ORGANS OF RESPIRATION. 33 On the Influence of the Contractility of the Lungs and of Respiration upon the Circulation 34 On the Condition of the Respiration in Disease 36 Remarkable Effects of the Inhalation of Chloroform in 37 Further Observations on the Cause of Tuberculosis Dr. J. G. Atkinson 38 On the Co-existence of Tuberculosis with Cyanosis; 39 On the Action of Cod-liver Oil as a Curative Agent in 40 On Expectoration as a Means of Diagnosis 41 On the Appearance of the Gums in Consumption 55 On a Case Illustrative of the Habitat of the Sarcina 67 On the Action of various Remedies in Diabetes 68 Diabetes treated by Alkalies 69 On the Treatment of Diabetes Mellitus by Rennet 72 On Morbid Conditions of the Urine connected with 78 On Extemporaneous Woven Wire Bandages, Splints, &c. 79 Description of a New Splint 80 Lifting Apparatus for Beds.-The Lawson Bed Transferer 81 On the Pedunculated Exostosis of the Long Bones 82 On the Treatment of Fractures of the Base of Cranium 83 On Diseases of the Joints 84 Mode of Examining the Hip-joint in Disease 85 On the Treatment of Hip-joint Disease 86 On Conservative Surgery, as applied to the Treatment of Diseases and Injuries of Joints 87 On Suppuration of the Joints from Infection of the Blood 88 On the Treatment of Anchylosis and Contractions of the Knee and Hip-joints by Forced Rupture 89 On the Excision of Joints 90 Cases of Excision of the Head of the Femur 91 On Excision of the Knee-joint 92 Cases of Excision of the Knee-joint 93 On a Case of Incision into the Knee-joint AUTHOR. PAGE E. Stanley, Esq. 155 156 and the 94 On a Case of Inflamed Bursa of the Patella; Evacuation of the Fluid 95 On Amputation at the Ankle-joint 96 On a Modification of Syme's Operation at the Anklejoint; Non-Excision of the Astragalus 97 On Disease of the Ankle and Tarsal Joints 98 Cases of Excision of the Wrist-joint 99 On Disease of the Carpus; Excision of the Wristjoint 100 Case of Excision of the Proximal Phalanx of the Thumb 101 On the Thickness of the Articular Cartilages at Different Periods of Life in the Human Subject 102 On Flap Amputation of the Thigh, Arm, and Fore-arm, producing very efficient Stumps 103 On the best Means of producing a good Stump after the Operation of Amputation Thomas Wakley, Esq. 198 104 On Cases of Popliteal Aneurism 105 On Injections of Perchloride of Iron as applied to the Treatment of Aneurism 106 On the Preparation of the Solution of Perchloride of Iron 107 On the Treatment of Nævi by Perchloride of Iron ride of Iron 110 On a Case of Spontaneous Gangrene ALIMENTARY CANAL. 111 On the Operation for Cleft Palate 112 Two Cases of Inguinal Hernia, in which the Sac was pushed back with the Intestine 113 On a New Rupture Truss, with Screw Adjustments PRACTICAL MEDICINE. &c., &c. DISEASES AFFECTING THE SYSTEM GENERALLY. ART. 1.-ON FEVER. BY DR. WILLIAM STOKES, Regius Professor of Physic in the University of Dublin. [The peculiarities of fever, as a disease, are of a negative kind: it is a disease which has no known or constant anatomical character, because even in the most marked cases of the disease, the patient may die, and yet the most skilful pathologist can detect no lesion or anatomical change in any of the structures of the body to explain the cause. Dr. Stokes remarks] I believe that we may go thus far and say, that when the fatal diseases of the world are considered, the malady which destroys most men is a disease in which there is no anatomical character. You all naturally ask, "If this be so, how did the French school come to commit the extraordinary error of declaring that in every case of fever there was an anatomical character ?" The reason is simply this, that they committed a great error in medical philosophy,-that of inferring the nature of a disease from the observation of its phenomena in one locality. Had Broussais and his followers studied fever in the wards of the Dublin hospitals, or had they gone abroad and examined fever in the West or in the East Indies, or on the coast of Africa, we should have heard nothing of the doctrine that fever was symptomatic of this or of that local disease. We find, moreover, that fever is a disease of periodicity-that it runs a certain period, varying in different epidemics and different individual cases. We find, further, that it is a disease in which a double danger affects the patient. One of these dangers is, that of death from simple depression; for so far from fever being a disease of plus vitality, it is a disease of minus vitality-a general condition, if we may so speak, of minus vitality, which of itself is often quite sufficient to destroy life, and the patient may die, and very often does die of debility alone. The poison of fever has thus a directly depressing influence on the system. But there is another condition, and this is what I wish to draw your attention to very strongly,—that, in the course of that special mode of life which we call fever, a liability exists to the production of secondary diseases. You will get a good general notion of this by con sidering the ordinary phenomena of a case of small-pox. The patient is taken ill; he has shivering, pain, fever, and he remains in this state for several days. And then we observe vesicles appearing on the surface, those vesicles filling with pus, afterwards drying, and then disappearing. No man will say, that the fever was symptomatic of the eruption. It is exactly the reverse; the eruption is the result of the fever. So it is with typhus. The local diseases are generated by the general. There is this difference, however, between what we term continued fever and the exanthemata that while in the latter the local disease is almost always, but not necessarily always, accompanied by certain characters, as, for example, in variola there is a certain kind of eruption, in scarlatina and in measles a certain condition of the skin,-it is not so with respect to the secondary diseases of typhus. Now this is a most remarkable circumstance connected with continued fever, that the secondary diseases are inconstant. They are doubly inconstant, in their seat, and in their amount; and, in the same epidemic, we see the greatest possible varieties in the seat and in the amount of those secondary affections. However, between the exanthemata and typhus fever there is this point of resemblance, that the secondary affection is utterly incompetent to explain the general phenomena of the disease. So that we may say, with regard to the secondary affections in typhus fever, that they are inconstant XXIX.-2 and incompetent to explain the disease. But they are of very great importance. It may be asked, what are those secondary diseases? are they inflammation? The present condition of medical science furnishes this answer;-they are not inflammation in a vast number of cases, when you consider them in their early stage, but in many instances, after they have existed in this non-inflammatory state for a certain time, there comes on a reactive irritation, and we have then a mixed condition. This is the history of the ulcerations of the intestine. In the beginning we find tumefaction and infiltration, but without any appearance whatsoever of inflammation. It has been proved, that in a vast number of cases the disease goes no further, and there is retrocession of the swelling and of the infiltration, just as we see retrocession of the eruption of small-pox; but, in others, the parts into which this typhoid matter has been infiltrated take on a reactive inflammation, and then we have a combination of the essential disease and of the local disease, which is now inflammatory, though it was not so at first. We shall have abundant opportunities of proving this. The treatment of fever is reducible to a simple formula. We cannot cure fever: no man has ever cured fever. Fever in this sense may be called incurable, because we don't know how to cure it. It is, however, curable by itself. If you leave it to its own course, it will often cure itself. The great object, then, is to preserve the patient's life from the dangers which threaten him, pending the existence of that condition of fever-of this special state of life. If you can keep him alive to the fourteenth day, or the eighteenth day, or the twenty-first day, he will recover. What are the dangers that occur in these cases? One I have already pointed out to you it is the danger of debility; the other is the danger arising from the accidental secondary affections. We cure the patient by preventing him from dying. We lead him on to that period when, by the extraordinary law of the disease, it will itself spontaneously terminate. We prevent him from dying of exhaustion, by food, by the use of stimulants, and by tonics. We save him from the danger which the local diseases may expose him to, by meeting them as early as we can discover them And herein lies the whole secret of the treatment of fever-to preserve the patient, at the least expense to his constitution, up to the time when, by the natural law, the disease will spontaneously subside.Med. Times and Gazette, Jan. 21, 1854, p. 55. [Dr. Stokes observed that since the period when he gave a systematic course on the subject of fever, his views on that disease had altered. He says:] Although we formerly held that the local alterations were secondary to the fever -that they were really symtomatic of the fever, not the fever symtomatic of them, as Broussais taught yet we did not sufficiently recognise the fact, that in most cases the inflammatory action associated with them was itself secondary to the local lesion that it was reactive, and, as such, had less pathological value than the local change which preceded it. Again, the opinions which were then inculcated as to the influence which the local diseases had in causing a fatal result must be in at least two respects modified. I formerly was of opinion that death in fever was mainly to be attributed to the virulence or number of the local diseases. Such is not my opinion now; for, although in examining the bodies of many patients who have died by fever, we find various local alterations, yet they are often insufficient to account for death. And we have had abundant proofs that the typhus state itself may cause death, without any manifest local disease in any part of the system. In another, and seemingly opposite point of view, our opinions have changed. For I think, that so far at least as the lungs are concerned, we did not sufficiently estimate the danger produced by the local disease independent even of the re-active inflammation. To this point I shall hereafter draw your attention more fully. We too exclusively considered the local affections as inflammations, though secondary to the fever; and did not sufficiently admit them as special typhous lesions or deposits, which might occur without any inflammatory action, or precede it. To sum up, then; whatever be the changes that may have occurred in my opinions about fever, they are rather developments of the doctrine formerly taught than its rejection, or the substitution of any essentially opposite view. In all point relating to the essentiality of fever, the influence which the law of periodicity exerts upon its phenomena, the secondary nature of its local affections, and, lastly, its contagious character, my views remain unchanged. But on those points to which I have already alluded, the alteration of our views is important as bearing on prac |