120 ACCOTNT OF THt EPIDEMIC FEVER IN .

food and clothitng exerted a power, not less than that those deduced from the same facts by Dr. Rigby and imputed to them in connection with dyspepsia. T'he Dr. Prout. On these and other diseases mentioned in accuracy of the above statemenit might, were it neces- the table, I must reserve my remarks to future op- sary, be illustirated by an analysis of the data on which portunities. the tabular results are founded. In conclusion of the present communication, I may The disease, which in point of frequency next briefly state, that the memoranda from which the table claims attention, is bronchitis, with which catarrh is drawn, were in the first instance preserved by me, is associated, to avoid the unnecessary multiplica. with the view of obtaining, for iny own observation tion of names. It is enough on this head to observe and use, sometlhing bordering on correct statistical that most, if not all of the cases under this division, knowledge of the prevailing diseases of the locality. were sub:acute or chronic in character, atid a large If froni this and other similar papers, any benefit arise proportion of them occurring -daring infancy- and to the realers of the Provincial Medical and Surgical thildhood. The number may be -consid.red small Journal, I shall consider my time well spent. when the topographical peculiarities of Suniderland are considered ; but, it is to be remembered, that the cases (To be continued.) in question were seen at mY own bouse, and that very few of them were in their acute stage. Hfence they cannot be regarded as any inidex of the actual preva- lence of bronchial affections in 'this locality. From SOME-ACCOUNT OF THE EPIDEMIC FEVER other sources of information, I would say that the inflammatory affections of the respiratory system are WHICH PREVAILED IN LIVERPOOL, IN THE very common. LATTER MONTHS OF THE YEAR 1844. Next in order we have hepatic disorder. Many of M.D., EDIN., these cases were simple congestion; others sub-apute BY GEORGE CHURCHILL WATSON, inflammation; few if any exhibited any decided imidi. Assocate Member of the Surgical Society of cations of organic disease. Many of the persons Ireland. affected were workmen in. various factories, in which (Continued from page 111.) they were subject alike to high temperatures and sudden I have obtained through the kindness of Mr. Gilmore, changes, from heat to cold, and not unfrequently to apothecary to the Workhouise, the localities from wlhichl currents of cool air. These cases serve as a good each of the fever cases of Drs. Dickinson and illustration of a generally adamitted physiological fact, Gouthwaite came, as far as they could be ascertained. viz., the consent or sympatlhy existing between the skin Fifteen of these were "tramps," &c., and therefore and the liver, and the influence of the fortner with its could not be located properly. The bulk forming a function over the latter. These cases for the most part majority by about one-third, came from places ranging were of the sub-acute inflammatory character, whilst within the general epidemic field, viz.:- the others consisted in mere functional disorder, Everton Ward . . 6 Workhouse 1 involving the quantity and nature of bile secreted. Abercrombie Ward . 7 London Road . . . 1 Rheumatism next claims attention; its prevalence is Scotland Road . . 15 . . . . 1 most readily accounted for by the topographical causes St. Anne's Road . . 6 Bootle and North Shore 2 already alluded to, and the Rodney Street . . 6 Infirmary . . . 1 occupation of the people * Workhouse . . 29 Blind Asylumn . . . I generally. On it there is little occasion for remark Edge Hill . . . . 2 Linme Street . . . 3 beyond the statement that most of the cases were West Derby Township 4 . . . 1 chronic and sub-acute, and vielded without much dif- 86 ficulty to colchicum and iodide of potassium. Many * The Fever Wards are attached to this. of the older cases presented calcareous deposits about the joints of the hands and fingers, and tendinous con- The rest Wvere from the districts which include tractions; both of these resisted all means of cure, witbin their hounds the old fever places. Some of though some of the, latter were much ameliorated. these eases may be set dowvn as typhus and continued In connection with rheumatism mav be mentioned fever. Six of them are stated toa have come from the heart diseases; most of these cases occuirred in parties very haunts of typhus; four were all of one family, who had, at some time or other, suffered from rheu- from St Paul's Ward; and two more were sisters from The districts are as matism in its acute and of which one cellar in Vauixhall Ward. form, disease they follows may very properly be considered a consequence. The most common lesion, so far as general aiid phvsical Gt. George's Ward . 19 1 Castle Street . . . 1 examiuation could ascertain it, appeared to be hyper- Pitt Street . .. . 14 Exchange ... . 2 St. Paul's . . .. 7 Vauxhall . . . . 11 trophv of the left side, withi, in a few cases, evident St. Peter's ..l.o. 3 .... . 4 change of structure in the valves. In a few cases there Bridewell . . . . 1 was enlargement without hypertrophy. 'I'he valves _ 662 most frequently affccted were the mitral and semi- The following table has been kindlv furnished me lunar. Another frequent complication with rheu by Dr. Sutherland fromii the books of the North matism was met with in amen'orrhbea and dysmenor- Dispensary, which has most of the fever districts of hlca,_in regard to which I have, from the most careful Town. Dr. Sutherland states, that "at the time wheta observation, arrived at conclusions very opposite to these cases were attended, there were very few cases t ACCOtNT Of THE EiDDEMIC FEVER IN LIVERPOOL. 121 in the usual fever district. All of those in the subjoined symptoms were most prominent; in other words, that list were cases of the peculiar epidemnic:-" whilst diam,ahea was an exception in the exposeddistrict, it was the general rule in the less ventilated and more Date. Sex. Age. Duration. populous parts. The sanitary condition of the lat- ter was found by experience to preclude depletory November 9th Female 16 11 days measures in this instance as decidedly as in the common ,, 12tlh Female 16 13 ,, typphoid fever, which is always more or less present in ,, ,, Female 7 14 these lower regions. The fact serves to enforce the 13th Female 4 , general necessity of observing the grand elementary ,, 14th Male 10 21 ,, ,, 16th Female 17 18 ,, proposition ruling the indications for cure,-that the ,, ,, Male 8 21 ,, disease of a healthy district, when invading an unhealthy ,. Fenmale 3 ,. one, will have its type so unfavourably modified by the Male 4 i t, unfavourable sanitary condition of the latter, as to Female 6 I,f invert even the therapeutic indications for the healthier ,, 18th Female 25 14 ,, in order to combat with success under its trans- ,, 19th Male 6 18, locality, ,, Female 12 16, muted formn, a disease essentially the same. Looking to ,, ,. Female 7 10 ,, the treatment of fever generally, to a superficial obser- ,, 20th Male 10 16 Pt vation nothing appears more crowded with contra- 21st Femnale 28 Sent to Fever Ward. dictions; but where mutability of type is fairly weighed, I, Male 4 14 days ,, 22nd Male 18 21 ,, as chiefly caused by the varying sanitary states of dif- ,, 23rd Male 6 10 ferent localities, a master key as it were to the solution x, ,, Male 11 35 , of the difficulty is obtained; the discrepancies are seen ., ,, Female 19 14, to be mnore apparent than real, and the various modes ,, 25tb Male 23 21, of treatment stand in tbeir true light. The real indi- 29th Male 13 14 become legible, while the effects , 30th Female 15 10 cations for cure thus December 3rd Male |5 6 ,, of measures which the hand of an empiric even 5th Femnale 23 13 may have possibly directed aright, admit of ready ,, 7th Male 14 21 explanation. ,, Female 5 12 I anm informed bv the House and Visiting Surgeons ,, 8th Female 26 14 , of the South Dispensary, that there were only two or ,, 9th Female 30 Still sick 12th Nfale 7 12 days three casea of the epidemic occuring in their lower ,, .. Female 8 Still sick district, bordering on the docks, (St. Jamnes's Street,) ,, 13th Female 32 Sent to Fever Ward Alnd two only in the higher district, (Park Road ;) but ,, 14th Male 14 12 days they considered these to present well-marked characters ,. ., Male 24 Stillsick of the epidemic. Dr. Duncan's fever pamphlet that in three Cases during the month of November .... 24 sh'ows of the worst wards of the town, the proportion of Cases during the month of Decemuber... fever cases to the whole population of these wards, Total Cases ...... 35 St. Paul's, Exchange and Castle Street Wards, was one in thirty-seven. In the "Liverpool Health of "Remarks.-In the cases treated from the Dispensary, Towns' Advocate," edited by Dr. Sutherland, and the pulse was invariably frequent, from 100 to 120; the published by the Liverpool Health of Towns' Associa- heat of skin was considerable, dry, and harsh; thirst was tion Committee, it is stated that the North and South not much comnplained of. Head-symptoms were not Dispensaries alone attended in the year 1841, five very prominent; slight bronchitis was generally present. tlousand seven hundred and seventy-nine fever cases, Thie tonguie was as if it had been dry, red, and glazed, which gives one in thirty-eight of the whole population run over a iron, but never very muchi by smnoothing of Liverpool as the subject of fever. I htave Dr. loaded. In a few bad cases there were sordes on the teeth, Sutherland's authority, as Senior Physician to the whilst vomiting and diarrha¢e were generally present; .Dispensaries, for the assertion that the amount of especially the latter. Pressure on the abdominal region fever cases for the epidemic year of 1844 in the old was of; the stools were mucous, and always complained fever districts was uncommonly small. The bulk of often mixed with blood. the fever cases come under the attendance of the " Treatment.-This consisted of simple febrifuge mix- North Dispensary. tures, (avoiding tartar emetic,) with hydrargyrum cum creta, and Dover's powder, in doses and frequency suited X.-Causes.-Medical Topography of the District. to the'age and urgency of the abdonminal or otlher -I do not flatter myself that under this head I shall symptoms. Rubefarients, as turpentine, over the be able to produce an amount of evidence, sufficient to stomnach, were found rery useful in checking the vomit- demonstrate the undeniable agency of the various ing; stimulants vere very seldom administered until ,eonditions of the soil, in satisfactory solution of our the tongue was blecoming moist. Depletion, local or problem. To do this, or to have a clhance of dbing it, general, was not employed in a single instance." (Re- would require an extension and accuracy of data port of the House Suirgeon.) which I cannot obtain now; nor perhaps could it ltave I wish here to invite notice of the fact, that whilst, bseen got, bad there been a special commission of by the records of cases occufrring on the higher parts of enquiry on the very spot. But there are some points Everton, the prevalence of thoracic symptomns was more of interest, because o£a practical bearing, which ought marked than that of abdominal ones, down in the more not to be passed over, simply because the amount of sheltered and crowded parts of the town the abdominal their effect cannot be accurately estimated 'or arrange4 12* I. tiS GENERAL tNfRMARY.

into a detmonstrative formula. Of these are the fol- LEEDS GENERAL INFIRMARY. lowing facts. The district of Old Swan, a place lying about two TWO CASES OF STRANGULATED miles east south-east of UMBILT- Everton, and rather in a CAL HERNIA, hollow, more protected by trees than Everton, and SUCCESSFULLY TREATED screened also by the latter from the first brush of BY OPERATION, WITHOUT OPENING THI: the sea breeze-having a substratum of clay about SAC. two feet below the surface, well calculated therefore CASE I. to retain the moisture, which had been superabuindant. Reported by Mr. S. S. SHACKLES. Here the earliest cases of the epidemic occurred, and William Brown, aged 70, a man of considerable here, too, the fever first declined, whilst it was spread- obesity, wlio was sufferiug severely from rheumatic ing its baneful influence along the ridge of Everto'n g;ut in his legs, was admitted into the hospital as an and Edge Hill, including the lower district of urgent case, on the evening of the 24th of July, 1845. and Bootle, which is washed by the estuary of the He was found to have a large umbilical hernia, which, Mersey. including the amount of adipose deposit, presented Everton: Here the chief power of the malaria was a globular protuberance equal In size to a small melon. and it is some exerted, probable that hundreds of cases Present condition:-He complains of great pain in presented tlhemDselves as more or less attacked by the the umbilical region; is much troubled with hiccough noxious agent. As we see, on glancing at the map, and obstinate vomiting; countenance pale, with anwxious and especially at the old view of Liverpool, in 1760, expression and burried respiration; pulse feeble. suburb as was the of Yerton, it then written, was at He dates six years back as the period of the first that time a high ridge of land, running north and existence of the hernia, and up to the present time south, and covering the town of Liverpool considerably could always reduce it at will. It from the alwavs returned iuto easterly winds, except from the south-east, the abdomen spontaneously during repose, with the ex- quarter, to which the town is exposed by the sinking ception of a small portion, which consisted of omentum, down of the shoulder of the ridge on tbe south and which was irreducible. The into the patient up to the tithe extremnity opeii plain on which Toxteth Park of strangulation has worn a truss with a hollow stands, (a suburb south of the pad. town) and which He states that he has suffered from rheumatic gout in stretches on towards the river at Runcorn, with but his feet and knees ever since the little It will be year 1815. Being exception. seen, from what we havw advised to try the waters of Buxton, he went there on pointed Everton must out, that present its broad side June 30 h, from Leeds, and in returning on the 21st to the mouth of the as river, the latter at its mouth; of July, got shaken very much by the motion of the runs due at nearly nortb, least, the shore of Bootle coach between Buxton and Sheffield. Trhis, together Bay, underneath Everton, tends to the north and north- with a slight cold he The contracted, made his gout much west. district must therefore be considerably worse, and produced serious disturbance of exposed to the sei constitution. breeze, blowing off the channel, On the morning of the 24th, about seven and to any land and sea breezes o'clock, he blowing across the discovered that the heruia was irreducible; had much Peninsula of Wirrall, i.e., from the nmouthl of the Dee, vomiting and p'in, the and the latter greatly aggravated on from distant range of Welsh mountains, one attempting the usual taxis. During the of which, for the informiation of day the tumour strangers, we may add, increased to double its ordinary size, and on admission can be readily recognized from the parts of Everton into the Hospital showed no on a clear sign of reduction by taxis, day. though every means consistent with the Mr. the overseer patient's safety Shaw, of Everton, told me that to his was tried both in bed and in the hot bath. there were In addition, knowledge thirty cases he could point out other means were employed, as within sixtv yards of his enemas, and a cold bouse, which is near the little lotion to the part, but without the desired effect. Post-office, and with the exception of the land on The whicht St. George's hernia had now been unreduced more than fifteen stands, about half-a-mile hours, and during that timne no flatus bad been passed off, is the highest part of Everton. As we have seen, per rectum. Everton and its Considering the great age and weak state immediate vicinity presented the chief of the it bulk of cases. The patient, was thought dangerous to permit the town of West Derby itself, lying night to pass without more tothe east, and redu,tioin, and it was decided in neighbouring to Old Swan, had consultation to cut down and release very few cases, I believe, at least as far as the bowel, if I have. possible without opening the sac. Mr. Smith then pro- learat. Everton has no bog soil, being geologically ceeded with the out of a the operation as follows:- cropping ridge of the new red sandstone. The patient I must call the attention of having been placed upon his back, an the Society to the existence incision about three inches in of large bodies of stagnant water under length was made in the Everton and course of the liea alba, the lower uich of the Edgehill, retained fromn percolating by strata of clay, incisiozt in the being oni the upper part of the tumour. There was a variegated sandstone. Also to an open drain, great running down from the foot thickness of fat to cut througb. When this was of Mill Lane, Everton, to accomplished, the Shaw Street, for two hundred yards, finger nail was 'used to expose the perhaps, quite shining surface of the tendinous fascia. open in its course. The new smuall houses, of late When this was found, a st;all puncture, about the eighth of erection at Everton, are not sufficiently drained, I asp an told. inch long, was made through it, and the peritoueum was seen; a steel curved director was now passed, the (To be continued.) tendon lifted up, and the opening very carefully enlarged until there was sufficient spae to allow of the introduction of a finger of the left band. The