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It has been judiciously observed in regard to intermittents in which the affection of a given organ is more strongly marked than those symptoms which characterise the disorder as an intermittent, that the affection thus evolved or brought out by the miasma of ague may require a special treatment distinct from, or even at variance with, that which its simple periodicity would suggest. In this point of view the supposed affection may be less appropriately called a masked intermittent, than a tendency to phlegmasia brought into an active state as often as the system is disturbed by the paroxysms of the intermittent. This disturbance, however, if of an inflammatory nature, may not terminate with the paroxysm except in appearance; but the system may be brought gradually into a condition in which the intermittent type may be lost, and a continuous disorder substituted.

The same discriminative tact is wanted here as in another equally indefinite disorder-Hysteria, in which a phlegmasia may easily combine itself with the nervous affection; a view of the subject, I apprehend, far more frequently applicable than that suggested by the terms simulating, proteiform, &c., often used as descriptive of hysteria. The disorder which this hypothesis represents as simulated is really existent, and must receive its specific treatment, modified by the judgment of the practitioner as he may best use it.

The above remarks may claim some importance in reference to the present state of intermittent diseases in our country. Ague has declined in frequency. But may we not in some degree exaggerate the effect of

presumed improvement in drainage and cultivation of land as the cause of this diminution? Is it not in some degree a change in the form of an endemic?

The frequently intermittent type of neuralgic disorders, their general susceptibility of benefit from those remedies which are specific in agues, is well known. But it is scarcely conceivable that so great a change should have been effected in the features of periodical disease as the substitution of head-aches, or an epileptic seizure, or a nervous pain, for a rigor, with its subsequent febrile accession, without grounds being at the same time afforded for a careful revision of our practice under these varied circumstances. Nor is this consideration weakened by the remark of Dr. Macculloch, in his valuable work, that the use of the most energetic remedies is in the neuralgic intermittent precisely the same as intermittent fever.

The questions to which an inquiry of this kind would give rise are threefold:

1st. How far the specific remedies of ague preserve their ante-periodic influence under these altered circumstances of the disorder ?*

2dly. How far this ante-periodic influence is in such cases safe or beneficial?

3dly. What other remedies have acted with apparent benefit as ante-periodics in such cases?

* Dr. Hunt, in his recent work on Tic Douloureux, has exhibited an intimate acquaintance with these remedies in the above relation.

CHAPTER VIII.

CONNECTION OF CEREBRAL WITH PULMONARY

DISEASE.

THE dependence of apoplexy with disease of remote organs is widely noticed. Its occurrence in this kind of connection with pneumonia is illustrated in the following cases :

A. B., a large, full, healthy-looking man, was brought into Carroll's ward in a state of insensibility, and died almost immediately. It appeared that he had been employed in the workhouse in bodily labour, and seemed in good health up to the moment of his seizure with apoplexy, that morning. He was described as having the day before eaten an enormous dinner of pork, &c. He went to bed apparently well.

AUTOPSY.The membranes of the brain were healthy, but the convolutions flattened. A very large coagulum, with some fluid blood, distended the lateral ventricles. The basilar artery was of great size; there were slight appearances of ossification in many arteries of the brain. The aorta was of great size, but healthy; the heart normal. The right lung almost uniformly in a state of red hepatization, portions from every part of it sinking in water; the left lung being gorged with blood, but perfectly crepitant. The stomach very

large; no solid contents in it; its walls thin; its surface having a colour exactly similar to that of coffeegrounds vomiting. The other viscera healthy.

In a patient of one of my colleagues, who died on the 15th of March, I observed the following appearances on examination the following day. In the upper and anterior part of the right lateral portion of the brain, the first slice removed from it disclosed a very large sanguineous effusion connected with and filling the right ventricle, and a part of the left. Between it and the cortical substance to which it was closely subjacent, the small intervening space of medullary substance was softened; and in this softened substance was a large branch of an artery, with a patent mouth. Whether this was the breach through which the blood had flowed, or whether it was divided by the knife, I cannot tell. It grated under pressure, and contained small osseous points. The heart and aortic valves were normal; in the arch of the aorta were small bony deposits.

The right lung was uniformly and firmly hepatised, of a deep red colour, all but a portion of the upper lobe, which was emphysematous.

All the other viscera were healthy.

On inquiry, I found that this man, aged 78, of a very muscular frame for his age, had been sent into the infirmary from the workhouse, on the morning of the 12th, in a state of imperfect coma, having been apparently well the night before. Except during the last twenty-four hours of his life he could be roused so far as to answer questions. It was ascertained that he had

been in a state of constipation for many days; and the nurse of the ward told me that he was known to be a

very large eater. A scruple of the Pulv. Jalapa c. Hydrarg. Chlorid. had been given him on coming in, and afterwards a drop of Croton Oil. His bowels were then largely relieved, with no mitigation of apoplectic symptoms. He vomited, only in the course of the last day, what appeared to the nurse to have a fæcal character.

In the first of these cases certainly, and in the latter probably, the pneumonia was antecedent to the apoplexy. In both it may be remarked, with nearly equal degrees of confidence, that the pneumonia ran its course with an insidiousness equally important both as regards the subsequent apoplexy, and on its own account.

On the inquiry set on foot in the spring of the same year, as to a presumed mortality of infants and children in the Marylebone Infirmary, I had occasion to notice to the Commissioners the remarkable freedom from pyrexia, and other customary symptoms of inflammation, under which pneumonia attacked these children during that spring and the preceding winter. Cough occurred, and a slightly quickened respiration, without any dyspnoea or raised temperature of the skin. After the symptoms had lasted a few days, the ear would generally observe extensive large crepitation over a lobe of the lungs. If at this time the patient sunk and died, extensive red hepatization, or a carnified appearance, with infiltrated pus, was discovered. If the patient lived longer, or finally escaped, the mea