges more 
 reddened and no longer raised, the mucous membrane 
 softened, not always reddened, sometimes of a dark 
 colour, and, as in many of the preparations on the table, 
 presenting a more or less mammillated appearance ; the 
 ulcers will be observed on the plicae of the mucous 
 surface, running along them in an elongated form. 
 
1 86 DISEASES OF TROPICAL CLIMATES lect. 
 
 Morehead attributes this to the effect of inflammation 
 in the early stages, stimulating the muscular coat to 
 increased contraction, and so disposing part of the free 
 mucous membrane to arrange itself in transverse folds. 
 You will observe this form of ulcer in almost all the 
 preparations on the table. Hardly any of the ulcers 
 will appear exactly alike \ they v^^ill naturally vary accord- 
 ing to their stage ; on the surface of some a deposition 
 of lymph will be seen, others will have a grayish coloured 
 slough ; in others, this thrown off, they will have the 
 muscular coat for their floor, and around some of the 
 ulcers the granular exudation of which I have presently 
 to speak will be observed. 
 
 As I have shown, Dr. Parkes, as the result of his 
 dissections in Burma, was of opinion that the ulceration 
 always began around the solitary glands. I do not know 
 that to us as practical physicians the point is one of 
 more than merely post-mortem interest ; but calling to 
 mind the cases examined by the late Dr. Shanks and 
 myself in the Secunderabad hospital, probably of a much 
 severer type than those seen by Dr. Parkes in Burma, 
 nothing was more common than to see cases in which 
 patches of the softened mucous membrane of varying size 
 were found partially detached from the submucous tissue, 
 hanging in a gangrenous condition and easily separated, 
 leaving large ulcers of varying shapes, with floors present- 
 ing the different appearances I have described ; some 
 covered with pus, others with black or gray fungous-looking 
 sloughs. This, I suppose, is pretty nearly what Morehead 
 describes as the lesion following "submucous suppuration." 
 
DYSENTERY 1S7 
 
 You have on the table before you specimens of the 
 exudative process seen more or less in nearly all cases 
 which come to the post-mortejn table, and the prepara- 
 tions before you exhibit this in almost every possible 
 degree. With a few rare exceptions there is thickening 
 of the intestine from exudative matter deposited between 
 the coats of the intestine, giving a thickness sometimes 
 of a quarter of an inch to the intestine : a condition in 
 emaciated subjects that can sometimes be made out 
 during life. I have elsewhere referred to the case of an 
 army surgeon, who was a patient of mine in this house, 
 who used to compare his colon to an " office ruler." In 
 the two tall jars before you, you have the whole extent 
 of the great intestine taken from the bodies of two men 
 who died of dysentery contracted in China. You 
 observe the thickening of the intestine to be very well 
 marked, and in addition the whole lining surface in both 
 preparations is covered with solid fibrinous, bran -like 
 masses of a yellowish colour. The bottom of both jars 
 is nearly covered with portions of this exudation whicli 
 has become detached in the process of maceration in 
 the spirit, leaving in some places ulcers, in others the 
 thickened and softened mucous membrane. I have 
 never seen cases presenting this exudation in such a 
 fully developed state ; on the table in some of the pre- 
 parations you see patches of it, in others it surrounds 
 the ulcers ; but in none of them is the whole intestinal 
 mucous membrane covered as in the preparations from 
 China. In the sloughing dysentery of the Hyderabad 
 barracks I never saw anything of the kind, and in this 
 
iSS DISEASES OF TROPICAL CLIMATES lect. 
 
 museum, so rich in the morbid anatomy of this and 
 other diseases of the tropics, are there any specimens 
 quite Uke them. 
 
 The foUowing is my colleague. Professor Aitken's 
 summary of the processes from which ulceration may 
 proceed: (i) After intumescence, softening and simple 
 ulceration of one or of several lenticular solitary glands ; 
 
 (2) After intumescence and sphacelus of many solitar}' 
 lenticular glands, and the intervening tissue in one mass ; 
 
 (3) After softening of the tubular structure and the 
 detachment of sloughs, ulceration follows the intumes- 
 cence and germination of growths from the tubes which 
 cover the surface as a " crupous, " " catarrhal," or 
 diphtheritic exudation, to which the name of " apthous 
 erosion " has been applied ; (4) After submucous 
 inflammation and new growths, with fibrinous and 
 mucinous effusion ; (5) After intertubular inflammation, 
 and inflammation surrounding the base of inflamed 
 glands ; (6) After the formation of submucous abscess ; 
 (7) By changes of an ulcerative nature, commencing in 
 the vascular exudation itself, as in scorbutic cases. 
 
 I now show you casts of the intestine thrown off" in 
 the course of the disease, some of large size, others 
 merely in shreds : a raw surface is left. The process is 
 said to be analogous to similar phenomena in croup, 
 diphtheria, and typhoid fever. The passage of these 
 tubular casts is effected with much straining, and causes 
 alarm. I have often been told by patients when my 
 attention has been called to an evacuation containing 
 them, more particularly when in the tubular form like 
 
DYSENTERY 1S9 
 
 some of those I show you, " I cannot get well now, I 
 have passed a part of my bowels." Some blood almost 
 always follows the separation of these exuviae, adding to 
 the alarm. 
 
 Here also are specimens of penetrating ulcers of 
 various sizes. The process of ulceration has extended 
 through the whole exudation, penetrating both the 
 mucous and peritoneal coats ; these are all taken from 
 chronic cases of long duration. You will observe also 
 in many of the preparations before you, that the mucous 
 membrane presents various shades of colour from slate 
 to black ; the melanotic exudation presenting sometimes 
 in masses chiefly in the sigmoid flexure of the colon, in 
 others the white gut presenting this dark grumous 
 appearance. This state of the intestine is believed by 
 pathologists to be due to "intense vascular action," 
 and "subsequent changes in the extravasated blood" 
 (Aitken). 
 
 The late Dr. Goodeve of Calcutta made valuable 
 observations, by examining the evacuations at different 
 stages. This he did by carefully washing the fsecal 
 matters from the sediment, which consists of ropy, gela- 
 tinous, brawny, or thready mucous ; lymph in the shreds 
 or granular masses, pus, fseces, and sloughs. On ' the 
 table hung up behind me you will observe how he classi- 
 fied the exuviae, and the lessons he drew from them. 
 
 (i) Ecchymosed sloughs indicate abraded or minute 
 ulcers; (2) Compact gray or light yellow sloughs va^vcdX^ 
 acute phlegmonous dysentery ; (3) Thick pus-infiltrated 
 mucus indicates erysipelatous dysentery ; (4) Ragged 
 
igo DISEASES OF TROPICAL CLIMATES lect. 
 
 sloughs denote gangrene ; (5) Da7-k olive sloiighs denote 
 secondary gangrene of mucous coat ; (6) Thin^ black, 
 plain, or tubular sloughs denote gangrene in either 
 mucous or cellular coat ; (8) Molecular or putrilage 
 indicate disintegration of tissue ; (9) Flaky epithelial 
 sloughs denote gangrene of mucous membrane; (10) 
 Shaggy sloughs indicate violent inflammatory action ; (i i) 
 Free filamentous (simple) sloughs denote primary gangrene 
 in submucous tissue ; (12) Free filameiitous pus-infiltrated 
 sloughs denote submucous cellulitis; (13) Ring-shaped 
 sloughs denote ring-shaped ulcerations in mucous folds ; 
 (14) Discoid sloughs indicate circular ulcers in ecchymosed 
 patches. 
 
 In the rapidly destructive sloughing dysentery of 
 Secunderabad, under the conditions I have described, it 
 was not uncommon to see the mucous and muscular 
 coats of the colon throughout one or more of its divi- 
 sions present nothing but a gangrenous mass, in which 
 it was impossible to distinguish a shred of healthy 
 tissue. 
 
 Cicatrisation of the ulcers of dysentery in different 
 stages is to be seen in all but the extreme cases just 
 referred to. There is reason to beheve that this process 
 is often effected rapidly. Parkes records the case of a 
 man who was five or six days under treatment for 
 dysentery ; his stools had become feculent, and he was 
 allowed to get up. He exposed himself imprudently to 
 the sun, was sun-stricken and died. In the sigmoid 
 flexure of the colon were several ulcers, round, and with 
 slightly rounded edges, evidently in an early stage, from 
 
DYSENTERY 191 
 
 their size and appearance ; the edges were pale, the 
 intermediate mucous membrane natural, the healing 
 process had commenced, on each was a deposit of 
 lymph. This lymph is deposited over the whole surface 
 of the ulcer until it rises to the level of the surrounding 
 tissues, contraction then takes place, with some pucker- 
 ing of the surrounding mucous membrane. These 
 cicatrised ulcers can be distinguished by their smooth 
 glistening appearance, and by the slight contraction 
 round them. It was Parkes who first accurately 
 described the process. As Ewart has shown, the cica- 
 trical tissue is devoid of solitary and tubular glands, and 
 sparingly supplied with blood-vessels. 
 
 In bygone years stricture of the gut was not an 
 uncommon occurrence in some of the victims to chronic 
 dysentery, from constriction of the intestine, the result 
 of contraction after cicatrisation of large circular patches 
 of ulceration. 
 
 The solid viscera of the abdomen do not escape. 
 The intimate relation between dysentery and pysemic 
 abscesses {for they are seldom single) of the liver, to 
 prevent repetition, will be dealt with fully in the lectures 
 devoted to the tropical diseases of that gland. It must 
 suffice here to state that the frequency of this formidable 
 complication or sequel varies in different parts of India. 
 Dysentery has always been a more fatal disease in the 
 Madras Presidency than either in Bengal or Bombay, 
 the mortality having been enormously swelled by its 
 fatal prevalence in Secunderabad. In the same Presi- 
 dency liver abscess in cases of dysentery has in 
 
192 DISEASES OF TROPICAL CLIMATES lect. x 
 
 bygone years amounted to nearly 60 per cent, while in 
 Bengal proper it has varied from 13 to 18 per cent. 
 It is a common sequel of dysentery in Algeria. It is 
 a notable fact that although the dysentery which pre- 
 vailed in the Millbank Prison was in most of its 
 symptoms and lesions not to be distinguished from the 
 dysentery of India, there was not a single liver abscess 
 in Baly's cases. Dr. Aitken, who was pathologist at 
 Scutari during the Russian War, 1854-57, found 
 hepatic abscess of rare occurrence. If it be true, as 
 I believe it is, that malaria plays an important part in 
 the causation both of liver diseases and dysentery, it 
 goes far to explain the fact that, in at least half the 
 cases of dysentery, the liver is functionally deranged. 
 
 The intimate relation between dysentery and malarial 
 fevers accounts for the frequency of splenic lesions. 
 I have never seen an abscess of this ductless gland in 
 India in a case of dysentery, but other observers have 
 seen this lesion, which is rare. Enlargement and 
 softening, as well as enlargement and induration are 
 common. In some severe cases of dysentery albumen 
 is found in the urine ; it is always a sign of evil omen, 
 particularly when seen early in the disease. The 
 morbid anatomy of the kidneys in such cases is; on 
 the authority of Zimmerman, quoted by Aitken, acute 
 congestion, the tubes being loaded with exudation cells 
 and detritus. 
 
LECTURE XI 
 
 DYSENTERY [cotitimied) 
 
 Symptojns. — As might be expected in so serious an 
 affection, the symptoms indicating important intestinal 
 mischief are preceded by those of general derangement 
 of the system, particularly if the coming attack is one 
 in which a large part of the intestine is threatened. 
 Speaking generally, these are loss of appetite, malaise, 
 a sensation of chilliness, and very often a notable 
 depression of spirits ; soon uneasy sensations in the 
 bowels succeed, urging the patient to go to stool, 
 when the feculent contents are wholly or partially 
 expelled ; or what at first appears an ordinary attack 
 of diarrhoea sets in, soon attended with griping, the 
 stools being watery and hot. The tongue is foul, 
 and there is a bad taste in the mouth. Chilliness 
 amounting to slight rigors and followed by heat of 
 skin succeed ; it will be well for the patient if at this 
 stage he seeks advice and acts on it. A little judicious 
 medication, rest in the recumbent position, a hot bath 
 to restore the suspended action of the skin, followed by 
 great care in diet, may arrest the disease at this stage. 
 
 o 
 
194 DISEASES OF TROPICAL CLIMATES lect. 
 
 It is seldom, that in barrack life among young and 
 inexperienced men, the physician has an opportunity 
 of dealing with dysentery in this its early manifestations. 
 It more often happens that relief is sought in the use 
 of the first stimulant available. Up to this time there 
 has been nothing in the nature of the evacuations that 
 can be said to be dysenteric. There is now a change ; 
 the patient becomes feverish and restless, and the pulse 
 more frequent; the calls to stool become urgent, and 
 with every stool there is tormina and tenesmus ; this 
 painful straining increasing with every motion. The 
 more the lower part of the bowel is affected the greater 
 is the tenesmus. The bladder is soon affected when 
 the rectum is much implicated, giving rise to dysuria, 
 sometimes to retention. Of this symptom I shall have 
 more to say presently. Griping and tenesmus go on 
 increasing, the patient being hardly off the close stool 
 before he desires to return to it, always under the 
 impression that he is about to void something that will 
 relieve him. Under this discipline the restlessness 
 increases, nervous depression sets in, the face becomes 
 pinched and anxious, the pulse increasing in frequency 
 decreases in force and volume ; there is abdominal 
 tenderness which is general, but in the interval between 
 the paroxysms the pain can be localised by careful 
 palpation. Meanwhile, what of the stools ? They have 
 changed their character altogether, and distinctly indicate 
 the progress of the intestinal mischief; they are now 
 scanty, consisting of mucus and blood, or in barrack 
 language "slime " and blood, the source of which is the 
 
DYSENTERY 195 
 
 inflamed glands, with shreds of exudation and a little 
 feculence ; they begin to give off the peculiar odour of 
 dysentery, due, it is believed, to the contents of the 
 ruptured solitary glands ; for this peculiarly offensive 
 odour is not perceptible until this muco-gelatinous 
 secretion appears in the stools. At this stage the 
 disease is still amenable to judicious treatment before 
 ulceration has made much progress ; this is the stage 
 at which, in hospital practice in the East, patients 
 are frequently first seen — not seeking relief until 
 sheer suffering drives them for advice. The stools 
 become more frequent, more offensive, contain more 
 exudative matter, soon followed by sloughs with more 
 or less blood, the depression becomes more marked, 
 the pulse more frequent, the countenance more 
 pinched and anxious, the abdomen more hard and 
 tender, the skin grows clammy, emaciation proceeds 
 rapidly ; the stools become more offensive and con- 
 tain shreds and sloughs of greater size. It is at this 
 advanced stage that a sudden change takes place in 
 the stools ; as I have elsewhere shown, they become 
 serous, of a brownish colour, copious, exhausting the 
 patient terribly, and insupportably foetid, cadaverous, 
 pervading the whole ward, even penetrating into neigh- 
 bouring rooms ; the abdomen becomes more tumid, but 
 pain ceases. 
 
 The patient sometimes flatters himself that all is well 
 with him, deeming the cessation of pain a favourable 
 symptom ; by and by his mind begins to wander, and, 
 as if in some degree to compensate for past sufferings, 
 
196 DISEASES OF TROPICAL CLIMATES lect. 
 
 his delusions take pleasing forms, and he dies exhausted 
 without more pain. 
 
 This is the ordinary course of acute dysentery in a 
 case that has been unchecked by treatment, or has had 
 no judicious treatment at all. You know enough of the 
 description of disease to be aware that a teacher can 
 only sketch in the leading outlines in his description ; 
 you must be prepared to meet with cases that will not 
 at all points answer to a general sketch of this kind. 
 The symptoms, while still in the main corresponding to 
 the typical case given, may differ in some of the details. 
 In one case the disease may be confined to the rectal 
 and sigmoid divisions of the gut, when the symptoms 
 will indicate this localisation by the severity with which 
 pain is referred to these regions ; or a much larger 
 part of the intestine may be implicated, giving rise to 
 constitutional disturbance of a more marked kind, and 
 to pain more diffused ; or the malarial element in the 
 case may modify the febrile symptoms, increasing their 
 severity, and giving to them that periodicity to which 
 I have more than once referred. It is in such cases 
 that you must be prepared to see a marked disposition 
 to haemorrhage at the time of the separation of the 
 sloughs ; or again, the symptoms may be affected by 
 the presence of scurvy, in which case the diseased 
 action will not be confined to the great intestine, but, 
 passing the ileo-colic valve, will implicate more or less 
 of the small intestine, and change the character of the 
 stools, which will be much more copious from an early 
 period, frothy, and voided with more force. At the 
 
DYSENTERY 197 
 
 same time the gums will give evidence of the presence 
 of this diathesis, as will the skin, which will present 
 either scorbutic blotches or minute purpuric spots, as 
 if red ink had been spattered over the surface with a 
 pen. 
 
 It is needless to say that the disease may stop 
 far short of death as described ; in the vast majority 
 of the cases it will yield to judicious treatment at vari- 
 ous stages, or the acute symptoms may glide into the 
 unhappy condition known as chronic dysentery, to be 
 presently described, with or without pysemic abscesses 
 of the liver. 
 
 Diagnosis. — This is not difficult; the only disease 
 with which it is likely to be confounded is diarrhoea. 
 The presence of tormina and tenesmus, the bloody 
 and slimy nature of the stools, the presence of the 
 dysenteric exuvise described, and the characteristic 
 odour of the evacuations, and the nervous depression, 
 always more or less present, mark it off with sufficient 
 distinctness. 
 
 Prognosis — Favonrable — (i) The original slightness 
 of the attack; (2) The absence of much nervous de- 
 pression, and other grave signs of constitutional dis- 
 turbance ; (3) A pulse of good strength and moderate 
 frequency ; (4) The absence of tympanites, not much 
 abdominal tenderness, absence of sloughs and gangren- 
 ous odour; (5) Early appearance of feculence, with 
 diminishing tormina and tenesmus; (6) An improved 
 expression of countenance ; (7) Absence of signs of 
 hepatic complication. 
 
Ur-'- ::.■ :':'c — ^Failure of the nervous and ciicula- 
 t:r'" 5" £:- ..r -__ -:i'Er ir.rreasing in ficequency and feil- 
 ::.^ :r. ;::t:._: .. : .zioHS countenance, restlessness, 
 
 L-::i.i :.- : r::: :: :.r stools, sudden subsiding of pain 
 widioai: c::ir: i:r:'.5 ;:' i~ rjvement, haemorrliage &om 
 the boweLs. i:::u:. : ;.:^ iud diy tongue, suppression 
 of urine, ctLir iurj.. 
 
 I spoke :: ;•;.: :: "t :::7:t55:~i ':;::" iry :;t.;;::::^;; 
 wfaidi are ;::rr. ::£tr"ti ~:.tz. rrt rt::urj. i; :..-:- 
 affected by the disease \ this leads me to relate to you 
 a case which caused us much distress in tt:; ;:.;;- and 
 hospitaL A medical officer of more than gre-i: premise, 
 I may say the most highly educated man who ever 
 passed through this school, had just completed his 
 course of instruction here when he joined the expedi- 
 tion to Abyssinia under General Mapier, afterwards 
 Lord Mapier of Magdala. He had a sharp attack of 
 dysentery during the campaign, and wrote to me with 
 great satis&ction of the speedy manner in which the 
 attack passed off under the treatment he had been 
 ^jL'iz-t ;.: >'rt!ey. When this little war was over he 
 r=r-:r'ti :: I ttley, at his own request, as an officer on 
 tie r.:::'. ;:' I :r,.: v.-diately occupied all his spare time in 
 ££i^: i:;^ : . : - I'.tirie ?r ftssDr Parkes, in the 
 i2.ieri::r I:i i -.t~ zzz'.-::.i ':.t :;-:r:e to me complain- 
 ing that his dysenteric symptoms had returned j he 
 was at once put under treatment medicinal and dietetic 
 for that disease. I pointed out to him Ihat while his 
 5:::.5 —ere not wanting in some of the appearances 
 c ;:::-. iitic of d^enteiy, there was not a trace of 
 
DYSENTERY 199 
 
 the odour so invariably present in true dysentery. The 
 symptoms pointed unequivocally to rectal localisation, 
 and obstinately resisted all treatment, after anxious 
 consultation with my colleagues, Professors Parkes and 
 Aitken. After a time urinary irritation, frequent calls 
 to micturate by day and night, became a troublesome 
 symptom, the urine being normal ; as the case went 
 on signs of constitutional disturbance became evident, 
 loss of flesh and colour; in a word, everything pointed 
 to the existence of malignant disease in or in the 
 vicinity of the rectum. Careful digital examination 
 gave only negative results. Finally f^cal matter ap- 
 peared in the urine ; the case went from bad to worse, 
 and after a prolonged struggle the patient succumbed. 
 Examination after death revealed the presence of a 
 large cancerous mass between the bladder and the 
 rectum high up, and beyond the reach of digital ex- 
 ploration, with, of course, communication with the 
 bladder. 
 
 If recovery or death does not result from such 
 an attack of acute dysentery as I have described, 
 the patient sinks into the lamentable condition of 
 chronic dysentery, which I have now to describe to 
 you. 
 
 This, when seen in an extreme degree, is the class of 
 cases described by the old army surgeons, and already 
 more than once referred to as presenting " a spectacle 
 of distress of as pitiable a kind as can be found in 
 the history of human suffering." 
 
 Chronic Dysentery. — As the patient sinks into this 
 
200 DISEASES OF TROPICAL CLIMATES lect. 
 
 condition he continues to lose flesh ; the stools, still 
 maintaining much of the dysenteric odour, are for 
 the most part fluid ; but they vary from day to day, 
 and even on the same day, being sometimes muci- 
 form, serous, and bloody, at others pultaceous, puri- 
 form, rarely if ever formed. Most commonly they 
 consist of thin feculence of a reddish brown colour 
 and offensive odour. If there is a scorbutic com- 
 plication they will be more copious, pale, and frothy, 
 and voided with force. Control over the sphincter 
 is impaired, sometimes lost. The appetite is capri- 
 cious or bad ; the tongue red, smooth, glazed, and 
 devoid of epithelium, and the patient is imperfectly 
 nourished ; the hair becomes thin, and he looks older 
 than he is. 
 
 The symptoms will vary according to the nature of 
 any complications that may be present — the malarial, 
 syphilitic, or scorbutic cachexy — or by the presence of 
 hepatic abscess. It is needless to add that much will 
 depend on the injury done to the mucous and glandular 
 structures of the intestine, the extent and number of the 
 ulcers in a state of abortive cicatrisation, the thickening 
 or atrophy of the intestine ; this last being the most 
 hopeless of all the lesions left by the disease. Much 
 also will depend on the extent to which the spleen and 
 kidneys are implicated. 
 
 Treatjnent. — I have no words sufficiently strong to 
 impress your minds with the importance of early treat- 
 ment. Where the physician, as in military and naval 
 life, is responsible for the health of large bodies of men 
 
DYSENTERY 
 
 in barracks, ships, or camps, no pains should be spared 
 to ensure it. 
 
 The evacuations of the sick should be from first to 
 last received in glazed vessels well charged with some 
 colourless disinfectant, and so disposed of as not to 
 pollute the soil or the source of the water supply. 
 After what I have said on the subject of preserving such 
 evacuations for inspection in hospitals, it is clear there 
 is risk in so doing. In India educated and trained 
 subordinates are always on duty. A note of the nature 
 of the discharges in each case should be made for the 
 information of the medical officer, and they should be 
 at once removed and disposed of. If it is desired in any 
 particular case to make a microscopic examination of 
 the dysenteric exuviae, after the manner of Goodeve, 
 the attendants should be instructed how to wash and 
 prepare them for this purpose. An abundant quantity 
 of water, charged with some disinfectant, is added to 
 the evacuation, allowed to stand for a little, and then 
 carefully poured oft"; the process is repeated again and 
 again until all feculence is washed away, and the dysen- 
 teric exuviae left cleansed for examination. 
 
 In cases where dysentery has followed exposure to 
 wet or cold or both, it is obviously a matter of import- 
 ance to restore the function of the skin. The simplest 
 and safest plan of effecting this is to place the patient 
 in a bath at a high temperature, keeping the patient 
 in it until signs of approaching faintness appear, dry- 
 ing him quickly, and placing him between blankets. 
 My late and much valued friend Morehead wrote dis- 
 
202 DISEASES OF TROPICAL CLIMATES lect. 
 
 paragingly of this plan ; but I cannot help thinking that 
 in his trials the man was brought to the bath, instead of 
 the bath to the man — to his bedside, in fact — which 
 makes all the difference between a good and a bad 
 remedy. If at the onset of the disease the feculent 
 discharges are scanty, and evidently a source of irrita- 
 tion, it will be well to aid Nature in her efforts to get rid 
 of them. I agree with Ewart that for this purpose a 
 tepid water enema of from 2 to 4 pints is the simplest, 
 safest, and least painful mode of effecting this purpose. 
 The utmost gentleness is required in the use of the 
 syringe, and the water should be thrown up slowly. 
 With a view to lessen the risk of chill, the enema should 
 be given before the bath, or if after, the bed-pan should 
 be insisted on when it is being passed. 
 
 The patient should now be brought under the influ- 
 ence of ipecacuanha as soon as possible; 15 drops 
 of the tincture of opium or liquor opii should be 
 given in a little chloroform water. The abdomen 
 should be covered with a treble fold of flannel, or a 
 sheet of spongio-piline, wrung out of hot water, and 
 sprinkled with a little turpentine, and covered with some 
 waterproof material. In half an hour after the ad- 
 ministration of the opiate, the ipecacuanha should be 
 given in a full dose of not less than half a drachm. The 
 patient should be ordered to lie quiet on his back, and 
 to abstain from drinking — if thirsty, a little ice may be 
 sucked ; this invaluable remedy, given in this way and 
 with the above precautions, rarely excites vomiting, 
 at all events until an hour or so after it is taken, 
 
DYSENTERY 
 
 when sometimes there is some watery fluid brought 
 up, without any of the powder. The drug may be 
 given in a soft bolus made up with a little syrup of 
 orange peel, or to those who are adepts in the art of 
 pill - swallowing, in that form, or in capsules, which 
 excite less disgust. It is certain that when given in 
 full doses it causes much less nausea and discomfort 
 than when administered in small doses, as was the 
 custom when first I was taught to use it in dysen- 
 tery. A diminution in the number of stools and also 
 in the suffering from tormina and tenesmus will cer- 
 tainly follow even the first dose ; I have often seen 
 the stools from 20 or 30 in 24 hours, reduced to 4 or 5. 
 In from 8 to 10 hours the dose should be repeated in 
 the same way, not neglecting stimulation of the external 
 surface. The question of continuing the use of the 
 remedy must be determined in each particular case by 
 its eifect on the general and local symptoms. If the 
 calls to stool are reduced to 2 or 3 in 24 hours, and losing 
 their dysenteric appearance have become feculent, and 
 are voided without tormina and tenesmus, if the restless- 
 ness has been calmed and the patient obtains refreshing 
 sleep, and the pulse resumes its normal frequency, or 
 distinctly tends that way, the large doses should be dis- 
 continued ; the patient should maintain the recumbent 
 position until every trace of the abdominal irritation has 
 subsided ; the diet in the acute stage should consist 
 of iced milk, with a little lime-water — then well-boiled 
 arrowroot or tapioca, advancing to chicken and beef- 
 tea — an excellent nutritious and unirritating article of 
 
204 DISEASES OF TROPICAL CLIMATES lect. 
 
 diet is well-boiled macaroni. A return to solid food 
 should be made with great caution. If any looseness 
 of the bowels remains, it should be met with small 
 doses of Dover's powder at bed-time, a mild infusion 
 of one of the vegetable astringents in fresh - made 
 mucilage, or some bismuth. A formula like this will 
 answer very well : Bismuthi Carb. oiii., Mucilag. Re- 
 centis oiss., Liquor Morph. Hydrochlor. 5iii., Aquse §ij. 
 Misce — Ft. Mistura — a teaspoonful three times a day. 
 Remembering all I have said on the scorbutic complica- 
 tion of dysentery, you will not fall into the old mistake 
 of rigidly excluding the vegetable element from the 
 patient's diet. The reputation of Bael-fruit in dysentery 
 rests not, I am sure, on any astringent property it may 
 possess, but on its being a pleasant and effective correc- 
 tive to this tendency. To our scorbutic patients with 
 dysentery arriving from sea at Netley, we give whatever 
 fruits may be in season, grapes excluding stones, which 
 may be a source of danger from getting entangled in an 
 intestinal ulcer and causing perforation. One young 
 officer at Secunderabad lost his hfe in this way through 
 a perforating ulcer of the colon, in which a large grape- 
 stone was found. Surgeon-General James Mouat will 
 remember the case well. Strawberries, stewed apples, 
 all answer, used in moderation. In tropical climates 
 suitable fruits are always available. 
 
 I have already given Dr. Docker his due meed of 
 praise for the service he did in recalling practitioners to 
 the right use of ipecacuanha ; it was originally intro- 
 duced into this country, not for its emetic properties at 
 
DYSENTERY 205 
 
 all, but as the radix anti-dysenterica ; it was used for 
 this purpose time out of mind in Peru. Helvetius, in 
 the year 1653, covered the walls of Paris with adver- 
 tisements announcing his possession of an infallible cure 
 for dysentery, very much in the manner of our own 
 " pill and ointment " men ; with this he treated and cured 
 the Dauphin of France, for which, and for his secret, 
 he was rewarded with 1000 louis d'or. It was intro- 
 duced into this country in 1660 or thereabouts, and 
 appears to have been much used. It fell into disuse. 
 It was a Mr. Balmain who, in the fifth volume of the 
 Memoirs of the Medical Society of London, again called 
 attention to it. In 18 13 Mr. George Playfair, of 
 the Bengal Medical Service, pubUshed a paper in 
 the Edinburgh Medical a?id Surgical Journal, on the 
 good effect of a combination of ipecacuanha and 
 laudanum in dysentery. Surgeon - General Cornish 
 exhumed from the old records of the Madras Medical 
 Board, a document which shows that Dr. Abercrombie, 
 of H.M. 34th Regiment, so far back as the year 1807, 
 successfully used ipecacuanha in large doses in the 
 treatment of dysentery, and that he communicated 
 this mode of treatment to Mr, M 'Mullens, surgeon 
 of H.M. 39th Regiment. This gentleman had treated 
 the disease in the mode then prevalent, by bleed- 
 ing, mercury internally and externally, blisters, and 
 such like means, with the usual results — a high death- 
 rate, and in the cases which did not die, great debility, 
 lingering convalescence, and frequent relapses. After 
 taking to Dr. Abercrombie's method, he appears hardly 
 
2o6 DISEASES OF TROPICAL CLIMATES lect. 
 
 to have lost a case, and to have won for himself a high 
 reputation as an exceptionally skilful physician. It 
 further appears that Abercrombie himself learned the 
 use of the radix anti-dysenterica from a gentleman of 
 the name of Graham, who had served on the west coast 
 of Africa. 
 
 How this remedy, almost deserving the name of a 
 specific, came to be superseded by calomel and opium 
 in the treatment of dysentery in the East is one of the 
 most curious questions in the history of tropical medicine. 
 It was my good fortune to do my probationary duty on 
 first arriving in India under the late Dr. Mortimer of the 
 Madras army, a gentleman who had the rare merit at 
 that time of having cleared his mind of the degrading 
 mercurial superstition which almost amounted to fetich- 
 ism. Dr. Mortimer knew the true power of quinine 
 over malarial fevers, and used it ; and he taught me 
 to treat dysentery with ipecacuanha, generally, how- 
 ever, only in small doses of 5 or 6 grains every four 
 or five hours : a method I need not say inferior to 
 the full doses once more in use, which he gave only 
 occasionally, but a hundred times more effective 
 than the method based on the constitutional action 
 of mercury. 
 
 It was while serving in the Mauritius that Docker 
 rendered to the British soldier the inestimable service of 
 reviving the use of ipecacuanha in full doses. Dysentery, 
 under the unsatisfactory treatment so often referred to, 
 was in his hands attended with a mortality of from 10 
 to 18 per cent. Under the ipecacuanha treatment he 
 
DYSENTERY 207 
 
 lost only I out of 53 cases, the fatal case being compli- 
 cated with hepatic abscess, thus reducing the mortality 
 to something less than 2 per cent. If you look at the 
 tables behind me, you will observe how year by year the 
 mortality fell as the use of the remedy spread, until now 
 that it is universal, we see 500 cases treated with only 
 2 deaths, and this, too, in Southern India, the very 
 quarter where this disease was most destructive. 
 
 How does this remedy act? Dr. Ewart in a few 
 words answers the question for you at least in its 
 practical bearings : " It is a non-spoliative antiphlogistic, 
 a certain cholagogue and unirritating purgative, a power- 
 ful sudorific, and a harmless sedative to the heart and 
 the muscular fibres of the intestines." Where it fails it 
 is because it has been given too late, when structural 
 changes incompatible with life have taken place in the 
 affected intestine, or from structural disease of spleen, 
 liver, and kidneys, or the combined ravages of the 
 malarial and scorbutic cachexies. 
 
 It may be given with absolute safety to pregnant 
 women. I add my testimony to that of Ewart on this 
 point, based on a large experience of its use in this class 
 of cases. 
 
 Children of the most tender age in the East are liable 
 to dysentery under the influence of malarial and dietetic 
 causes, aggravated by dentition ; for them ipecacuanha 
 is as great a boon as it is to adults. For an infant of 
 six months half a grain rubbed up with twice as much 
 bicarbonate of soda and a little sugar of milk is enough ; 
 a grain with twice the amount of alkali for every year of 
 
2o8 DISEASES OF TROPICAL CLIMATES lect. 
 
 age is about the rule ; it should be repeated at proper 
 intervals until the desired effect is attained. The rules 
 given for the diet of children with diarrhoea are applic- 
 able here. May I add a word of caution as to the 
 necessity of watchful carein the acute diseases of children 
 in India. Parents will forgive, if they cannot always 
 forget, want of attention to themselves and their ailments; 
 but nothing more effectually and finally damages the 
 reputation of a young physician, I suppose everywhere, 
 in the East certainly, than failure in the nursery, more 
 particularly if that failure can be traced to what is 
 commonly called "want of attention," or to put it 
 plainly, "want of care." I have only to add that in 
 men or women suffering from dysentery, with a distinct 
 malarial complication, evidenced by anything like distinct 
 periodicity in the febrile movements in the course of the 
 disease, quinine should be given in the intervals between 
 the doses of ipecacuanha, in full and effective doses. I 
 have used quinine in this way without having seen it in 
 a single instance counteract the action of the ipecacuanha 
 or aggravate the intestinal disease. 
 
 Treatment of Chronic Dysentery. — The first point is 
 removal to a temperate climate, under certain conditions: 
 (i) due regard to season of the year; (2) to warm 
 clothing; (3) to careful dieting on the voyage. I 
 repeat here what I have said and written times without 
 number, that to put a malaria-struck man or one labour- 
 ing under chronic dysentery on a salt ration is to poison 
 him. Dysentery, plus scurvy, has sent' nearly as many 
 victims to the bottom of the ocean in the olden time as 
 
DYSENTERY 209 
 
 shipwreck. Once more then, see that your patient is 
 not scorbutic ; if he is, cure the scurvy and you go more 
 than half-way to cure the chronic dysentery ; if you 
 neglect this you can never cure the dysentery. If the 
 patient comes under your care with symptoms of a 
 relapse, or from any cause with sub-acute dysentery, 
 treat him without hesitation as you would in a first 
 attack. I well remember the case of a young officer 
 landed on the pier here from India ; he was sent 
 home for chronic dysentery ; either from exposure to 
 cold or from some grave error in diet, he had a severe 
 relapse, and when brought here was called to stool about 
 thirty times in twenty-four hours. This young man was 
 so reduced in strength that the orderlies who carried 
 him into the house rested the stretcher on the ground 
 several times for fear of shaking out what appeared the 
 poor remnant of vitality left. To the astonishment of 
 some of your predecessors passing through the course of 
 instruction here at the time, I ordered, with the usual 
 precautions, 2 5 grains of ipecacuanha ; this dose re- 
 duced at once the number of stools from thirty to five in 
 twenty-four hours. His recovery was rapid, and about 
 six months after his discharge, accidentally meeting him 
 in Portsmouth, I had some difficulty in recognising in 
 the chubby-faced lad who accosted me the emaciated 
 being landed at Netley to all appearance in the grasp of 
 death. 
 
 So long as there are any sub-acute symptoms milk 
 must be the staple article of diet. Potatoes are in this 
 condition not admissible : they cannot be digested and 
 
 p 
 
2IO DISEASES OF TROPICAL CLIMATES lect. 
 
 cause great suffering. Nutrition without irritation must 
 be the chief object, and variety is essential ; fresh fish 
 when available, nutritious soups, not a daily routine of 
 beef-tea, which becomes at last • as distasteful to a sick 
 man as a glue-pot. The return to solid meat must be 
 made with caution. Diarrhoea must be held in check 
 by bismuth, by vegetable astringents, and by the tonic 
 influence of the pernitrate of iron, which is much used 
 here. Once more I commend to your attention the 
 water-belt advised in a former lecture. 
 
 At best the cure of chronic dysentery is a work of 
 time as well as care, and much patience both on the 
 part of doctor and patient is required. Washing out 
 the lower part of the bowel with a weak solution of 
 nitrate of silver seems to assist in the healing of the 
 ulcers.^ 
 
 ^ Just as this lecture was going to press I received an interesting 
 letter from my friend and former Netley pupil, Surgeon-Major F. 
 Arthur Davy. He writes to me from the Queen's Depot, Poona- 
 mallee, near Madras; his letter is dated 29th May 1886. The 
 following is an extract : " We have a very fine hospital here, to 
 which all the bad chronic cases from the various stations in the 
 Madras Presidency and Burma are sent. In three years there has 
 not been a single death from dysentery. I have been here seven- 
 teen months, and very nearly lost one case. I believe he was 
 saved by the following means : l drachm of nitrate of silver in 
 3 pints of water. I caused this solution to flow through the 
 colon, not by injecting it, but introducing it through a long tube, 
 carefully passed into the bowel, the fluid finding its way by gravity 
 from the end held high above the patient. It was only done twice, 
 and healed the ulcers. I forget," he adds, " who first advised this 
 method." 
 
DYSENTERY 
 
 No death from chronic dysentery in three years at Poonamallee ! 
 Some of the old army surgeons, who now rest from their labours, 
 and who knew that place when there was no " fine hospital " there, 
 and were accustomed to two or three deaths in a week, would hear 
 Dr. Davy's statement with incredulity. I cannot omit this oppor- 
 tunity of expressing my regret that so little serious notice has been 
 taken in the service of this officer's investigations on the prevalence 
 of heart-diseases in the army, and the hourly mischief wrought on 
 the drill grounds by the drill sergeants. The late Dr. Hilton 
 Fagge, in the second volume of his Principles and Practice of 
 Medicine, was one of the few who appreciated their value. 
 
LECTURE XII 
 
 CHOLERA 
 
 The subject on which we enter to-day is one of para- 
 mount importance. Cholera is a disease, the interest of 
 which is not now confined to the East and to physicians 
 whose sphere of labour is in that quarter. While I 
 speak, it is raging in a seaport of France, and threaten- 
 ing to extend its ravages to other cities in the south of 
 Europe, and may at any moment revisit our shores. 
 The suddenness of its attacks, the number of people it 
 strikes down in a city or district where it prevails, the 
 rapidity with which it kills, all tend to impress the 
 imagination with awe, to create panic, and to arouse 
 governments to action, with a view to determine its 
 cause, the laws which govern its propagation, and the 
 best means of staying its progress. 
 
 The history of this disease is deeply interesting ; but 
 the time at my disposal will only admit of the merest 
 outline of it. I must direct you to look up this part of 
 the subject for yourselves in two admirable works in 
 the library here, which will amply repay perusal. The 
 Afinals of Cholera, by Dr. John Macpherson, and the 
 
CHOLERA 
 
 213 
 
 History of Cholera, by ISIr. C. Macnamara, both medi- 
 cal officers of H.M. Bengal army, will give you all that 
 is or can be known of this history. The Anfials of 
 Cholera, in particular, is a work of learning and research. 
 I commend both books to you, because the authors, 
 in addition to the literary merits of their works, have 
 had unrivalled opportunities of studying the disease, 
 not in books only, but at the bedside in the hospitals 
 of Calcutta, a city justly styled by Dr. Macpherson the 
 " Home of Cholera." 
 
 Far from being, as was long popularly believed, a 
 " new disease," that sprung like a wild beast out of the 
 jungle on the camp of the Marquis of Hastings in 
 Bundelcund in 1817, it is, as Dr. Macpherson says, one 
 of the most ancient of which distinct descriptions exist. 
 Its nomenclature is important. I give you from the 
 Annals the names in a tabular form : — ■ 
 
 Hindostanee . 
 
 Murree 
 
 Deadly disease. 
 
 >5 
 
 Jurree murree . 
 
 Sudden pestilence. 
 
 !> 
 
 Maha murree . 
 
 Great pestilence. 
 
 Arabic . 
 
 Taoun 
 
 Pestilence. 
 
 „ 
 
 Duba 
 
 Common for cholera and 
 plague. 
 
 Chinese . 
 
 Ho louan 
 
 Meaning sudden attack. 
 
 Sanscrit . 
 
 Visuchika 
 
 Vomiting and purging. 
 
 Haidsa is the name by which it is universally known 
 
 to Mohammedans. In the part of India where I spent 
 
 many years, viz. Hyderabad, in the Deccan, the name 
 
 n common use by all classes there was Ookal Julab, 
 
 vomit-purge. The word found by the Portuguese in 
 
214 DISEASES OF TROPICAL CLIMATES legt. 
 
 use to distinguish the disease when they arrived in 
 Western India was Mordeshee or Morshee, a Mahratta 
 word, of great importance, as Macpherson shows, "in 
 tracing the course of cholera." It was corrupted by 
 the French into Mort de Chien. This word Mordeshee, 
 long in use by Europeans in India, is no longer so ; I 
 never heard it out of the mouth of any one, native or 
 European. In Tamul cholera is known as Eneru?7i 
 Vandee ; in Telegoo, Vantee, both meaning vomiting 
 and purging. 
 
 yoXe.pa is the term used by the Hippocratic writers. 
 Hippocrates and Celsus both describe cholera in a 
 sporadic, but not in an epidemic form, and Macpherson 
 quotes with approval the treatment recommended by 
 the latter. Cholera is described in the Shastras as 
 early as the second century, and epidemics at least akin 
 to cholera were known to Avicenna. Macpherson has 
 carefully examined the records of the various intestinal 
 affections, dysenteries, diarrhoeas, colics, choleraic affec- 
 tions, which prevailed in Europe from 1500 a. d. to 181 7, 
 and arrives at the conclusion that a disease indis- 
 tinguishable from cholera, as we moderns understand 
 the term, prevailed in Europe between the above dates. 
 He quotes the description given by Van der Heyden in 
 1643 of the disease known as Trousse Gallant^ called 
 Cholera Morbus. No one reading this description who 
 has ever seen a case of Asiatic cholera can doubt that 
 what Van der Heyden saw was cholera and nothing 
 else. 
 
 The Portuguese reached India in 1497, and made 
 
XII CHOLERA 215 
 
 Goa their seat of government in 15 10. The evidence 
 that they found cholera in Western India is as clear as any 
 fact in history. The Portuguese writers never hint at its 
 being a new disease, and as Dr. Macpherson shows, the 
 evidence, which is cumulative — that is, derived from 
 " many little facts not in themselves sufficient, but when 
 taken together irresistible," point to the fact that cholera 
 was endemic in India ages before Vasco de Gamez 
 doubled the Cape of Good Hope. Macpherson quotes 
 a description of a frightful epidemic of cholera at Goa 
 
 in 1543- 
 
 Garcia d'Orta, a Portuguese physician, published at 
 Goa in 1563 "the earliest European work on Indian 
 medicine, and the first book printed in India." It is 
 in the form of colloquies, and Macpherson quotes the 
 colloquy in which the description of cholera is given. 
 " The Indians," says D'Orta, " call it moj'xi, which we 
 corrupt into mordeshi. The Arabs call it hachaizn, 
 which has been corruptly read by Rhazes as saida^ 
 D'Orta describes the disease and its treatment, referring 
 particularly to the use of the cautery to the ankles by 
 the native practitioners, and to ligatures round the 
 limbs. Macpherson uses this native treatment by 
 cautery as a valuable clue in tracing out cholera. 
 
 It is quite impossible for me with the time at my 
 disposal to follow out the evidence of the presence of 
 cholera in India from the days of the early Portuguese 
 occupation to the present, both in an endemic and 
 epidemic form. In the times with which we have been 
 dealing European intercourse with India was mainly 
 
2i6 DISEASES OF TROPICAL CLIMATES lect. 
 
 with the western coast ; it is therefore not surprising 
 that we know much less of its early history in its modern 
 site or " home " in Lower Bengal. Mr. C. Macnamara, 
 to whose excellent History of Asiatic Cholera I have 
 already referred, has worked out the history of the temple 
 of the goddess of cholera at Calcutta, where she was 
 worshipped as Oola Beebee. From the history of this 
 idol, whose worship was so assiduously carried on that 
 at one time the offerings in money amounted to 4000 
 rupees a year, and in rice to nearly 9 tons, it is 
 evident that cholera was a common disease in Bengal. 
 
 There is abundant evidence from the records of 
 travels of learned missionaries that cholera prevailed in 
 Southern India in 17 13 very much as it does now, both 
 in a sporadic and an epidemic form ; and coming down 
 to later times, the records of the Madras Medical 
 Board show that it prevailed in that Presidency in 
 1769-70-1774, 1781, and 1790. It reached the Isle of 
 France in 1775. 
 
 Macpherson expresses surprise that when a terrible 
 outbreak of cholera attacked a division of Bengal troops 
 at Ganjam on the 2 2d of March 1781, it was the cause 
 of much astonishment. He attributes this to the im- 
 perfect communication existing in those days between 
 one part of India and another. Jameson has left us a 
 record of this epidemic. The disease "assailed the 
 troops with inconceivable fury. Men in perfect health 
 dropped down by dozens, and others, less severely affected, 
 were dead, or past recovery, within an hour. The spasms 
 of the extremities and trunk were dreadful, and distressing 
 
XII CHOLERA 217 
 
 vomiting and purging were present in all." The deaths, 
 out of a strength of 5000, did not fall short of 700. 
 The camp followers were first attacked, then the Sepoys, 
 and then the Europeans. Few officers were affected, 
 and only one died. 
 
 This epidemic reached Calcutta in April of the same 
 year, where, according to Warren Hastings, it caused 
 a great mortality among the native population, lasted a 
 fortnight, and then pursued its way northwards. 
 
 In 1783 there was a terrible outburst of cholera at 
 Hurdwar. Macpherson describes it. So far as my 
 knowledge goes this is the first mention of this cele- 
 brated spot in connection with cholera, although on 
 this point I speak with diffidence. It is hardly neces- 
 sary to remind you that it is at Hurdwar the waters of 
 the sacred Ganges issue into the plains ; there is no 
 place so sacred in the estimation of the Hindoos ; they 
 resort to it in numbers every year at the full moon of 
 April. But it is only every twelfth year that the people 
 assemble in vast numbers for the purpose of bathing in 
 the holy stream. The number of pilgrims on such 
 occasions often exceeds a million. In the year named 
 cholera broke out at the beginning of the ceremonies, 
 and Macpherson estimates the number of the victims 
 in eight days at 20,000. 
 
 I have already referred to the popular belief that 
 cholera was a "new disease" in 181 7; enough has 
 been said to show you that this belief is unfounded. 
 It is not even true that there was no cholera in the 
 years immediately preceding 18 17. There was com- 
 
2iS DISEASES OF TROPICAL CLIMATES lect. 
 
 parative quiescence, and that was all. There is evidence 
 of its presence in various parts of the Madras Presi- 
 dency up to the end of the eighteenth century, and a 
 Bengal column, in April 1790, was attacked in the 
 same place and in the same way as that of Colonel 
 Pearse already related. In 1793 cholera was in Tra- 
 vancore, and in 1794 it " destroyed thousands" in the 
 same district. Undoubtedly in and about Calcutta 
 from 1808, 1809, 1811, 1812, 1813, and 1814 only 
 dropping cases of the disease were seen, which at- 
 tracted little attention. 
 
 We now come to the great epidemic of 181 7. Dr. 
 Macpherson and Mr. Macnamara have exploded the 
 popular error that it began at Jessore. In May and 
 June the disease was raging in Kishnaghur and My- 
 mensing. In July it was in the Dacca district, and it 
 did not reach Jessore till August. It reached Calcutta 
 a few days earlier. The consternation was extreme, 
 and once more the temple of Oola Beehee was crowded 
 with worshippers. It is a notable fact that the pesti- 
 lence appeared on this occasion in the month of August, 
 the usual cholera season being the hot weather in 
 Calcutta. Dr. Macpherson, however, records that he 
 saw in the month of September 1859, i.e. during the 
 rains in that city, the worst epidemic of cholera he ever 
 witnessed among Europeans, and he uses this remark- 
 able expression, which shows his belief in the hot 
 weather being its Calcutta season of prevalence : " the 
 disease very soon resumed its old habits — may be said 
 to have soon righted itself.'''' Thus it broke out again in 
 
xir CHOLERA 219 
 
 the end of February 1818, and raged during the hot 
 weather months. 
 
 From the year 1845 to the end of 1855 I -was at- 
 tached to the Pohtical Residency of Hyderabad in the 
 Deccan, close to the great city O- that name. In all that 
 time cholera prevailed more or less during the hot and 
 dry season, from March to the end of May, with the 
 exception of one year, when there was not, so far as I 
 could learn, a single case of the disease. 
 
 We come now to the memorable outburst of the 
 disease in the camp of the Marquis of Hastings on the 
 6th of November 18 17 in Bundelcund. On this occa- 
 sion 5000 men perished in five days. Europeans and 
 natives were alike struck down, and before the epidemic 
 subsided it had carried off 9000 men. The Marquis of 
 Hastings gave directions that in the event of his suc- 
 cumbing to the disease his body should be buried in 
 his tent. 
 
 The disease reached Burma in 1818 ; Penang, 
 Sumatra, Siam, Ceylon, Mauritius 1819; China 1820, 
 1822, 1823, and 1824 (I met with it there in 1841 
 committing great ravages along the course of the Yang- 
 tsi-Kiang River) ; Chinese Tartary 1827. 
 
 On its western course it was at Muscat in the Persian 
 Gulf in 1821; Persia 1822, again in 1823, 1829, and 
 1830; Astrachan 1823. In 1829 it was at Orenburg. 
 By May 1831 it reached Moscow and Warsaw, St. 
 Petersburg in July; by October it was at Berhn and 
 Vienna, and in the same month it had established 
 itself at Sunderland ; and in the following month it 
 
220 DISEASES OF TROPICAL CLIMATES lect. 
 
 was in and about Edinburgh. It reached Quebec in 
 1832. 
 
 It appeared again in Europe in 1848-49, in 1853-54, 
 and it effected a lodgment in Southampton in 1866 : 
 this being the first occasion on which the southern 
 coast of England was invaded ; the disease was raging 
 in the basin of the Mediterranean, with which South- 
 ampton was in weekly steam communication. 
 
 The following is an epitome of its march : "It has 
 advanced eastwards to China, southwards to Ceylon, 
 northwards to Archangel, westwards to Britain — raging 
 at all seasons of the year, in all terrestrial temperatures, 
 from the highest tropical heat to the lowest Arctic cold — 
 in all states of the air as to humidity, barometric pres- 
 sure or wind, at sea and on land — on all soils from the 
 most moist to the driest, from the most barren to the 
 most fertile. At all elevations, from the level of the 
 sea to the highest inhabited region, among all races of 
 mankind, whose country has lain in its line of march ; 
 in all varieties of political condition or civil station ; in 
 short, in every variety of circumstances in which it is 
 possible to regard human beings. Is there any disease 
 of acknowledged miasmatic origin to which the same 
 observation can be applied? Is there any other mode 
 of explaining why malignant cholera seems as it were to 
 seek man out wherever he congregates, except by ad- 
 mitting that he carries it with him from congregation to 
 congregation ? " 
 
 What is the cause of cholera ? Gentlemen, I do not 
 know! Far be it from me to say we shall never know 
 
XII CHOLERA 221 
 
 — never b e able to give an __gza £t- answer to t he above 
 question. Of this, however, I am quite sure — it can 
 never be answered by merely official authority; by 
 throwing cold water on the opinions of those, whether 
 right or wrong, who are seeking after truth ; sneering at 
 and snubbing, and in every way discouraging men who 
 dare to hold opinions that do not square with those 
 which happen, it may be for political reasons, to find 
 favour with those in positions of medical or other 
 authority. Something too much of this we have seen of 
 late years. Such a system is in a high degree unjust to 
 those against whom it is either directly or indirectly put 
 in force, and worse than that, it is fatal to all honest 
 inquiry and to the advancement of truth. I hope and 
 believe we have seen the last of this bad system. 
 
 I have admitted that I cannot tell you the cause of 
 cholera. It has been attributed to " s ome additio iLjo 
 the ordinaTy_atmosphere " — in other words, to an aerial 
 poison of the zymotic class ; others look to the soil, to 
 climate, food, water. Tytler, of the Bengal army, attri- 
 buted the outbreak of 1817 to "diseased rice," a mere 
 guess, which in no way explained the facts even within 
 the limited area to which his experience was confined, 
 much less over the vast extent of country affected by the 
 epidemic. Professor Hallier and De Barry about the 
 year 1868 pressed a fungoid theory of cholera on the 
 attention of the scientific world, which found favour 
 with many until Drs. Lewis and Cunningham, both 
 Netley men, appointed by the Secretaries for War and 
 India, on the recommendation of the professors of this 
 
222 DISEASES OF TROPICAL CLIMATES lect. 
 
 school to investigate this theory, effectually disposed of 
 it by their researches in the "home of cholera." They 
 demonstrated that no special fungus is developed in 
 cholera stools, and that the fungus of Hallier and De 
 Barry is certainly not confined to such stools. 
 
 Of all the theories put forward on the etiology of 
 cholera none has obtained such a wide acceptance as 
 the bacterial theory of Professor Koch. A belief that 
 the cause of cholera was to be found in some organic or 
 even organised substance, has from time to time been 
 entertained by some members of the profession, but 
 Koch, after his researches on cholera in Egypt and 
 India, is the pathologist who has put forward the theory 
 of a comma-shaped bacillus being the cause of cholera 
 in a distinct and plausible manner. 
 
 Koch did not succeed in finding in the blood of 
 cholera patients any micro-organisms, only very few 
 in the vomit, but abundance in the evacuations. In 
 the bowels of those affected, more particularly in the 
 lower part of the small intestine, he found immense 
 numbers of bacilli, presenting the comma -like shape 
 which has given them their distinctive name. This 
 subject was investigated with his usual patience and 
 skill by Dr. Lewis, the Cholera Commissioner already 
 referred to, and well known to you all as at this time 
 Assistant Professor of Pathology in this school,^ who 
 went to Toulon during the late epidemic of cholera 
 there, to study the question. Dr. Lewis came to the 
 
 1 Alas ! now (May 1886) no more, adding one more honoured 
 name to the long list of victims to science. 
 
XII CHOLERA 223 
 
 conclusion that this so-called cholera bacillus is a spir- 
 illum, and in the laboratory here was able to demon- 
 strate its existence in the saliva of his illustrious friend 
 Professor Max von Pettenkofer, whose observation on 
 seeing the famous comma -bacillus taken from this 
 unlooked-for source, was : " Lewis, you have removed a 
 bandage from my eyes !" 
 
 This, to the best of my knowledge and belief, is the 
 present position of the comma-bacillus theory of cholera. 
 I think the safest verdict on it at this time is "not 
 proven."^ 
 
 1 Just as this sheet was going to press the following notice 
 appeared in the British Medical Journal of July 3, 1886. The 
 last word on the comma-bacillus, it is evident, has not yet been 
 said : — 
 
 The Bacillus of Cholera. 
 
 During the summer of 1885 an epidemic of cholera occurred at 
 Shanghai, and proved fatal to a considerable number of Chinese 
 residents. Dr. Macleod and Mr. Milles, who are associated in 
 practice at Shanghai, and whose names will be familiar to some of 
 our most experienced bacteriologists in London, with whom they 
 were recently fellow-workers here, seized the opportunity of in- 
 vestigating cholera from the bacterial aspect of the question. Their 
 full report is not yet ready ; but a preliminaiy statement, supplied 
 to Dr. Henderson, the health officer of Shanghai, has been printed 
 in the Report of the Municipal Council of that settlement. The 
 statement briefly sets forth that the investigation was entered into 
 for the purpose of testing Dr. Koch's results ; and his methods, so 
 far as they have been made known, were employed. 27 cases of 
 Asiatic cholera, 7 cases of diarrhoea, 2 cases of dysentery, and 4 
 specimens of healthy saliva, furnished the material ; and the follow- 
 ing are some of the results : i. Koch's comma-bacillus, dis- 
 tinguished by {a) shape and size, as seen in specimens of the stools 
 under the microscope ; {b) vital characteristics, furnished by growth 
 
224 DISEASES OF TROPICAL CLIMATES lect. 
 
 The theor)- of Pettenkofer is one that has exercised 
 great influence on the minds of the profession ; it is 
 briefl)' this : He takes for granted that there is " a 
 cholera poison,"" which on reaching the soil undergoes 
 
 in pure cultivations, was found in 25 out of 27 cases of cholera. 
 In two cases it was not found ; but in these the stools were not 
 collected during the stage of collapse, and were not characteristic, 
 being fcetid and fsecal. (The bacillus found in the rice-water stools 
 of a given case is frequently absent from the later non-characteristic 
 stools of the same case.) 2. Microscopic examination of the stools 
 of 7 cases of diarrhoea and 2 cases of d)'senteiy, also of 4 speci- 
 mens of saliva from healthy individuals, demonstrated the presence 
 of comma -shaped bacilli; but the cultivation test (which had 
 succeeded in the cholera cases) failed in every instance ; thus 
 proving them, though identical as to size and shape, to be different 
 in the more important vital characteristics of growth under the 
 same conditions. 3. The rice-water stools, as they are called, that 
 is, the characteristic stools of cholera, always contained these 
 organisms, and often an almost pure cultivation of them, few, if 
 any others, being present ; whilst, in the less characteristic stools 
 of the later stages of the disease, they were difficult of detection and 
 sometimes absent, there being often as many as four or five other 
 micro-organisms present. 4. The organism was not found in the 
 tissue of the intestinal wall, as stated by Koch ; but, as he has not 
 published his method of detecting it in that position, failure ma)^ 
 have been due to a different method of examination. 5. The 
 organism was destroyed by being dried, whilst it was found capable 
 of growth after being kept moist for more than four months. 
 Probably, it is capable of much longer preservation in this state. 
 6. The bacillus grew luxuriantly at a temperature of from 75° to 
 100° F., slowly between 50° and 60° F., little, or not at all, 
 below 40° F., but was still capable of resuming growth when 
 the temperature was raised. A series of experiments for the pro- 
 duction of the disease in guinea pigs is now being conducted, but 
 is not advanced sufficiently for report. 
 
CHOLERA 225 
 
 changes, which depend on the presence of a certain 
 amount of moisture. Even if this condition is fulfilled 
 there will be no epidemic unless certain unknown 
 meteorological conditions are present, and a predis- 
 position to the disease in those coming within the 
 influence of the disease in the affected area. 
 
 He lays great stress on what he calls the " ground 
 water." Cholera is worst in Lower Bengal in iVpril, 
 when the level of the water is lowest \ in Upper India 
 in August and September, when the water-level is either 
 rising or subsiding. It will be seen that according to 
 this view the soil is the 7iidus where the poison is pre- 
 pared, more particularly if that soil be alluvial, allowing 
 free intercourse between the air in the soil and that 
 above it. Basing his opinion on the above he deems 
 that cholera follows not the course of traffic but that of 
 the subsoil water. 
 
 The cholera poison, according to Pettenkofer, requires 
 earth, organic matter, salts in the soil, and water neither 
 in excess or the reverse for its propagation. Now 
 cholera is a great traveller ; it has, as I have already 
 shown you, found its way and exercised its destructive 
 power over vast areas, where it is contrary to reason and 
 to experience to suppose that Pettenkofer's conditions are 
 to be found. It appears to me that this theory has been 
 framed without keeping this important fact sufficiently 
 in view. 
 
 Is cholera a child of dirt? Much may be said in 
 favour of this opinion. That its birthplace is Hindostan 
 does not admit of doubt, — I speak of course of Cholera 
 
 o 
 
226 DISEASES OF TROPICAL CLIMATES lect. 
 
 Asiatica, not of those milder affections which, having a 
 certain resemblance to the grave and destructive disease 
 with which we are concerned here, are to be found 
 almost everywhere occurring sporadically, but not with 
 the wide-sweeping energy of a disease capable, as we 
 have seen, of destroying its thousands in a few days out 
 of an army of moderate size. The soil of the populous 
 parts of India where this disease is chiefly endemic has 
 for ages been saturated and sodden with faecal impurities. 
 Many of the races of India may in a certain sense be 
 said to be cleanly in their persons, regular in the per- 
 formance of ceremonial ablutions. I use the term 
 ceremonial advisedly, for in crowded centres of popu- 
 lation it is notorious that the water with which these 
 ablutions are performed is nothing but slightly-diluted 
 sewage. How notably this is the case in the tanks in 
 and about the crowded native quarters of Calcutta is a 
 matter of notoriety, to be seen in. almost every page of 
 the reports of the sanitary officers of that city. What is 
 true of the native quarters of the great cities of India is 
 doubly so of the villages scattered in prodigious numbers 
 over the face of the country. For ages the habits of the 
 people have remained the same, and those habits in the 
 matter of the disposal of human excreta in the vicinity 
 of their dwellings have been such as to bring about a 
 condition of soil and water such as those only who have 
 made this unsavoury subject a matter of inquiry and 
 observation can fully understand. 
 
 We know that in our own land, with our yearly- 
 increasing population, the disposal of our sewage is one 
 
xii CHOLERA 227 
 
 of the most difficult and costly problems submitted to 
 the consideration of sanitarians and engineers. What 
 would have been the condition of this country had this 
 question been left, as it has been in India, to take care 
 of itself? I think the answer is not far to seek : we 
 should in time have been admonished by some develop- 
 ment of fsecal-bred disease as destructive as cholera, if 
 not cholera itself in propria persona, not as an occasional 
 visitor, but as an endemic disease developing from time 
 to time, under the influence of those unknown agencies 
 to which we give various names, into destructive 
 epidemics, such as now sweep over large areas of 
 Hindostan. 
 
 Nor in this connection can we shut our eyes to a fact 
 as notorious as any fact can be, that when cholera is in 
 movement in Europe it iinds out the cities and the 
 quarters of cities where the reign of dirt is supreme. 
 Cholera in this country has not been an unmixed evil ; 
 it has come to us with a scorpion whip in its hand, and 
 has scourged the communities that have understood the 
 chastisement into, at all events, an approach to that 
 cleanliness which is akin to godliness. Those who take 
 its lessons to heart in earnest will probably see its 
 terrible face no more, while those who seek to appease 
 the wrath of an offended deity by processions of Our 
 Lady of this and Our Lady of that, or the relics of this 
 or that departed saint, will fare as do the votaries of 
 Oola Beebee, the Lady of the Flux, in Calcutta, until they 
 learn the worship of — Hygeia. 
 
 Propagation. — Here we enter on controversial ground. 
 
228 DISEASES OF TROPICAL CLIMATES lect. 
 
 Much as I desire to avoid controversy in my lectures 
 here, it is impossible for me to affect neutrality on a 
 matter of such importance as this. The official reports 
 of the sanitary officers of India are received here, and 
 are to be seen and read in the library ; they are, more- 
 over, carefully reviewed in the medical journals, and I 
 think you have a right to expect from your teachers in 
 this school a distinct expression of opinion, and not 
 merely a colourless statement on such a question as the 
 propagation of cholera, more particularly from the pro- 
 fessor whose duty it is to instruct you on military 
 medicine. 
 
 The first part of this subject to be brought before 
 you is the theory of the late Dr. Bryden of the Bengal 
 army, which has attracted much attention not only in 
 India, but in Europe. Bryden defined what he called 
 the endemic area of cholera, its breeding-place, with a 
 precision never before attempted. This is a region in 
 Lower Bengal, extending over 122,500 square miles, 
 containing within its limits the deltas of two great 
 rivers, the Ganges and the Mahunuddy. This endemic 
 area is a flat diluvium on the seaboard, little raised 
 above the level of the sea ; its climate is hot and 
 moist, a large part of it is yearly under water, and vege- 
 tation under the stimulus of heat and moisture is rank 
 and vigorous. 
 
 From this region spring up " bodies of cholera," 
 which overflow the boundaries of the endemic area 
 from time to time, invading not only what he called the 
 epidemic area of Hindostan, which included every 
 
XII CHOLERA 229 
 
 region outside the endemic area, but occasionally spread- 
 ing beyond this over Asia, Africa, and Europe, which 
 happen to be in their course ; the materies of cholera, 
 whatever it may be, has a period of growth, existence, 
 decay, revitalisation, and death — these being under the 
 influence of time, place, and atmospheric conditions. 
 Bryden was of opinion that cholera was as much an im- 
 ported disease in the so-called epidemic area of Hindo- 
 stan as it is in Europe. 
 
 Under the drying influence of the sun in the hot 
 and dry months of February, March, April, and May, 
 the materies of cholera is extracted from the soil, and 
 prevails in the endemic area more or less. The first 
 heavy fall of rain extinguishes it there ; but in years 
 when it assumes epidemic energy it " invades " the 
 epidemic area, taking moisture for its vehicle, and the 
 monsoon wind for its "locomotive power." 
 
 According to this view the earth-born germs of the 
 disease are carried by the moist wind from their birth- 
 place. To human intercourse — to man or his move- 
 ments — or to any other agency, Bryden assigns an insig- 
 nificant and subordinate part in the propagation of 
 cholera ; and he asserts that when introduced into the 
 epidemic area by any other agency than that of the 
 moist monsoon wind, it never assumes epidemic force, 
 
 Bryden's study of many epidemics convinced him 
 that the disease invariably invades the epidemic area 
 with a certain periodicity, "prevailing most in the 
 endemic area from October to May, in the months when 
 it fades away in the upper provinces ; it is never seen 
 
230 DISEASES OF TROPICAL CLIMATES lect. 
 
 there in an epidemic form from the beginning of Octo- 
 ber until the 20th of April. The disease, appearing in 
 an epidemic form about the above date, will last until 
 the third week in September, A cholera epidemic in 
 the east of India may be entirely diverted from the 
 north-west into Western India — a change of direction 
 which takes place during the north-east monsoon." 
 
 Such, in general terms, is a summary of this theory 
 which has exercised a great fascination over the minds 
 of many men, very notably over that of Dr. James 
 Cuningham, for many years the Sanitary Commissioner 
 with the Government of India. At one time this 
 unquestionably able man held strongly opinions dia- 
 metrically opposed to the exclusive theory of Bryden, and 
 in his Annual Report for the year 1867, after describing 
 the distribution of cholera by the pilgrims returning 
 from the great Hurdwar Fair, he thus expressed himself: 
 " Whatever theoretical differences of opinion may exist 
 as to the propagation of cholera, the facts of the great 
 epidemic of 1867, and its spread over Northern India, 
 teach no doubtful lesson, and it is this : that human 
 intercourse plays a very great part in the diffusion of the 
 disease, and that returning pilgrims in particular are 
 very dangerous arrivals." 
 
 In 1 88 1 the same authority expressed himself to the 
 following effect : " The experience of fairs and other 
 gatherings in this country (India) has again and again 
 testified to the truth of the conclusion, that cholera is 
 not carried by persons from one locality to another, so 
 as to cause persons, not themselves exposed to the neces- 
 
XII CHOLERA 231 
 
 sary local influences, to become affected by the disease." 
 In fact Dr. Cuningham, in the last years of his official 
 life, made, as my colleague. Professor De Chaumont has 
 expressed it, "a tabula rasa of everything, and denied 
 the transportability of cholera by persons and by 
 water." 
 
 It is impossible to resist the conclusion that, con- 
 sciously or unconsciously, political considerations weighed 
 with this able officer when he changed his opinions in 
 this remarkable rnanner. It is certain that the Govern- 
 ment of India was alarmed lest, if it could be estab- 
 lished that cholera followed the great lines of human 
 ■ intercourse, foreign nations, in their jealousy of British 
 commercial prosperity, should establish, to the detriment 
 of Indian trade, quarantine regulations of an oppressive 
 character. It is certain that both Dr. Cuningham and 
 some of the high officials of the Civil Government lost 
 no opportunity of expressing in strong terms their 
 opinion, that to reason from facts before them, showing 
 the influence of human intercourse or water in propa- 
 gating cholera, on the part of medical officers, was highly 
 culpable, and a practice to be reprobated. Any other 
 theory than the one advocated in the annual reports of 
 the Sanitary Commissioner with the Government of 
 India was wrong, and the officer who sinned in this 
 way was branded as a mischievous theorist. 
 
 I would rather have avoided any reference to this 
 unpleasant subject, but it is part of the history of cholera 
 in India, and I cannot pass it over in silence. 
 
 Gentlemen, when we study the history of cholera we 
 
232 DISEASES OF TROPICAL CLIMATES lect. 
 
 must not confine our attention entirely to India. I ask 
 you to keep in mind tiie sketch I gave you at the be- 
 ginning of this lecture of the progress of cholera from 
 Hindostan, its indubitable birthplace. I think it will 
 be difficult for any candid person, whatever his precon- 
 ceived opinions may be, to deny the broad fact so 
 clearly indicated, that cholera, in its epidemic move- 
 ments, follows the great lines of traffic and human inter- 
 course, that it does " seek out man wherever he congre- 
 gates, and that he carries it with him from congregation 
 to congregation." 
 
 Was it the wind that carried cholera from the Medi- 
 terranean to the neighbouring town of Southampton in 
 1866 when for the first time it invaded England on its 
 southern shore? If so, why did the wind not deposit 
 it on some other parts of the coast, say the Isle of 
 Wight, which, as it happens, covers the very mouth of 
 Southampton Water? Why was it that on board the 
 steamship which carried it, the only persons attacked 
 were those who drank water taken from a tainted source 
 where the disease prevailed at a Mediterranean port ? 
 Why was it that the first case of cholera in Southampton, 
 after the arrival of that ship, was in the house of one of 
 the men who, having partaken of this tainted water, was 
 suffering from diarrhcea when he landed, and afterwards 
 had the disease in his own home ? To such questions 
 the invariable answer of the late Sanitary Commissioner 
 with the Government of India would be " such events 
 are coincidences." 
 
 I ask you to accept provisionally the following pro- 
 
xrr CHOLERA 233 
 
 positions, and to act in your dealings with cholera on 
 the practical lessons they teach, until by observation 
 and practical experience you satisfy yourselves that they 
 are untrue : — 
 
 {a) While it is certain that Bryden's dictum that the 
 only endemic area of cholera in Lower Bengal is inac- 
 curate, inasmuch as there are other breeding-places, 
 it is true that in the region indicated by him, without 
 defining its limits so exactly, cholera is more or less 
 a;lways present there from October to May inclusive. 
 
 {b) What the nature of the force is which gives it 
 epidemic energy in certain years is unknown. Cholera 
 certainly as a rule assumes epidemic intensity after 
 heavy rain, followed by intensely hot weather. 
 
 {c) "The south-west monsoon appears to be the 
 indirect cause of the dissemination of cholera over the 
 country, in that it brings with it moisture — a necessary 
 element for the development of the disease' — but more 
 especially because, it is before this wind that the large 
 fleet of country boats moves up the Ganges, conveying 
 men and goods from the home of endemic cholera to 
 be disseminated over the upper provinces. Thus the 
 disease springs up, not only in the great cities on the 
 Ganges at which these boats stop, but it also appears in 
 the large towns on the Jumna — cholera thus progress- 
 ing with man along the great high roads upon which he 
 travels, spreading no faster than he moves, and being 
 generated in wet and hot weather." — Macnamara. 
 
 {d) So far the influence of the south-west monsoon. 
 But it is a notable fact that when cholera has been 
 
234 DISEASES OF TROPICAL CLIMATES lect. 
 
 raging in Burma, it has never been carried to the Anda- 
 mans, in the Bay of Bengal, with that wind in its favour. 
 There is evidence by trustworthy observers — Scott, 
 Leith, and Cornish — that the disease can travel great 
 distances against the monsoon, that in fact it makes its 
 way along its track as fast with the wind against it as 
 when it blows in its favour. 
 
 (e) The infective property of cholera is in the stools 
 of cholera patients when they have undergone certain 
 changes — fresh stools do not possess this infective 
 property. 
 
 (/) The stools of infected persons can convey the 
 disease through the medium of drinking water. 
 
 (g) It is probable that dried cholera stools (cholera 
 dust) may be carried by the wind, and infect those who 
 breathe the air thus contaminated. How far it may be 
 carried in this way, retaining its infective property, is 
 uncertain. 
 
 (/z) Articles of food polluted by cholera dejections 
 when taken into the system induce the disease. 
 
 (z) Articles of clothing soiled with cholera dejections 
 will retain, and may communicate, the infection. 
 
 (j) Bodies of men, regiments, or pilgrims can carry 
 the disease with them, and propagate it along their line 
 of march and dispersion. 
 
 {k) A healthy regiment meeting and communicating 
 with an infected one will certainly be infected. 
 
 (/) A regiment or other body of men entering a 
 tainted district will almost certainly be infected. 
 
 (w) If it encamps on ground previously, and com- 
 
XII CHOLERA 235 
 
 paratively recently, occupied by a cholera-infected body 
 of men, it will certainly be infected. 
 
 {ri) When ships leaving port with a clean bill of 
 health are attacked by cholera in mid-ocean, it will be 
 found, if the cause is duly sought for, that the outbreak 
 of the disease has been coincident with the opening up 
 and exposure of some part of the cargo, or the baggage 
 of passengers, from an infected place, it may be, far 
 from the port of departure. 
 
LECTURE XIII 
 
 CHOLERA {contiimed') 
 
 Some evidence in support of the propositions offered for 
 your acceptance in last lecture you have a right to 
 demand at my hands. That the specific poison of 
 cholera is contained in the dejections of cholera patients 
 is, I think, demonstrated by the following fact related by 
 Macnamara : — 
 
 " A small quantity of a fresh rice-water stool passed 
 by a person suffering from cholera was accidentally 
 mixed with some four or five gallons of water, and the 
 mixture exposed to the rays of a tropical sun for 12 
 hours. Early the following morning 19 people each 
 swallowed about an ounce of this contaminated water — 
 they only partook of it once — but within 36 hours 5 of 
 these 19 persons were seized with cholera. In this 
 instance the choleraic evacuation did not touch the 
 soil : as it was passed so it was swallowed ; it had been 
 largely diluted with impure water, and the mixture had 
 been exposed to the light and heat of a tropical sun for 
 12 hours." 
 
 Parkes' Manual of Practical Hygiene is in your 
 
LECT. xiii CHOLERA 237 
 
 hands, — indeed in this school seldom out of your hands, 
 — if you will turn to page 5 o of that work you will find an 
 admirable summary of the evidence on the propagation 
 of cholera by contaminated water, both in Europe and 
 India. No part of that evidence is more important than 
 that which shows how towns are protected from the 
 disease when the water supply is pure, and how they 
 suffer when it is contaminated ; also how towns which 
 have suffered in one epidemic have escaped a later one, 
 the only difference being that, in the interval, the supply 
 of water has been improved. Calcutta has certainly 
 suffered less since the water supply has been improved, 
 and there is the best reason to believe that when this 
 comparatively pure supply is more generally diffused the 
 improvement will be still more striking. As the case 
 stands, the reports of the health officers show that it is 
 the consumers of contaminated water that constitute the 
 enormous majority of the sufferers. The same is true 
 of Madras. 
 
 Take the following examples : The first was com- 
 municated to Dr. Hastings, civil surgeon of Cannanore, 
 by the Rev. M. Delpech, Roman Catholic missionary 
 of the district where the event happened, and published 
 by Dr. Hastings in the Indian Medical Gazette of 
 I St December 1879. The narrative derives importance 
 from the fact that the reverend gentleman had no theory 
 of cholera to support, and is not therefore open to the 
 reproach of being a " theorist," by the scorner of all 
 theories — his own excepted. 
 
 The village of Vendakencoulam is situated about 
 
238 DISEASES OF TROPICAL CLIMATES lect. 
 
 thirty-five miles south of Palamcottah. This village, 
 towards the close of the year 1877, was subjected to a 
 heavy rainfall, which by percolation filled to the brim 
 the five or six wells which are situated in the village. 
 Towards the second half of the month of December an 
 epidemic of cholera broke out in the village, which in 
 fifteen days carried off more than 100 souls of the high- 
 caste population. Not a single person of low caste was 
 attacked, a street only separating the two castes. In 
 some places the abodes of the two castes were contiguous. 
 Still, the disease only affected those of the high caste. 
 
 In the village were two wells, A and B, which, 
 situated in the centre of the village, the high castes 
 reserved for their exclusive use ; the low-caste people 
 dared not even approach them. At the time of the 
 cholera the high castes used the well A ; for many 
 years it was around this well that men and women made 
 their ablutions or health baths ; there they washed the 
 clothes they have worn for one or two days ; there they 
 purified their linen and their bodies when they have 
 assisted at funeral ceremonies. The approaches to this 
 well were always wet, and more or less contaminated 
 with animal matter and foetid mud. Rice cooked in 
 this water had a bad smell. It has been said that not 
 one of the low-caste people died. The reporter, the 
 Rev. V. Delpech, Roman Catholic missionary of Venda- 
 kencoulam, says : " I was mistaken — one, and one only, 
 died of this cholera, and this was the washerman of the 
 high-caste people. Now this man, who, on account of 
 his caste, could not approach the well A, drank never- 
 
XIII CHOLERA 239 
 
 theless of this water, for by a special privilege the washer- 
 man's wife got her pitcher filled by a high-caste woman. 
 " Suspicion therefore fell upon the well in question, 
 and by common consent it was resolved no longer to 
 draw water from it ; from this time the disease sensibly 
 diminished, and soon disappeared altogether. M. Delpech 
 fairly enough asks how it came to pass that well A was 
 more impure than those used by the low-caste people. 
 The answer given is significant : the low-caste people 
 performed their ablutions for the most part in their 
 cholam-gardens, the high-caste men bathed and washed 
 their clothes at well A. The low-caste wells were sur- 
 rounded by a parapet, like those of the high castes, but 
 unlike the latter, the water used in washing and bathing 
 could run off, whilst at well A there was a big hole 
 through which the foul water ran into the well " 
 (Abridged from M. Delpech's narrative, translated from 
 the French by Surgeon W. J. Hastings, M.D., Civil 
 Surgeon, Cannanore, and published in the Indian 
 Medical Gazette, ist December 1879). 
 
 The next fact bearing on the propagation of cholera 
 by impure water I give on the authority of Dr. Blanc of 
 the Bombay army, published in the La7tcet, 21st August 
 18755 P- 270. 
 
 The Yerconda central gaol is situated in the Deccan, 
 1865 feet above the level of the sea. At the time of 
 the following occurrence it contained 1279 prisoners. 
 
 On the morning of the 2 7 th May a case of cholera 
 occurred, and by noon of the following day 20 cases 
 were admitted. They came from nine different barracks. 
 
240 DISEASES OF TROPICAL CLIMATES lect. 
 
 and at first it appeared as if the outbreak was general, 
 but on closer inquiry, it was discovered that the epidemic 
 was limited to a certain number of prisoners who had 
 lately been employed in making a new road from the 
 gaol towards the Moola River, there to join the Poona 
 road. 
 
 It was then discovered that the whole of the men 
 affected had drunk water taken from the Moola River 
 below the dam \ the prisoners who were not affected only 
 drank water above the dam, that is from a point not 
 affected by sewage from Poona. 
 
 Cholera prevailed a little at the time, and it was 
 established that the bodies of two men who died of 
 cholera, as well as their clothes, were washed twenty yards 
 above the spot where the road gang had taken water. 
 Was this "a mere coincidence"? I have already 
 given you evidence of the propagation of enteric fever, 
 dysentery, and cholera in the pre -sanitary age from 
 ill-kept privies. 
 
 Take the following example of cholera propagation by 
 soiled clothing, on the authority of my friend, Inspector- 
 General Arthur Anderson, C.B., at the time in question 
 principal medical officer of Malta. That garrison suf- 
 fered from a severe epidemic of cholera in 1865 3 the 
 disease died out ; there had not been a case for more 
 than a fortnight ; suddenly a soldier's wife was attacked 
 and died. It was proved that this poor woman had 
 been in attendance, during the epidemic, on a woman 
 who died of the disease, had purloined a night-dress 
 soiled with the cholera excretions of the woman she was 
 
CHOLERA 241 
 
 attending. After keeping this article of clothing for 
 more than a fortnight, she put it on her person without 
 having it even washed, was seized with the disease, and 
 died ; this being the last case seen in the garrison. 
 
 How cholera may be propagated by food contamin- 
 ation is shown in the following example related by Dr. 
 Fairweather of the Bengal army, quoted and much 
 dwelt upon by Professor Parkes, in the Army Medical 
 Report for the year 1873. It is impossible to read this 
 narrative without the reflection arising that it cannot be 
 a solitary example ; that, in fact, innumerable examples 
 of the same kind of propagation must have taken place 
 without record ; the habits and customs of the people 
 are such that funeral feasts, conducted much in the 
 same way, must have been often attended with like 
 results. 
 
 A man arrived in Delhi from Lucknow, where 
 cholera prevailed ; immediately after arrival he was 
 seized with cholera, and died on the 20th of November. 
 The floor of the room in which he died had been 
 saturated with the cholera discharges ; this floor was 
 said to have been " cleaned," and subsequently washed 
 in the native manner with cow-dung and water; the 
 man belonged to the Reghar caste, who are tanners by 
 trade, and live in a community by themselves. A funeral 
 feast was given ; the hot steaming mass of rice, dohl 
 (lentil), and clarified butter was heaped on a mat, and 
 placed on the floor, which, as above stated, had been 
 saturated with the cholera dejections of the deceased 
 man. The feast was attended by numerous male 
 
 R 
 
242 DISEASES OF TROPICAL CLIMATES lect. 
 
 friends of the deceased, of his own caste, with one 
 or two exceptions. Some of the men took home part 
 of the food to their wives and daughters. This feast 
 took place on the 26th of November; a few hours after- 
 wards an outburst of cholera took place, confined at 
 first to those who attended the feast ; by the 2 9th of 
 November 47 cases and 15 deaths had occurred, by the 
 4th of December there were 73 cases and 46 deaths. 
 The deaths were not confined to those who were at 
 the feast, for be it remembered portions of the food were 
 taken home by some of the males, whose wives and 
 daughters partook of it ; but it was confined to the com- 
 munity who were either at the feast or partook of the 
 food brought from it. Dr. Fairweather satisfied himself 
 that the water was not in fault, and that the food, pur- 
 chased from a good source, was unexceptionable. There 
 was no cholera in or about Delhi at the time, and there- 
 fore no cholera miasm could have affected the sufferers. 
 
 We are thus driven to the conclusion that the food 
 was infected through the medium of the tainted floor. 
 
 As to the carriage of cholera by troops, pilgrims, and 
 other bodies from place to place, the matter admits of 
 no dispute. In Southern India, in particular, it is a 
 commonplace of cholera experience. In that part of 
 India, in days when regiments marched and did not 
 travel by rail, hardly a year passed during the relief 
 season without one or more examples of the kind. The 
 same is true of the proposition regarding the danger of 
 encamping on ground soiled by previous occupation of 
 a body of tainted troops, pilgrims, or other travellers. 
 
XIII CHOLERA 243 
 
 With regard to the danger of moving troops into a 
 district infected with cholera, I select for illustration an 
 example which is historical. A body of time-expired 
 artillerymen, with their wives and families, were under 
 orders to move from Mhow to their port of embarkation, 
 Bombay, The medical and civil authorities intimated 
 to the general in command at Mhow that cholera in an 
 epidemic form prevailed in the district through which 
 this detachment had to pass, and counselled delay. 
 The general in command did not think it his duty to 
 follow this advice. The march took place into the very 
 centre of the tainted district, the detachment was 
 immediately attacked by the disease, and a lamentable 
 mortality among men, women, and children followed. 
 The press of India took the matter up, commented upon 
 this loss of life with unsparing severity ; in due time it 
 attracted the attention of Parliament, an " inquiry " 
 followed, which resulted in the general commanding the 
 Mhow division of the Bombay army being deprived of 
 his command. I think it only due to that officer to 
 mention that in his defence he was able to show that 
 on a previous occasion he had delayed the march of 
 troops within his command on account of the prevalence 
 of cholera on the line of march, and was reprimanded 
 for so doing. When a mistake of this kind is in con- 
 templation, remember the " Mhow case," and do your 
 utmost, by representation in the proper quarter, to 
 prevent it. 
 
 With reference to the outbreak of cholera in mid- 
 ocean, the believers in wind, as the sole carrier of cholera, 
 
244 DISEASES OF TROPICAL CLIMATES lect. 
 
 maintain that when an event of this kind occurs, the ship 
 passes through a cholera-bearing stratum of the atmo- 
 sphere. The sanitary officials of the U.S. Government 
 account for the fact in a more prosaic way, and say, as 
 the result of their inquiries, that in every instance cholera 
 has been imported into the United States by infected 
 passengers, and that where this has happened in the case 
 of ships leaving European ports with . a clean bill of 
 health, passengers on board have come from infected 
 places on the Continent, and that in some well authen- 
 ticated examples the outbreak of cholera at sea was 
 synchronous with the opening up and exposure of bag- 
 gage belonging to passengers coming from such infected 
 places. 
 
 Symptoms. — We have now to look at this pestilence 
 in its clinical aspect. There is no disease more easy of 
 recognition. When cholera prevails in an epidemic 
 form premonitory diarrhoea is the rule : a point to be 
 carefully kept in mind in dealing with the disease. 
 This rule obtains in Europe and India alike ; the term, 
 however, must be restricted to the diarrhoea which pre- 
 cedes the characteristic symptoms by at least twenty- 
 four hours. 
 
 The real attack begins with a motion which empties 
 the whole intestinal tract of its faecal contents ; with this 
 comes mortal faintness and vomiting of a watery fluid, 
 in which whitish-coloured flakes are suspended ; nothing 
 remains on the stomach. The characteristic stools now 
 appear, so closely resembling the appearance of water 
 in which rice has been boiled that they are always 
 
CHOLERA 245 
 
 described under the name of " rice-water stools." The 
 pulse rises in frequency and quickly loses its force, dying 
 away until it becomes imperceptible ; faintness and sink- 
 ing increase; respiration is quickened, becoming shallow 
 and difficult ; the voice is feeble, hoarse, and character- 
 istic ; cramps add to the misery of the scene. I have 
 never seen this painful symptom so severe as it is described 
 by Jameson and .others who saw the disease in 181 7. 
 When present this symptom, while it adds to the patient's 
 discomfort, is not per se, at least where not excessive, an 
 unfavourable sign ; certainly in innumerable cases of the 
 most fatal form of cholera that have come under my 
 observation this symptom has been absent from first to 
 last. When, however, cramps are severe, frequent, and 
 long-continued, they tend rapidly to exhaust the patient 
 and hasten the end.^ There is now great restlessness, 
 extreme prostration, a ghastly expression of countenance, 
 with hollow, sunken eyes with dark circles ; the body is 
 cold, more or less bluish, and cold sweats appear ; the 
 hands look as if they had been macerated ; the breath 
 and tongue are cold, and secretion is suspended : this 
 is the stage of collapse, in which the patient resembles 
 a corpse covered with a clammy sweat. Throughout, 
 the thirst is intense, and a "burning" sensation at the 
 
 1 While this sheet is passing through the press cholera is raging 
 in the north of Italy, as well as at Trieste and Fiume. The Italian 
 physicians report on "the extreme severity of the cramps in the 
 stomach, and the extraordinary rapidity with which death ensues in 
 the fatal cases, often only an hour or two from the first seizure." 
 This was the experience of those who had to deal with the epidemic 
 in Bengal in 1817. 
 
246 DISEASES OF TROPICAL CLIMATES lect. 
 
 pit of the stomach is often complained of. A ther- 
 mometer in the axilla will stand at 86° or 90° F., while 
 in the rectum it will be as high as 103'^ F. All this 
 time, if a change for the better does not take place, the 
 patient goes from bad to worse ; the voice grows weaker, 
 the eyes sink more and more, vision becomes more 
 indistinct, and death creeps on, life passing away almost 
 imperceptibly. The temperature rises soon after death. 
 The signs of reaction are these : The rice-water stools 
 cease, they become of a pale yellowish colour ; some bile 
 then appears, giving them a greenish appearance ; then 
 they take on a distinctly yellow colour, become more con- 
 sistent, and finally faecal in appearance and odour. The 
 pulse returns and regains its force, the temperature is 
 restored, the skin loses its cold and clammy condition, 
 the secretion of urine, entirely suspended during the 
 attack, is restored : this is the stage of reaction, a more 
 or less febrile condition. The time during which urine 
 is suppressed varies, ten or twelve hours is the average. 
 If the period of suppression much exceeds the above 
 it is an unfavourable symptom ; cases are on record in 
 which it has been suspended for three days and yet the 
 patient has recovered ; but this is foreign to my experi- 
 ence. Bloody stools are sometimes seen ; this was not 
 frequent in my Indian experience, except in the case 
 of patients attacked with cholera when suffering from, or 
 convalescing from, acute dysentery. It appears to have 
 occurred more frequently in the last epidemic in London ; 
 and Dr. Sutton notes that patients who pass bloody 
 stools seldom live more than twelve hours. The same 
 
xiii CHOLERA 247 
 
 physician remarks, " that if a patient remains for a long 
 time pulseless, with a natural colour, a greasy perspiring 
 skin, with a wet face and hair, he will generally pass 
 bloody stools and die." 
 
 I have seen in intemperate Europeans in India many 
 cases that have entered hopefully on the stage of reaction 
 attacked by vomiting of green paint-looking matter, 
 doubtless bile acted upon by acid secreted by the stomach. 
 I regard this as a symptom of evil omen, and once this 
 condition is fairly established it is almost impossible to 
 control it. I call to mind the case of an officer, a free 
 liver, who survived the algide stage for seventeen days, 
 and iinally succumbed to an attack of this kind which 
 lasted for many days. 
 
 In some cases patients struggle through both the 
 algide and reaction stages only to sink into a low typhoid 
 condition ; others perish with symptoms of uraemic 
 poisoning when suppression of urine is long continued : 
 this is one of the penalties of long-continued intemper- 
 ance, resulting in degeneration of the kidneys. 
 
 In weakly Asiatics sloughing of the cornea is not an 
 uncommon occurrence. 
 
 To what is the algide stage of cholera due ? Dr. 
 George Johnson accounts for it on the hypothesis that 
 the " cholera poison " in the blood, in addition to being 
 the cause of the cramps, excites contraction of the 
 muscular walls of the pulmonary arteries, thus arresting 
 the flow of blood into the lungs ; the empty condition 
 of the lung capillaries and loss of weight of the lungs 
 (first pointed out by Parkes), he deems proof of this 
 
248 DISEASES OF TROPICAL CLIMATES lect. 
 
 theory; now the Uver, spleen, and kidneys have lost 
 weight also. If this theory was put forward by itself 
 we might say of it that it was an ingenious hypothesis 
 and pass on. But on it is based a system of treatment 
 which, in the opinion of the best authorities on tropical 
 medicine, is in a high degree dangerous. This part of 
 the theory is not new; many of the old Indian practitioners 
 acted upon it, and purged their patients in the hope 
 of expelling the " cholera poison." A survival of this 
 school I knew in the Deccan, who, without ever having 
 heard of the action of this poison on the muscular 
 walls of the pulmonary arteries, lived and died under 
 the conviction that purgation was the road to safety, 
 and conscientiously acting on this conviction, earned 
 for himself, among the Mussulman troopers committed 
 to his care, the sobriquet of Azrael, the Angel of 
 Death ! 
 
 Cramps, as I have told you, are often absent in the 
 most fatal forms of cholera, when the poison, whatever 
 it be, ought, according to this hypothesis, to be most 
 active. Again, the author of this theory holds that it 
 finds support from the fact that men who have hardly 
 purged at all die of cholera. Open the bodies of such 
 men and you will find, the small intestines particu- 
 larly, gorged with the rice-water dejections of the disease. 
 Then, in a cholera epidemic, cases are constantly brought 
 to hospitals and dispensaries who have passed through 
 the stage of purging before they are seen. This is a 
 matter of notoriety in every Indian hospital, and it was 
 noticed by Annesley more than half a century ago. 
 
CHOLERA 249 
 
 But the argument most fatal to this theory is that if 
 we can arrest the first sign of the disease, the diarrhoea, 
 in the vast majority of cases, we save the patient. Mr. 
 Macnamara, a distinguished pupil of the author of this 
 theory, went to India strongly imbued with it, but soon 
 learned in the school of experience that its ingenuity 
 was its only recommendation. Believe me, gentlemen, 
 cholera can purge and kill without the well-meant assist- 
 ance of the physician. 
 
 Mo7'bid Anatomy — the Blood. — The researches of 
 Schmidt, Dorpat, Robertson of Edinburgh, the late 
 Professor Parkes, and Dr. Garrod, show "that im- 
 portant changes in the chemical constitution of the 
 blood take place, and that these changes lead to 
 the loss of temperature, the embarrassed breathing, 
 and finally, the arrest of the circulation." They note 
 that both the voluntary and involuntary mechanical 
 arts of breathing are not materially affected, and that 
 the heart acts until no more blood is supplied to its 
 left cavities. 
 
 Schmidt has investigated the steps which attend the 
 transudation from the blood of the serum and fibrin 
 into the intestinal canal, and has shown the order in 
 which this takes place. " The water goes before the 
 solids of the serum, and the inorganic before the organic 
 solids. Chlorides go before the phosphates ; the salts of 
 soda before the salts of potash. The blood is left with 
 an excess of albumen and of blood-cells." Parkes, 
 calling to mind the great share taken by the blood- 
 globules in the respiratory and heat-producing processes, 
 
250 DISEASES OF TROPICAL CLIMATES lect. 
 
 concludes "that their loss of salts is connected with 
 the characteristic cyanosis and lowered temperature in 
 cholera." 
 
 The bodies of those dead of cholera resist decom- 
 position longer than others, a fact attributed to the loss 
 of water. The rise in temperature after death has 
 already been noticed, and nervous twitchings are 
 common. 
 
 Heart is unchanged ; if any blood is found in its 
 
 cavities it will be on the right side. 
 Lungs are lighter, in other respects no alteration of 
 
 structure. 
 Intestines invariably packed into a small space. The 
 small intestines contain more or less of the rice- 
 water stools, with epithelium. 
 Spleen small and shrunken. 
 Liver usually contains little blood, and weighs less 
 
 than normal. 
 Bladder empty. 
 
 Kidneys. — The changes noted by some observers, 
 particularly Lebert at Zurich, viz. enlargement 
 from congestion, both of cortical and medullary 
 substances, are certainly not common, and when 
 found are probably due to other causes, particu- 
 larly intemperate habits. 
 Treatment. — What I said of yellow fever I have to 
 repeat of cholera ; although a specific disease there is no 
 specific treatment for it. 
 
 Fremottitory Diarrhoea. — I have already said if you 
 can arrest the premonitory diarrhoea, you save the patient; 
 
XIII CHOLERA 251 
 
 hence the vast importance of early treatment. When 
 you have to deal with bodies of men, large or small, no 
 pains should be spared to bring those affected with this 
 symptom under early treatment ; nothing but frequent 
 inspection will accomplish this. An experienced medical 
 officer, or in India a well-trained medical subordinate 
 familiar with the disease, should see every man in the 
 regiment and every man on guard or other duty three 
 times a day j availing himself of the various parades, 
 roll-calls, or any other cause which assembles the men, 
 he will go down the ranks attentively observing their 
 faces. If a man has had several, or even one large 
 choleraic stool, he will carry the trace of it in his face. 
 It is difficult to describe it in words ; once seen, it is 
 easy to recognise the " drawn," somewhat pale, slightly 
 anxious countenance, with, it may be, a slightly sunken 
 condition of the eyes. Mark that man well. You will 
 soon notice by his gait that already he is weak, and that 
 if left to himself he would gladly lie down. At once let 
 all who exhibit, in however small a degree, such symp- 
 toms be brought under treatment. Place him in the 
 recumbent position, and administer a stimulating draught 
 with opium. Most medical men have a favourite formula. 
 Some give half or a full glass of brandy in hot water, 
 with 20 or 30 drops of Tinct. opii, or a smaller quantity 
 of the liquor opii sedativ. ; and it is also advisable to 
 apply a large sinapism to the abdomen, and warmth to 
 the feet. If the diarrhoea is not at once checked by 
 this, 5 or 10 drops may be given of the mixture against 
 diarrhoea in the Medical Field Companion^ with the 
 
252 DISEASES OF TROPICAL CLIMATES lect. 
 
 addition of a few drops of diluted sulphuric acid ; or 
 this mixture in a full dose with the above addition of 
 opium may be given from the first. ^ It is at this, the 
 early stage, that opium, used in a rational manner, is 
 useful. It has no place in the treatment of cholera 
 when once the patient has entered on the stage of 
 collapse. The reason is obvious : when taken during 
 collapse it is either at once vomited or retained ; in the 
 first case it is useless, in the second all experience proves 
 it is hurtful. As the patient struggles out of the algide 
 stage into that of reaction the system is embarrassed by 
 the presence of opium in the stomach which interferes 
 with nutrition, delays the secretion of urine, and thus 
 increases the risk of fatal head symptoms from uremic 
 poisoning. 
 
 The treatment of the stage of collapse resolves itself 
 into abstention from useless or mischievous medication, 
 and good nursing; the patient should have as much 
 iced water to drink as he pleases, more than this, if 
 sluggish, it should be pressed on him. To withhold 
 water is an act of useless cruelty. On the plea that it 
 increased vomiting it was long withheld. It w^as once 
 my ill fortune to have an attack of cholera. I directed 
 a confidential servant to give me well-cooled soda-water 
 to drink as long as I could swallow it. This he did, and 
 
 1 Some prefer what is known as Graves' Pill, viz. 4 grains of 
 acetate of lead, with i of opium. This is very handy on the line of 
 march, and can be given, if necessary, to the extent of three pills 
 at a proper interval, followed by the mixture in the text, t\ie formula 
 for which will be found in the Appendix. 
 
xiii CHOLERA 253 
 
 I partook of it freely. I vomited much and often ; but 
 I well remember how it refreshed me, also that I observed 
 with satisfaction the energy with which the act of vomiting 
 was performed, even projecting what I had taken through 
 an open door near my bed into the next room, which I 
 justly regarded as a proof of viability — very comforting. 
 Is the application of external heat of any avail ? I do 
 not think so. It was naturally the first thing thought of 
 when European- physicians had to treat the disease in 
 India; it has long been given up there as a useless 
 annoyance. When cholera reached England, the most 
 elaborate prepai'ations for the application of external 
 heat were made, and complete sets of hollow tin armour, 
 adapted to fit every part of the person, are to be seen as 
 relics of a past superstition in cholera hospitals at home 
 to this day. Such appliances are not only useless but 
 hateful to all patients ; and I take it we must look for 
 the explanation to the high temperature of the interior 
 of the body. Asiatics are peculiarly impatient of 
 blanketing. 
 
 You will ask me, " Can we do nothing in this stage?" 
 Are stimulants of no use in this condition of collapse ? 
 Like the application of heat this was one of the first 
 remedies thought of; it is the first to which an inex- 
 perienced man flies. The time for stimulants is, as I 
 have already said, at the first onset of the disease in the 
 stage of premonitory diarrhoea. Like opium or any 
 other remedy, it is either rejected or retained; if the 
 first it is of course useless, if the second it is hurt- 
 ful, as the collapse passes away. I affirm that the 
 
254 DISEASES OF TROPICAL CLIMATES lect. 
 
 presence of brandy is a hindrance not a help to the 
 system, and if in excess is a positive danger, delay- 
 ing the secretion of urine, increasing the febrile condi- 
 tion, and either directly promoting or increasing cerebral 
 mischief. 
 
 And here, gentlemen, let me sa}-, once and for all, 
 that remedies administered in the stage of collapse are 
 futile ; they cannot, in the existing state of the system, 
 be assimilated, even if retained, and are better left. in 
 their proper place — the dispensary : this was not the 
 opinion of a large number of practitioners in the year 
 1865-66, when cholera was epidemic in this countrj^ 
 The public were stunned by the number of " remedies " 
 clamorously announced, not in the medical press only 
 but in the newspapers. Those " remedies " were usually 
 composed of the most active drugs in the pharmacopoeia, 
 and of the most opposite action on the system. It 
 seemed as if the opinion was that every one attacked by 
 cholera must die, unless drugged with something ; and 
 if recovery took place it was credited to the "remedy," 
 whatever it was, and under the heading of a " Cure for 
 Cholera " the event was duly announced in the news- 
 papers. Some of the remedies had an element of the 
 ridiculous ; one in particular I remember, of which 
 it is hard to say whether absurdity or mischievous- 
 ness predominated in its conception. An ingenious 
 gentleman contrived an apparatus for mechanically 
 preventing the escape from the body of the cholera 
 excretions already in the intestine, in the belief that 
 he could in this manner save his patient, and in 
 
CHOLERA 255 
 
 perfect good faith published his plan as a " Cure for 
 Cholera." 
 
 Some of the "remedies" were too serious for a joke. 
 An array surgeon put forth a statement that in strychnia 
 he had found a remedy for cholera that seldom failed. 
 So confidently was this statement made that a circular 
 was issued by authority to the medical officers of the 
 army, then contending with an epidemic of cholera at 
 Malta; advising a trial of it. The dose of strychnia 
 recommended was distinctly dangerous, so much so that 
 I published in the Army Medical Department Report for 
 that year an earnest caution against its use. I have the 
 authority of the then principal medical officer at Malta 
 for saying that not only was the " remedy " useless, but 
 that all those to whom it was given in the manner 
 objected to, who survived to enter on the stage of 
 reaction, exhibited unequivocal symptoms of its poisonous 
 action. 
 
 I hope and believe that we have seen the last of 
 these "leaps in the dark;" still, I deem it my duty to 
 give you this word of caution, when you hear the cry, 
 Lo ! here is a remedy for the collapse of cholera ; 
 exercise a wholesome scepticism, more particularly if the 
 new remedy is of the nature of an active poison ; cholera, 
 believe me, can wage successful war against the human 
 race without the aid of any such alliance. 
 
 Nitrite of amyl has been recommended with reference 
 to Dr. Johnson's theory ; on that theory the recom- 
 mendation is rational. I have never seen it used, nor 
 have I met with any trustworthy records of its use. 
 
256 DISEASES OF TROPICAL CLIMATES lect- 
 
 Calabar bean has been used on account of its power of 
 expanding the peripheral blood-vessels, in other words, 
 on the same grounds on which nitrite of amyl has been 
 suggested, that is, based on Dr. Johnson's theory. I 
 have used this remedy in tetanus with success ; I have 
 no experience of it in cholera. I cannot conceive that 
 in the algide stage it can be absorbed, and am sure that 
 in that of reaction it is not required. 
 
 All this you will say is purely negative ; is there 
 nothing to be said on the positive side ? Well, my first 
 duty is to show you "how not to do it," or rather 
 attempt to do it. Undoubtedly much can be done to 
 aid the system struggling out of the algide stage into 
 that of reaction, and conducting the patient safely through 
 that stage, which is not without its dangers. In this 
 way many lives may be saved. 
 
 I have already advised that the patient should have 
 water given him ad libitum, plain or aerated as he desires, 
 in either case iced ; not given in large draughts, but litde 
 and often — or he may suck ice from first to last. If the 
 vomiting is excessive, and more particularly if it is pro- 
 longed into the stage of reaction, the epigastric region 
 may be covered with a large sinapism, or a cloth wrung 
 out of hot water, and sprinkled with turpentine may be 
 used : or the stimulating application may be applied in 
 the course of the pneumogastric nerve. Cramps are best 
 met by a few whiffs of chloroform, by the same remedy 
 locally applied, and by friction. When the first signs of 
 reaction appear the patient should be wiped dry ; if his 
 linen is damp and soiled, it should be changed without 
 
XIII CHOLERA 257 
 
 taking him out of the horizontal posture, which is in a 
 high degree dangerous. 
 
 Now should begin the assiduous nutrition of the 
 patient. I have tried a great variety of articles of diet 
 for this purpose, and have found that for the first few 
 hours nothing answers so well in the majority of cases as 
 thin water arrowroot, given in small quantities, almost 
 spoonful by spoonful, so as not to provoke vomiting ; 
 enemata of beef-tea should be given every four hours, 
 with a little brandy; iced milk is much relished, and 
 white wine whey can be given from time to time ; 
 chicken-tea, then stronger beef-tea, as the stomach can 
 bear it. To restore the secretion of urine is a point of 
 paramount importance ; dry cupping and fomentations 
 and stupes over the loins are useful ; and Macnamara 
 advises ten drops of the tincture of cantharides in water 
 every hour until a drachm has been taken. Should 
 vomiting recur, more particularly the green bilious matter 
 of which I have spoken, some Indian practitioners 
 advise calomel in full doses. Macnamara gives his 
 high authority in favour of a scruple dose. My objec- 
 tion to so " heroic " a remedy is, first, experience 
 has shown that in such doses a large part of the 
 drug passes unchanged through the system, and is 
 therefore unnecessary ; secondly, because we are cer- 
 tain to meet in practice an uncertain number of 
 people whose idiosyncrasy is such that mercury in such 
 large doses is certain to produce salivation to a dis- 
 tressing degree, without any compensating benefit, and 
 in some serious destruction of the tissues of the throat 
 
 s 
 
258 DISEASES OF TROPICAL CLIMATES lect. 
 
 and mouth. 1 Before having recourse to calomel at all 
 try the effect of ice, of counter-irritation to the epigas- 
 trium, and in the course of the pneumogastric, and of 
 drop doses of the liquor arsenicalis every half-hour, until 
 a medicinal dose has been taken. In men of intem- 
 perate habits it may be necessary to give stimulants, 
 which should be administered in beef-tea, or egg emul- 
 sion, by the rectum. 
 
 When driven by the failure of the above means to 
 the use of calomel, give it in small doses of not more 
 than from 2 to 3 or 4 grains. I speak from a large 
 experience when I say that all this remedy can effect will be 
 attained in this way without risk or the chance of serious 
 inconvenience to the physician and something worse to 
 the patient. Professor Botkin employed quinine in the 
 treatment of cholera, "the result being a mortality of 
 17.3 per cent." Happy Professor Botkin, I congratulate 
 him on his success, but venture to add that he was 
 fortunate in the kind of cholera he had to deal with. 
 And here let me remark that remedies used towards the 
 close of an epidemic often obtain an undeserved repu- 
 tation. Account for it as we may, the fact is that all the 
 world over the disease is twice as virulent and fatal at 
 the beginning of an epidemic as towards its termination. 
 
 ^ In a case of dysentery reported by Parkes (Remarks on 
 Dysenteiy), a scruple of calomel was administered without his 
 knowledge. When the stomach was opened a whitish powder 
 was seen to cover the places where numerous ulcerations on the 
 mucous surface of the large curvature were found ; and, he adds, 
 ' ' I have seen these ulcers produced by calomel in another case. " 
 So have I. 
 
xiii CHOLERA 259 
 
 There is one paramount duty on which I must insist, 
 and that is the right disposal of the excretions. To 
 permit them to be so buried as to risk contamination of 
 the water supply is nothing short of criminal. I could 
 wish, with my colleague. Professor de Chaumont, they 
 could be destroyed by fire. They should be received in 
 glazed vessels at once, strongly disinfected, and then 
 buried deeply in a safe place ; the linen and bed- 
 clothes should at once be plunged into a solution of 
 chloride of lime, then into boiling water, then, if possible, 
 exposed to a high temperature in a disinfecting chamber, 
 before being sent in the usual way to the wash. To send 
 cholera-soiled clothing to the laundry (or the dhobie in 
 India) without being dealt with in this way, I say it 
 again, is criminal. 
 
 Prevention. — This emphatically is better than cure. 
 
 In India flight is now reduced to a system as regards 
 troops. It is not optional ; the telegraph as a rule gives 
 notice in many instances of a " body of cholera " being 
 on the march, and along the great lines of communi- 
 cation its progress is reported from day to day, even 
 from hour to hour. The regulations require that within 
 a reasonable distance of all stations where European 
 troops are quartered, the quartermaster -general of the 
 division shall keep in a good sanitary condition an 
 encamping place to which the troops can be moved 
 as soon as the station is invaded. To this they go 
 at once. The strictest sanitary discipline is to be 
 observed at this camp, and if the disease clings to 
 the regiment at the new encampment, a fresh move- 
 
26o DISEASES OF TROPICAL CLIMATES leg 
 
 ment to another by a short and easy march is to 
 be made. 
 
 The rule is an admirable one, and when carried out 
 has in many instances been successful. I need not 
 dwell on the details of this measure; they are all precisely 
 laid down, and are part of the standing orders of every 
 cantonment in India. In moving from place to place 
 to escape cholera-infected spots, it is recommended to 
 march at right angles to the prevailing wind. Avoid 
 pitching on the banks of rivers ; if a river is in front 
 cross it at once and get away from it. On the line of 
 march it is well that trustworthy non-commissioned 
 officers should be supplied with pills of acetate of lead 
 and opium, 4 grains of the former to i of the latter ; of 
 these one may be given at once to any man attacked 
 with diarrhoea ; and if more than once purged he should 
 be placed in one of the carriages provided for the sick. 
 The pill can be repeated, z/" necessary, once or twice. 
 
 Avoid communication with an infected body of men, 
 and above all encamping on ground suspected to have 
 been occupied by travellers from infected places. Spare 
 no pains to secure the best water, and to guard its 
 source from contamination. Dispose of the dead so as 
 not to injure the living. In camp coffins are not avail- 
 able, but whatever the cerements be, the body should 
 be deeply buried and secured against exhumation by 
 unclean beasts of prey. In this way I have known the 
 disease to have been spread. 
 
 I have said nothing on the subject of Dr. Chapman's 
 neuro-dynamic treatment of cholera, not because it is 
 
XIII CHOLERA 261 
 
 based on a hypothesis ; I am not a scorner of theories. 
 I agree with Sir Andrew Clark " that even a false theory 
 has its uses, and, instead of hindering, hastens the 
 advance of knowledge ;" and " that when men of science 
 disclaim hypotheses, they are either unfit for their vocation, 
 or, like Newton, they are better than their creed." Dr. 
 Chapman's treatment consists in the use of the ice-bag 
 to the spine. There is evidence to show that this methoa 
 does sometimes control the vomiting and soothes the 
 patient. Once more I say, when we consider the high 
 internal temperature, even during the collapse of cholera, 
 we can to some extent understand this. Very recently I 
 saw a case of obstinate vomiting in the person of a non- 
 pregnant lady, which had resisted the usual remedies 
 very carefully applied by an able physician. The lady, 
 of her own accord, applied ice to the throat and neck ; 
 the vomiting ceased. Was this due to the sedative effect 
 of the ice on the pneumogastric nerve ? Probably. 
 
 What I say in reference to Dr. Chapman's conscien- 
 tious belief that the ice-bag offers a cure for cholera is 
 this : Every one to whom it was applied did not die. 
 Numbers of cholera patients do not die, even if they 
 have no treatment but cold water ; and at least a half of 
 the cases even in a bad epidemic recover under various 
 forms of treatment. Until evidence be forthcoming 
 that a large number of cases, not at the end but the 
 beginning of an epidemic, yield to the ice-bag, I must 
 maintain that a " cure for cholera " is yet in the future. 
 
LECTURE XIV 
 
 DISEASES OF THE LIVER 
 
 Acute Congestion 
 
 In this course I confine myself to the affections of the 
 liver, which, if not quite peculiar to hot climates, are 
 most common to them, viz. acute congestion and 
 suppurative inflammation, or, as Murchison preferred to 
 call it, "tropical abscess." 
 
 Within easy reach you have in the great work of 
 Frerichs, and those of Budd and Murchison, complete 
 treatises on diseases of the liver. All these eminent 
 men now rest from their labours, but I do not think 
 that what they have written has, on any very material 
 point, become obsolete. 
 
 India and " liver " have become inseparably associated 
 in the popular mind. Every " old Indian " is supposed 
 to have left half of that organ behind him, or to have 
 brought home with him a development of it unknown in 
 temperate climates. Yet, as Morehead pointed out, if 
 we take a large view, it will be found that this organ 
 suffers rather more from disease in Europe than in India. 
 The two affections named above are those most commonly 
 
LECT. 5IV DISEASES OF THE LIVER 263 
 
 seen there, and one of them, namely, tropical abscess, is 
 one of the most serious diseases with which you will have 
 to deal in your future career, and therefore demands 
 most careful consideration here. 
 
 There is one term I have often wished struck out of 
 our nomenclature, viz. hepatitis, acute and chronic. In 
 past years the term was used to cloak careless diagnosis. 
 I have known enlargements due to malarial fevers, 
 lardaceous and fatty degeneration, hydatid tumour, and 
 even malignant disease sent home as chronic hepatitis. 
 I have for years past in my lectures here dwelt on this 
 point ; I do not know whether or not I can take credit 
 for the fact, but a fact it is, mistakes of this kind have 
 become rare, " small by degrees and beautifully less," 
 until I may say they have ceased. 
 
 If you aspire, as I hope you all do, to accuracy in the 
 diagnosis of hepatic disease, you must make yourselves 
 masters of what the late Dr. Sibson called the " medical 
 anatomy " of the organ. Without having always in your 
 mind's eye the most intimate recollection of its size, limits 
 in every direction, and relation to other organs in health, 
 and its size and abnormal forms in disease, you will be 
 constantly led into the gravest errors. Do not suppose that 
 this knowledge is of easy acquirement. On this subject 
 Frerichs remarks, " This is a less simple matter than 
 might at first sight appear; manifold difficulties, which may 
 lead to mistakes, meet us at every step." This author 
 in his great work devotes several chapters to the relative 
 size and weight of the liver in health and in disease, and 
 to the diagnostic value of its abnormal sizes and forms. 
 
264 DISEASES OF TROPICAL CLIMATES lect. 
 
 " The surface of the hver," he goes on in the same 
 passage to say, " which is in contact with the wall of the 
 chest and abdomen, is the part of the organ upon the 
 size of which we must depend for information. The 
 extent of this surface, however, is very variable, even 
 when there is no alteration in the volume of the liver, 
 inasmuch as the position of the organ is liable to change. 
 Extension in a downward direction, such as results from 
 the pressure of tight clothing, from deformity of the lower 
 part of the chest, and softening of the hepatic parenchyma, 
 brings a larger portion of the surface into contact with 
 the abdominal wall, and so produces an apparent enlarge- 
 ment ; whilst, on the other hand, elevation of the organ, 
 and the change in position produced by distension of the 
 lower part of the abdomen, bring the anterior sharp 
 margin of the organ in opposition to the abdominal wall, 
 and thus give rise to an apparent diminution. These 
 conditions, as well as congenital and acquired mal- 
 formations of the liver, constitute our first difficulties in 
 diagnosis ; others arise from displacement of the entire 
 organ, and from the obstacles which are experienced in 
 determining its boundaries, owing to pathological changes 
 in the adjoining parts." 
 
 There are four regions which must be carefully 
 examined by palpation and by percussion when we wish 
 to map out the limits of the liver, viz. the median, the 
 mammary, the axillary, and the dorsal lines, carrying the 
 examination in every case below the false ribs. 
 
 Briefly, then, the liver occupies the right hypochon- 
 drium, the left lobe projecting into the epigastrium, where 
 
XIV DISEASES OF THE LIVER 265 
 
 it is uncovered by the arch of the ribs which conceals the 
 right lobe ; the convex surface fits into the concave base 
 of the right lung, the diaphragm being interposed ; it pro- 
 jects into the thorax, the thin lower margin of the right 
 lung separating its upper portion from the walls of the 
 chest — at this point the pulmonary note is distinct. The 
 liver from the point where the ensiform cartilage joins the 
 sternum, is directed towards the vertebral column in a 
 direction backwards and slightly downwards ; its under 
 surface is in close relation with the stomach, the large 
 intestine, and the right kidney. The right mammary line 
 descends perpendicularly from the right nipple ; in this 
 line we find the upper margin of the liver in the fifth 
 intercostal space, where, as already said, the lower margin 
 of the lung overlaps it. The right axillary line falls 
 perpendicularly from the centre of the axilla ; in this 
 line its upper margin is in the seventh intercostal space. 
 The dorsal line falls perpendicularly from the lower 
 angle of the scapula ; in this line the upper margin is in 
 the ninth intercostal space. In the right mammary line 
 the extent of dulness is 4 inches, in the axillary line 
 between 4 and 5 inches, in the dorsal line 4 inches, and 
 between 3 and 4 inches in the median line anteriorly 
 (vide Sibson's Medical Anatomy). 
 
 By the term acute congestion of the liver, you are to 
 understand active arterial congestion, not the passive 
 congestion seen in cardiac disease, or the enlargement of 
 malarial fevers. To what is this acute congestion due ? 
 Among Europeans in India, Englishmen more particularly, 
 two causes are actively engaged in predisposing to this 
 
266 DISEASES OF TROPICAL CLIMATES lect. 
 
 condition, viz. the inordinate use of animal food, and 
 indulgence in alcoholic drinks. 
 
 Our countrj'men carry to the East their flesh-eating 
 propensities, and, as a rule, are slow to understand that 
 the habit of consuming animal food two or three times a 
 da}' is in the long run incompatible with health. Meat 
 to breakfast, luncheon, and dinner is more than the 
 systems of most people in average health can turn to 
 good account in their native land, unless their habits of 
 life are somewhat akin to those of navvies. This practice 
 carried to the East, as it is by hundreds of our country- 
 men and women, has always been a fertile source of 
 hepatic disease, more particularly when any considerable 
 portion of this food is consumed in the shape of hotly- 
 spiced and rich curries. I am informed that in the 
 present day curries have gone out of fashion among the 
 upper classes of Englishmen, but our European soldiers 
 use them as much as ever. Curries no doubt enter largely 
 into the food of rich natives, but for the most part they 
 are vegetable curries, used as a corrective to the flatulence 
 induced by the great bulk of the vegetable element which 
 constitutes the greatest, and, in some castes, the sole 
 element of their diet, ghee (clarified butter) excepted. 
 The amount of animal food entering into the ration of 
 the English soldier at home is scanty enough. It is 
 different in India ; there meat is cheaper, and the pay 
 of the soldier enables him to make a considerable addition 
 to his daily allowance. I have just been reading a very 
 clever and faithful record of life in India by the wife of 
 a civilian. I quote from her diary the menu of an Indian 
 
XIV DISEASES OF THE LIVER 267 
 
 breakfast as it is in the present day. " The orthodox 
 Indian one " is thus described : " The latter (breakfast), as 
 given in ninety-nine houses in a hundred, is merely a mis- 
 timed dhtner, differing in hardly any respect from dinner 
 except in not beginning with soup. You sit dowTi to a 
 blank table covered only with flowers, and the servants 
 hand round course after course — fish, curry, cutlets, aspic, 
 game — winding up by placing finger-bowls and dessert on 
 the table ! " To the above add a meat luncheon, and, I 
 need not add, a heavy meat dinner. Of course all do 
 not eat in this way, but many do, and blame the 
 " climate " for the consequences. 
 
 With regard to over-indulgence in alcoholic drinks, 
 it is with pleasure I say it, the improvement in this 
 particular in the habits of the educated European classes 
 is greater even than at home. Time was when it was 
 far otherwise. In regimental messes, within my own 
 recollection, not to press wine or beer or spirits on guests, 
 to the verge of intoxication, was regarded as almost a 
 breach of hospitality ; the two former during, the latter 
 after dinner. I have often seen palankeen bearers in 
 waiting quietly smoking their " hubble-bubble " pipes, 
 ready to carry home the " killed and wounded " from the 
 mess-table on " guest nights." Even before I left India 
 scenes of this kind were " more honoured in the breach 
 than the observance," and excess is now as rare at a 
 mess-table as in the society of ladies, no more to be seen 
 among officers and gentlemen than the "pig-tails" of which 
 a wit long ago sung that they are "now cut off." There 
 is, however, a practice, not unknown, I am sorry to say, at 
 
268 DISEASES OF TROPICAL CLIMATES lect. 
 
 home, which prevails among young men, which I unhesitat- 
 ingly stigmatise as in a high degree pernicious ; I mean 
 what is known as " peg-drinking." The " peg " with grim 
 pleasantry refers to a nail in the coffin — " tap, tap, says the 
 hammer to the nail on the coffin-lid." The spirit in the peg 
 is by many thoughtless ones supposed to be rendered quite 
 innocuous because it pleasantly effervesces in soda-water. 
 
 Gentlemen, I ask you by precept and by example to 
 set your faces against a practice which has been the first 
 step to ruin in innumerable examples, not of health only, 
 but of all that makes life worth living. 
 
 I am glad to say, as I have already said in my intro- 
 ductory lecture, that this improvement is not confined to 
 commissioned officers and to those in the upper classes, 
 but has largely extended to non-commissioned officers 
 and soldiers, and with all the earnestness of which I am 
 capable I ask you to do all in your power to promote 
 the temperance movement in India. Excess, then, in the 
 use of nitrogenous food, and the abuse of alcoholic drinks 
 has been in the past, and to some extent still is, a pre- 
 disposing cause of acute congestion of the liver, more 
 particularly among those who lead indolent lives. 
 
 I have already called your attention to the evidence in 
 the shape of the prevalence of more or less scurvy in the 
 ranks of European regiments in India in proof that a 
 sufficiency of the vegetable element does not enter into 
 the diet of the soldier. An attempt, as you all know, 
 was made some years ago to cloak the failure of an 
 Arctic expedition from scurvy by attempting to prove 
 that it was not due to deprivation, against not medical 
 
XIV DISEASES OF THE LIVER 269 
 
 advice only, but dear-bought experience, of the vegetable 
 element in the diet of the seamen. The attempt con- 
 spicuously failed. As if to emphasise that well-deserved 
 failure, we have the record of the Swedish Arctic Expedi- 
 tion under Nordenskiold, a triumphant vindication of 
 what a diet based on sound scientific principles can do 
 to maintain health under the most trying circumstances. 
 Into this diet the vegetable element entered largely, and 
 the result, it is to be hoped, will for ever silence the 
 stupid attempts to undervalue it as an article of diet. 
 
 Some degree of congestion of the liver attends every 
 meal, and the larger and richer the meal the more 
 marked is the congestion. Those who habitually exceed 
 in this way in hot climates, and at the same time neglect 
 the regulation of their bowels are the most prone to 
 suffer from acute congestion. 
 
 The most frequent exciting cause of this condition 
 is exposure to a sudden change of temperature after 
 being heated by exertion, as after such games as 
 rackets or tennis ; when engaged in without the ob- 
 servance of the common precautions which experience 
 proves to be needful even in temperate climates. In 
 the one case an attack of catarrh or pleurisy, or rheu- 
 matism, in the other acute congestion, sometimes going 
 on to suppuration of the liver, are the consequences of 
 exposing the body to a chill from a current of relatively 
 cold air, when perspiring freely. Protection after such 
 exertion by loose light flannel clothing is as necessary 
 in India as it is at home. I call to mind some striking 
 examples not only of acute congestion of the liver 
 
270 DISEASES OF TROPICAL CLIMATES lect. 
 
 brought on in this way, but of fatal suppurative inflam- 
 mation. Martin long ago pointed out the frequency of 
 such an occurrence in Calcutta in men and women 
 coming out into the cold wind of the early morning 
 after dancing. 
 
 Acute congestion is not difficult of recognition. Its 
 symptoms are uniform and smooth enlargement of the 
 liver in all directions, with a sense of fulness always 
 amounting to uneasiness, sometimes to pain • with, if 
 the enlargement is considerable, hurried breathing, dorsal 
 decubitus, aggravated if the patient is made to assume 
 a position on his left side ; yellowness of the eyes, 
 a muddy complexion, sometimes jaundice, nausea, and 
 constipation of the bowels. Some elevation of tempera- 
 ture, malaise, and general discomfort. 
 
 Treatment. — This is simple, and generally effective. 
 The application of leeches to the side or to the verge 
 of the anus is very seldom required. The latter is an 
 operation much disliked by patients, and the bleeding 
 is sometimes troublesome to arrest. Free purgation, 
 with the application of a turpentine stupe, low diet, and 
 the use for some days of some of the bitter German 
 waters when available — the Friedrichsall, Hunyadi Janos, 
 or Pulna waters — suffices. Here let me give you a 
 word of caution as to the use of saline purgatives when 
 cholera is about. Every practitioner in Calcutta is aware 
 of the danger. Seamen who have been dissipating on 
 shore return to their ships feverish and uncomfortable, 
 and apply to their captains for a " dose of salts," which 
 is usually given, being a cheap remedy, with a liberal 
 
xiT DISEASES OF THE LIVER 271 
 
 hand, largely diluted ; the effect being first profuse 
 watery diarrhoea going on into rice-water stools, cholera, 
 and death. I call to mind a melancholy example. A 
 young engineer officer, fresh from Addiscombe, was 
 my fellow-passenger in a P. & O. steamer which I 
 joined at Madras for Calcutta ; this young man, 
 without advice, took a large dose of Epsom Salts in 
 the manner described, a few days after landing, was 
 violently purged, and died in the collapse of cholera in 
 a few hours. The disease was not prevalent at the time. 
 Chevers, I think, noticed this long ago. The fact is 
 notorious, and I have seen the same thing among 
 seamen brought to the Madras General Hospital from 
 some of the punch-houses where they have been living 
 while on shore. 
 
 Patient's should be cautioned to alter their habits of 
 life and to accommodate themselves to their novel 
 conditions, and told that after having suffered several 
 times, they will be more prone to fresh attacks from 
 slight causes ; above all, that acute congestion may be 
 the first stage on the road to suppuration, the most for- 
 midable disease to which the liver is hable. By men 
 with a tendency to congestion of the liver, animal food 
 should be most sparingly used ; and if alcoholic liquors 
 are used at all, they should be of the lightest and con- 
 sumed only in moderation. I have sometimes been 
 asked why we do not see many cases of cirrhosis of the 
 liver and its sequels in the medical wards of this hospital ; 
 the reason is not far to seek, drunkards in India find 
 shorter roads to their graves. 
 
272 DISEASES OF TROPICAL CLIMATES lect. 
 
 Suppurative Inflammation of the Liver. 
 
 This is a rare disease in temperate climates ; when 
 seen the abscess can be traced to inflammation, the 
 result of direct injury, such as a blow in the right 
 hypochondrium, or to pyaemia, from suppuration of 
 bone, ulceration of the intestines, the stomach, the gall- 
 bladder, or gall-ducts. Abscesses may form around 
 foreign bodies lodged in the liver, such as needles, as in 
 the example I show you, where there is a cavity in the 
 right lobe, with a needle two and a half inches long 
 lodged in it. This was taken from the body of a man who 
 died of phthisis. The man had swallowed the needle 
 two years before death; the pus had drained away 
 through a small opening into the duodenum immediately 
 below the pyloric orifice of the stomach. Here is a 
 remarkable specimen showing the liver perforated in 
 every direction by lumbrici, around which small abscesses 
 had formed. The gall-bladder and biliary ducts are, as 
 you observe, filled with these filthy intruders ; some 
 were found in the stomach and duodenum, in the nares 
 and frontal sinuses. The specimen was taken from the 
 body of a Maltese boy, who died of dysentery. 
 
 I have only seen one example of abscess of the liver 
 following a blow. A soldier of intemperate habits, 
 while intoxicated,' was run away with by a pony, his 
 right side coming into violent contact with a gate post ; 
 an enormous abscess followed which proved fatal. 
 Examples of pysemic abscesses of the liver following 
 
XIV DISEASES OF THE LIVER 273 
 
 suppuration in distant parts of the body are not un- 
 common in hospitals at home. Dance, Cruveilhier, 
 Jackson of Calcutta, and other authors record cases 
 of abscess of the liver following such operations as 
 cauterisation of a rectal cancer, fistula in ano, the extir- 
 pation of hsemorrhoids, and roughness in reducing pro 
 lapsus of the rectum ; the abscesses from such causes 
 result from suppurative inflammation of the hgemor- 
 rhoidal veins, and are always multiple. 
 
 I saw some years since an example of hepatic abscess 
 following long-continued suppuration near the anus ; I 
 have every reason to believe it was single. The man 
 was a miller who had never been out of Hampshire. 
 Unlike the multiple abscesses . arising from one or other 
 of the above causes, this one presented a well-defined 
 fluctuating tumour ; it was relieved by aspiration, and 
 did not recur. 
 
 To the frequent occurrence of liver abscess in 
 tropical dysentery I have already called your attention 
 in my lessons on that disease. The late Dr. George 
 Budd, who for many years was one of the physicians 
 to the Dreadnought Seamen's Hospital in the Thames, 
 believed that all, or nearly all, abscesses of the liver 
 could be traced to contamination of the portal blood, 
 either by pus, formed by suppurative inflammation of 
 one of the small intestinal veins, or by matter of other 
 kind resulting from softening of the tissues ; or by the 
 fcetid gaseous and liquid contents of the large intestine 
 in dysentery, absorbed and conveyed immediately to the 
 liver. That this pyaemic theory accounts for the multiple 
 
 T 
 
274 DISEASES OF TROPICAL CLIMATES lect. 
 
 abscesses found as a sequel or accompaniment of tropical 
 dysentery is probably quite true, but the following facts 
 published by me in 187 1 in Russell Reynolds' System 
 of Medici?ie (article, " Suppurative Inflammation of the 
 Liver," vol. iii.) proves that this theory of Budd's is too 
 exclusive. In the pathological collection here there are 
 48 specimens of abscess of the liver, most of them are 
 on the table before you ; in 34 of the cases there was 
 no intestinal lesion ; in 9 there was a dysenteric history, 
 but no trace of intestinal lesion post-??iortem; in 5 
 hepatic abscess and intestinal lesion coexisted. In 50 
 of Morehead's fatal cases of dysentery there was no 
 hepatic abscess, and in 2 1 of his fatal cases of abscess 
 there was no ulceration of the intestines. Parkes found 
 liver abscess in 21.74 per cent of his fatal cases of 
 dysentery. Waring gives the percentage of liver abscess 
 in dysentery at 2 6. 1 5 ; the same author gives 2 7 per 
 cent as the proportion of cases of liver abscess preceded 
 by dysentery. The above is proof sufficient that Budd's 
 theory is too exclusive. 
 
 Suppurative inflammation of the liver is a disease of 
 hot and malarious countries, but is not equally prevalent 
 in all. Thus it is a common and fatal disease in India, 
 while in the West Indies it is rare and the mortality 
 from it small. In both countries the temperature is 
 high, and as regards the use and abuse of alcohol, the 
 habits of our countrymen are much the same. The 
 planters, in the palmy days of West Indian prosperity, 
 to any other virtues they possessed did not add that of 
 temperance; the same is true as regards soldiers serv- 
 
XIV DISEASES OF THE LIVER 275 
 
 ing there ; new rum was abundant, and was abund- 
 antly used. The difference in diet in past days was 
 considerable. Animal food was dearer in the West than 
 in the East, and for a long time, for this reason, salt 
 meat entered largely into the soldier's ration, a fact which 
 in such a climate led to a smaller consumption than in 
 India. The insular climate no doubt exercised a salu- 
 tary influence; although the temperature in the West 
 India islands is usually high during the day, it is not so 
 continuous as in India, and the nights are cooler. More- 
 over, the air is tempered and purified by the regular action 
 of the sea-breeze in a manner quite unknown in India, 
 save in the parts of that great continent near the sea. 
 In the West Indies Europeans expose themselves to the 
 sun with comparative impunity. English soldiers in past 
 days undergoing penal discipline were made to labour in 
 the quarries and on the roads, and yet did not suffer. 
 In India this would be impossible. Excluding dysentery, 
 the causes of suppurative inflammation of the liver are 
 the same as those which give rise to acute congestion, 
 viz. excess of nitrogenous food, intemperance, sudden 
 changes of temperature acting on systems depraved 
 by the cachexia induced by residence in a hot and 
 malarial climate. Indolence and excess in eating, 
 combined with heat and malaria, are probably the most 
 active causes of the disease amongst men and women 
 in the higher classes not given to intemperance in 
 drinking. 
 
 According to Waring's invaluable statistical inquiry 
 into the pathology of abscess of the liver, out of 40 
 
276 DISEASES OF TROPICAL CLIMATES i.ect. 
 
 cases in which the habits of the sufferers were noted, 
 67.5 per cent were intemperate. 
 
 Moriid Anatomy. — There is first a stage of hj'peraemia, 
 dicnmscribed or diffiise, according to the extent of tissue 
 implicated; when cut, blood flows freely, and the cut 
 sm:&jce has a granular appearance. It is only on rare 
 occasions we have the opportunity of seeing the liver at 
 this stage. Bounding this hyperaemic part, a buff- 
 coloured ring of uncertain size is observed, sometimes 
 involving a large part of the affected lobe ; then lymph 
 is efiiised into the congested portion, which assumes a 
 pale colour; when cut into, pus spots will be seen 
 thickly distributed through the section — these pus spots 
 rapidly coali^ce and form an abscess. In a liver con- 
 taining multiple abscesses their formation will be seen in 
 all the different stages. 
 
 Abscess^ vary infinitely in number. In Waring's 
 collected cases the number varied from i to 36. 
 Parkes in one case counted 90. In the collection on 
 the tabl^ before you, 37 are single and 11 multiple. 
 You observe how they vary in position — some are 
 superficial, otheis deep-seated, circumscribed or diffuse 
 entg'sted, or limited by an ill-defined and incomplete 
 lymphy deposit ; a few are enclosed in cysts of varj'ing 
 thickness. Here is an example where the cyst is almost 
 cartilaginous, and in this jar I show you an inverted one 
 which is as thick as wash-leather; the significance of 
 this you wiU see presently. These cysts are obviously 
 formed by the consolidation and organisation of the 
 effused lymph. You observe that some of the interior 
 
XIV DISEASES OF THE LIVER 277 
 
 walls of the abscess are rugged, others are smooth ; the 
 first were of recent formation when thus preserved, the 
 others were of older standing. 
 
 Note the varied positions of the abscesses in the 
 preparations before you; in ^6 cases the abscess is 
 on the convex and upper and outer part of the right 
 lobe, on its concave surface in 3 — the left lobe is 
 affected in 7 cases — in i the abscess is intermediate, 
 and both lobes are affected in 5. 
 
 The quantity of pus will of course vary according to 
 the size and number of the abscesses. Here is a pre- 
 paration in which you observe the whole organ is 
 converted into a great bag which contained 17 pints 
 of pus, and 2 of thin serous fluid floating above it. 
 
 The quality of pus in a hepatic abscess varies ; usually 
 it is as the old surgeons used to say, " laudable,'" that is 
 of the colour, consistence, and slight odour of a so- 
 called healthy abscess ; sometimes it has a red or 
 pinkish colour, derived from blood more or less in- 
 corporated with it : this red colour it always gets if 
 discharged through the lung. If air obtains access to 
 the cavit)' of a hver abscess, as after siu-gical operations, 
 it quickly loses its laudable character, and becomes 
 offensive. 
 
 J/oJes of JDischaf^ge. — Abscesses may remain intact 
 until death, or may find issue : (i) Externally through 
 the abdominal walls ; (2) through the diaphragm into 
 the right lung or pleura : (3) into the pericardium ; 
 (4) into the stomach : (5) into the duodenum or colon ; 
 (6) into the abdominal cavity; (7) into a pouch of 
 
278 DISEASES OF TROPICAL CLIMATES lect. 
 
 peritoneum • (8) into the hepatic vein. In the pre- 
 parations before you 29 remained intact at death, some 
 tending towards the outer walls, others to the diaphragm ; 
 2 were discharged by operation ; 6 opened into the 
 right lung ; 3 into the cavity of the chest ; 3 into the 
 pericardium ; 2 into the stomach ; i into the duodenum ; 
 I into the colon, and i into a pouch of peritoneum. 
 
 Is an abscess of the liver ever absorbed ? On the 
 table are a number of portions of liver wath puckered 
 cicatricial depressions. In India I have sometimes seen 
 examples presenting appearances of this kind, and in 
 common with others have deemed them the cicatrices 
 of small abscesses that have been absorbed ; they are 
 now recognised as of syphilitic origin, particularly when 
 they contain gummatose nodules, with palpable evidence 
 in other organs of constitutional syphilis. 
 
 Morehead, however, gives 3 cases in which the 
 process of absorption had certainly taken place, and 
 another in which it was probable. In the cases where 
 absorption had evidently occurred, a " putty-like sub- 
 stance " alone remained in the cavity, identical, I pre- 
 sume, with the "cheesy matter" described as found by 
 Frerichs in similar cavities in process of closing. 
 
 In the article on "Acute Hepatitis," written by me 
 for Russell Reynolds' System of Medicine, I made the 
 following observations, and I see no reason to alter the 
 opinion there expressed. There is no disease so difficult 
 to describe as suppurative inflammation of the liver, and 
 paradoxical as the saying may be, I suspect this difficulty 
 is experienced most by those who have most experience 
 
XIV DISEASES OF THE LIVER 279 
 
 in dealing with it. There is a disease which resembles 
 it so closely in many of its symptoms, and which is 
 sometimes confounded with it, that I must advert to it 
 here — I mean inflammation of the investing capsule, the 
 perihepatitis of Frerichs and other writers. 
 
 Much of the support still given to blood-letting in 
 suppurative inflammation of the liver is based on the 
 apparent success that follows the large abstraction of 
 blood, in preventing, as is imagined, the formation of 
 abscess, whereas, in a certain number of cases, the 
 measure has been directed against this disease, which 
 has no tendency to suppuration but rather to adhesion. 
 
 Perihepatitis is met with under two forms, or rather 
 under two different conditions : first, as an idiopathic 
 disease, and secondly, consecutive to abscess of the 
 parenchyma. In the first case the symptoms resemble 
 those of pleurisy much more than those of inflammation 
 of the parenchyma ; the pain is sharper, more acute 
 and "stabbing" than in suppurative inflammation of 
 the gland ; it is much increased on a full inspiration, 
 and is like what patients call "a stitch in the side"; 
 there is no enlargement of the gland in any direction, 
 the urine is not high-coloured, but there may be some 
 febrile excitement with of course a rise in temperature. 
 The above symptoms set in somewhat suddenly, after 
 exposure to chill, or, as I have seen, from permitting wet 
 clothes to dry on the person in a cold wind. The 
 result is sometimes exudation of lymph between the 
 capsule and the gland, with adhesion, and sometimes a 
 thin layer of purulent matter. In the case of a man 
 
2So D/S£AS£S OF TROPICAL CLIMATES lect. 
 
 from India who died at Xetley from aneurism of the 
 thoracic aorta, the liver was so closely embraced by its 
 adherent capsule as to cause atrophy of the whole 
 organ. This man had a history of "hepatitis," and 
 had doubtless been treated for inflammation of the 
 parenchyma. 
 
 The second form of perihepatitis is that which is met 
 with when an abscess of the parenchyma involves the 
 capsule as it makes its way to the surface. The symp- 
 toms will vary according to the position of the abscess, 
 as we shall presently see. The important point is this : 
 when an occurrence such as I have described takes 
 place, a grave mistake in diagnosis may result, leading to 
 as grave an error in treatment. Active treatment may 
 begin on the setting in of the symptoms evidencing im- 
 -plication of the capsule by an advancing abscess, which is 
 intended to prrceyit suppuration. To put it in another 
 way, if this mistake is made, we are dealing with the 
 last link in the chain of phenomena instead of the first 
 I know no point in the whole history of hepatic inflam- 
 mation of so much importance as this. Let me illustrate 
 it by two most instructive cases. 
 
 A brother officer of mine in India, of a delicate con- 
 stitution, had suffered from dysentery, and occasionally 
 passed some muco-purulent matter by stool ; while 
 visiting me one day he suddenly had a distinct rigor, 
 with a feeling of faintness. I obser^-ed that he looked 
 ill when he arrived, and he admitted that for some days 
 he had been ailing, without any marked svmptoms 
 beyond loss of appetite, a feeling of malaise, and a dis- 
 
XIV DISEASES OF THE LIVER 281 
 
 inclination for physical or mental exertion. In the 
 evening he rallied sufficiently to drive to his own 
 quarters, some miles distant Next day he resumed 
 duty, experiencing now and then transient chills followed 
 by flushes of heat In a few days after the above he 
 was suddenly seized with acute stabbing pain in the 
 right hypochondrium, with sharp fever, followed by cough 
 and sympathetic pain in the right shoulder — in a word, 
 the s}-mptoms usually given in text-books to describe 
 "acute hepatitis." Had I seen him then, I certainly 
 would have dissuaded him from following the treatment 
 his own judgment suggested, x\z. general and local ab- 
 straction of blood, purgation, and subsequently calomel. 
 I saw him thirt\--six hours after the setting in of the above 
 symptoms, free from pain, but much prostrated, and 
 expectorating purulent matter, evidently from a liver 
 abscess discharging through the right lung. The case 
 proved fatal On examination post-morUfii I found an 
 abscess on the convex surface of the liver communicating 
 with the lung, with two other abscesses deep in the 
 substance of the same lobe, and extensive ulceration of 
 the great intestine. 
 
 I never entertained a doubt as to the true nature of 
 this case. The active treatment began when it could 
 avail nothing. The acute S}-mptoms indicated not the 
 beginning of inflammation in the parenchyma, but of 
 the capsule, a conservative process glueing it to the 
 diaphragm, and preventing extravasation of the purulent 
 matter of an abscess antecedently and insidiously formed. 
 It is certain that all the mischief revealed post-7nortem 
 
282 DISEASES OF TROPICAL CLIMATES lect. 
 
 existed long before the setting in of the acute symptoms. 
 This was clearly a case of liver abscess cpnsecutive on 
 dysenteric ulceration of the intestines. 
 
 Here is another case equally instructive, but with a 
 more fortunate issue. 
 
 A young officer, who arrived at Madras fromSecundera- 
 bad, in the Deccan, was placed under my care. He was 
 twenty-four years of age, had been two years in India, 
 and in this short time had done his best to ruin his health; 
 he was an inveterate " peg "-drinker, kept late hours, and 
 exposed himself recklessly to the sun. For days before 
 I saw him he had been ailing, eating little, but drinking 
 much, " keeping himself up " with frequent " pegs." His 
 complexion was dark and muddy, his eyes congested, his 
 breath alcoholic, his pulse did not much exceed 80, and 
 he had little fever. He made no complaint of pain; 
 his liver was enlarged, the decubitus was dorsal, but he 
 allowed me to use great freedom in the way of palpa- 
 tion and percussion without complaint ; his tongue 
 was foul, his urine was high-coloured and loaded with 
 lithates. I felt convinced that serious mischief had taken 
 place in this young man's liver. Even had I been dis- 
 posed to put antiphlogistic treatment in force, there was 
 ample reason in his habits to forbid it : the application 
 of even a few leeches to his side would have been fol- 
 lowed by delirium tremens. 
 
 Short of this I did what the case admitted of, and 
 gave orders to be called as soon as the acute symptoms, 
 which I confidently looked for, should set in. 
 
 I was soon sent for. After a sharp rigor he had 
 
XIV DISEASES OF THE LIVER 283 
 
 Stabbing pain in his right side, with fever, cough, a well- 
 marked to-and-fro sound at the base of the right lung, 
 followed soon by purulent expectoration. 
 
 My friend, Dr. Paul, of the General Hospital, saw 
 the case with me ; we were of the same mind about the 
 treatment. We well knew that before he came under 
 my observation an abscess was there, on the convex 
 aspect of the liver, and that it was now in process of 
 discharge. His strength was sustained by suitable means, 
 and an embargo placed on his "pegs." Such pain as 
 there was was allayed by fomentations. The mineral 
 acids with quinine were given, and in a short time he 
 was sent to England convalescent. There had been no 
 dysentery, the abscess was single, and from its fortunate 
 position it had taken the route of discharge which gives 
 the greatest number of recoveries. 
 
 Take home the lesson this instructive case teaches. 
 Had this young man been seen for the first time, when 
 the acute symptoms appeared, by one ignorant of his 
 antecedents and his habits, and had he been treated 
 according to routine, I think the issue would have been 
 different. Blood-letting could not have prevented the 
 formation of an abscess — that was there already — the 
 effect would have been probably to develop the formid- 
 able malady that dogs the footsteps of the drunkard, 
 certainly to weaken him ; if mercury had been given, 
 and it had acted, as it is supposed to act, viz. by pre- 
 venting the effusion of lymph, or causing its absorption 
 after effusion, the result would have been equally un- 
 fortunate : adhesion of the opposing surfaces of the 
 
284 DISEASES OF TROPICAL CLIMATES lect. 
 
 capsule and diaphragm would have been prevented or 
 destroyed, in either case the conservative operations of 
 nature would have been interrupted, and escape of pus 
 into the abdomen must have ended the case. 
 
 Symptoms. — After what I have said you will be pre- 
 pared to hear that an abscess may form deep in the 
 substance of the liver without giving rise to symptoms so 
 marked, so easy of recognition, as you might suppose, 
 from the descriptions given in some of our text-books. 
 I ask you to bear in mind that the liver is not a very 
 sensitive organ, and you cannot fail to see from the 
 examples I have given you, that acute and, so to speak, 
 loudly expressed pain in some cases indicates not the 
 beginning but the end of the phenomena. One caution, 
 however, I give you : in every case of disease that comes 
 under your care in India, keep a watchful eye on the 
 condition of this gland. I unhesitatingly say that the 
 successful treatment of dysentery has largely diminished 
 the number of cases of pysemic abscesses following 
 dysentery coming into this hospital from India — dimin- 
 ished them by more than a half. The more you are 
 successful in dealing with dysentery in its early stages the 
 less you will see of pysemic multiple abscess of the liver. 
 
 A most insidious and fatal form of hepatic abscess is 
 seen in those parts of the country where great heat and 
 concentrated malaria are combined. During the con- 
 struction of the irrigation works on the River Godavery 
 by Sir Arthur Cotton, the late Dr. Lowe of the Madras 
 Army was in medical charge of the great body of native 
 labourers employed on the works. Dr. Lowe published 
 
XVI DISEASES OF THE LIVER 2S5 
 
 in the Madras Quarterly Journal of Medicine an in- 
 teresting description of this form of suppuration of the 
 liver under the above-mentioned combination of great 
 heat and malaria, issuing from the alluvial soil largely 
 disturbed by the operations of the engineer. He tells 
 us that in numerous examples the first he saw of his 
 patients was when they presented themselves at his 
 hospital with hepatic abscesses fully developed, I do 
 not say that in Europeans, except in men far advanced 
 in malarial cachexy, you are likely to see many cases of 
 this kind, but in Asiatics, under the conditions described, 
 they are not uncommon. 
 
 The symptoms of acute hepatitis tending to suppura- 
 tion are commonly said to be a sense of fulness and 
 weight in the right hypochondrium, pain, inability to lie 
 on the left side, fever, disturbance of the digestive organs, 
 cough, sympathetic pain in the right shoulder, sometimes 
 jaundice. Let us examine the above symptoms in their 
 order. 
 
 (i) Fulness and Weight in the right Hypochondrium. — 
 This is more a sign of general congestion than of hepatic 
 inflammation. It is extremely rare that so much of the 
 liver is implicated in inflammatory action as to give rise 
 to this symptom in a marked degree. 
 
 (2) Pain. — This is always influenced by the depth 
 at which the inflammation is going on — well-marked, 
 particularly under pressure, when that is superficial, less 
 so or absent where it is deep-seated. It seems to be a 
 more prominent symptom in Algeria than in India. 
 Rouis observed it in 85 per cent of his cases. 
 
286 DISEASES OF TROPICAL CLIMATES lect. 
 
 (3) Fever. — You have in the clinical thermometer an 
 advantage over those who went before you. The thermo- 
 meter will give you an indication of great value where the 
 hand will deceive. The hand is a bad index of temperature 
 everywhere, particularly in India. It has often astonished 
 me to see how little reliance can be placed on the pulse. 
 This very day I carefully noted the pulse in the case of 
 an officer in the sick officers' quarters in this hospital. 
 This gentleman has an abscess of the liver obvious to 
 the eye and the hand, and is to have it evacuated 
 this day by operation, yet his pulse was only 90 ; during 
 the acute stage before the formation of pus it was 
 no doubt higher. As a rule the temperature in liver 
 abscess rarely exceeds 103° F. ; in India it would pro- 
 bably exceed this. 
 
 (4) Frerichs says truly that when abscess commences, 
 " the tongue becomes covered with a gray or yellowish 
 coat." The amount of gastric disturbance, loss of appe- 
 tite, and so on, will depend upon the extent of liver 
 tissue implicated, and above all on its situation. 
 Vomiting when an abscess is pressing on the stomach 
 or duodenum is hardly ever absent. Some years ago 
 I published in the British Medical Journal (ist August 
 1873) the case of a young officer, a near relation 
 of my own, for the particulars of which I was in- 
 debted to my friend and brother officer, Dr. Liston 
 Paul. This young man ascended the small hill station 
 of Rahmandroog, near Bellary ; when he reached the 
 summit he was much heated, and perspiring freely. 
 In this state he was suddenly exposed to a strong 
 
XIV DISEASES OF THE LIVER 287 
 
 current of relatively cold air ; the outcome was an 
 attack of acute hepatitis. The inflammation was, to 
 all appearance, subdued, and he was sent to Madras 
 with a view to a sea voyage. For some days he 
 was, on arrival there, sufficiently well to go about 
 without inconvenience, and was about to embark; 
 suddenly vomiting came on. Under the care of Dr. 
 Paul every rational means was tried to arrest it without 
 success ; nutrition was impossible, and after a severe 
 struggle he succumbed. Fost-morkfn examination re- 
 vealed a small abscess not larger than an orange on the 
 under surface of the liver, pressing on the duodenum. 
 Had his strength held out for a few hours longer he 
 would have been saved ; a minute opening through the 
 wall of the abscess into the bowel had already been 
 made ; in a few hours more this would have enlarged 
 sufficiently to enable the thick pus to escape, and 
 there would have been an end of the case. In this 
 way I have known patients recover when death 
 was near, even at the door. Sir Joseph Fayrer, 
 seeing the report of this case, followed it up in the 
 same journal with the results of his experience in like 
 cases. 
 
 (5) Respiration. — This is disturbed or not according 
 to the position of the inflammatory action ; this symp- 
 tom is very notable when the inflammation is on the 
 upper and convex aspect of the gland. 
 
 (6) Cough. — The last observation is applicable to 
 this symptom also ; it is invariably present when the 
 capsule is inflamed and the adhesive process between 
 
288 DISEASES OF TROPICAL CLIMAIES lect. 
 
 it and the diaphragm is in progress. The " tussa arida, 
 sicca" at this stage is a very old observation. 
 
 {']) Jawidice is a very rare symptom. Morehead's 
 experience was to the same effect. In Algeria the 
 French army surgeons appear to have seen it more 
 frequently. 
 
 (8) Urine. — This should be closely examined ; it 
 gives most valuable information, in the exquisite forms 
 of acute hepatitis, as witnessed in hot climates ; it is 
 highly febrile, and the pigment is greatly increased. 
 
 (Parkes). — In March 187 1 Professor Parkes read a 
 paper before the College of Physicians, " On some 
 points connected with the elimination of nitrogen from 
 the human body." In this paper Dr. Parkes remarked 
 that he had examined the urine in a considerable num- 
 ber of cases of hepatitis and hepatic abscess ; in some 
 instances he found abundance of urine, in others 
 scarcely any ; in some it appeared to be wanting alto- 
 gether. And it occurred to him " that the cause of 
 the difference was the amount of suppuration." When 
 this was excessive and the secreting substance of the 
 liver was almost destroyed, the amount of urine was 
 greatly lessened in a degree proportioned to the amount 
 of liver substance destroyed by the abscess. On the 
 contrary, when the liver was not suppurating, but was 
 actively congested and enlarged, with rapidly secreting 
 cells, the amount of urine and of uric acid seemed to be 
 increased. When Dr. Parkes renewed his investiga- 
 tions on this subject at Netley, I happened to have in 
 my wards a patient from India, from whose liver I drew 
 
XIV DISEASES OF THE LIVER 289 
 
 off at various times the enormous quantity of 600 ounces 
 of purulent matter by aspiration. Dr. Parkes examined 
 this man's urine. After every operation he ralhed 
 wonderfully, but he subsequently succumbed; in this 
 large jar you see his liver ; an immense abscess occupies 
 the whole of the right lobe, leaving only a very narrow 
 margin compressed by a thick cyst ; the left lobe con- 
 tains many abscesses of small size. The man had a 
 distinct dysenteric history, which accounts for the 
 multiple abscesses. This man's urine (three months and 
 a half before his death) was collected for six days, and 
 carefully analysed by Dr. Parkes. The daily nitrogen of 
 his food was determined chiefly by calculation ; after a 
 liberal allowance for excess of calculation, the daily 
 nitrogen was put at 192 grains. It was calculated that 
 in six da3'S he received 1152 grains of nitrogen; he 
 passed by the urine, as determined by burning with 
 soda-lime, during the six days 792 grains, leaving 40 
 per cent to be accounted for ; 25 grains daily were 
 allowed for bowel excretion, 150 -grains in six days — 
 leaves 210 grains to be accounted for. His temperature 
 at night was 100°, 103° when the abscess was full, which 
 ought to have increased the urea. " Considering how 
 completely the exit covers the entrance in health, the 
 retention of 210 grains of nitrogen in six days shows 
 either that the growing pus cells appropriated nitrogen, 
 or that the interruption to the proper action of the liver 
 cells hindered the formation of urea. The latter seems 
 more probable, because subsequently, after several opera- 
 tions, when the liver cells and vessels would be much 
 
 u 
 
290 DISEASES OF TROPICAL CLIMATES lect. 
 
 less compressed, and, therefore, for the time would be 
 able to act, urea increased considerably, though after 
 each operation there was no doubt a still more rapid 
 growth of pus cells." 
 
 Referring further to the disappearance of urea in 
 yellow atrophy of the liver, when sometimes every liver 
 cell is smitten with a rapid atrophy or dissolution, Dr. 
 Parkes concluded from his observations in the words of 
 Miessoner, " that withering and destruction of the liver 
 tissue is connected with an important diminution in the 
 formation of urea." 
 
 It is hardly necessary, after the above, to insist on 
 the obvious fact, that not only will a careful examination 
 of the amount of urea eliminated by the urine, be a 
 great aid to diagnosis in doubtful cases, but will enable 
 the careful physician not only to form some estimate of 
 the amount of liver tissue destroyed, and what is of more 
 importance, will enable him to decide whether, after 
 operation, suppuration is still going on. 
 
 In young sthenic subjects, who have not been long 
 -in the tropics, who have been living freely, exposing 
 themselves to the sun, and to chills afterwards, you will 
 have little difficulty in making an accurate diagnosis ; 
 the pain in the side, the impatience of palpation and 
 sharp percussion in the hepatic region, the feverish con- 
 dition and rise of temperature, the foul tongue, loss 
 of appetite, and, generally speaking, constipated bowels, 
 and the febrile urine, will, taken together, unequivocally 
 point to active hepatic mischief. Again, in hot, low-lying 
 malarial places, and particularly in the case of those whose 
 
XIV DISEASES OF THE LIVE I? 291 
 
 constitutions have been impaired by long residence in a 
 hot climate and imprudent living, the symptoms will be 
 more " silent " and insidious ; in all, the position of the 
 affected part, as regards nearness to the surface, or the 
 reverse, and the extent of liver tissue implicated will 
 exercise a marked influence on the symptoms. Once 
 more, remember how frequently pyaemic multiple ab- 
 scess of the liver follows dysentery ; let the remem- 
 brance of this fact stimulate you to careful treatment 
 of that malady, with the view to save your patient from 
 this grave complication. 
 
 Sigfts of Siippuratio7i. — These are constitutional and 
 local. The constitutional signs will depend much upon 
 the size and position of the abscess. If deep-seated 
 and small, and not interfering by its pressure on other 
 organs, these will be slight, not more perhaps than 
 a rise in temperature of a degree or a degree and a 
 half, with slight rigors and trifling night sweats. If, 
 on the other hand, a considerable part of the liver 
 tissue has suppurated, the constitutional disturbance 
 will be well marked ; the evening temperature will, as 
 a rule, be 103° F., or a few points above; the rigors 
 will be more distinct and the night sweats copious, with 
 a rise in the frequency of the pulse, not, however, as 
 I have already remarked to a high degree of frequency, 
 unless the abscess is superficial and has involved the 
 capsule ; soon the patient begins to lose flesh, particu- 
 larly if diarrhoea sets in, as it often does. If the 
 abscess presses on the stomach or duodenum, the 
 digestive functions will be interfered with, and sooner 
 
292 DISEASES OE TROPICAL CLIMATES lect. 
 
 or later obstinate vomiting will set in ; if the abscess 
 points upwards on the convex aspect and presses on the 
 diaphragm, pain in that region, hurried respiration, and 
 a dry cough will soon appear. 
 
 The local symptoms consist of swelling, more or 
 less according to the size of the abscess, in one or 
 other of the hepatic " lines," with fluctuation, if the pus 
 is not very deep-seated ; some oedema of the skin over 
 the abscess is not uncommon, and aids the diagnosis. 
 
 I cannot better finish this part of the description 
 than by giving you, as briefly as I can, the details of 
 the case of the soldier whose urine was analysed by Dr. 
 Parkes as already related, with a view to determine the 
 effects of liver-cell destruction on the amount of urea in 
 the urine. 
 
 Private T. O'K., i8th Hussars, age 31 — home 
 service, seven months ; foreign, eleven years eight months. 
 Invalided from Secunderabad, India, at which station 
 he served three years. 
 
 History. — Embarked for India in August 1858 ; had 
 good health until February 1869, when he contracted 
 dysentery, attributed to chill when lightly clothed on 
 night duty ; was in hospital until March of the same 
 year, when he returned to duty. In April he had a 
 relapse, from which he recovered in a few days. In 
 May he was admitted with acute hepatitis, and was 
 under treatment for a month, returning to duty to all 
 appearance well. Before the end of June he was in 
 hospital again with a return of his hepatic symptoms in 
 an acute form, and was under treatment for five weeks. 
 
XIV DISEASES OE THE LIVER 293 
 
 In December of the same year he was sent to Poona- 
 mallee, near Madras, the invahd depot, and embarked 
 for England on the nineteenth of that month. 
 
 On the passage home he had severe hepatic symp- 
 toms, with loss of flesh and strength, and was admitted 
 into the Royal Victoria Hospital, Netley, on the 8th of 
 April 1870. 
 
 State on Admission. — Presents a sallow, sickly ap- 
 pearance, is emaciated, skin and conjunctivae slightly 
 icteric. 
 
 Chest. — On a deep inspiration, the lower part of the 
 right side is immovable ; a line drawn from the nipple 
 round to the spine would accurately cut oif this portion. 
 The right chest on percussion is dull, posteriorly as 
 high up as the angle of the scapula, and anteriorly from 
 two inches below the ensiform cartilage to the level of 
 the nipple ; a distinct fulness of the right side is per- 
 ceptible from the sixth rib downwards, and the left lobe 
 can be traced into the left hypochondrium. The swell- 
 ing in the right hypochondrium is uniform and smooth ; 
 and the right side is larger than the left by two inches, 
 the swelling giving an obscure sense of fluctuation to the 
 finger. Veins were observed to ramify over the surface, 
 extending downwards to the abdomen. The skin was 
 harsh and dry, and pain in the right shoulder "of a very 
 wearing kind " is present at times, but has intervals of 
 ease and comfort. Decubitus dorsal — morning tem- 
 perature 99°; evening 100°, 102°, 103°; pulse 100; 
 respiration 2 o ; dry cough. 
 
 This is a rough sketch taken from nature at the bed- 
 
294 DISEASES OF TROPICAL CLIMATES lect. 
 
 side. I think it tells you more than pages of dry general 
 description. 
 
 On the following day i6 ounces of pus was drawn 
 away by aspiration from the most prominent part of the 
 swelling, between the seventh and eighth ribs anteriorly. 
 Great relief followed the operation ; the temperature fell 
 two degrees. On the next day it rose again two degrees, 
 and as the swelling was not diminished much by the 
 first operation, the aspirating needle was introduced 
 again 2 inches external to the first puncture, and 64 
 ounces withdrawn. Two hours after the operation 
 the temperature fell to 98°, the pulse to 90, and the 
 swelling of the side was less by an inch and one-eighth. 
 
 For five or six days the patient's condition improved ; 
 he took his food well, slept comfortably, had no night 
 sweats, no pain in side or shoulder, and no cough, but 
 for several nights the ward medical officer had noted a 
 slight rise in the evening temperature, and on the 
 morning of the sixth day after last operation it stood at 
 102, and as there was again an evident increase of 
 swelling, the aspirator was again used between the sixth 
 and seventh ribs about an inch anterior to a line drawn 
 from the centre of the axilla; 62 ounces of puru- 
 lent fluid were drawn off, 52 of which consisted of 
 reddish frothy-looking serum, the last 10 being thick 
 tenacious pus, quite inodorous. 
 
 The greatest relief followed the operation, the tem- 
 perature, pulse, and respiration falling as before in a 
 most remarkable manner. 
 
 The operation was repeated sixteen times after the 
 
xi\r DISEASES OF THE LIVER 295 
 
 above, and before his death, which took place on the 
 6th of October, purulent matter had found its way from 
 an abscess on the convex part of the liver into the right 
 lung, and was freely expectorated. In all, the enor- 
 mous quantity of 600 ounces of pus was drawn off by 
 aspiration. On each occasion the thermometer gave 
 the indication to repeat the operation, which was invari- 
 ably followed by great relief of all this suffering man's 
 symptoms. 
 
 This was a typical example of multiple pysemic 
 abscess following dysentery of the most aggravated kind. 
 You have in this large jar the preparation made of the 
 parts, and you can see the ravages of this terrible 
 disease. 
 
 Should a case like the one I have described fall to 
 your lot, take a shorter method with it than I did ; 
 introduce a good sized drainage tube under strict anti- 
 septic conditions. When O'Keefe's case was under 
 treatment, an aspirating apparatus was a novelty, and I 
 had more faith in it than I have now, as I shall presently 
 explain. 
 
 Prognosis. — Abscess of the liver is at best a danger- 
 ous disease, and demands a cautious prognosis. When 
 it occurs as a sequel of dysentery, for the reasons given 
 above, the prognosis must be unfavourable. 
 
 An important element is the point of discharge. An 
 abscess bursting into the pericardium or peritoneum is 
 always fatal. As a rule, the issue is seldom fortunate 
 when the discharge is into the pleura ; and not much 
 better when it points externally through an intercostal 
 
295 DISEASES OF TROPICAL CLIMATES lect, 
 
 space. When it takes place at the ensiform cartilage, 
 in other words, when the abscess is in the left lobe, 
 the prognosis is favourable. We see in this house many 
 men return from India bearing evident traces of the 
 successful discharge of an abscess at this point, and I 
 may say all the cases that pointed in this way in this 
 house have done well. Before the operation of evacuat- 
 ing abscesses by aspiration became common in India, 
 nothing was more rare than to see the cicatrix of a liver 
 abscess in an intercostal space ; we know that many 
 abscesses do point in this direction, and I draw the 
 natural inference that the issue of such cases there has 
 not been fortunate. The largest number of recoveries 
 unquestionably follows discharge through the right lung, 
 and next to that into the bowel. When air obtains free 
 access into the cavity of a liver abscess, the result is 
 seldom favourable, whatever be the position of the 
 abscess. The occurrence of much hectic, emaciation, 
 or diarrhoea is of evil omen. 
 
 It is needless to add that the prognosis is greatly 
 influenced by the abscess being single or multiple. It 
 is not always possible to give a confident opinion on the 
 question of the existence of more abscesses than one. 
 If the case is one with a dysenteric history, the pre- 
 sumption is that the abscess is multiple, and the 
 prognosis as already said is bad. If an abscess has 
 discharged, or is discharging through the lung, and the 
 patient does not improve, but continues to suffer from 
 hectic or diarrhoea, or both, and emaciates from day 
 to day, it is nearly certain that other abscesses are 
 
XIV DISEASES OF THE LIVER 297 
 
 present, and the prognosis must consequently be un- 
 favourable. 
 
 Diagnosis. — The diagnosis between suppurative in- 
 flammation and perihepatitis has already been given. 
 It is hardly possible to mistake a hydatid tumour for 
 a liver abscess ; if we attend to the history of the case, 
 a hydatid tumour is developed without pain or fever, 
 it is perfectly smooth, and usually globular in shape. 
 When percussed it communicates a peculiar thrill to the 
 finger, quite different from the sluggish movement of 
 the purulent contents of an abscess ; if a doubt remains, 
 the introduction of a fine exploring needle will settle 
 the point. 
 
 T)'eatme?it — Let me repeat at the outset of this part 
 of my subject a word of caution I have elsewhere given. 
 Before entering on a course of active treatment, look 
 narrowly into the history of the case lest .you fall into 
 the serious error already adverted to in this -lecture, of 
 mistaking the end for the beginning of the case, in other 
 words, of directing treatment to prevent what has already 
 happened. 
 
 In a disease involving such serious destructive changes 
 of structure, the first question that presents itself for 
 careful consideration is the abstraction of blood either 
 from the general system by venesection, or locally by 
 cupping or leeching. When I first went to India, a 
 medical man who treated a case of acute inflammation 
 of the liver without one or other of the above measures, 
 or both, would have exposed himself to the charge of 
 trifling with a serious case. It was my fortune to serve 
 
29S DISEASES OF TROPICAL CLIMATES lect. 
 
 under a physician, in the early days of my service, who 
 was a conscientious beUever in the necessity of bleeding 
 his patients, and who unfailingly acted on his belief. 
 I narrowly watched the results, and came to the con- 
 clusion, long before bleeding went out of fashion, that 
 in the majority of the cases it was futile, in most, hurtful. 
 Certain it is that in this gentleman's practice it availed 
 little to avert suppuration, that where it apparently did 
 avert it, the price paid for the good obtained was too 
 heavy. Believe me, gentlemen, it is easy to abstract 
 the vital fluid, but not so to restore it ; a hot and 
 malarious climate is not favourable to the growth of red 
 blood. My advice to you is, seek measures for the 
 better and more equable distribution of the blood, not 
 its diminution. No doubt bleeding will often relieve 
 pain, abate fever, and reduce the force and frequency 
 of the pulse ; but if we can attain the above ends by 
 other means, why make our patients anaemic ? I have 
 seen the signs of suppuration follow so quickly as to 
 suggest one of two conclusions, either that pus was 
 formed before the bleedings were practised, or that its 
 formation had been hastened by the proceeding. Where 
 no such untoward event followed, the effect of the large 
 abstraction of blood was to induce prostration, anaemia, 
 a long stay in hospital, and protracted convalescence. 
 
 Mercury — Calomel. — Faith in the power of this drug 
 to control inflammation of the liver was at one time 
 almost universal ; it went hand in hand with bleeding, 
 and powerfully aided that measure in blanching the 
 patient, and protracting convalescence. 
 
XIV DISEASES OF THE LIVER 299 
 
 The aim was to bring the patient as rapidly as possible 
 under the constitutional influence of the drug; the 
 theory being that if this could be accomplished, sup- 
 puration would be prevented. A mere delusion. I 
 have seen it used with this end in view by men deemed 
 exceptionally skilful in its use, and was never satisfied 
 that any good followed its use, other than could be 
 explained by its purgative action, and I have seen sup- 
 puration of the liver occur when the patient was actually 
 salivated. This was Morehead's experience also. 
 
 In Waring's short but pregnant chapter on treatment, 
 appended to his " Inquiry," he gives ample evidence 
 that at best " it is of doubtful utility," and that its free 
 use is undoubtedly "no preventive of hepatic abscess." 
 
 In thus dwelling on the futility of mercury as a 
 remedy against hepatic abscess, I feel that I am engaged 
 in what is sometimes called "pulpit exercise," putting 
 up a man of straw for the satisfaction of knocking him 
 down. I know, I have the best reason to know, that 
 the practice is obsolete. Were it otherwise we should 
 see with the arrival of every batch of invalids from India, 
 one or more of them presenting in their persons evidence 
 of excessive mercurialisation, which is not now the case. 
 My object is to fortify your minds against a possible 
 revival of the practice in the future by some enthusiast 
 with little knowledge of the bad history of this " remedy." 
 Such revivals are not so unusual in the history of our 
 art as we might wish. 
 
 The proper place of calomel in the treatment of 
 acute inflammation of the liver is as an important in- 
 
30D DISEASES OF TROPICAL CLIMATES lect. 
 
 gredient in the purgative, which should be at once 
 administered as the first step in the treatment ; free 
 evacuation of the bowels being a point of paramount 
 importance. 
 
 I have argued strongly against the practice of bleed- 
 ing, but there is a method of abstracting a small quan- 
 tity of blood directly from the liver which I should be 
 inclined to try were I again in a position to deal with 
 this disease in healthy subjects in India. On several 
 occasions in this hospital I have had the following 
 experience. We have had men admitted here with 
 symptoms pointing to the existence of hepatic abscess, 
 with, at the same time, sharp local pain in the liver over 
 well-defined limits ; into such spots I have several times 
 introduced the hollow needle of an aspirating syringe in 
 the expectation of finding pus. On applying the syringe, 
 instead of pus, 5 or 6 ounces of blood have been 
 drawn off with immediate relief of all the symptoms, 
 and without any unpleasant results. I have thus been 
 led to think that in this way, at the sacrifice of a small 
 quantity of blood in the acute stage of inflammation of 
 the organ we might look for good results. I am sure of 
 this, that I have seen this small bleeding much more 
 effective than the abstraction of twice or even three 
 times as much from the integuments over the liver by 
 leeches or cupping. 
 
 I throw this out as a hint worth trial in cases where 
 the symptoms are so acute as to raise in your minds a 
 suspicion that the direct abstraction of blood might re- 
 lieve pain and ward off the danger of suppuration. ^ 
 
DISEASES OF THE LIVER 
 
 The next step in the treatment after purgation, which 
 I advise, is the administration of ipecacuanha in a full 
 and effective dose, after the manner urged in the 
 treatment of acute dysentery ; not less than half a 
 drachm. I think you will find this to be a very effective 
 remedy ; it quiets the circulation, and the nausea and 
 diaphoresis it causes are highly conducive to the end in 
 view. I can quote the evidence of Surgeon-General 
 Massy, of Deputy Surgeon-General Laing, formerly of 
 the 23d Royal Welsh Fusiliers, both officers of great 
 Indian experience, and of many others who have used 
 this remedy, in support of its efficiency. It has the in- 
 estimable advantage, already much insisted on, that 
 unlike mercury it leaves no sting behind it. If necessary, 
 the dose can be repeated in eight or ten hours. It often 
 brings away large bilious evacuations to the manifest 
 relief of the patient. 
 
 A combination of tartarised antimony in combination 
 with nitrate of potash was much used by the late Dr. 
 Cutchliff of the Bengal army, and is very effective. Two 
 grains of tartar emetic are combined with 2 drachms of 
 nitre, and divided into 8 powders ; one is given every 
 hour or half-hour in cases where the pain is urgent and 
 the febrile condition well marked. Dr. Massy found 
 this formula very successful. 
 
 I have often, in acute cases where the circulation is 
 excited, in addition to the ipecacuanha, given aconite in 
 drop doses every quarter of an hour, until 6 or i o drops 
 have been taken with marked benefit in reducing tem- 
 perature, as well as the force and frequency of the pulse. 
 
302 DISEASES OF TROPICAL CLIMATES lect. 
 
 In addition to tlie above the side should be diligently 
 fomented ; a few drops of turpentine being from time 
 to time sprinkled on the cloth. 
 
 In a large proportion of cases the above means will 
 prove successful ; even should they fail and the case 
 go on to suppuration, the patient will be in a better 
 condition to face this process than if he had been sub- 
 jected to loss of blood and the depraving action of 
 mercury. 
 
 An abscess having in spite of your efforts formed, or 
 this having taken place before the patient came under 
 treatment, the case is converted into a surgical one, and 
 must be treated on sound surgical principles. Is the 
 abscess to be allowed to take its course, that is to find 
 a point of discharge by one or other of the routes already 
 indicated, or are we to evacuate it by operation ? You 
 will find my name often quoted in text-books as strongly 
 opposed to surgical interference. I think I had some- 
 thing to say for myself in support of my opinion in the 
 days when the surgical interference consisted in first 
 "exploring" the liver with coarse instruments in the 
 shape of large trocars, such as are used in ascites. When 
 an instrument of this kind entered an abscess its con- 
 tents were at once drawn off. Air entering took the place 
 of the pus ; the consequences were almost invariably 
 disastrous ; the relief at first from the operation was 
 always considerable ; but sooner or later, and often very 
 soon, extension of the suppurative process went on, and 
 gangrene around the orifice of the puncture generally 
 closed the scene. When nature opens an hepatic abscess 
 
XIV DISEASES OF THE LIVER 303 
 
 she effects her purpose in quite a different way. Small 
 openings are gradually made through the integuments, 
 the pus slowly drains away, the walls of the abscess con- 
 tract, little air enters, there is therefore much less chance 
 of decomposition of the contents, and of the consequent 
 destruction of tissue, and finally gangrene. Again, I 
 often had occasion to notice that when an abscess, 
 tending upwards to discharge into the lung, has been 
 " successfully " entered by the trocar, and the abscess 
 emptied, the end has been unfortunate, for the simple 
 reason that the abscess has been evacuated by the route 
 which gives the smallest percentage of recoveries, instead 
 of by that which gives the largest. 
 
 These objections, gentlemen, were not merely theo- 
 retical, they were based on a large experience. I saw 
 the method I have described carried out frequently by a 
 surgeon of no mean acquirements. I refer to the late 
 Dr. Murray, at the time I speak of, Inspector-General of 
 H.M. Hospitals in Madras, who, when I was acting 
 under his orders in the Queen's Garrison Hospital there, 
 never missed an opportunity of endeavouring to save 
 patients in this way. At Hyderabad in the Deccan my 
 experience in cases of this kind was very great. I 
 modified the operation in various ways ; I made valvular 
 openings, I used canulas, with stop-cocks to exclude 
 atmospheric air — all in vain — in spite of my efforts it 
 found access, and as antiseptics were not in those days, 
 the outcome of my efforts was rarely encouraging. 
 
 As soon, however, as proper instruments were at my 
 disposal, I venture to say that I used them, and sane- 
 
304 DISEASES OF TROPICAL CLIMATES lect. 
 
 tioned their use in. this hospital as often as any man 
 now hving. I was the first to use the syringe of Bow- 
 ditch to evacuate an abscess of the Hver, and successfully 
 too, in the case of a soldier admitted from Abyssinia, 
 Since more elaborate aspirating instruments have come 
 into use, they have been turned to account in this 
 hospital in every case deemed suitable, not only by 
 myself, but also by my much valued colleagues, Drs. 
 Fyffe, Webb, Veale, and Cherry. 
 
 With the fine needles in the aspirating apparatus the 
 liver may be searched with safety for an abscess as soon 
 as the local and constitutional symptoms indicate its 
 existence. At first I was in the habit, after emptying 
 an abscess, of waiting until the thermometer gave the 
 indication to repeat the operation. I am indebted to 
 Dr. Veale for a better method, and that is not to 
 wait, but to introduce the needle every second or third 
 day, and thus to prevent the accumulation of pus, and 
 further destruction of lung tissue. 
 
 But where the abscess is large, as evidenced by the 
 extent of swelling, I advise you to proceed in a diiferent 
 way. Evacuate the abscess, and, under the strictest 
 antiseptic method, introduce a good-sized drainage tube 
 into the cavity, allowing it to discharge into a mass of 
 antiseptic tow or other material. This method has 
 given us in this house most satisfactory results in cases 
 the most unpromising. 
 
 Is it needful to add that the patient's strength must 
 be sustained by suitable food, by the mineral acids, with 
 small quantities of quinine, and the regulated use of 
 
XIV DISEASES OF THE LIVER 305 
 
 Stimulants ; placing the patient under the best possible 
 hygienic conditions, and the most watchful care to secure 
 him fresh and pure air, and plenty of it. The recoveries 
 that take place under the above system are often very 
 surprising, and in a high degree encouraging. 
 
 It has several times occurred to me to see the good 
 effects of pure air in the case of patients seen in con- 
 sultation with some of my professional friends in South- 
 ampton. Patients landed from tropical climates dis- 
 charging an hepatic abscess, say through the lungs, go 
 at first into lodgings at a low level near the sea ; when 
 moved up to the higher parts of the town they improve 
 in a very striking manner. 
 
 In cases which have not gone on to suppuration 
 some care and watchfulness are required. The bowels 
 require to be regulated, and the best way of effecting 
 this is by the use of some of the bitter saline waters, — 
 Friedrichsall, Pulna, or Hunyadi Janos, — with a course 
 of nitro-muriatic acid, long continued, and the use of the 
 hydropathic belt already described under the head of 
 Dysentery ; and it is well to have the water-pad in this 
 apparatus moistened with water containing diluted nitro- 
 muriatic acid. Cases resisting this treatment, showing 
 symptoms usually described as those of chronic hepatitis, 
 with dull aching pain, and some degree of enlargement 
 of the liver, with loss of appetite, a muddy complexion, 
 irregularity of bowels, and loss of flesh, should be 
 sent home ; and, speaking on this point from a 
 large experience, I advise all those in this condition, 
 whose means admit of it, to seek the relief they will 
 
 X 
 
3o6 DISEASES OF TROPICAL CLIMATES lect. 
 
 surely find by a course of the waters of Karlsbad or 
 Homburg. 
 
 You may remember that I showed you a preparation 
 of a cyst that once invested a liver abscess. Here it is 
 again. You observe that it is as stout as a bit of wash- 
 leather. Now, patients suffering under symptoms of 
 acute hepatitis, followed by the signs of suppuration, 
 sometimes surprise their doctors by gradually recovering. 
 The uneasiness in the liver subsides, the signs of con- 
 stitutional irritation pass away, and they resume active 
 life, sometimes very active life. This cyst, which I hold 
 in my hand, explains it all. The abscess is there, but 
 it is cut off from the rest of the gland, it has become 
 stoutly encapsuled. In process of time, perhaps, it thins 
 at some point, and when straining at stool, or lifting a 
 neavy weight, or something of that kind, the pus, or a 
 portion of it leaks out, and alarming symptoms set in, 
 always fatal, or the contents escape with a gush — collapse 
 instantly follows. I have recorded some cases of this kind 
 in Russell Reynolds' System of Medicine, and I know of 
 several others. One was a cavalry officer who surprised 
 his doctors and friends by an apparent recovery from 
 hepatic abscess under apparently hopeless conditions, 
 who after several years of good health died suddenly in 
 the manner described. In another case, also of a cavalry 
 officer, who suffered from acute hepatitis in India, for 
 which he was sent home, the symptoms gradually sub- 
 sided, and he enjoyed life as much as most men, riding 
 to hounds with great boldness. Curiously enough, in 
 this case, it was not during or immediately after violent 
 
xiv DISEASES OF THE LIVER 307 
 
 exercise in the hunting field, but when living quietly, 
 that fatal symptoms and collapse occurred. After death 
 it was found that the cyst of a small abscess in the right 
 lobe had thinned and given way, followed by extravasa- 
 tion of the pus it had so long confined. I can give you 
 no statistics as to the frequency of this occurrence ; but 
 if you examine the preparations before you, you will see 
 that a large number of them have an investing cyst. 
 Clearly, however, it is only where the abscess is small 
 and the investing cyst stout, that the pus can be confined 
 in the manner I have described. 
 
LECTURE XV 
 
 BERIBERI 
 
 Without taking up your time in an attempt to give you 
 an explanation of the derivation of this barbarous term, 
 let me say that by universal consent it is used to desig- 
 nate a disease which, so far as India is concerned, pre- 
 vails mostly on the Malabar coast, not extending inwards 
 more than 60 miles from the sea, and most prevalent in 
 the districts known in the Madras Presidency as the 
 Northern Circars (the Five Northern), an old division 
 of that Presidency. The Five Northern Circars were 
 formerly Chicacole, Rajahmundry, Ellore, Condapilly, 
 and Guntoor ; but the tract now comprised within them 
 is divided into the districts lying along the coast occur- 
 ring in the following order, proceeding from south-west 
 to north-east — Guntoor, Masulipatam, Rajahmundry, 
 Vizagapatam, Ganjam. It is a common disease in 
 Ceylon. The district between Masulipatam and the 
 Chilca Lake extends about 400 miles along the coast, 
 and is bounded by the sea to the north-east and to land- 
 ward by deeply wooded hills, which, except in the hot 
 weather, are the most destructive to health of any in 
 
LECT. XV BERIBERI 309 
 
 India (Malcolmson). Along this coast are many belts 
 of salt and fresh water swamps, flooded by the rains 
 and high tides ; the soil is sandy, and has to a consider- 
 able extent been formed by the retirement of the sea. 
 The swamps in many places are below the level of the 
 sea, and are separated from it by sand-hills thrown up 
 by the surf and blown inland. Rice grounds freely 
 watered abound, with also a considerable portion of dry 
 cultivation. Malarial fevers, often of a malignant form, 
 are common, greatly favoured by back waters formed by 
 the overflowing tides and floods. 
 
 Beriberi is an extremely fatal disease, characterised 
 by anaemia in an extreme degree, numbness and motor 
 paralysis, chiefly of the lower extremities, scanty and 
 high-coloured urine, general oedema, with effusion into 
 the serous cavities, chiefly the pleura and pericardium, 
 occasionally acute pain and oppression at the epigastrium; 
 death occurring generally suddenly, either from dropsi- 
 cal effusion into the thoracic cavities, failure of the heart, 
 or embolism. 
 
 Causes. — These are obscure. From what I have said 
 it will be seen that the conditions of soil, climate, and 
 water are not conducive to health in the districts in 
 which it most obtains. It is towards the close of the 
 rainy season that the disease prevails most, when the 
 alternations of temperature are most considerable — 
 poverty, with what it brings in its train, want of sufficient 
 clothing to guard against the changes of weather, poor 
 food, and the long-continued action on the system of 
 impure water ; in a word, all the causes that tend directly 
 
3IO DISEASES OF TROPICAL CLIMATES lect. 
 
 and indirectly to bring about ansemia, are among the 
 chief factors. Anything like good drinkable water is 
 rare in the district where this disease is most common. 
 The late Dr. Evazard, a contemporary of mine in India, 
 dwelt on the effects of the brackish water in the Masuli- 
 patam district as one of the most powerful agents in the 
 production of the ansemia so common there. The jail 
 population in the Northern Circars, more particularly 
 when their diet was poor and deficient in anti-scorbutic 
 elements, suffered severely from beriberi. Speaking from 
 personal observation, the same cause in my time was in 
 active operation among the Sepoys serving in Burma. 
 Giving up a large part of their pay for the support of 
 their families left behind in India during their service in 
 Burma, it is notorious they pinched themselves to the 
 sacrifice of their health, living on half the allowance of 
 tood they were accustomed to in their own country ; 
 they invariably returned half-starved, and more or less 
 scorbutic, and in this anaemic condition, if exposed to 
 the climatic conditions of the beriberi districts, numbers 
 of them suffer from that disease. 
 
 This was very notably the case after the first Bur- 
 mese war among the native regiments returning from 
 that service and quartered in the Northern Division. 
 
 I am strongly of opinion that scurvy plays a much 
 more important part as a predisposing cause than is 
 generally suspected. Having inspected more than one 
 regiment recently returned from Burma, and having been 
 in medical charge of one which had served there for 
 three years, having in fact returned to India with it, I can 
 
XV BERIBERI 311 
 
 testify to the fact, that a very large proportion of the 
 Sepoys were scorbutic, and that after landing in India, 
 beriberi appeared among them, although they were 
 quartered, not in the Northern Division, but within a few 
 miles of Madras. In support of this opinion I point to 
 the fact that European soldiers in India do not now 
 suffer from the disease. In two and twenty year's service 
 there, I never saw a case of beriberi in a European ; yet 
 in bygone times it was not uncommon. Malcolmson 
 mentions deaths from it at Masulipatam in the ist 
 Madras European Regiment, and among the European 
 pensioners at Vizagapatam, and British soldiers in 
 Ceylon quartered on the coast suffered from it. Why 
 not now? I believe the chief reason is the enormous 
 improvement in the food of the soldier, and above all, 
 in the extent to which scurvy has been banished by the 
 more constant use of anti-scorbutic ingredients in the 
 ration. 
 
 Syjnptoms. — Like many other diseases we see it in 
 two forms : acute and chronic. Looking into the re- 
 corded cases collected by Dr. Malcolmson in his essay 
 on beriberi, we are struck by the suddenness with which 
 many of the sufferers were struck down without apparent 
 warning — the whole duration of the case not exceed- 
 ing twenty-four hours — with intense anaemia, paralysis, 
 general oedema, and effusion of fluid into the cavities. 
 One is led to suspect that in many cases with such a 
 history as the above, there were probably warnings in 
 the shape of symptoms either disregarded or concealed. 
 Any one acquainted with the ways and habits of native 
 
312 DISEASES OF TROPICAL CLIMATES lect. 
 
 soldiers knows their unwillingness, as a rule, to submit 
 themselves to medical treatment in hospital, where they 
 are to a great degree cut off from intercourse with their 
 families and friends. Take the following example re- 
 corded by the surgeon of the 37th Regiment Native In- 
 fantry : — 
 
 " A Sepoy belonging to the Grenadier company, a 
 remarkably stout man, was admitted into hospital on the 
 morning of the 21st October, with urgent dyspnoea, total 
 inability to move his body or limbs, which, as well as his 
 face, were much swollen, with a sensation of fulness and 
 tightness of the skin, pulse 90, full and firm — no sick- 
 ness at stomach or complaint of pain in any part of his 
 body — said he went to bed quite well last evening, after 
 a hearty supper of rice as usual, and this morning early 
 was attacked by his present symptoms. He was bled to 
 16 ounces, and calomel with squill was ordered. The 
 dyspnoea returned severely in the evening, continued all 
 night, and he died rather suddenly next morning, having 
 been ill only for twenty-four hours." There is no record 
 of any post-moi-teJti examination. 
 
 This is a typical case. Sometimes the paralytic 
 symptoms are marked, in others the dyspnoea and 
 dropsical symptoms are more urgent, sometimes the 
 paralysis is preceded by pain, it may be in the thigh, or 
 in the ankles, or low down in the lumbar region. In all 
 there is evidence of intense ansemia, more or less 
 anasarca, prostration, quick and usually small pulse, 
 temperature a degree or a degree and a half below the 
 normal, an exanguineous state of the tongue and con- 
 
XV BERIBERI 313 
 
 junctivse, and scanty urine, and, as in the case I have 
 given you, death is usually sudden. Looking over the 
 records, in my possession, as well as those in print, I find 
 " found dead in bed," a frequent entry. 
 
 In the more chronic cases the symptoms are the 
 same in kind, differing only in degree. In the acute or 
 inflammatory form there is distinct feverishness, the 
 numbness and loss of power preceding the acute oedema, 
 dyspnoea, and effusion into the serous cavities. 
 
 The form of the disease of which I have seen most 
 occurred in Sepoys returning broken down and worn out 
 by foreign service in climates uncongenial to them, 
 where they have undergone privations and used food to 
 which they were not accustomed. In some cases the 
 disease is to all appearance arrested, but often reappears, 
 and in others when least expected acute symptoms 
 supervene and the patient is quickly cut off. 
 
 Diagnosis. — -This in India is not difficult. There, in 
 the present day, it is almost entirely confined to natives, 
 and, as we have seen, mainly to those who have 
 resided for some, time in the districts where the disease 
 is endemic. The numbness, followed by motor paralysis, 
 the general oedema, the rapid effusion into the serous 
 cavities, the anaemia, the pale tongue, costive bowels, 
 and fluttering heart sufficiently distinguish it. 
 
 Prognosis., — After what has been said, this, it is evi- 
 dent, is unfavourable, the rapidity with which oedema sets 
 in, and the pericardium and pleural cavities fill, and the 
 frequency of sudden death either from this effusion, or 
 sudden failure of the heart's action from degeneration of 
 
314 DISEASES OF TROPICAL CLIMATES lect. 
 
 its muscular structure, or perhaps, more frequently than 
 from other causes, embolism must be kept in mind. 
 Statistics show it to be a disease almost as fatal as 
 cholera. The more rapid the general oedema, the more 
 urgent the dyspnoea, the more uncertain and feeble the 
 heart's action, the greater is the danger. Nausea, 
 vomiting, a dry and black tongue, and hiccup, indicate 
 danger. On the other hand, the more gradually oedema 
 sets in, the less the chest organs are affected, the more 
 favourable is the prognosis. When the digestive func- 
 tions are little implicated, and the kidneys continue to 
 secrete a fair amount of urine, a favourable issue may be 
 looked for. 
 
 Morbid Aiiatomy. — The most constant condition 
 found after death is a watery condition of the blood, 
 with an immense diminution in the number of red 
 globules, and the presence of water in every organ and 
 tissue of the body. The lungs, the heart, the substance 
 of the brain, its ventricles, the pleura, pericardium, 
 and peritoneum are all more or less charged with fluid. 
 The heart is generally enlarged, soft and flabby ; and in 
 some cases hypertrophied, the result, we may suppose, 
 of the difficulty of driving the hydrsemic blood through 
 the system. The spinal cord is almost always congested ; 
 fluid is found in the spinal cavity — conditions which 
 explain the paralytic symptoms during life. Malcolmson 
 in his essay on beriberi (1835) gives a drawing of the 
 cord, showing a mass of lymph opposite the fourth 
 lumbar vertebra, and another lower down in process of 
 becoming organised, vessels containing red blood passing 
 
BERIBERI 315 
 
 into its substance. The kidneys are usually enlarged, 
 soft, and easily torn, not otherwise diseased. 
 
 Treatment. — This, it must be confessed, is not gene- 
 rally satisfactory. As I have mentioned, numerous cases 
 from the suddenness with which urgent symptoms threat- 
 ening life appear, are seen when little time is left for 
 the action of remedies. The indications are plain 
 enough : to ward off the danger of sudden death, to 
 relieve the organs of the fluid, with which they are 
 charged, to cure the anaemia, and correct the scorbutic 
 diathesis, which I am persuaded underlies this constitu- 
 tional disorder, and to relieve the cord from the pressure 
 which is the cause of the paralytic symptoms. 
 
 When we turn to the record of treatment preserved 
 for us in the Essay of Malcolmson, so often referred to, 
 taken mostly from the case books of native regiments 
 serving in the Northern Circars, the endemic area of 
 beriberi, we are surprised to see that in a large number 
 of the cases, treatment took the shape of bleeding and 
 mercurialisation. We cannot read the history of such 
 cases without seeing how little at that time the teaching 
 of Laennec had penetrated into India. Bleeding was 
 directed evidently against the urgent dyspnoea, due to 
 the presence of fluid in the chest cavities, or to failure of 
 the heart's action, or both ; it is not difficult to under- 
 stand that against such conditions it was not only a 
 futile but a hurtful measure. Malcolmson himself 
 condemned it save in a few exceptional cases. Mercury 
 acting constitutionally could only add to the already 
 depraved condition of the blood. This, again, Malcolm- 
 
3i6 DISEASES OF TROPICAL CLIMATES lect. 
 
 son saw, and not only points out its inutility, but says 
 he has seen men have their first attack of beriberi when 
 salivated. 
 
 In cases where careful physical examination of the 
 chest convinced me of the danger of a patient being 
 " drowned out " by a great accumulation of water on 
 both sides, say nearly up to the clavicles, so that he was 
 struggling for breath and incapable of lying down, as in 
 many of the recorded cases of the acute variety, I would 
 unhesitatingly perform paracentesis thoracis by aspiration. 
 
 Where the symptoms are less urgent and time is 
 afforded for the action of remedies, I would use Bow- 
 ditch's solution of iodine to the chest (553. to gi. of spiritus 
 etheris sulphurici), maintaining with this a considerable 
 amount of stimulation of the skin. By the use of 
 digitalis, acetate of potash, and where strength admitted, 
 hydragogue purgatives, particularly the bitter German 
 waters where available, — Friedrichsall, Hunyadi, or 
 Pulna, — I would stimulate the kidneys and bowels to 
 relieve the general dropsy. 
 
 By a liberal diet, a generous allowance of good wine, 
 and steady perseverance in the use of iron and quinine, 
 I would seek to improve the condition of the blood, 
 and to sustain the heart, taking care at the same time 
 so to regulate the diet as to correct the scorbutic 
 diathesis. 
 
 The stimulating application advised for the chest 
 I would use as freely down the whole length of the 
 spine. The paralytic symptoms still continuing, as soon 
 as the more urgent chest symptoms are reUeved, I advise 
 
XV BERIBERI 317 
 
 a course of iodide of potassium in combination with 
 quinine, which often acts extremely well. To the above 
 should be added warm clothing to enable patients to 
 resist sudden changes of temperature, to which they are 
 extremely sensitive. I need hardly add that where 
 possible removal of the sick out of the endemic area of 
 the disease is a point of the first importance. 
 
 There is no condition of the system more difficult to 
 deal with than ansemia, particularly when it attains to 
 such a degree as we see in this disease. I have great 
 faith in the judicious use of arsenic in this condition, 
 and would use it freely in the chronic forms of beriberi. 
 
 I cannot pass from this subject without a remark on 
 the necessity for better treatment of native troops when 
 sent on foreign service. As the matter stands they are 
 neither fed nor clothed sufficiently, and the consequence 
 is they suffer fearfully, die in large numbers, and are 
 useless for the service on which they are sent : this is 
 a condition of things which ought not to be — it is neither 
 politic nor humane. I should hope that a reform in 
 this matter will soon take place. I have said that the 
 system of sending native troops to die on foreign service 
 because they are not properly fed and clothed is not 
 politic; the survivors who return, broken in health for 
 life from some of our wars, carry with them reports of 
 their treatment, which, circulating among the class to 
 which they belong, are not conducive to the stability of 
 our Government. 
 
 There is no man living at this time whose opinion on a 
 question of the health of our army, European and Native, 
 
3i8 DISEASES OF TROPICAL CLIMATES lect. 
 
 is of greater value than that of Surgeon-General Sir 
 Anthony Home, V.C. I have this experienced officer's 
 authority for the fact that some of the native regiments 
 sent into Afghanistan in our late campaigns were at 
 once rendered useless from scurvy, the outcome of a 
 diet defective in anti-scorbutic elements. It is time that 
 those who have to concern themselves with the food of 
 soldiers, both Native and European, in peace as well as 
 in war, should awaken to the fact that scurvy is not 
 confined to those who " go down to the sea in ships." 
 
 I must not pass from this subject without referring 
 to two remedies in much use among natives in the 
 Northern Circars in the treatment of beriberi, viz. Treak 
 Farrook and Oleum Nigrum. It was Mr. Geddes of the 
 Madras Army, who finding bleeding, mercurials, diuretics, 
 and purgatives of little use in curing his patients, first 
 tried Ti-eak Far7vok, which he found more successful in 
 removing the oedema and lowering the pulse than any 
 other remedy ; he did not find, however, that it had 
 any influence on the palsy. The composition of this 
 medicine is not known ; it is made in Venice, and 
 reached India through the Arab physicians. It professes 
 to be the Theriaca Andro7nachi. I have seen it, and can 
 confirm the description given of it by Dr. Aitken, viz. 
 that " it is a thick extract into which some terebinthine 
 material largely enters." It is given in pills in com- 
 bination with rhubarb and aromatic confection. In this 
 form it acts as a mild purgative, and although Mr. Geddes 
 in his trials did not find it effective as regards the 
 paralysis, other medical officers of the Madras Presidency 
 
BERIBERI 319 
 
 who used it, speak more favourably of it. With it, how- 
 ever, it is to be noted that a Uberal diet of "animal food, 
 wheaten cakes, and milk '"' is considered essential by the 
 Native doctors. Was it this good diet or the Ti-eak 
 Far7-ook that brought about the improvement ? 
 
 The so-called Oleum Nigrum remains to be noticed. 
 This is an empyreumatic oil prepared from the seeds of 
 the Celastrits niitaiis, a plant which grows in the jungles 
 which cover the hills of Ramteak, north of Nagpore. 
 The native name of the seeds is Malkungnee. Benzoin, 
 cloves, nutmegs, and mace enter into the composition of 
 this drug. The natives use this in betel leaf; when 
 given to Europeans it is made up into pills, which are 
 inconvenient from their size. This remedy was largely 
 used by Dr. Herklots of the Madras Army, who declared 
 he only lost i in 50 of his patients under its use, 
 while under other means of treatment he had 1 1 
 deaths out of 15 cases. Dr. Herklots gave it in 
 1511]^ doses twice a day; "the effect being to mitigate 
 the symptoms on the second day, when the oedema 
 begins to lessen ; by the fourth day the oedema is gone, 
 and the medicine is relieved." 
 
 Trials made by others, among them Malcolmson, 
 established the fact that the remedy has some power as 
 a diuretic in removing the oedema, and sometimes it 
 acted on the skin causing free perspiration without 
 exhaustion. Malcolmson found even a dose of 8 
 drops inadmissible when there is tenderness at the 
 epigastrium ; it caused pain in the stomach, a red and 
 fiery tongue, and other signs of gastric irritability. In 
 
320 DISEASES OF TROPICAL CLIMATES lect. xv 
 
 short, the experience of others does not appear to have 
 borne out the confident statement of Herklots. 
 
 I think a cautious trial of Jaborandi might be made ; 
 it would be quite as safe as elaterium, which has been 
 freely used, and not without good effects in this disease. 
 
 Bandaging the lower extremities with flannel ban- 
 dages is always a comfort to patients, and it promotes 
 absorption of the fluid. ^ 
 
 1 In the text I have pointed to the fact that beriberi is hardly 
 ever seen in the present day among European soldiers in India, 
 and I have attributed this to the great improvement in the diet of 
 the soldier. . While the lecture on beriberi is passing through the 
 press, the IC'dlniche Zeiticng reports that the Dutch European 
 forces in their Eastern possessions are suffering severely from this 
 disease. In the four years from 1879 -1883, 17,722 soldiers 
 were under treatment for beriberi. Between deaths and invaliding 
 the annual loss is said to amount to 1 100. This is not all, more than 
 half the strength of the force is reported unfit for active service from 
 the sequelse of the disease. The predisposing cause is bad food, and 
 the Dutch newspapers demand that the troops shall be better fed. 
 The Dutch are a frugal people, but they evidently have to learn a 
 lesson our ovsm authorities had to acquire in the dear school of 
 experience, that it is bad economy to save money on the food of 
 their troops serving in bad climates (Vide British Medical Jotunal, 
 7th August 1886). 
 
LECTURE XVI 
 
 GUINEA-WORM 
 
 It is not my intention to enter on the natural history of 
 this nematoid parasite known as the Filaria Medinesis, 
 or Dracunculus. You find all that is known on this 
 subject in the great work of my colleague, Professor 
 Aitken, embodying, as his chapter on the subject does, 
 the researches of Bastian, Carter, Forbes, Busk, and 
 other authors. I merely wish to invite the attention of 
 those about to serve in India, more particularly those 
 whose practice will be much among native soldiers, and 
 natives of India generally, that they will have much to 
 do with this intruder into the human body. Dr. Aitken 
 quotes a statement made by my late friend Dr. Lorimer, 
 of the Madras Army, to the effect that every native 
 regiment which has occupied the lines near the Hossein 
 Sagur tank at Secunderabad, suffered from Dracunculus. 
 Now, for more than ten years my sphere of duty as 
 Residency Surgeon at Hyderabad, within a few miles of 
 this great tank, gave me ample opportunities during the 
 months of March, April, June, and July of seeing the 
 extent to which this parasite afflicts the people in that 
 
 Y 
 
322 DISEASES OF TROPICAL CLIMATES lect. 
 
 neighbourhood. At my hospital hardly a day passed 
 without my seeing one or more, sometimes four and five 
 cases, and without our having to open one or two 
 abscesses, each containing a dead Dj'acunculus. In 
 some, by no means in all, the worm had been broken in 
 attempts at extraction, irritation, inflammation, and 
 abscess followed ; but in many instances the worm 
 was unbroken. The wandering nature of this parasite 
 is well known, and although it is generally said that its 
 favourite habitat is the lower extremity, I have found 
 these creatures presenting themselves in all parts of the 
 body, back, side, arms, and not unfrequently in the 
 scrotum. I by no means wish it to be understood that 
 all patients thus presenting themselves came from the 
 neighbourhood of the above named tank ; many did, but 
 in no part of India have I seen so many cases of 
 Dractinculus as in the out-patients of the Residency 
 Hospital. 
 
 Symptoms of the Presence of Guinea -Worm in the 
 Human Body. — It is only when the creature has ac- 
 complished its destiny, fulfilled the purpose that leads 
 it to use the human race as its host, that men are 
 conscious of its presence ; in other words, the symptoms 
 appear when the worm is making its exit. These are 
 pricking, itching, a sense of heat, then a vesicle appears 
 of varying size ; when this is opened or bursts, the head 
 of the worm appears, or this may not be for some weeks. 
 As soon as enough of the worm emerges from the 
 aperture, the custom is to wind it up on a bit of stick or 
 small twisted roll of paper. The native barbers, with 
 
G UINEA - WORM 323 
 
 their small and light hands, are great practitioners in 
 this art, and seldom break the worm ; the practice of 
 douching the part with cold water aids the extraction, 
 and this practice is universal in India. The worm is 
 usually about one or two feet in length ; some writers 
 speak of worms of six feet ; out of the many hundreds 
 of guinea-worms I have seen, I never saw one exceed 
 three feet, much more frequently from one to two is the 
 ordinary length. This mode of extracting the worm has 
 been practised in the East for ages. It is needless to 
 add that great gentleness is required in the process, for 
 although it possesses considerable elasticity, anything 
 approaching to roughness is certain to break it, and this 
 is invariably followed by local irritation, often followed, 
 as I have mentioned, by abscess. 
 
 The late Dr. Cobbold seems to have abandoned the 
 now usually accepted opinion that the worm finds access 
 to the human body through the ducts of the skin. He 
 seems to have embraced the opinion of the Russian 
 naturalist, Fedschinko, that the males and females of the 
 guinea-worm, after acquiring their larval state in the 
 bodies of certain aquatic crustaceans, are transferred to 
 the human stomach, where they copulate, producing a 
 progeny, the males then perishing and passing away per 
 anum, while the females remain, to migrate through the 
 tissues to the surface of the body. 
 
 The experiments of Forbes seem to make it clear 
 that the young guinea-worm Filarm cannot live in the 
 mucous membrane of the stomach. The fact mentioned 
 by Carter, which Cobbold quotes, viz. that out of fifty 
 
324 DISEASES OF TROPICAL CLIMATES lect. 
 
 boys bathing in a tank swarming with microscopic tank 
 worms, no less than twenty-one were attacked with 
 Dracunculus during the year ; whilst the boys of other 
 schools, bathing elsewhere on the island of Bombay, 
 were, with one or two individual exceptions, not affected, 
 does not seem to support the theory of Fedschinko, 
 rather, it appears to me, the other way. 
 
 While on the subject of worms let me mention a fact 
 that escaped my recollection when dealing with Remittent 
 Fever. 
 
 It constantly occurred to me to have children 
 brought to me, girls and boys, from the city of Hydera- 
 bad, at ages ranging from ten to fifteen, in a high fever, 
 with foul tongues, tumid beUies, and marked loss of 
 flesh. On giving to such patients pretty full doses of 
 quinine suited to their age, I have been amazed at the 
 enormous number of round worms {Ascaris lumbricoides) 
 killed and expelled after the first or second dose of 
 quinine ; as many as fifty at a time I have known 
 to be expelled in this way. After a time I became so 
 familiar with the appearance of those thus affected that I 
 could recognise them at a glance ; an almost invariable 
 appearance was rawness about the mouth, extending 
 sometimes for a quarter or half an inch on both cheeks, 
 the same raw condition appearing about the nose, the 
 result of incessant " picking " under the reflex irritation 
 caused by the presence of these intruders. The addition 
 of iron in some shape, doubtless from its action on the 
 mucus in which the worms lodge, was found a powerful 
 aid in expelling them. 
 
GUINEA-WORM 325 
 
 When on service in China in 1840-42 our men, 
 Native and European, suffered severely from the Ascaris 
 lumhricoides. Speaking from personal experience I 
 hardly know anything to equal the misery, dreadful 
 nausea, and distress caused by the presence of a large 
 worm of this kind when it finds its way into the stomach. 
 An emetic is the only remedy, which should be followed 
 up at once by quinine and iron for the destruction of 
 one or more companions left to haunt the small intestine. 
 
THE CLIMATE OF INDIA 
 
 It was my intention to have prefixed to this Summary 
 of my Lectures on Tropical Diseases an account of the 
 topography and chmate of India. I soon found that a 
 topographical description of this kind to be of any value 
 for health purposes, would require a volume nearly as 
 large as the one devoted to the diseases of the country, 
 particularly if to topography a minute account of the 
 climate of all the natural divisions of this vast region 
 was added. I have therefore determined not to add 
 to the bulk of this manual by any attempt of this kind. 
 Year by year the Government astronomers contribute to 
 the Reports of the Sanitary Commissioners of the three 
 Presidencies notes on the meteorological phenomena of 
 every month in the year ; in time very valuable data 
 will thus be accumulated, which cannot fail to be of 
 great value from a sanitary point of view. 
 
 The Royal Commissioners who inquired into the 
 health of the army of India, placed in Mr. Glaisher's 
 hands all the documents in their possession relating to 
 the climate of India ; Mr. Glaisher prepared for them a 
 short summary of the geographical distribution of atmo- 
 spheric phenomena over the peninsula of Hindostan. 
 
THE CLIMATE OF INDIA 327 
 
 " India,',' according to Mr. Glaisher, " enjoys in its 
 temperature perpetual summer on the plains ; it has 
 there no frost or snow; the heat, however, is as exces- 
 sive there in some months as the cold is in India in 
 others ; and rain is as abundant in the rainy season as 
 it is frequent in England. He shows that the observed 
 elements of climate vary with the latitude, longitude, and 
 elevation ; that there is higher temperature and a much 
 larger amount of dissolved water in the air than inEngland, 
 although the relative amount of moisture to temperature 
 is less in India. But as far as relates to the influence 
 of moisture on health, the actual amount of dissolved 
 water may be taken as indicating the amount of organic 
 matter in the air, of which water is the solvent and 
 vehicle ; and hence, although the relative amount of 
 water in the air in India is less than it is in England, 
 the atmosphere, considered in relation to the effect of 
 humidity on health, is more humid than in England. 
 
 " The sensible effects of climate in India vary as 
 widely as the physical characters of the country. On 
 the plains and deltas the climate is hot and moist with 
 considerable rainfall. In the southern parts of India 
 there is heat and dryness. On the mountain ranges 
 the temperature falls with the elevation ; and at certain 
 altitudes diminution of heat is accompanied by a per- 
 ceptibly moist condition of the air. Along the face 
 of mountain ranges exposed to the monsoon, there is an 
 excessive rainfall, to be measured by feet rather than 
 by inches, while within a short distance to leeward, the 
 atmosphere is dry and clear, with little rain. The 
 
328 DISEASES OF TROPICAL CLIMATES 
 
 climates of the seaboards vary with the direction of the 
 wind ; sometimes they are comparatively cool, while at 
 others they are warm, moist, and depressing. The 
 climates of certain mountain groups and tablelands are 
 almost as healthy as those of southern Europe ; while at 
 the base of the same mountains there are local climates, 
 which are absolutely pestilential. 
 
 " At the majority of the stations occupied by British 
 troops there is a high mean temperature, accompanied 
 with much dissolved moisture. At many of them there 
 is a considerable difference between the day and night 
 temperature, accompanied by night and morning fogs, 
 and by a feeling of coldness succeeding a high tempera- 
 ture during the day. 
 
 "Heat, moisture, and variation between night and 
 day temperature are the three special climatic conditions 
 to which the soldier in India is exposed, and except in 
 so far as the degree of humidity is the result of local 
 defects in drainage, these conditions cannot be changed, 
 unless by resorting to mountains or tablelands as sites 
 for military stations." 
 
FAREWELL ADDRESS 
 
 It may interest some of my old Netley pupils to read 
 the following farewell words addressed at the conclusion 
 of my last course to the surgeons on probation, then 
 passing through the school : — 
 
 " It is an open secret that the lecture I have just 
 finished is the last I shall ever deliver. My teaching 
 career is over ; some other duties remain to be discharged 
 before the tie that binds me to this school is severed ; 
 but when next term opens another will stand in this 
 place and address those who will occupy these benches. 
 I have determined to retire while such powers of exposi- 
 tion as I could ever boast of remain to me unimpaired, 
 before it can with truth be scornfully said that 
 ' Superfluous lags the veteran on the stage.' 
 
 " Before I was called from India to fill the chair I am 
 about to vacate, after a period of somewhat varied ser- 
 vice, ten laborious years were spent in the difficult work 
 of teaching the medical sciences to the Mohammedan 
 students through the medium of their own language ; 
 the success that attended this attempt, the first of the 
 kind in India, led to my being invited to undertake the 
 responsible duty of the Chair of Military Medicine in this 
 
330 DISEASES OF TROPICAL CLIMATES 
 
 school — a position I have held for more than twenty-three 
 years. Without affectation or mock modesty, I cannot 
 look back on these long years without a consciousness 
 of many shortcomings. Had the selection of an Indian 
 medical officer to fill this chair rested with me, another 
 would have been chosen. I can only honestly claim to 
 have done my best to acquit myself of my great re- 
 sponsibilities, and I can with truth say, that a conscious- 
 ness of those responsibilities has hardly ever been absent 
 from my mind during every waking hour of my life since 
 I undertook them. 
 
 "' Since this school was opened by the late Lord 
 Herbert, in October i860, 1476 medical officers for 
 the British Army, the Royal Navy, and the Medical 
 Service of the Government of India have passed through 
 it. Out of this large number some have died on distant 
 fields of battle, many more, with equal honour, have lost 
 their lives while doing their duty in hostile climates, far 
 from their native land. Many remain scattered in the 
 service of their country in different parts of this great 
 empire. To them my thoughts naturally turn this day. 
 They iww, and you in the early future, are and must be 
 the best judges of the kind and quality of the instruc- 
 tion given from this chair. Those who have gone out 
 into the world from this school have put to the test the 
 weapons wherewith they have had to fight the disease 
 of many climes ; if those weapons have broken in their 
 hands, then my life here has been a failure, I have 
 laboured in vain, and been an unprofitable servant. 
 
 "The price paid by this country in human life for 
 
FAREWELL ADDRESS 
 
 its greatest possession, has been, in the language of com- 
 merce, a ' long ' one. As you have often been told on 
 the authority of the Royal Commissioners, who reported 
 on the health of the army of India in 1859-60, the 
 mortality of the European portion of it oscillated round 
 the enormous figure of 79 per 1000. How stands the 
 case now ? 
 
 "In 1882 the death rate for all India was only 13.07 
 per 1000 from all causes. 
 
 " In Bengal for the same year it was 12.07. 
 
 "In Bombay it was only 10.37 j ^.nd in Madras for 
 the year 1883 (a cholera year) it was only 10 per 1000. 
 In what I have often here called the ' pre -sanitary age ' 
 
 1 have known one disease, tropical dysentery, kill i 
 in 5 of those attacked. I have known a regiment with 
 an average strength of 1098 have 2497 admissions into 
 hospital in one year, with 104 deaths, mostly from two 
 diseases, dysentery and its common sequel tropical 
 abscess of the liver; being nearly 10 per cent of 
 strength. In the same part of India in the year 1883, 
 out of a force of 13,000 men, with over 500 cases of 
 dysentery only 3 proved fatal, and malarial fevers, once 
 so destructive, in the same body of men caused only 
 
 2 deaths. 
 
 " To bring about such an enormous saving of life 
 many factors have contributed. They have all been 
 much insisted on, not only by me, but also by my 
 colleague, the Professor of Hygiene, whose province it 
 is to deal with general health questions. I do not 
 undervalue them, far from it, no one can be more im- 
 
332 DISEASES OF TROPICAL CLIMATES 
 
 pressed with their immense importance than I am. I 
 am all the more entitled to say so because, long before 
 I became connected with this school, I take leave to 
 say, there are few of the ameliorations in the life and 
 surroundings of the British soldier in India, embraced in 
 the comprehensive term ' Sanitary Reform,' that were 
 not urged by me on the attention of the authorities in 
 that country through every channel open to me, and this 
 at a time when advocacy of this kind was not always 
 pleasing to those in power, or calculated to lead to 
 personal advancement. After the largest possible allow- 
 ance has been made for the beneficent operation of the 
 means referred to, a share in the splendid results may 
 reasonably be claimed for the successful treatment of 
 disease. Notwithstanding the great sanitary improve- 
 ments that have taken place, a vast amount of disease 
 of the gravest kind remained to be dealt with by the 
 medical ofificers of the army, for the most part trained in 
 this school. Unless treatment had to a large extent 
 kept pace with sanitation, the results we contemplate 
 with so much satisfaction could not have been obtained. 
 If this is so, and the fact appears to me undeniable, we 
 may claim for this school that the money spent on it has 
 not been spent in vain, and the wisdom of those who 
 founded it has been justified. 
 
 " As another opportunity may not offer, I embrace 
 the present one to give, not an apology, but an explana- 
 tion, which is quite a different thing, in reply to a writer 
 in a professional journal who has censured the professors 
 generally, and, if I rightly understand him, the professors 
 
FAREWELL ADDRESS 333 
 
 of surgery and medicine in particular, for withholding 
 from the profession the clinical experience gained in this 
 hospital. 
 
 " Speaking on this matter entirely for myself, I must 
 explain that in the early days of my professorship I 
 began to publish, from time to time, some of the lectures 
 delivered by me here; my object being, so far as I 
 could, to keep touch as it were with old friends and 
 pupils who had left the school for duty in the service, 
 and it was my fixed purpose to continue this practice 
 from time to time as interesting and important material 
 for lessons in miUtary medicine turned up. An ' un- 
 toward event ' happened which, rightly or wrongly, I do 
 not say, defeated this intention. An epidemic of yellow 
 fever broke out in an important station in the yellow 
 fever zone, attended with a lamentable mortality. A 
 graphic narrative of this outbreak, and all the circum- 
 stances preceding and attending it, was published in the 
 following year by the principal m^edical officer who had 
 been hurriedly sent to the scene of the epidemic. This 
 was published in the Official Departmental Blue Book. 
 
 "In this outbreak 14 officers out of 30, nearly 50 
 per cent, died, 4 out of 6 medical officers, one of whom 
 had just left this school, lost their lives, and out of 290 
 men attacked 107 died. That this lamentable loss of 
 life, which took place between the 5 th and 15 th of 
 September 1864, was due to causes distinctly prevent- 
 able has never been disputed by any competent authority.. 
 This epidemic, as it was my duty to show in this lecture 
 room, did not come upon its victims without giving 
 
334 DISEASES OE TROPICAL CLIMATES 
 
 ample notice of its approach, and time for providing for 
 the safety of the troops. Warning of the coming danger 
 was given by competent medical authority, which warn- 
 ing was neglected until the day of grace was past. 
 
 " Here was an opportunity of teaching an impressive 
 lesson in military medicine by an example. Accordingly 
 I made the narrative the 'text,' as it were, of a lecture, 
 which, after delivering it here, I published. I did not 
 invent the facts, I took them as I found them in a 
 published official document, I only ' pointed the moral ' 
 of a 'tale' told by another, an eye-witness. I do not 
 pretend that the commentary was flattering to those 
 concerned, but it did not go beyond w^hat the case 
 demanded, if any lesson was to be taught from the facts. 
 
 "No sooner did this lecture appear than a great 
 storm arose and burst on my head. So far as I was able 
 to gather, the local authorities did not dispute the facts, 
 they were angry at the publicity given to them. General 
 Peel, then Secretary for War, was appealed to by those 
 who felt themselves aggrieved ; mostly, I believe, the 
 municipal authorities of the place. My lecture, by the 
 war minister's desire, was submitted to his inspection. 
 The judgment of this high authority, to whom alone 
 I was responsible, was that he had no fault to find 
 with it. At the same time with a view, I presume, to 
 prevent similar disturbances and complaints in the time 
 to come, the Secretary for War was pleased to direct 
 that in future all lectures delivered here should be 
 submitted to him before publication. From that time 
 to the present no lectures delivered in the Army Medical 
 
FAREWELL ADDRESS 335 
 
 School by any' of the professors have been pubUshed, 
 with the exception of merely formal addresses delivered 
 at the opening of the sessions, and then only for private 
 circulation. 
 
 " I wish it to be distinctly understood that I have 
 never in word or thought called in question the absolute 
 right of the Secretary for War to issue such an order. 
 That goes without saying. But, speaking in this matter 
 entirely for myself, it operated as a check on me, for I 
 am so constituted that I cannot publish under a censor- 
 ship however mild, judicious, or even generous. 
 
 " But, although for this reason unable to publish the 
 lessons delivered here, it is for you and those who have 
 gone before you to say whether or not I have withheld 
 from you the instruction I have myself acquired in the 
 magnificent field of medical observation this hospital 
 has afforded me. 
 
 " Passing from this subject, on which I have touched 
 with reluctance, let me say I do not affect to conceal 
 that it is not without a pang I find myself at the end of 
 my active life. It pains me to think that never again 
 can I see before me young, ardent, and ingenuous faces 
 looking frankly into mine, and to reflect that in the time 
 that remains to me in this life, I must be cut off from 
 intercourse that has ever been one of the greatest 
 pleasures of my life, and which I have often thought, 
 by a reflex action, has kept me young in mind if not in 
 years. 
 
 " Of the colleagues with whom I have so long 
 laboured I can hardly trust myself to speak — one is 
 
336 DISEASES OF TROPICAL CLIMATES 
 
 not whose mere name, 'appealing' as it does 'to feel- 
 ings and affections kept within the heart like gold,' is 
 a household word here, and whose work will not soon 
 die. Of those who remain, and of those who in past 
 years have been my assistants in my own department of 
 work here, I can only say I deem it a great honour and 
 distinction to have been thought worthy to be their col- 
 league and fellow-labourer, and I assure them my feelings 
 of warm friendship can pass away only with myself. 
 
 " One word more, I wish, were it only as a parting 
 memorial of the deep and abiding interest I take in the 
 future of this school, to express a hope, I can do no 
 more, that it will long continue to fulfil the purpose for 
 which it was established \ that the fundamental principles 
 on which it was based and has hitherto rested, will be 
 respected. They were settled by a wise and far-seeing 
 statesman and man of affairs, aided by educational 
 experts the most competent of their day. All educa- 
 tional institutions are of course susceptible of improve- 
 ment, but every point in the constitution and government 
 of the school was carefully thought out, and I am certain 
 cannot be tampered with without danger to the whole 
 fabric. It is a matter of the greatest satisfaction to me 
 that I am to be succeeded by a medical officer of 
 distinction, a gentleman who has filled a position of 
 importance in one of the medical colleges in India, 
 where he has made for himself a high reputation as a 
 professor of medicine, a practised teacher in full 
 possession of those powers of exposition which are 
 rarely to be found in men who have not been in 
 
FAREWELL ADDRESS 337 
 
 positions where alone such powers can be acquired and 
 cultivated. 
 
 "And now, gentlemen, not to prolong a parting 
 scene which is painful to me, and cannot I believe be 
 pleasant tcTyou,' let^me thank you for the courtesy with 
 which you have, one and all, invariably listened to 
 nae, and accepted my anxious efforts to do my duty in 
 fitting' you for your responsible duties ; let me wish you 
 God-speed, and with my warmest wishes for your future 
 health, happiness, usefulness, and honour, bid you, so 
 far as my position as a teacher is concerned, a long 
 farewell." 
 
APPENDIX 
 
 Dr. WARBURG'S TINCTURE 
 
 1^ Aloes (Socotr.) libram. 
 Rad. Rhei (East India). 
 Sem. Angelicce. 
 Confect. Damocratis ; ana uncias quatuor (of the London 
 
 Pharmacopoeia of 1746). 
 Rad. Helenii (s. Enulte). 
 Croci sativi. 
 Sem. Foeniculi. 
 
 Cretae prasparat, ana uncias duas. 
 Rad. Gentianse. 
 Rad. Fedoarire. 
 Pep. Cubeb. 
 Myrrh, elect. 
 Camphor. 
 Bolet. Larcis ana unciam. 
 
 The above ingredients are to be digested with 500 ounces proof 
 spirit in a water-bath for twelve hours, then expressed, and 10 
 cxmces of disulphate of quinine added ; the mixture to be replaced 
 in the water-bath till all be dissolved. The liquor, when cool, is 
 to be filtered, and is then fit for use. 
 
340 APPENDIX 
 
 MARTIN'S ACID BATH 
 
 Pure concentrated hydrochloric acid by measure 3 parts. 
 Strong nitric acid 2 parts. 
 Mix the two acids carefully and slowly, so as to avoid evolution 
 of heat. After 20 minutes add distilled water 5 parts, and mix the 
 whole carefully. 
 
 For a foot or sponging bath, 6 ounces of the above acid mixture 
 is to be added to 2 gallons of water at 98° or 100° F., and well 
 mixed. 
 
 FORMULA FOR THE DIARRHCEA MIXTURE 
 IN THE "FIELD COMPANION" 
 
 ^ 01. Anisi. 
 01. Cajeput. 
 01. Juniperi aa 5iss. 
 ^■Etheris gss. 
 
 Liquor Acid Halleri 5ss. w' 
 
 Tine. Cinnam ad oii- 
 Dose — Ten drops every quarter of an hour in a tablespoonful of 
 water. 
 
 Shake the bottle before pouring out each dose. 
 
 Printed by R. & R. Clark, Edinburgh. 
 
■MM 
 
 
 . ■ .,;'x#l'#*''^l>l_. 
 
 , . J' V J:.:J''.VP.[.V'' lilS^H