production primarily on the systole. For unless either ventricle contract with sufficient force to distend the artery emerging from it, aortic or pulmonary, there can be no resistance, and no back stroke to close the semilunar valves and produce a second sound; and, as it is impossible that ventricular contraction can take place without tension of the auriculo-ventricular valves, and, therefore, without a systolic sound, so it would seem equally impossible that a first sound should occur twice without a second sound following immediately upon it. A condition such as is described would then give a double first or second sound in the period of one arterial pulsation—a phenomenon which, I believe, has never been met with.

At the same time, there are conditions, as I have before said, when the ventricular walls being greatly weakened and irregularly weakened, there is an irregularity of contraction. Here, however, the auscultatory phenomena are of two kinds, according to the degree of feebleness of the two contracting ventricles; in one of these cases one ventricle contracts with sufficient force to produce valvular tension, while the other produces but feeble tension, and the effect is a weakened systolic sound; in another set of cases both ventricles contract so feebly as to produce imperfect valvular tension on both sides, the effect being to produce a confused rustle, in which no systolic sound can be detected, and often but a feeble second sound. We meet with this frequently in cases of large disorganized heart, when the mus

cular structure has undergone extensive degeneration, with thinning of the parietes.

From these observations, I should infer that what is considered a repeated first sound is, in fact, the first intensified stroke of a double second sound; but I would not venture to offer these remarks dogmatically, and as necessarily true, although the explanation carries to my own mind the conviction of a truthful rendering of a difficult problem.

BEARINGS ON PRACTICE AND TREATMENT.

The study of those cases in which reduplication of one of the heart's sounds is detected, opens to us various considerations having relationship to other affections marked by analogous general symptoms.

I believe that in many of these cases, where there are symptoms of palpitation, oppression of breathing, especially during sleep (nightmare), and irregular pulse, the symptoms, usually attributed to indigestion, are due to a disturbed balance between the pulmonary and the systemic circulations. This want of balance may arise from different causes: from temporary congestion of lung after an undue supply of food to the system; from irregular contraction of the heart under the influence of disease affecting one or other ventricular wall; from pressure on the diaphragm by collection of flatus in the stomach and intestines.

Treatment. There is nothing more obvious than the fact that, in the treatment I pursued in the case which affords the subject of the present commentary,

I was entirely on a wrong track. The man was correct when he said that he was made worse by the medicines (tonics) which were prescribed for him. They suppressed secretion, which was the physiological act requiring more excitation; they confined the current of the blood, and, in proportion as they did so, they supported the disturbance in the circulation.

It is equally obvious that the treatment by the hot bath, given though it might have been almost by accident, and certainly without any idea of relieving an embarrassed right ventricle, was the rational, as it was therefore by necessity the successful treatment. Any other form of derivation would have given relief-the abstraction of a little blood, a sharp purge, or diaphoretic; but the warm bath was and is the simplest remedy.

I have learned much from this case of reduplication; the essence of all which is to the effect that whenever, without evident sign of disease of the lungs or of organic changes in the heart or nervous centres, there are manifested indications of vascular irregularity commencing at the heart itself; then, however clear may be the signs of anæmia and debility, no good will come from any treatment in the absence of some system of derivation; that tonics, administered alone, invoke more mischief; and that coincident debility disappears without them, when the troubled heart is set at liberty.

ESSAY IV.

CONTRIBUTIONS TOWARDS A MORE PERFECT CLINICAL HISTORY OF SCARLET FEVER.

FOR some years past, I have been directing particular attention to Scarlet Fever, with a view to bring forward certain facts tending to supply a more correct clinical history of this, as yet, formidable disease. Some of my labours in this direction have already been laid before the members of the Epidemiological Society, and have appeared in abstract in the periodical literature of the day. I propose, on the present occasion, to collate these scattered materials, and, with certain new observations, to condense into one clinical essay the result of all that I have as yet accomplished. It is little enough, I am well aware; but such as it is, it is herewith offered.

POINTS RELATING TO THE NATURAL HISTORY OF
SCARLET FEVER.

The question of the occurrence of scarlet fever at different periods of life is one of much interest, and has occupied the attention of various observers. Regarding this, an opinion has been promulgated that the disease is rare, if not absent, in babes at the breast and

in children under two years of age. This statement was, I believe, first made by the distinguished Withering; but Dr. Nieuwenhuys, of Amsterdam, in an admirable paper on small-pox and scarlet fever, has repeated, within these late years, an almost similar opinion. He seems to have been led to this view by seeing cases in which infants had escaped the disease whose mothers were suffering from it, and were occasionally suckling these same children during the period of the disease. If this statement were true, it would convey one of the most curious facts in medicine. It is, however, one of those errors which occasionally will creep into the works of the ablest writers, if they give the history of their individual knowledge alone.

It happened to me that, in the first case of scarlet fever I ever saw in a puerperal woman, the infant at her breast died of the disease, and that another child of hers, under two years, took the malady and suffered from it in the malignant form. Here, then, were facts at once offered which showed that no rule such as that which has been suggested really obtains, or at least that such rule had its exceptions. I thought, therefore, that it would be interesting to follow out the subject, and, from a rigid analysis, to learn the fatality of scarlet fever in the early terms of existence.

In this direction I took, in the first place, my own reports of cases of the disease, and collected from the printed return-books of three friends who held parochial appointments (viz., the late Mr. Brown, of Saf