bique. I had frequent opportunities of observing the prophylactic effect of the quinine wine. In only one instance did fever follow its use, and that was of a mild character. This contrasts strongly with the seizure of a whole boat's crew with fever in March, 1851, when no wine was administered, as it was lost in crossing the bar of the river. The men greatly prefer it to the bark."

"The gig was detached in the Boom-kittam; quinine wine, in the usual dose, was given night and morning, and continued for fourteen days after its return. A boy, (William Roberts), from dislike to the quinine, took at most but three doses. He was the only one of the boat's crew that suffered from fever, which occurred ten days after leaving the river."

"While coaling at Sierra Leone, the weather was very wet, and on their several duties both men and officers were unavoidably much exposed to the rain. An extra allowance of grog and quinine was given to each man, and continued afterwards for a day or two to such as seemed to require it. Mr. however, placed no faith in its preventive influence, and would not take it, and he alone suffered an attack of fever, which proved fatal."

"A boat's crew, belonging to the Pluto, were employed for twentyfive days, up the Congo. The wine was regularly supplied, but it caused one of the men to vomit, and therefore he discontinued its use; he was the first to suffer from fever. Only one other case occurred among the crew.'

"During our stay in the river Lagos quinine wine was regularly offered to the men morning and evening, all took it, I believe, except two midshipmen and two seamen belonging to the galley. These four persons subsequently each suffered a severe attack of fever." While, in the whole force, consisting of upwards of 220 men, there occurred only a few other cases of trifling importance.

"When in the river Lagos the men had more than an ounce of quinine wine morning and evening, and not a case of fever occurred, though the vessel was nine days in the river."

"Thirty-six men belonging to the Water Witch were employed at the attack on Lagos; they were in the river four or five days, and, with the exception of three, all took quinine wine while there, and for fourteen days after they left it. Of the whole number, five only were attacked with fever, namely, the three men who did not take the wine, and other two, who most imprudently exposed themselves to the sun, and bathed while much heated by violent exercise."

"On the morning of the 25th of November, seventy-seven men from this ship went up the river Lagos, to attack the town. Before starting, every officer and man were ordered to take a glass of quinine wine; and a sufficient quantity was put into the boats to repeat the same at night. All, to the best of my knowledge, took it, with the exception of Mr. D., master's assistant, who rather plumed himself on having escaped taking a dose of physic. This young gentleman, on the 10th

of December, just a fortnight after, was seized with a violent attack of remittent fever; and of the whole number who entered the river, he is the only one who, up to this date (the 7th of Jan.) has been attacked.Med. Times and Gazette, Jan. 7, 1854, p. 6.

3. ON THE TREATMENT OF FEVER, AS ILLUSTRATED BY ABOUT 80 CASES IN THE ROYAL FREE HOSPITAL.

By DR. WILLIAM BRINTON, Senior Physician to the Hospital. [These cases have extended over a period of twenty months, and in this paper Dr. Brinton gives the chief points worthy of remark, and endeavours to connect the pathology with the rational and successful treatment employed. Of seventy-seven of the cases grouped as fever, forty-six were typhoid, and twenty-one typhus; of the other ten, seven were mild typhoid, and two mild typhus. Dr. Brinton then proceeds to say:]

It is hardly necessary for me to dilate upon the marked contrast of symptoms upon which this diagnosis was generally based. In most instances of but moderately severe fever it is scarcely too much to say that the distinction between typhus and typhoid is ultimately as evident as that between measles and scarlatina. Two symptoms alone would often suffice to distinguish them from each other-the character of the rash on the skin, and the presence or absence of the signs of ulceration in the bowels. Thus in typhoid, the eruption appears late, has a rose colour, is thinly scattered, and fading in one place, gradually gives way to a new and equally sparing crop elsewhere: and ulceration of the solitary and agnimate follicles is invariably present. While in typhus, the rash is a single, thick eruption, of a darker colour, coming out at the beginning of the second week, and gradually fading, without any replacement by a fresh crop.

It is impossible to avoid seeing that such a contrast is a very strong argument for the real distinctness of the two diseases. To say nothing of this vast difference in the eruption, let any one figure to himself two maladies, which, though attended by constitutional symptoms common to themselves and to various other complaints, differed in the fact, that a particular set of cutaneous glands in a specific region—such as the convolute glands of the axilla-did and did not suppurate and ulcerate in the two respectively. Or let him imagine two kinds of plague, one with, and one without, axillary buboes. Surely he would call these two distinct diseases. And yet neither of these imaginary contrasts would be one whit more remarkable than that which really exists in the typhoid and typhus fevers. Nor does morbid anatomy ever sustain a more direct or faithful relation to pathology than where, as in this instance, it reveals a characteristic lesion, the mere sight of which would generally cause it to elude a superficial inspection.

But although these two symptoms often decide the nature of any particular case, still they are frequently insufficient to establish what may be called an useful diagnosis—I mean such an early diagnosis as is almost necessary to the proper treatment of these diseases. Here, as elsewhere, though a slight symptom, or hasty glance at a case, will often betray its nature to a practised observer-just as in out-patient practice the twitch of a nostril sometimes puts us on the track of thoracic mischief, or the aspect of the skin warns us to expect renal disease-still a satisfactory diagnosis demands the condensation into one focus of all the light that various circumstances can throw upon it. The rash alone often fails us: and before the end of the first week, is absent from even the typhus fever. And a great many of the milder cases of both forms, especially of such as occur in young and well-nourished subjects (where the fever often seems to be eliminated by critical sweats,) never exhibit any rash at all. Again, in many of these patients the typhoid eruption is represented by one or two scattered spots, which few but those very familiar with the disease would like to accept as its pathognomonic marks. In similar subjects the rash of typhus is often equally indistinct, appearing as an indistinct mottling, that can only be seen in a good light, or in some particular position of the surface it occupies. But even in the absence of all distinct eruption, the hue of the skin will often distinguish the case. For before the appearance of the rubeoloid spots, the skin of the typhus patient sometimes exhibits an amount of dusky redness and turgor, which can scarcely be mistaken for the limited, feverous flush on the face of the typhoid patient,-contrasted, as the latter generally is, by a peculiarly white and velvety character of the skin covering the surface of the body between the scattered rose-coloured spots.

The evidence afforded by the state of the bowels is equally late and uncertain, not to say unsatisfactory. For though, as regards the earlier stages of typhus and typhoid, it may be laid down that constipation is certainly the rule in the former disease, and the exception in the latter; yet, on the other hand, not only does this law often fail to apply, but there are many cases of typhoid where purging is absent throughout; and, conversely, of typhus where violent diarrhoea is added to the abdominal symptoms of tympanites and pain so common in very severe cases. Thus, out of the nineteen cases of typhus alluded to, three were fatal, and each of these had been preceded by diarrhoea of considerable severity. But in all three the intestines were both predicted and found to be free from any structural lesion. It seems not improbable that such diarrhoea is essentially nervous, being an indirect result of the cerebral disturbance which had caused death, While upon this topic I may mention that several examinations of typhoid subjects lead me to think that excessive frequency of the purging in this disease is connected with an extension of ulceration to the solitary follicles of the large intestine, rather than to its spread in the ileum itself;-a fact that confirms the truth of a valuable remark

VOL. XXIX.

which we owe to Dr. Baly, as to the prominent share taken by the first of these parts of the alimentary canal in severe diarrhoea generally.

Dismissing a variety of minor aids to diagnosis which but rarely come into use, such as the mere length of the attack, the peculiar odour of the sweat and other secretions, I may allude to one which would almost have enabled me to name every one of the entire group of seventy-seven cases. This is the remarkable manner in which the physiognomy of the two diseases is, as it were intensified, when seen in a number of cases that affect the epidemic form. Thus, during the earlier part of the period I have mentioned, almost all the cases were typhoid; while, latterly, I have scarce treated any but typhus. In both these groups the slighter diagnostic marks of colour and appearance became so evident when compared in several instances lying side by side, that many of the cases in which the rash was but illmarked could be identified at once; while even where it was quite absent there was little difficulty in coming to a probable conjecture. And happily most of the cases where diagnosis is thus doubtful, only require a very uniform and simple treatment.

Before passing on to describe the remedies pursued, I may briefly diverge to two points connected with the pathology of fever. The first is, the date from which we ought to fix the access of the disease, a circumstance of some importance in estimating the length of the attack. Thus it is quite useless to accept the statements of the patients themselves, who, if of the poorer classes, will sometimes continue at work long after the appearance of even the graver symptoms, and if among the affluent, are often "laid up by those premonitory to the disorder itself. It is evident we want some more trustworthy symptom than one which is often regulated by the mere necessity or power of endurance-a symptom which shall be at once of marked character, and not too long duration. Such a symptom is afforded by the first onset of shivering and pain in the back. It is so characteristic, that there are very few patients who do not both notice it at the time, and remember it afterwards; and as it rarely lasts more than two or three days, it affords a date the average errors of which are scarcely more than twenty-four hours either way.

The next point is one which concerns the question as to whether typhoid and typhus are varieties of one fever or two specific diseases. Distinct as they are in most of their characters, such as duration, symptoms, anatomy, and geographical distribution, it is probable that many still doubt whether they are not essentially one and the same malady. The doubt ought I think to be small, although at present we are perhaps bound to remember it. It is obvious that a decision will rest mainly upon the answer given to two questions. (First.) Does each of these propagate itself, and never the other? (Secondly.) Does the imperfect protection which each appears to afford its subject against a future attack, only apply to itself, or does

it extend to the other disease? To the first question we can hardly expect a very satisfactory affirmative, so numerous are the channels of contagion which remain open to the most secluded individuals. But as regards the second, if, in deference to many of the best authorities, we assume this protection, it would probably not be difficult to get better information. The kind of information wanted, I may illustrate by the statement of a man whom I treated for unmistakable typhoid, and who assured me that he had had a fever which his surgeon called typhus about six months before. More trustworthy instances of this kind would be very valuable.-Lancet, Dec. 17, 1853, p. 568.

[Where Dr. Brinton sees the patient in the early stage he follows the old plan, first giving an emetic. He says:]

The following were the reasons which induced me to do so. Whatever view we may take of the nature of the fever poison, and of the mode in which it reproduces itself in the fluids or solids of the organism it attacks, we have good grounds for conjecturing that it is really removed and eliminated from the system by the various secretions and exhalations of the body;-which latter thus contribute (at least indirectly, and perhaps directly) to the arrest of the disease. Now it seems to me that we can scarcely accept this view without admitting another proposition as a corollary to it-namely, that when the chief stress of the symptoms falls on any particular glandular surface, causing the increased flow of a more or less perfect secretion from it, this action represents a determination of the poison thither, and an effort of nature towards its elimination thence. And hence, where the secreting surface is one not easily disorganized, and amenable to the influence of drugs, it is important to try whether stimulating it to increased action will not help to eliminate the poison, and thus to mitigate the disease. Indeed as respects the skin, some such view as this appears to be commonly entertained and acted upon, both in this and other disorders, where a spontaneous local determination is often aided and increased by diaphoretics, to the great benefit of the patient. And it is probable that we may extend this view to the stomach. For the vomiting of all the exanthemata is so specific in its date and characters, as evidently to have some direct connexion with the disease--a connexion not unlikely to be that of elimination just mentioned. And as regards the action of emetics, I may add that I have been able to establish a point of great interest and importance, explanatory of their value, not only in this, but in other disorders. On injecting a solution of tartar-emetic into the veins of a dog, this mineral was shortly afterwards found occupying the fluid contents of the animal's stomach, in a state of concentration far exceeding that in which it must have been mixed with the mass of the blood. So that it would appear, that whatever the share taken by the stomach itself in the vomiting, this act will at least fulfil the object of removing the drug from the system. And presuming that during the